Belongingness among first-generation students at Stanford School of Medicine

Background Nationally, underrepresented minorities represent a significant proportion of the first-generation student population. These students also tend to report lower levels of belongingness compared to their peers, which may impact their wellness and be an important factor in their academic success. This study aimed to explore whether status as a first-generation student was associated with belongingness amongst medical students. Methods In 2019, a previously validated 16-item survey was used to examine potential disparities in belongingness amongst groups of first-generation medical students. Differences between groups were assessed using a Mann-Whitney U-test for each individual item and three composite groupings of items regarding social belonging, academic belonging, and institutional support. Results First-generation to college and first-generation to graduate school students reported lower belongingness across most individual items as well as in all three composite groups. Conclusions Given that peer relationships and institutional support play an important role in medical student belonging, these findings represent an opportunity to address the specific needs of individuals from underrepresented groups in medicine. Doing so can support the academic and professional success of first-generation students and help close the diversity gap in medicine.


Introduction
The case for increasing diversity and inclusion in medicine dates back several decades 1 .In 2010, the Association of American Medical Colleges (AAMC) Roadmap to Diversity described compelling reasons for achieving medical school class diversity, emphasizing that medical students from diverse backgrounds often serve diverse patient communities in need of greater health care access later in their clinical practice 2,3 .As the U.S. population becomes more diverse, there is an ever-greater need for a physician workforce that reflects this diversity 4 .However, the pipeline of minority trainees remains insufficient.U.S. medical school admissions data indicate continued disparity in the acceptance rate of non-White students, with marginal improvement of this metric over time 5 .Individuals from groups underrepresented in medicine make up a large percentage of first-generation college students, but these students leave science and medicine at disproportionately higher rates than their peers 6,7 .Studies show that first-generation students lack a sophisticated knowledge of the medical school "admissions game," underestimate their chances of admission to medical school, and underestimate their chances of completing the degree [8][9][10] .Systematic variations in belongingness experienced by first-generation students in college and medical school may impact their wellness and be an important factor in their academic success 11 .
Goodenow and Grady defined school belonging as "the extent to which students feel personally accepted, respected, included, and supported by others in the school social environment" 12 .While there are several theoretical models of belongingness, two are especially relevant for the purposes of this study.First, the Identity-Proximity model-an extension of Kohut's theory-posits that one's identity is understood through proximity to "other" groups 13 .Through affiliation or relationships with the "other," or lack thereof, one determines a sense of belonging.For instance, race and racism in medicine lower Black male students' sense of belonging in medical school 14 .Second, the ecological framework of Bronfenbrenner's Environmental Satisfaction model puts forward that the way in which an individual interacts with others and how they experience their environment leaves them with a sense of either satisfaction and belonging or dissatisfaction and not belonging 15 .Therefore, school belongingness can be understood as a product of the daily lived experiences of medical students as determined by their interactions with one another, their engagement with environmental factors such as diversity and inclusion programming, and their satisfaction with institutional culture and policies.
The literature provides insight into the tensions faced by groups underrepresented in medicine, including first-generation medical students, and indicates a need for closer examinations of their experiences 16 .A better understanding of student belongingness in medical school may help improve student learning through better-designed institutional efforts to support them.Unfortunately, data about student belongingness among first-generation U.S. medical students are lacking, representing an important gap in the literature.Precise measures of belongingness are needed to understand the current environment and to evaluate for targeted interventions to improve student experiences 17 .
This study aimed to explore whether status as a first-generation student was associated with belongingness at Stanford School of Medicine.Exploring the prevalence of this outcome creates potential opportunities for meaningful interventions that may help close the diversity gap in medicine.

Study overview
We conducted a cross-sectional study of students at Stanford School of Medicine to examine belongingness amongst first-generation students.We collected survey data in August 2019 that we analyzed from 2020 through 2022.

Population
Stanford School of Medicine in Palo Alto, California is a research-intensive school with a total enrollment of approximately 488 students.Over half of these students finish their studies in 5 or more years to pursue a second degree or conduct research.Stanford is an ideal setting for this study because the school attracts a diverse student body, has selection processes aimed at achieving class diversity across many domains, and boasts a comprehensive first-generation mentoring program.Eligible study participants included all students who had completed at least 1 year of medical school.

Ethical considerations
We explained the risks of study participation in a solicitation letter and completion of the survey implied informed consent.We entered participants in a raffle for a $100 gift card as an incentive to complete the survey.The Stanford School of Medicine Institutional Review Board approved this study (protocol #51320).

