Q&A with two authors of JAMA Open landmark study on GHHS demographics

The Gold Foundation interviewed lead author Katherine Hill and senior author Dr. Dowin Boatright to learn more about new research showing few disparities across GHHS membership

Gold Foundation Editor in Chief Brianne Alcala interviewed lead author Katherine Hill and senior author Dr. Dowin Boatright to learn more about new research showing few disparities across GHHS membership.

Katherine Hill, a medical student at Yale University, and Dr. Dowin Boatright, previously at Yale and now Associate Professor of emergency medicine at New York University, collaborated with 9 other colleagues on the largest study so far to examine membership in Gold Humanism Honor Society (GHHS) and Alpha Omega Alpha (AOA), two medical school honor societies. This study is also the first to look at potential disparities in the honor societies across four categories: race/ethnicity, sex, sexual orientation, and childhood family income. Their research was published in September 2022 in JAMA Open, which is available open access here and also summarized in a news article by the Gold Foundation. Their research examined a national sample of more than 50,000 MD medical students who graduated during 2016 to 2019 for their likelihood of selection into GHHS and/or AOA. They found stark differences between the two honor societies.

The nonprofit Arnold P. Gold Foundation created GHHS in 2002 to recognize leaders of humanistic care, which the Gold Foundation defines as care that is compassionate, collaborative, and scientifically excellent. GHHS now has 180 chapters and nearly 45,000 members. The Gold Foundation spoke with both Ms. Hill and Dr. Boatright, to better understand the study, its implications, and potential reasons for the findings. Ms. Hill is not a member of GHHS or AOA. Dr. Boatright was selected for GHHS as a resident physician, not in medical school.

Could you both tell us a little bit about your expertise and interest in this area? Let’s start with Dr. Boatright, who’s been studying honor society demographics for years, starting with Alpha Omega Alpha.

Dr. Dowin Boatright: Sure. I did residency training in Emergency Medicine in Denver. And when I was there, I became very active in the diversity committee, trying to identify evidence-based interventions to promote diversity in the healthcare workforce and structural barriers that could limit the diversity of the healthcare workforce.

After residency, I went to Yale for fellowship training with the Robert Wood Johnson Foundation Clinical Scholars. My research really did, at that time, focus on bias and discrimination in medical education, and again, trying to identify structural barriers that might limit diversity. And something that we found was that honor society membership — and at that time we were specifically looking at AOA — seemed to be a very prestigious honor that medical students could obtain. But it also seemed to be part of the selection criteria for many residency programs, in terms of who will be offered an interview and also who ultimately would be selected as a resident for training at those sites – especially in some of what people describe as the competitive surgical subspecialties. Some of those specialties even note that they wouldn’t even offer an interview to an applicant unless they were a member of AOA.

We thought it would be an interesting metric to study to see if there were disparities, at that time looking just at race and ethnicity. And that’s how that started: It was a research question. And interestingly, we did find significant disparities based on race/ethnicity with medical students of color being less likely than their white counterparts to be honor society members, despite similar qualifications and standardized test scores.

And Katie, how did you get into this realm?

Katherine Hill: I’m a medical student at Yale, and I had also been interested for a while in diversity and equity in the biomedical workforce. I worked with Dr. Boatright on several different projects, looking at things like mistreatment of medical students, medical school climate. This is my first time researching honor societies. I’ve been really excited to have the opportunity to work on this project with Dr. Boatright.

Thank you both again for taking this time with us. Dr. Boatright, you mentioned a little bit already about why it’s important to have a clear understanding of who is being selected to honor societies. It sounds like the pipeline to get into some of these competitive specialties is affected. What are other reasons why we need to have a clear understanding about who has membership in these groups?

Dr. Dowin Boatright: Sure, absolutely. I initially mentioned those competitive, maybe surgical subspecialties, and that was what we focused on before, because we heard that those groups in particular were screening applicants based on honor society membership. But we actually did additional work later and found that, even in fields that people don’t necessarily consider to be as competitive, honor society members still had an advantage over non-honor society members.

So really, we were seeing this across the spectrum of fields. One of the things that Katie mentioned in her work on this, as well, is that not only does it give you an advantage in terms of matching into whatever your preferred specialty of choice is, but there are also opportunities for scholarships, for research funding, and networking, which is also critically important for everyone’s career development. And when we look at various underrepresented groups, research shows that those groups have less access to mentorship. So, honor society membership could play a particularly important role for the career development of people from underrepresented groups, as well.

