Recommendations for Improvement of Equity, Diversity, and Inclusion in the CaRMs Selection Process

Equity, diversity and inclusion (EDI) in the medical field is crucial for meeting the healthcare needs of a progressively diverse society. A diverse physician workforce enables culturally sensitive care, promotes health equity, and enhances the comprehension of the various needs and viewpoints of patients, ultimately resulting in more effective treatments and improved patient outcomes. However, despite the recognized benefits of diversity in the medical field, certain specialties, such as Radiology, have struggled to achieve adequate equity, diversity and inclusion, which results in a discrepancy in the demographics of Canadian radiologists and the patients we serve. In this review, we propose strategies from a committee within the Canadian Association of Radiologists (CAR) EDI working group to improve EDI in the CaRMS selection process. By adopting these strategies, residency programs can foster a more diverse and inclusive environment that is better positioned to address the health needs of a progressively diverse patient population, leading to improved patient outcomes, greater patient satisfaction, and advancements in medical innovation.


Introduction
A diverse and inclusive physician workforce leads to a more comprehensive understanding of patients' varied needs and perspectives, resulting in more effective treatments and better patient outcomes. 1By incorporating equity, diversity, and inclusion (EDI) considerations during the selection process for medical professionals, these values are not only upheld but also significantly influence patient care, innovation, and workplace culture. 2 Research has demonstrated that a diverse medical workforce enhances patient outcomes, increases patient satisfaction, and strengthens problem-solving abilities, paving the way for more innovative healthcare solutions. 3hysicians with diverse backgrounds are better equipped to comprehend the unique needs of different cultural and socioeconomic groups, ultimately fostering a more inclusive working environment.
However, certain medical specialties, such as Radiology, have struggled to achieve adequate gender and ethnic diversity. 4In 2019, women represented only 32% of Canadian Radiologists despite representing 63% of current medical graduates. 5As of 2021, racial diversity data in Canadian Radiology practice and CaRMS application is still lacking.Radiology is considered one of the least diverse fields of medicine with regards to the presence of visible minorities.Many residency training programs are now implementing diversity plans in their selection committees with the goal to promote a more equitable selection process. 6adiology, in addition to other medical specialties, benefits from diversity in its workforce due to the specialty's reliance on communication, teamwork, and collaboration. 6By improving EDI in the CaRMS selection process, we can ensure a more equitable approach in selecting diverse candidates, paving the way for a more inclusive Radiology field and medical profession as a whole.To improve and promote equity, diversity and inclusion in the residency selection process, the Canadian Association of Radiologists (CAR) EDI committee recommends the following actions for all Canadian residency selection committees, as best practice guidelines.

Recommended Timeline for Implementation
Enhancing EDI in the CaRMS, selection process will be a continuous endeavor; there is no fixed timeline for adopting these guidelines.It is advised that the selection committee annually allocate time before the CaRMS file review commences to assess their process from an EDI perspective and make ongoing adjustments as needed.Likewise, after each CaRMS, cycle, it is recommended to set aside time for reflecting on the process and identifying potential improvements for the subsequent year.

Implicit Bias Training for All Members of the Selection Committee
Unconscious or implicit bias is defined as inherent attitudes or stereotypes that affect our understanding, actions, and decisions toward a particular ethnicity, gender, or social group in an unconscious manner.These biases can be positive or negative.It is important to distinguish implicit or unconscious bias from conscious beliefs that certain demographic groups are inferior or less deserving of opportunities; these are examples of explicit, not implicit biases, such as racism, sexism, and homophobia.These biases may influence committee members' evaluations of potential candidates, potentially limiting diversity within the medical profession. 7t has been shown that physicians have the same level of implicit biases as laypersons.In the setting of a residency selection committee, a committee member may unknowingly hold negative or positive implicit biases about a potential candidate and these biases can influence decision making on the rank order of the candidate. 8mplicit biases can be reduced when there is a conscious effort by individuals to recognize and acknowledge their own bias to do so, and there are several recommendations that the selection committee can implement to raise people's awareness of their unconscious biases and provide tools to adjust automatic patterns of thinking, with the goal of mitigating or eliminating discriminatory behaviors. 9,10s an initial step and to combat these biases, it is essential that all members of the selection committee undergo implicit bias training.2][13] This resource provides useful information regarding unconscious bias for search committees in academic medicine.
Individual completion of training alone does not guarantee that equity will be applied as a guiding principle throughout the selection processes.A crucial next step is for the selection committee to meet as a group, discuss, and reflect on implicit bias and its impact on the selection process.Where resources permit, an interactive implicit bias mitigation workshop moderated by a trained facilitator is recommended.A final recommendation is to hold a debrief session of the selection committee following the completion of the selection process Taylor et al.
to reflect on the process and consider areas for improvement for the following year.It is important that implicit bias awareness and mitigation training be ongoing and a part of the annual process for members of the selection committees rather than a "one-off" event.

