Physician Pipeline and Pathway Programs: An Evidence-based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine

Improving the diversity and representation in the medical workforce requires intentional and deliberate efforts to improve the pipeline and pathway for underrepresented in medicine (UIM) applicants. Diversity enhances educational experiences and improves patient care and outcomes. Through a critical review of the literature, in this article we offer evidence-based guidelines for physician pipeline and pathway programs (PP). Recommendations are provided regarding considerations on the types of programs and surrounding implementation to ensure a sound infrastructure and framework. We believe this guide will be valuable for all leaders and faculty members seeking to grow the UIM applicant pool in our efforts to advance diversity, equity, and inclusion within medicine.

Improving the diversity and representation in the medical workforce requires intentional and deliberate efforts to improve the pipeline and pathway for underrepresented in medicine (UIM) applicants. Diversity enhances educational experiences and improves patient care and outcomes. Through a critical review of the literature, in this article we offer evidence-based guidelines for physician pipeline and pathway programs (PP). Recommendations are provided regarding considerations on the types of programs and surrounding implementation to ensure a sound infrastructure and framework. We believe this guide will be valuable for all leaders and faculty members seeking to grow the UIM applicant pool in our efforts to advance diversity, equity, and inclusion within medicine. [West J Emerg Med. 2022;23(4)514-524.] * † ‡ § ¶ || statistically significant increases in representation, suggesting that current efforts are insufficient. 8 When the 20 largest specialties in medicine were analyzed between 2007 to 2018, none represented Black or LatinX populations in proportions comparable to the overall United States (US) population. 8 One study found that Black and LatinX representation was still sparse at the medical school faculty level (7.5%), despite 14.1% representation among medical students and 30% at the US population level. 8 Within emergency medicine (EM), women account for only 25% of physicians, while Black, LatinX, and Native American physicians comprise less than 10% of all active emergency physicians. 9 Furthermore, a 1 *The Association of American Medical Colleges (AAMC) defined the term underrepresented minority (URM) to reflect the racial groups of Black, Mexican American, mainland Puerto Rican, and Native American (American Indian and natives of Alaska and Hawaii). In 2003, to encompass the racial and ethnic populations within medicine who are underrepresented when compared to their respective numbers in the context of the greater population, this was further clarified to "underrepresented in medicine"(URiM or UIM). Although we recognize the use of URiM or UIM interchangeably, for consistency, we will use the term UIM throughout this paper.

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Best Practices for Diversity, Equity, and Inclusion from CORD in EM recent study projects that EM will take about 54 years to reach the level of LatinX faculty representation commensurate with that of the US population. 8 Pipeline and pathway programs (PP) 1*2 increase opportunities for UIM candidates through outreach, mentorship, and other critical structural support needed to advance diversity, equity, and inclusion (DEI) in medicine. In this paper, we delineate pipeline, pathway, and outreach, mentorship, and other critical structural support needed to advance diversity, equity, and inclusion (DEI) in medicine. In this paper, we delineate pipeline, pathway, and outreach programs, discuss components of PPs, and steps toward successful implementation of DEI initiatives.

CRITICAL APPRAISAL OF THE LITERATURE
The Council of Residency Directors in Emergency Medicine (CORD) Best Practices Subcommittee publishes a series of articles entitled CORD Best Practice reviews; this manuscript is ninth in the series. [10][11][12][13][14][15][16][17] With the assistance of a medical librarian, we conducted a literature review from inception until January 2021 through MEDLINE via PubMed using the terms and Medical Subject Headings focused on DEI (Appendix). Additionally, a bibliography review was conducted for additional articles. Two reviewers independently screened the 2080 articles, finding 58 relevant for this review.
We created best practice recommendations based on the literature appraisal. Whenever supporting evidence was unavailable, consensus opinion and the authors' combined expertise were used. The Oxford Centre for Evidence-Based Medicine criteria (Tables 1 and 2) 18 were implemented to provide the level and grade of evidence for each best practice statement. Prior to submission, the manuscript was reviewed by the CORD Best Practices Subcommittee, followed by a two-week review on the CORD website for feedback from the CORD community.