Katherine Hill: Just one thing I want to add is something we found when we were researching this paper is that over 75% of medical school deans are Alpha Omega Alpha members, which shows just how powerful membership in these societies can be.

Dr. Dowin Boatright: Yes, it’s a great point, Katie.

Let’s talk about the study itself. Katie, you are the lead author. Can you summarize the study for a broad audience? What were you looking to find out?

Katherine Hill: In broad strokes, what we really wanted to know was whether certain students are more likely than others to be members of Alpha Omega Alpha and Gold Humanism Honor society, which are, as you already know, medical student honor societies.

What we found was that students of color, so Black students, Hispanic students, Native American students, Asian students, and then also lower-income students, and lesbian, gay, and bisexual students are all underrepresented in Alpha Omega Alpha as compared to what we’re seeing in the general medical student population. So, for example, if 20% of white students are members of Alpha Omega Alpha, then a much lower percentage of some of these other groups are members of Alpha Omega Alpha.

In terms of the Gold Humanism Honor Society, we also found that lower-income and Asian students are underrepresented in GHHS. However, we didn’t find really any other differences in membership by race. So as far as we can tell, white, Black, Hispanic, and Native American students are all about equally as likely to be members of Gold Humanism Honor Society. And we also found that women and lesbian, gay, bisexual students are actually more likely than their peers to be members of Gold Humanism Honor Society.

Dr. Dowin Boatright: And Katie, do you mind talking about the cumulative advantage or disadvantage?

Katherine Hill: So, I’m talking about all these identities as if they’re separate. But really, for example, a Black woman is probably going to have a much different experience of medical school that a white woman or a Black man. These experiences, these different identities all interact. We were curious to learn about what if someone is holding multiples of these sorts of marginalized identities? Is someone who is non-white and lesbian, gay, bisexual and low income less likely to be a member of an honor society than someone who only holds one of those identities?

And what we found was that for Alpha Omega Alpha, the more sort of these quote-unquote marginalized identities a student has, the less likely they were to be members of Alpha Omega Alpha. However, for Gold Humanism Honor Society, we didn’t see the same effect. So as far as we could tell, holding multiple of these identities did not put you at a greater disadvantage of Gold Humanism Honor Society membership then did holding only one of these identities.

You mentioned the different identities, and the study is called “Association of Marginalized Identities with Alpha Omega Alpha Honor Society and Gold Humanism Honor Society among Medical Students.” Can you help us understand the term “marginalized identities”? Another term that comes up often in medicine is URM or underrepresented in medicine. What is the difference?

Katherine Hill: Thank you for asking that question because I think the terminology can often be really confusing. Basically “underepresented in medicine” is exactly what it sounds like: Black, Hispanic and Native American students are all considered underrepresented in medicine because there are fewer, for example, Black students in medicine than there are in the general population. In contrast, “marginalized identities” refers to any demographic group that has historically faced barriers and discrimination in medicine, regardless of their overall representation. For example, today men and women are about equally represented in medical schools. However, women are more likely than men to experience bias, discrimination, sexual harassment, and other things that really prevent them from progressing through the medical hierarchy. And therefore, women would be considered a marginalized group in medicine, but not an underrepresented group in medicine.

And that’s true for the Asian students, too – is that right?

Katherine Hill: I think a lot of times people have difficulty figuring out how to classify Asian students because they tend to be well represented in medicine. But there is a lot of research showing that they do experience discrimination in medicine. Also, as you go up the medical hierarchy, Asian people tend to be less and less represented, which I think also is due to discrimination. For those reasons, we considered Asian students to be a marginalized group for this study.

This is definitely something that Gold Foundation is interested in learning more about. And it seems like the data is also more complex?

Dr. Dowin Boatright: Exactly, and I’ll let Katie talk more about it. But obviously it’s just a very broad category with individuals from so many different areas with very different histories, as well. What are your thoughts, Katie?

Katherine Hill: That was exactly the point I was going to make, and to some extent, that’s true for all of these different categories. I have a friend who really likes to say the experience of a Mexican-American woman who lives in El Paso is very different than the experience of a Puerto Rican woman living in New York City. These are all very broad categories. But especially when you’re talking about Asian students, you’re grouping together about 60% of the world’s population in one category, and you’re including international students, you’re including Chinese American students from the Bay Area, you’re including second-generation Hmong American students who grew up low income in St. Paul, Minnesota. And so all of those students have very different life experiences.

