In 1934, the first year the American Board of Pediatrics (ABP) began certifying pediatricians, the ABP certified its first African American pediatrician, Dr. Alonzo deGrate Smith. It was not without controversy, due to a series of policy barriers regarding board eligibility and membership in medical associations.1 Over 85 years and more than 131,000 pediatricians later, the ABP is committed to continuing to address systemic barriers to racial and ethnic equity. As part of this effort, the ABP began collecting, analyzing, and reporting on race and ethnicity data for pediatric trainees and certified pediatricians in 2018. This commentary provides an introduction to the ABP’s data collection efforts, its newly released data, and implications for the ABP and pediatric community.
Collection of Race and Ethnicity Data
Before 2018, the ABP had not systematically collected race and ethnicity of pediatricians. When deciding how to include question(s) regarding race and ethnicity, the ABP followed their Research Advisory Committee’s recommendation to implement the format proposed in 2015 by the United States Census. That format collapsed two separate questions on race and ethnicity into a single question, incorporating Hispanic, Latino, or Spanish Origin ethnicity (“Hispanic”) within the same question as race. Second, a new category, Middle Eastern or North African (MENA), was proposed, which had been previously aggregated with “White.”2 Despite the empirical evidence that these enhancements led to more accurate and complete responses, they were not included in the 2020 census. Beginning in 2018, this single question was placed on the ABP’s census surveys conducted with pediatric trainees and upon re-enrollment in continuing certification, with the addition of the category “I prefer not to answer.”
Sample and Analyses
Since 2018, the ABP has collected data for over 51 000 pediatricians and combined it with internal administrative data (eg, gender, training status, certification status, certification year, subspecialty type [if applicable], and age). To permit easy access to these data, the ABP recently posted an aggregated version in dashboard format on the ABP’s web site.3 The dashboard includes interactive comparisons, in-depth findings by single and multiple selections of race and ethnicity, statistical analyses with estimates for the pediatric trainee and certified physician population, comparisons by demographics, methodology, limitations, and more. The following are sample data from the dashboard.
Figure 1 displays an example of one analysis in the report comparing data collected by the ABP to data collected by the Association of American Medical Colleges (AAMC) for physicians in general and the United States Census for the general population and children. Pediatricians were more likely to self-identify as Hispanic compared with all physicians as shown by the AAMC data, but the proportion was smaller than for both the overall and child US populations. The proportion of pediatricians self-identified as Asian was similar to the AAMC data, but higher than the overall and child United States populations. In contrast, the proportion of self-identified Black or African Americans among pediatricians was similar to the AAMC but 6% and 7% lower than the overall and child United States populations, respectively. Both the ABP and AAMC data indicate there are more Black or African American females than males.
Comparisons of race and ethnicity percentages between ABP, AAMC, and US populations.
aEstimated race and ethnicity percentages for both those in training or recently graduated and/or not yet certified and those certified as general pediatricians or pediatric subspecialists.
bThe Association of American Medical College’s (AAMC) 2018 data on the overall physician population, not including trainees.
cReference data were unavailable for the “White and Middle Eastern or North African (MENA) (Including Hispanic)” population from both the AAMC and United States Census under 18 population. Similarly, the reference data for “Other” were unavailable for the United States Census population overall. Following the groupings of the United States Census, those selecting “Hispanic, Latino, or Spanish origin” are noted both in this category and other categories if multiple selections were made.
Comparisons of race and ethnicity percentages between ABP, AAMC, and US populations.
aEstimated race and ethnicity percentages for both those in training or recently graduated and/or not yet certified and those certified as general pediatricians or pediatric subspecialists.
bThe Association of American Medical College’s (AAMC) 2018 data on the overall physician population, not including trainees.
cReference data were unavailable for the “White and Middle Eastern or North African (MENA) (Including Hispanic)” population from both the AAMC and United States Census under 18 population. Similarly, the reference data for “Other” were unavailable for the United States Census population overall. Following the groupings of the United States Census, those selecting “Hispanic, Latino, or Spanish origin” are noted both in this category and other categories if multiple selections were made.