Barriers to Entering the Health Professions
Barriers exist that hinder students from entering the health professions. Recognition of the barriers (Table 3) for UIM, female, and economically disadvantaged students provides perspective on the challenges that must be overcome to pursue a career in medicine. [19][20][21][22][23][24][25] This further highlights the importance of pathway programs to ensure a diverse, equitable and inclusive medical workforce.
Simply recognizing these barriers is not enough. Deliberate actions to mitigate or remove these barriers is imperative, including creation of novel educational and training frameworks that focus on improving trainee performance. 5,[26][27] Pathway programs create a supportive network and inclusive culture 26 to reduce the isolation experienced by UIM. The greatest barrier to successful entry into health professions for UIM students is the undergraduategraduate interface, due to the high attrition rate, with only 38.1% of all UIM doctoral candidates completing their degrees, as opposed to 51.3% of all non-UIM doctorates. 26

Overview of Pipelines, Pathways, and Outreach Programs
A scoping literature review found the most frequent approaches to increase minority representation in the Case series/Qualitative studies or lowquality cohort or case-control study*** 5 Expert/consensus opinion *defined as <80% follow up; **includes survey studies and crosssectional studies; ***defined as studies without clearly defined study groups. RCT, randomized control trial. Best Practices for Diversity, Equity, and Inclusion from CORD in EM Parsons et al. medical workforce were PPs (43%), changes in affirmative action laws (23%), and changes in admission policies (21%). 5 Pipeline/pathway terminologies are often used interchangeably to describe programs created to increase minority matriculation into medical schools and healthcare workforce diversity. Starting as early as elementary school, these programs offer mentorship to UIM students, 28 offering opportunities to identify and support future diverse medical students. 5,28,29 Outreach programs are typically discrete events, consisting of a single or a select number of time points (Table 4). 3,28,29 They may include second-look visits or weekends for UIM applying to medical schools, often run by the school's diversity committees or Student National Medical Association groups. 3 Pathway programs effectively enhance academic performance and increase the likelihood that UIM and other disadvantaged undergraduate students enroll in a health professions school. However, the long-term success when targeting high school students remains <20%, suggesting that work still needs to be done to bridge this gap. 28 Table 4. Outreach activities for students underrepresented in medicine. 28,29 • Workshop on getting admitted to medical school • MCAT guidance • Workshop on writing a personal statement • Education on financing medical school • Mock interviews • Shadowing opportunities such as "Day in the Life of a Medical Student." • Sample lectures, labs, and small-group discussions • Second look visits or weekends for UIM applying to medical schools MCAT, Medical College Admission Test; UIM, underrepresented in medicine.

TYPES OF PATHWAY PROGRAMS
Pathway programs are a key strategy for increasing the enrollment of UIM students into medical schools. 28 These programs, described below, are created to target different age groups of learners, to provide a variety of educational or developmental benefits, 28 and to encompass different goals.

Elementary/High School-to-College Program Pathways
Elementary and high school programs help pre-college UIM students succeed through their primary and secondary education, to continue progressing down the pathway toward medical school. Early introduction and exposure to healthcare has been shown to effectively influence career decisions. 32 Studies have found that among all ethnic groups, the major hurdles to attending medical school are obtaining a high school diploma and bachelor's degree. 33 Once this hurdle is overcome, the proportion of UIM college graduates to apply to medical school are similar to proportions of White college graduates. 33 Goals of these programs include preparing students for college life, 27,34 exploring different healthcare careers, 27,[35][36][37] increasing research exposure, [38][39] and improving basic science knowledge. 2 Programs vary from summer experiences 2,37,40 to longitudinal experiences during the school year 19 and offer educational components, such as core sciences (eg, biology, chemistry) 2 or healthcare-related topics (eg, disparities, physiology, patient interview sessions). 19,27,32,41,42 Interactive sessions such as simulation, physical exam practice, workshops, and seminars are also included. 19,31,32,36,41,43 College preparation is a significant component of many elementary-to-high-school PPs, and include exposure and guidance to the university admissions process, 2,19,41 financial aid guidance, 2,19,41 and college fairs. 43 Because standardized test scores continue to be a barrier for UIM, Scholastic Assessment Test preparation is also a frequent element of these programs. 2,39,44 Mentorship is a crucial component of elementary-to-highschool PPs and may be provided by medical students, graduate students, or working professionals. 2,29,37,41,45 Shadowing opportunities are important, 2,35 including patient care in free clinics. 42 Multiple studies suggest that educational content and