That really helps us understand the complexity. There are so many findings in this study. What are your thoughts about the implications of these findings?

Katherine Hill: The big implication that we found is that a lot of marginalized groups are still facing barriers to honor society membership. But the other big message, and the hopeful message, is that these barriers may not be inevitable. The fact that we saw such large differences in membership composition between AOA and GHHS really suggests that changes can be made to honor society admission process to make it less biased and to admit more students from marginalized groups.

Dr. Dowin Boatright: I completely agree. One of the things that we found really surprising is normally when you look at an award or an achievement that’s considered to be rare and prestigious, we definitely not only see evidence of bias but also this phenomenon of cumulative disadvantage – which, in most cases [in GHHS], we didn’t see any evidence of cumulative disadvantage and then we saw significantly less evidence of disparities based on marginalized identity in Gold Humanism.

So I think we have a significant opportunity here to look at the practices and processes of membership selection of the Gold Humanism Honor Society as a template for successful interventions for equity and moving forward.

This is really hopeful. You mentioned that the peer nomination portion of GHHS may be one of the things that could be emulated to help. Do you mind talking a little bit more about how that might be making a difference? And I realize, at this point, we’re outside of the data and speculating.

Katherine Hill: There is actually some interesting research out of the business and psychology world that goes back a while. And that shows that when you poll a large group of experts about a subject, they tend to have a more accurate judgment than does one expert acting alone. For example, this is one of the oldest examples: If you ask 500 people how many jelly beans are in a jar, you’re going to get a much more accurate answer, actually, than if you just ask one person how many jelly beans are in the jar – which is a lot different than honor society membership! – but it is research that exists. And I think one of the big strengths of peer nomination is you are essentially polling a large number of people who all have different information or are, in some ways, experts on their classmates about what they think. And so hopefully you’re going to get a less biased answer than if you’re just asking one person who maybe interacts with certain students more than others or has their own worldview. And then even within medicine, we’ve seen studies showing that peer nomination can be accurate and reliable, and also that peer evaluations can be consistent across raters and stable over time.

Dr. Dowin Boatright: I completely agree. This is not an area that we have actually investigated, but I think it does represent a key distinction between the way members are selected in Gold Humanism and AOA. The fact there’s such a stark difference in the selection process seems like it would be an ideal area for future study. And I think that’s something we’d like to look at too, in terms of how peer nomination can promote equity either in other honor societies or maybe even in clinical assessments where we also know there are disparities, but just as a potential tool to promote equity moving forward.

Let’s talk about one of the areas that would be good to understand a little bit more, and that’s the lowest socioeconomic group – that they are less likely to be members of GHHS. I wonder if you have any thoughts about why that might be and what you might want to understand better about this or any thoughts that might point to hope about how we could adjust this in the future.

Katherine Hill: As you know, it’s important to state that at this point this is all speculation. So, all we could tell from the studies that these differences do exist. We don’t know why, but we are sort of speculating that if you are a low-income student, you might have a lot of responsibilities on top of medical school.

Maybe you are holding down a job on top of medical school. Or maybe you have a lot of familial obligations, which is really common, especially among low-income students, where students are really providing for their parents rather than the other way around. Medical school is already very time-consuming. Maybe at that point you don’t have time to participate in community service or do some of these other things that Gold Humanism Honor Society and other honor societies really value and that could prevent you from becoming a member.

I wonder how we would understand this more. Do you have any thoughts on how we might investigate it more or how we could adjust for it?

Katherine Hill: Since we’re really just speculating here, some qualitative research might be really important – actually going out and interviewing low-income students and seeing where their time is going and what they see as barriers to honor society membership, as well as just to fully participating in medical school.

Dr. Dowin Boatright: I think that’s exactly right. I don’t know how much more we can get just from quantitative data. I think we’re actually going to have to do the qualitative work and get a better idea of the lived experience of students from different backgrounds.

Going back to the data on women, it shows that women are overrepresented proportionally to the overall class in GHHS. And you have some speculation on as to why that might be, that they might be more likely stereotyped more compassionate, or might be using more patient-centered communication. Could you elaborate?