To further examine proportions of pediatricians by race and ethnicity, data were aggregated to create a category for those pediatricians from an underrepresented in medicine (URiM) background, given small group sizes. The URiM category—as defined by the AAMC in 20044 —is the aggregation of those self-reporting as American Indian or Alaska Native, Black or African American, Hispanic, or Native Hawaiian or other Pacific Islander. A higher percentage of pediatricians in training or recently graduated and/or not yet graduated self-identified as URiM (17%) compared with certified pediatricians (14%), paralleling recent data from Montez et al.5 Overall, females more commonly reported a URiM background (16%) compared with males (13%), as did those with a Doctor of Medicine degree (16%) compared with those with a Doctor of Osteopathic Medicine degree (7%) and those self-identifying as international medical graduates (24%) compared with United States medical graduates (13%). Certified pediatric subspecialists were less likely to self-identify as URiM (13%) compared with certified general pediatricians (15%). Adolescent medicine had a notably higher percentage of those self-identifying as Black or African American (16%), compared with the average for certified pediatric subspecialists (4%).
Other analyses available on the dashboard investigate trends over time, using each certified pediatrician’s first year of certification as the initial time point and then grouping those points into five-year intervals. There were two exceptions; those who were certified in 1990 or before were grouped together, given higher rates of missing data, and those pending certification (eg, those in-training or those finished with training but not yet certified) were grouped together given their similar status since 2018. The analyses demonstrate that those self-identifying as White dropped from 80% in 1990 or before to a low of 54% in 2021 for the group pending certification. Conversely, the percentage of those self-identifying as Asian increased from 8% to 21% and the percentage of URiM increased from 10% to 14.5% during the same time period. The categories of “two or more selected” and “MENA” both showed increases of around 2% to 3%. Separate comparisons to the United States child population over time describe the same gaps noted elsewhere,5 with underrepresentation most notably seen among Black or African American and Hispanic pediatricians.
Where Do We Go From Here?
Like Dr deGrate Smith experienced, personal and structural racism within medicine are obstructions that must be overcome lest we “immerse [those of diverse backgrounds] in an environment that does not support them.”6 Progress has been made but much collaborative work across pediatrics is needed. The Federation of Pediatric Organizations (FOPO), which includes the ABP and six other organizations, is making efforts to lead and synchronize efforts to address structural racism in pediatrics. As the recent FOPO report7 and ABP Web site8 describe, the ABP has committed to a number of efforts. First, the ABP, plans to refresh its dashboards as new data become available. Race and ethnicity remain evolving social constructs and the ABP will continue to watch for changes made by the United States Census. In addition, the ABP is employing these data to examine possible bias in its exams, both at the exam question level—through differential item analyses and review by a Bias and Sensitivity Review Panel—and at the level of exam pass rates. The ABP now uses internal dashboards to track and foster ABP committee diversity. More broadly, the ABP is incorporating competencies in antiracism, social determinants of health, and elimination of health disparities in relevant assessments and activities (eg, exam questions, entrustable professional activities, Maintenance of Certification activities).
Data alone will not lead to change; we welcome the use of these data for policy and planning considerations. Beyond the ABP and FOPO, we hope these data help inform interventions at the individual (eg, early recruitment efforts, mentorship programs, and academic progression), organizational (eg, policy revisions, trainings, and physical surroundings), and national level (eg, medical education, and assessments). We look forward to partnering with others to create a more diverse, equitable, and inclusive pediatric workforce.
Acknowledgments
We thank the ABP’s Research Advisory Committee members and members of the ABP Foundation for their review of the dashboard related to this article. Similarly, we thank the following individuals for their review and contributions: Christian Mpody, MD, PhD; David G. Nichols, MD, MBA; Judy Schaechter, MD, MBA; and Joshua Sheak, MD, PhD.
Mr Turner, Ms Gregg, and Dr Leslie conceptualized, designed, and implemented the data analyses and linked dashboard, drafted the initial manuscript, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: Dr Leslie, Mr Turner, and Ms Gregg are employees of the American Board of Pediatrics.
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