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Best Practices for Diversity, Equity, and Inclusion from CORD in EM mentorship can be provided by medical students. 32,46 Another strategy was the creation of Health Professions Affinity Clubs, in which volunteers visited high schools to introduce students to health professions via projects, mentoring, and shadowing opportunities. 29

College-to-Medical-School Pathway
Undergraduate level pathways serve to expose UIM students to the health professions. The structure of these programs vary in length, 30,31 frequency of meetings, 47 time of year, 39 and depth of contact. 47 Another common PP is summer internship programs offering opportunities in education, 27 research, 39,47 clinical care, 48 or a combination of these ( Table 5). [48][49][50][51] Longitudinal pathways exist to offer "living and learning communities," consisting of a designated dorm floor for pre-health students to enhance networking and surround undergraduate students with a supportive cohort. 47 Undergraduate pre-health organizations also provide career counseling, test support, networking opportunities with health professions students and faculty, and shadowing opportunities. 47

Bachelor of Science-Medical Doctor (BS-MD) Pathway
The combined BS-MD program can be a high school or undergraduate school to medical school pathway. For example, the Premedical Honors College, an eight-year college-to-medical-school program targeting South Texas medically underserved counties, 52 of which the majority of the population (81%) identifies as LatinX. It provides conditional acceptance to medical school based on the completion of the bachelor of science and includes rigorous undergraduate curriculum, enrichment experiences, clinical experiences, tutoring, and a summer research program. 52 It has successfully produced 134 medical school matriculations, 110 (82%) of which are UIM and 106 (79%) are LatinX. 53 Other BS-MD programs offer undergraduates conditional acceptance to medical school. The Mount Sinai School of Medicine created a Humanities and Medicine program, an early admissions program that allows sophomore-year undergraduate students to apply and pursue their interests in humanities and social sciences prior to matriculating to medical school. 39 These programs often do not require Medical College Admission Test (MCAT) scores and thus remove one barrier to gain acceptance to medical school. 54

Community Colleges (CC) to Medical School
Another undergraduate-to-medical-school route is the community college (CC) pathway. Defined as two-year postsecondary education institutions, CCs serve as a common pathway to the attainment of higher education for low-income and UIM students. Talamantes studied medical students' educational path to better understand the use of CCs, 54 and found that of students using a CC pathway, LatinX were the most common racial-ethnic group (34%), followed by Black (28%), White (27%), and Asian (27%) matriculants. 54 This data suggests that PPs targeting CCs may be a promising approach to increasing the diversity of medical students. An improved process to transfer credits from CCs to four-year institutions is recommended. 55

Post-Baccalaureate Pathway Programs
Post-baccalaureate pathway programs (PBPP) are an important strategy for increasing diversity among medical school matriculants. The UIM and disadvantaged students tend to be at greater risk for academic difficulties and lower MCAT scores, which are known barriers to medical school admission. 35,56 The PBPPs frequently involve a  51 These PBPPs consist of small cohorts (2-8 students) and are often supported through institutional funding to provide financial support and tuition waivers. 31,38 In 2014, 36% of national PBPPs identified themselves as having a special focus on UIM or economically or educationally disadvantaged students. 58 Many programs offer early or conditional acceptance to degree-confirming MD, PhD, and combined MD/PhD programs, pending successful completion of the program. 2,31,35,39,51,52,58 A few PBPPs confer master's degrees or certificates upon successful completion. 2,51,56 Academic or civic credit may also be awarded to students for participating. 34,48 Students are selected via a national open application, 38 with preference often given to those who had been unsuccessful in their medical school applications. 31,51 Despite having academic profiles that were not promising for medical school admissions on entering the Medical/Dental Education Preparatory Program (MEDPREP) program, 83.3% of graduates successfully matriculated in medical school. 56 Of those, 53% worked in primary care and 40% worked in medically underserved areas after graduation. 56 Long-term data has shown that PBPP graduates have pursued careers in every specialty and are more likely to provide care in underserved areas or for vulnerable populations. 28

