My opinion

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As elicited by Balhara et al [1], graduate medical education (GME) in the United States (US) is finally lapping up to objectively recognize and ostracize bias [2]. However, this pursuit of equitable recruitment freed of unconscious and implicit bias will be incomplete without addressing the conscious and explicit bias based on applicants’ work authorization status. Understandably, national policy may preclude GME from recruiting non-resident aliens unless there is a shortage of eligible US persons (citizens, nationals and permanent residents). However, categorization in Electronic Residency Application Service (ERAS) applicant worksheet apparently highlights that it may only be about the bottom line with non-resident aliens’ visa sponsorship entailing monetary and non-monetary costs to the GME programs [3]. As non-resident aliens may NOT have any say in shaping the national and institutional policies, they can only hope that their applications are not overlooked during screening, interviewing and ranking by the GME programs due to their work authorization status. If GME programs want to ensure equitable opportunities to non-US persons applying for GME while concurrently avoiding the risk of misrepresentations by non-US persons in their ERAS applications to take advantage of perceived systemic bias against non-US persons, documentary evidence for identity and work authorization will have to be required from all applicants (US persons as well as non-US persons) during ERAS season so that GME programs can screen them at least before ranking the applicants because GME programs will need to uniquely quantify monetary and non-monetary costs as pertaining to each applicant. Although the faraway future may entail foreseeable mandatory global background check for all ERAS applicants [4], it is not difficult to envisage mandatory documentary evidence of applicants' identity and their work authorization status happening in the immediate future considering that we are already relying on the authorities rather than the applicants to submit supporting documents like Medical Student Performance Evaluation, Medical School Transcripts and Letters of Recommendation on applicants’ behalves. Although documentary evidence of identity and work authorization status should come directly from the authorities, the copies of documentary evidence owned and submitted by the applicants to ERAS may be a good start. Interestingly, once the documentary evidence for identity and work authorization status has been uploaded, the data fields in ERAS applications can be auto-populated as according to the submitted evidence so as to avoid any inadvertent misrepresentation by the applicants in their applications. If the digital system itself cannot automatically recognize the conflicting information in application contrasting the supporting documentary evidence, the manual check by ERAS personnel at a predetermined fee surcharge can be envisaged in the interim till the digital system turns mature enough to screen the authenticity of ~50,000 GME applicants per year. Summarily, to avoid blanket bias against all as based on their work authorization status [5], it is important for ERAS to walk away from self-reported identity and work authorization status by applicants and to move towards documentarily evident identity and work authorization status (passports, driver licenses, permanent resident cards and visa pages to name a few) as submitted by the applicants and/or as confirmed by the authorities so as to allow appropriate screening by ERAS before the GME interview season begins.

Reference(s)

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1. Balhara KS, Weygandt PL, Ehmann MR, Regan L. Navigating Bias on Interview Day: Strategies for Charting an Inclusive and Equitable Course. J Grad Med Educ. 2021;13(4):466-470. doi:10.4300/JGME-D-21-00001.1
2. Coalition for Physician Accountability. The Coalition for Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee (UGRC): Recommendations for Comprehensive Improvement of the UME-GME Transition. https://physicianaccountability.org/wp-content/uploads/2021/08/UGRC-Coalition-Report-FINAL.pdf Accessed on September 8, 2021.
3. AAMC Electronic Residency Application Service. ERAS Applicant Worksheet. https://students-residents.aamc.org/m edia/9726/download Accessed on September 8, 2021.
4. Gupta D, Kumar S. Can the letter of recommendation become an electronic standardized letter of reference? https://www.hcpro.com/RES-329315-2699/Can-the-letter-of-recomme ndation-become-an-electronic-standardized-letter-of-reference.html Accessed on September 8, 2021.
5. Gupta D, Kumar S. Can ERAS allow blind interview calls? https://www.h cpro.com/RES-328855-2699/Can-ERAS-allow-blind-interview-calls.html Accessed on September 8, 2021.

Source(s) of Funding

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NOT APPLICABLE

Competing Interests

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NOT APPLICABLE