Little is known about how taking a leave of absence is associated with medical students’ successful placement into graduate medical education (GME). While Black, Hispanic, and Indigenous students are more likely than their White peers to take a leave of absence from medical school,¹ whether leave of absence differentially mediates GME placement by race and ethnicity in unknown. We examined the association between leave of absence and placement into GME by race and ethnicity.

We conducted a retrospective study of 2014-2015 and 2015-2016 medical school matriculants who graduated and applied to residency via the Electronic Residency Application Service using Association of American Medical Colleges (AAMC) data. Leave of absence, for any reason, is reported by medical school registrars to the AAMC. Students self-reported their sex and race and ethnicity, which included American Indian and Alaska Native, Asian, Black and African American, Hispanic, Native Hawaiian and Other Pacific Islander, White, and other. Students who reported more than 1 race and ethnicity were categorized as multiracial. Students who reported other or had missing race or ethnicity were categorized as unknown/other. Students with unknown sex were excluded from analyses.

We compared leave of absence status by race and ethnicity using the χ² test, with a 2-sided P < .05 indicating significance. Using multivariable logistic regression, we then modeled the likelihood of placement into GME by leave of absence, race and ethnicity, and an interaction term between leave of absence and race and ethnicity, adjusting for sex, US Medical Licensing Examination Step 2CK score as a proxy for academic performance, and number of programs to which students applied, since GME placement success may correlate with number of applications submitted. This study followed STROBE reporting guidelines and was deemed exempt by the Yale Institutional Review Board. Statistical analyses were performed using Stata version 18.0 (StataCorp).

Among 37 485 students who applied to residency, 2129 (5.68%) had taken a leave of absence. A higher proportion of American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander (16 of 130 [12.03%]), Black (227 of 2313 [9.81%]), and Hispanic (237 of 2272 [10.43%]) students took a leave of absence compared with Asian (463 of 7289 [6.35%]) and White (748 of 19 506 [3.83%]) students (P < .001) (Table 1).

Among all students, 1741 (4.64%) were not successfully placed in GME. Compared with not taking a leave of absence, taking a leave of absence was associated with a higher likelihood of being unplaced in GME (20.29% vs 3.70%; adjusted odds ratio, 5.73; 95% CI, 5.05-6.51). The highest rates of unsuccessful GME placement were among students reporting Black (33.48%), Hispanic (26.58%), and unknown/other (25.58%) race and ethnicity (Table 2). Taking a leave of absence had a greater association with GME placement for Black students than for White students (P = .01 for interaction). No significant interaction was found for other racial or ethnic groups. Taking a leave of absence among Black students was associated with a greater likelihood of being unplaced in GME compared with not taking a leave of absence among White students (adjusted odds ratio, 13.10; 95% CI, 9.72-17.66) (Table 2).

Taking a leave of absence was associated with a lower risk of placing in GME compared with not taking a leave. Although leave of absence was negatively associated with placement in GME for all students, there was a significant interaction of Black race and ethnicity with leave of absence with respect to the rate of GME placement.

Prior studies have shown leave of absence to be associated with lower graduation rates and to be more prevalent among students identifying as non-White race and ethnicity.¹ This study suggests that taking a leave of absence may also be associated with racial and ethnic disparities in GME placement. Black and Hispanic students are less likely to place in GME compared with White students irrespective of leave of absence status. This disparity widens with leave of absence. As such, leave of absence may contribute to the lack of racial and ethnic representation in the physician workforce.^2,3

Study limitations include that the reasons for leave of absence were unexplored. Financial burdens and family obligations have been reported as contributing factors.⁴ Additionally, for non-White students, experiences of mistreatment and discrimination are associated with burnout and attrition.⁵ These same experiences may influence leave of absence. Also, there may be factors unexamined in this study influencing students’ successful placement into GME, such as residency specialty. Step 2CK scores rather than Step 1 were used to measure academic achievement; however, Step 1 and Step 2CK scores are highly correlated.⁶ Finally, the cohort is limited to Electronic Residency Application Service participants and the GME Track Resident Roster and excludes a small proportion of residents from nonresponding GME programs. Future studies examining students’ reasons for leave of absence and how leave of absence may differentially influence the career trajectories of non-White students are essential to promote a diverse physician workforce.

Accepted for Publication: March 7, 2024.

Published Online: April 15, 2024. doi:10.1001/jama.2024.4797

Corresponding Author: Mytien Nguyen, MS, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510 (mytien.nguyen@yale.edu).

Author Contributions: Ms Nguyen and Dr Boatright had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Nguyen, Boatright.

Acquisition of data: Nguyen, Boatright.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: Nguyen, Boatright.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Nguyen.

Obtained funding: Boatright.

Administrative, technical, or material support: All authors.

Study supervision: Boatright, Desai.

Conflict of Interest Disclosures: None reported.

Funding/Support: Ms Nguyen is supported by National Institutes of Health Medical Scientist Training Program training grants T32GM136651 and F30AI157227. Dr Boatright is supported by National Institutes of Health grant R01GM137411.

Role of the Funder/Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This material is based on data provided by the AAMC. The views expressed herein are those of the authors and do not necessarily reflect the position or policy of the AAMC.

Data Sharing Statement: See the Supplement.

Additional Contributions: Critical review of the manuscript was performed by the AAMC.