Historically Black Colleges and Universities
Historically black colleges and universities (HBCU) and historically black medical schools (HBMS) have a significant impact on the diversity of medicine. 61,62 The HBMSs are instrumental in the overall representation of Black chairs, faculty, and students in US medical schools. 62 Xavier University and Howard University are the top two producers of Black graduates of medical schools. 63 Black students who graduate from HBCUs were found to be more likely to go to graduate school and complete their doctoral degrees than Black students from other schools. 61 The HBCUs were found to devote greater effort to premedical training, developing strong relationships with medical schools and offering a range of sponsored enrichment opportunities to their students. 63 Successful interventions include providing all premedical students a core curriculum instead of allowing them to choose their courses, providing tutors for all first-and second-year students, and beginning MCAT practice during their first year of college. 61 The HBCUs are also successful in building strong pathway partnerships with medical schools, educating on health disparities, and teaching cultural competency skills. 61 Best practice recommendations are summarized in Box 1.

INFRASTRUCTURE AND FRAMEWORKS FOR IMPLEMENTING PATHWAY PROGRAMS
Factors related to implementing PPs are important determinants of the success of these programs. Below, we explore the following implementation elements: frameworks and theories; funding; participant selection; academic enrichment and instructional design; and mentoring, advising, and networking.

Frameworks and Theories
Several articles outlined PPs' frameworks and theoretical underpinnings. Young built on the knowledge translation framework to generate a six-part framework for developing PPs (Figure 1). 64 When developing a portfolio of comprehensive PPs across the educational continuum, Grumbach suggested that institutions adopt a "distal-toproximal" strategy to prioritize later-stage participant support (eg, post-baccalaureate programs) and then work backwards to include earlier stage programs. 65 Johnson and Bozeman constructed the asset bundles model from other models and theories that focus on human capital (eg, knowledge and technical abilities), social capital (eg, ability to tap into resources embedded in relationships), and the ways in which institutions perpetuate marginalization. 25 Asset bundles are "the specific sets of abilities and resources that individuals develop that help them succeed in educational and professional tasks." 25 The authors assert that these five asset bundles are critical to retaining UIMs on successful educational pathways (Table 6). 25 Many PPs incorporate individual assets, but few programs work to enhance all the assets. 25

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Best Practices for Diversity, Equity, and Inclusion from CORD in EM

Funding
Sustainable funding is critical for the success and survival of PPs. Programs are usually funded from multiple sources, including federal, foundation, and institutional investments. 27,29,31,34,37,38,41,44,48,50,57 Less commonly, programs received funding from non-profit professional organizations, private entities, and state legislative appropriations, 36,38,41,44,47,57 or program alumni efforts. 57 Federal funding for PPs has been dramatically reduced over the years. 65 In drafting this manuscript, we searched for several of the federal funding sources for cited programs, which currently are not taking new applications. As external funding for PPs shrink, greater onus is on universities and health systems to fund these initiatives.
The program budgets ranged widely from $2,600 (2007 dollars) for a student-run, specialty-specific initiative, to $25,000 (2018 dollars) for a two-day workshop, to several million dollars for a comprehensive collection of PPs. 30,34,47,49,65 The University of Illinois at Chicago's Urban Health Program is funded by the state and seven university colleges to amass an approximately $4.3 million budget (2012 dollars) that serves hundreds of preschool through graduate school students annually. 47 The state's financial contribution was tied to metrics that demonstrated success in supporting UIM students matriculation to the health professions. In 2011, highly effective PBPPs typically cost $20,000. 65 Those aimed at UIM scholars tended to discount fees for students and rely mostly on institutional sources of funding. 52 Some programs offered students stipends, scholarships, and/or wages to cover the costs of travel, tuition, fees, attendance at conferences and workshops, and other financial needs. 2,19,27,31,38,40,49,52,58

