An urgent priority for the neonatal-perinatal medicine (NPM) workforce is enhancing diversity, specifically increasing the representation of underrepresented (URM) providers in medicine. It is known that the patient outcomes are much better when there is ethnic concordance between the patients and their physician providers [1]. Major interventions are necessary to enhance diversity in the healthcare workforce. These include increasing youth engagement in medicine, addressing inequitable recruitment practices, and cultivating inclusive training environments. In particular, a reform is urgently needed in recruitment practices. The number of URM candidates applying for medical schools has decreased over the past decade [2], along with a decline among those entering pediatrics and subsequently specializing in NPM [3]. Those who review medical school applications have historically focused on the reputation of the training institution, the scores achieved in standardized examinations, and research/ scholarly experiences. These elements are markedly skewed against the candidates from historically disadvantaged backgrounds, reducing the numbers of URM candidates to be successfully recruited into pediatric specialties for the care of children from all backgrounds [4].

The article by Peña et al. addresses these issues, and provides tangible steps to improve the recruitment of URM candidates into NPM. The authors highlight the need to eliminate exclusionary practices in fellowships, develop infrastructure to support URM trainees, and champion diversity, equity, and inclusion initiatives. They stress the need for programs to establish relationships with URM candidates, mitigate implicit bias amongst recruitment teams, and establish authentic holistic review processes [5] and interview experiences with a genuine commitment to diversity. Peña et al also emphasize that institutions must deliberately develop rank lists aiming to enhance URM recruitment, and continually monitor the progress of such efforts.

Recognizing this challenge, the Organization of Neonatology Training Program Directors (ONTPD) implemented an annual survey of NPM fellowships regarding URM recruitment practices [6]. Programs are increasingly tracking URM recruitment data (64% in 2021, 77% in 2022). Despite indicating an interest in increasing URM recruitment, less than 1/3 of programs established specific goals. Some cited barriers include a need for guidance on equitable goal setting and inadequate resources. Programs received a median of 14.5 URM applicants per year (IQR 8-22 in 2022) and interviewed URM and non-URM applicants at similar rates. Although it is critical to provide opportunities for URM applicants to interact with URM trainees and faculty during interviews, this happens infrequently. In only 50% of interviews the organizers arranged for the candidates to interact with other URM trainees, and in 61% of interviews the organizers arranged interactions with the URM faculty. Establishing national specialty-specific monitoring of URM recruitment rates in NPM has been vital and will guide future efforts.

The goal of an inclusive neonatal workforce can only be realized by improving diversity at all educational stages, from grade school through fellowship. Deliberate efforts to increase NPM’s visibility as a fulfilling career choice with a high potential to impact one’s community are needed. Strategies to engage early learners include community involvement, mentorship, advocacy, and establishing NPM representation in local schools, STEM, and enrichment programs [7]. Institutions should establish and continually monitor metrics for URM recruitment at each level. Educators must be cognizant of potential biases about a learner’s prospects based on their appearance and social standing; it is common for students to be pigeonholed based on perceived behavior or academic interests. It is vital to present medicine as a viable career option and nurture those who show interest. Adhering to best recruitment practices is essential when selecting candidates for medical training programs. Holistic review [5], which considers experiences, attributes, and academic performance as well as potential value a candidate would offer as a learner in a program, requires programs to fundamentally retool their approach to evaluating applications. It encourages recruitment committees to assess an applicant as a whole rather than disproportionately concentrating on certain factors, but this strategy is time and resource intensive.

URM workforce issues persist even after matriculation into medical training programs. It is well established that learners from historically disadvantaged backgrounds experience unfair bias in evaluations. URM trainees leave pediatric residencies prior to completion of their training at disproportionately higher rates than their non-URM colleagues. Additionally, across all specialties, despite representing a smaller proportion of trainees, URM residents have significantly higher rates of adverse dismissal than their white peers [8]. Given the small numbers of URM students matriculating into medical schools annually and URM physicians leaving training at higher rates (either by expulsion or by choice) [8], the result is a very limited pool of URM neonatologists.

Recruitment, retention, grant funding, and promotion to leadership positions are additional challenges to developing and retaining URM neonatologists. Addressing these issues requires gathering and analyses of data from multiple sources [9]. The Accreditation Council on Graduate Medical Education, American Board of Pediatrics, ONTPD, and Training and Early Career Neonatologists are committed to understanding longitudinal trends in URM recruitment and retention. However, data on prevalence of URM neonatologists and those with leadership positions (department chairs, section chiefs, medical directors, and program directors) have yet to be systematically collected. Anecdotally, few URM NPM physicians hold leadership positions. In addition, recruitment and retention of URM physicians will be challenged if applicants interested in NPM cannot get the needed mentorship and role modeling by faculty and if opportunities for career advancement cannot be envisioned. However, this may further challenge institutions with limited URM community numbers and poses a high risk for “minority tax [10].”

Looking to the future, it is imperative that the critical shortage of URM providers in the NPM workforce is addressed and that an environment of diversity and inclusion is cultivated. The paper by Peña et al. is indeed a call for our community to take action. The commitment to increase URM NPM providers begins long before medical school and can only be achieved through community partnerships. Fundamentally changing expectations for applicants to medical training programs, focusing not only on opportunities afforded to candidates but seeking out qualities that suggest a candidate will provide empathetic, high-quality clinical care to all infants in their community, is an important step. During NPM fellowship, we must provide support–socially, psychologically, and academically– to ensure that all learners thrive. Through shared commitment, we will ultimately achieve our goal of a workforce that accurately reflects our diverse patient population and better serves our communities.