Standardizing Application Metrics
A recommendation for consideration is to set a baseline threshold for academic evaluation, including situational judgment tests such as the CASPer test, for candidates to be selected for an interview.Once candidates above a specified threshold have been selected for interview, committee members will then be blinded to academic metrics. 14nother recommendation is to standardize each application using numerical values for each parameter with set objective criteria.The use of a standardized rubric and scoring system for evaluation of application criteria such as letters of reference, research productivity, extracurricular activities, etc. is recommended for use by the selection committee to minimize potential personal biases of members of the committee.Standardizing application metrics promotes transparency and consistency in the selection process.By using clearly defined evaluation criteria, committees can ensure that all applicants are assessed fairly and objectively.This allows candidates to better understand the expectations and requirements of the selection process and helps to maintain the integrity of the medical profession.It also facilitates a better comparison and evaluation of the candidates.By using a standardized set of criteria, selection committees can more accurately compare applicants and identify those who are best suited for a particular residency program. 15e Use of Situational Judgement Tests in the Application Process The use of situational judgment tests (SJT), such as the CASPer test, in the admissions process has been shown in some studies to have the potential to widen access to medical education for underrepresented medical groups.SJTs aim to evaluate non-academic competencies like communication, collaboration, and empathy, which are essential qualities for healthcare professionals. 16lthough SJTs are implemented with the intent to provide additional relevant data beyond academic evaluations, there have been concerns raised that some students from a more advantaged socioeconomic status may have access to additional coaching or preparatory material, which may influence their CASPer scores.This may inadvertently perpetuate existing disparities in access to medical education, as these students may be better equipped to perform well on SJTs, regardless of their actual non-academic competencies.
Many programs find the CASPer test to provide useful objective data in the assessment of potential candidates.However, selection committees should be aware of the potential for some students to have access to resources that would allow them to obtain a higher CASPer score than others who do not have the same opportunities.Cultural differences may also impact a candidate's CASPer score, which should be taken into consideration. 17

Structured and Standardized Interviews
Interviews are a crucial component of the CaRMS selection process, as they offer residency programs a chance to assess applicants' interpersonal and communication skills, values, and overall fit for the program.However, interviews, especially those that are unstructured, can result in bias by the members of the committee.The ability of a committee to objectively evaluate an applicant over the course of a few minutes is limited under the best of circumstances.
The use of rating scales to evaluate an applicant's responses improves reliability, validity, and fairness of interview scores and increases an interviewers' ability to compare applicants who have been evaluated using a common scale.For example, the Association of American Medical Colleges (AAMC) has published a guide on creating rating scales for interviews titled "Best Practices for Conducting Residency Program Interviews". 18

Standardizing the Virtual Interview Environment
Virtual interviews require the residency selection programs to be invited into the personal spaces of applicants.One effective approach to reducing biases in virtual interviews is to recommend standardized backgrounds, such as neutral-colored walls devoid of personal belongings.This ensures that all candidates are evaluated in a consistent environment, preventing any unintentional judgments based on factors unrelated to their qualifications or suitability for the program.Standardizing the virtual interview environment also helps to minimize distractions and allows committee members to focus on the candidate's responses, rather than their surroundings. 19

Diversification of the Selection Committee
A diverse selection committee mitigates individual implicit biases and offers multiple perspectives during the selection process.To achieve this, the selection committee must be composed of members representative of a variety of backgrounds, which may require intentional restructuring of the committee.At least one or more members should have experience or training in advancing EDI in medicine to ensure that these principles are effectively incorporated into the selection process.1][22] This effort is crucial to promote equity and inclusion in the selection process, as diverse committee members offer unique perspectives and experiences that can enrich the evaluation of applicants.

Use of Self-Identifying Diversity Data
Candidates are currently offered the option to self-identify in several areas related to EDI in their CaRMS application.Selection committees have the option of requesting access to this information through CaRMS and may find it a useful tool to ensure a diverse group of applications is selected for interviews.In order to have access to this data, at least one and ideally multiple of the members of the selection committee must undergo training provided by CaRMS on the appropriate use of this information.By considering self-identifying diversity data, committees can better understand applicants' backgrounds and experiences, facilitating a more equitable and inclusive selection process.
Self-identifying diversity data can be used to inform various aspects of the selection process, including the development of selection criteria, the design of interview questions, and the allocation of resources for targeted outreach and recruitment efforts.Additionally, this information can help to identify potential barriers and challenges faced by underrepresented applicants and inform strategies to address them. 23,24

Conclusion
Promoting EDI in the CaRMS process is critical to ensure a more representative and equitable physician workforce.Selection committees can create an inclusive and psychologically safe environment in the residency selection process by implementing strategies, such as implicit bias training, diverse composition of the selection committee, inclusion of selection committee members with EDI expertise, standardized application metrics, situational judgment tests, structured and standardized interviews, and standardized virtual interview environments.These strategies can pave the way for a more comprehensive understanding of patient needs and perspectives, ultimately resulting in advancements in medical innovation.