Participant Selection
Most PPs aim to support and facilitate educational and healthcare career advancement for UIM racial and ethnic gr oups. 19,27,30,31,35,38,41,[47][48][49][50]52,[56][57][58]60,66,67 Few programs share their participant selection criteria in detail and rarely state race/ ethnicity criteria. 30 Commonly, programs used proxy criteria  • Focuses on academic performance, which is primarily determined by students' high school math and science curricula and teacher quality. • Advance courses such as advanced placement, international baccalaureate, and college prep, as well as hands-on laboratory experiences, study groups, tutors, and systemic educational reform to improve math and science curricula can enhance this asset.
Human Capital: Science Socialization • UIM students may need additional encouragement to envision themselves as physicians and scientists, as it is unlikely that they have regular access to role models in these fields in their homes or proximal communities due to systemic underrepresentation. • This can be done by 1) emphasizing the relevance of science and technology to addressing problems in their community; 2) exposing students to successful identityconcordant scientists and physicians; and 3) developing individualized plans to benchmark students' progress toward their career goals. Best Practices for Diversity, Equity, and Inclusion from CORD in EM Parsons et al.
for race/ethnicity including being from educationally/ economically disadvantaged backgrounds. 27,30,31,35,38,47,48,66 To attract UIM students, some PPs recruited from majority UIM schools and communities, focused on racial/ethnic health inequities, or selected students whose attributes and interests reflected the institution's mission. 27,31,[34][35][36]38,39,41,44,[48][49][50]52,58 Few programs stated they used holistic review to select participants. 31,41,47,58 Traditional measures of academic success (ie, grades and test scores) were only occasionally included as selection criteria. 2,19,36,38,40,49,50,52,56,67 One program only used academic measures to exclude candidates with extremely low scores, 48 while another program intentionally sought candidates whose academic performance may not have matched their potential. 38 Nevertheless, satisfactory test scores and grades were used as measures of successful completion of the program. 31,35,52,58 While most programs included interest in medical or science careers in their selection, 2,19,27,30,35,[44][45][46]50 one program specifically excluded students who had previously shadowed physicians or participated in medical-related community service in order to capture students who needed an initial exposure to medicine. 42 Most programs only required written application materials, but the MEDPREP program also required on-site reading comprehension testing and two faculty interviews. 56 The MERIT program invited students to a three-week "tryout" medical leadership course, evaluating students based on peer interactions, homework, and punctuality as indicators of their passion and potential, as opposed to traditional academic measures. 41 Note that this program made a significant and longitudinal investment in their participants for seven years, prompting their intensive screening process. A detailed target population resource based on target population, selection criteria, and application components can be seen in the Appendix.

Mentoring, Advising, and Networking
Mentorship helps to transform students' thinking, enhance knowledge, develop technical skills, broaden aspirations and confidence in a future scientific career, and improve "professional socialization." 68 Although the characteristics students valued in a mentor varied based on the students' demographics, all agreed that engaged mentors were the most effective. The importance of concordant mentors (racial/ ethnic, gender, and sexuality) was also underscored in several studies, citing the intangible benefit of having a mentor that "looks like you" in helping students visualize themselves as successful physicians. 26,27,38,69,70 Having a concordant mentor may minimize beliefs that their aspirations are unattainable and mitigate experiences of isolation that are linked to low self-efficacy. 25,26,39,31,70 Mentorship may be structured, small group-led faculty or one-on-one mentoring. 27,30,31,[34][35][36]38,41,49,56,66 Rarely, mentoring and coaching was longitudinal, including after participants complete the program and during major transitions (eg, from high school to university). 37,38,41,49 Peer and near-peer mentoring and advising was also a component of some programs. 36,38,45,47-50,53,56,68.72 In addition to formal mentoring, PPs also facilitate networking opportunities in small groups for students to interact with physicians, scientists, medical graduate students, and alumni. 30,31,36,[38][39][40][41]43,47,50,66 Often, formal networking occurs over scheduled lunches. Informal networking occurred during events like career fairs, didactics, research symposium, shadowing, and barbecues. Several programs also offered mental health counseling and other intensive

LIMITATIONS
This paper focused on pipeline, pathway, and outreach programs. Recognizing the vastness of DEI, other topics (eg. faculty recruitment and retention, holistic review, mitigating bias in residency recruitment) will be covered elsewhere. It is possible that we may have missed some relevant articles in our search. To mitigate this, a comprehensive search strategy with the aid of a medical librarian was conducted, supplemented by bibliographic review and additional recommendations from topic experts. Much of the research on DEI is observational, and multicenter RCTs are often lacking. Our findings may represent associations as opposed to causation given the nature of the research available. Finally, much of the literature of pathways focuses on general fields in health professions education; there is limited literature specifically focused on pathways within EM.

CONCLUSION
Pathway programs are critical to increasing diversity within medical schools. Increasing diversity in medical schools is critical to increasing diversity in EM and other specialties. This paper summarizes components of PPs and steps toward successful implementation through best practice recommendations. We hope this manuscript will inform readers on how best to form and sustain new PPs at their institutions.