Katherine Hill: There probably are a lot of different things contributing. There’s some research suggesting that women are more likely than men to participate in community service. Also, there’s some research suggesting that women are more likely to exhibit patient-focused skills in medical encounters. Another potential contributor is that in our society, we do sort of stereotype women as being more compassionate. If that’s a stereotype that people are bringing into this honor society nomination process, they may be more likely to nominate women who they’re seen as compassionate for a humanism award.

Dr. Dowin Boatright: I agree. Those are our two leading hypotheses. That being said, in terms of whether or not women are overrepresented in Gold Humanism because of preconceived notions of being more compassionate and so forth, we think that may contribute to some degree, but it’s very rare for a bias to actually work in someone’s favor for something like a prestigious award.

My thought is that it’s actually the fact that women probably are actively more engaged in these types of activities, as the research has shown also. And I think that increased activities actually are just leading to more honor society representation.

Let’s turn to a different group, students who are LGB. And I noticed it’s LGB not LGBT, or LGBTQ. I wonder if you could talk about that. There are some interesting findings around representation, too.

Katherine Hill: I think that’s a really important point that we were really only looking at lesbian, gay, and bisexual students, not transgender students, or students who identify as queer or in other ways, and the reason for that is because that was the data we have. We only have data on lesbian, gay, and bisexual students. I think it’s really important to explore how transgender and non-binary students and other students really are experiencing medical school and their honor society membership in the future.

Dr. Dowin Boatright: One of the things Katie and I talked about, as well, is that oftentimes individuals from marginalized groups, again, have experienced a system that may not work for them or advocate for them. Historically, in other fields, there’s data showing that individuals from marginalized groups want to change the system. And it’s possible that students from marginalized groups, such as LGB students, may engage in these activities that Gold Humanism values because they’ve seen or experienced biased care or inadequate care, as well. There may be an inclination to go into the system and make positive changes for the better, and these are potentially activities and actions that Gold Humanism values, as well.

Katherine Hill: I think it’s important to know – even though we’re talking about LGB students here – that there’s also been research showing that underrepresented-in-medicine medical students and physicians may be more likely to engage in community service and also research important topics like health disparities. They’re more likely to serve underserved populations, as we’ve already noted. Those all could be contributors for why we’re not seeing the same disparities that we did in AOA. It could just be that, again, those groups are very engaged in community service and other humanistic behaviors.

Thanks for helping us understand that better. With all of this new data, some might say that if studies show some bias in honor societies, that’s potentially cause for closing honor societies. And others might say, no, honor societies serve a purpose and the real issue is how to create a more equitable culture. I wonder if you could share any thoughts about the idea of getting rid of honor societies versus making sure that membership is equitable and fair?

Katherine Hill: That’s a really complicated and interesting question, and I’m mostly going to, I think, punt it to Dr. Boatright. But I think you touched on an important subject, which I think is really important to think very deeply about: What is the purpose of this honor society? Is the purpose, for example, to bring attention to certain behaviors that aren’t valued as much in the medical school selection or in the residency selection process, but really should be valued, such as humanistic behaviors or community service, or is it just about rewarding people who already have sort of been rewarded throughout the entire application to medical school and medical school residency process? And so, I think people who are involved in honor societies really should take a step back and think deeply about what they are trying to accomplish and what steps they’re taking to make sure that their honor society actually accomplishes that.

Dr. Dowin Boatright: That’s a great point, Katie. I think it’s an absolutely great point. And Brianne, I think you’re right. I think it can be a little bit alarming when we see the degree of disparities in some honor societies and the implications that could have. And I think that sense of alarm could initially kind of create the response that maybe we should just get rid of honor societies.

But I think that negates the fact that these disparities really are kind of a reflection of the medical school learning environment that we live in and also our society. Getting rid of the honor societies is not going to change the way people universally in this country are treated and the bias and discrimination they are going to continue to experience in medical school, irrespective of the existence of honor societies. So, I think, just kind of going back on what Katie says, I think it just shows that honor societies do have additional accountability but also have additional power to promote equity.

I think there can be greater transparency in the existence or lack of existence of these disparities. And if we see disparities that can be stimulus to try to implement change, and then in cases where we don’t see disparities, like we do in many cases with Gold Humanism, that can be an example for further research to identify successful interventions that we can then disseminate to other honor societies, but then to the learning environment in medicine as a whole.

I think in many ways, we can actually see this as an opportunity, if we have the courage to address it.

Read a news article by the Gold Foundation about this landmark study.

Brianne Alcala

Brianne Alcala is the Editor in Chief and Chief Communications Officer for the Gold Foundation.