Survey instrument
We adapted Ingram's survey tool on belongingness in college students, a modification of Hurtado and Carter's original General Sense of Belonging tool 18,19 .We chose this instrument because of the potential to lend greater precision and clarity to the concept of belongingness by clearly differentiating and examining components of belonging and the relationships among them.The Ingram tool includes 23 items that encompass student belonging in four composites: general belonging (3 items), social belonging ("feeling socially comfortable and connected with peers as a member of the college community"; 8 items), academic belonging ("feeling respected and supported by faculty and in the classroom to do well academically"; 7 items), and perceived institutional support ("feeling that institutional support and student services are accessible on campus"; 5 items) 18 .Ingram summarized the survey items, factor loadings, and Chronbach alphas for the instrument.Correlations among three composites of belonging (social belonging, academic belonging, and institutional support) all have a p-value < 0.01 19 .
For the purposes of this study, we removed several items from Ingram's tool to minimize survey fatigue.These included items in social belonging and academic belonging that each had the lowest factor loadings within their composites, and items in social belonging due to redundancy and a low correlation with belongingness.We combined general belonging and social belonging, as was done by Ingram 19 .We deleted the word "women's" from one item under institutional support to make the question relevant to students of all genders.The final instrument included 16 items grouped into 3 composites.As done by Ingram, we arranged survey responses to each item on a 5-point Likert scale: strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, and strongly agree.

Data collection and outcomes
We emailed all eligible participants an electronic survey designed using Qualtrics (Qualtrics Inc., Seattle, Washington) during a 4-week enrollment period.We sent reminders to non-respondents.We did not maintain individually identifying information and we did not solicit demographic information beyond the statuses described below to protect participant anonymity.A copy of the survey used can be found under Extended data 20 .
We examined all survey data using three participant outcomes: (1) first-generation American status, (2) first-generation college status, and (3) first-generation graduate school status.
First-generation American status "First generation" is sometimes defined by citizenship.For this study, we examined belongingness among participants who were in the first generation of their families to be born in the U.S. We asked students, "Are you a first-generation-born American or immigrant to the U.S.?" We categorized participants as either "Yes, first generation born in the U.S.", "Yes, immigrant to the U.S.", or "No".We did not analyze data for immigrants to the U.S for this outcome because they did not meet our definition of first-generation American-born.This left two variables: "first-generation American" and "non-first-generation American."First-generation College status "First-generation" is sometimes based on whether a student's parents attended college, so we examined belongingness among participants who were in the first generation of their families to attend college.We asked students to report the highest level of education attempted by any parent.We categorized participants as either "no college" if their parents did not pursue a college degree or "college" if at least one parent completed a college course of any kind anywhere in the world.We considered participants in the "no college" cohort to be "first-generation college students." First-generation Graduate school status Similarly, we examined belongingness based on a parent's pursuit of a graduate degree.This is especially relevant in the context of medical school and belongingness as many students are the children of physicians, and those students are thought to have greater advantages in medical school because of their familiarity with the profession.Thus, we categorized participants as either "no graduate school" if their parents did not pursue graduate studies or "graduate school" if at least one parent completed a graduate course of any kind anywhere in the world.We considered participants in the "no graduate school" cohort to be "first-generation graduate school students."

Analysis
For each of the three composite groups, we added corresponding item scores (Social [Q1-7], Academic [Q8-11], and Institutional [Q12-16]) into a single score for each individual participant.We then assessed the sums for differences between groups using a Mann-Whitney U-test.We did not use an item more than once in a composite group.

Results
Of the 405 eligible participants, 82 (20.2%) completed the survey.Of these, 39% (32/82) identified as "first-generation American students," 23.1% (19/82) identified as "first-generation college students," and 41.4% (34/82) identified as "first-generation graduate school students."There were no significant differences observed between first-generation American students and non-first-generation American students for any of the individual survey items or the composite groups of items (Table 1).However, first-generation college students scored significantly lower on 15 of the 16 items (p < 0.05) and on all three composites of belonging (p < 0.01) than participants whose parents had at least some college education (Table 2).First-generation graduate school students also had significantly lower scores on 12 of the 16 items (p < 0.05) and on all three composites of belonging (p < 0.02) than students whose parents had at least some graduate school education (Table 3).The full raw data can be found under Underlying data 20 .

Discussion
Our findings indicate that parental education is strongly associated with belongingness among first-generation medical students.These results imply that parents who have had similar educational experiences might be able to better prepare and support their children for the unique stressors experienced in medical school.Interestingly, students who are first to attend college or graduate school had significantly lower belongingness scores on the social belonging and institutional support composites.This suggests that the capacity to experience meaningful relationships with peers and access adequate support through institutional resources play significant roles in determining belongingness in medical school.Surprisingly, we found no difference in belongingness based on a parent's  place of birth for students who were born in the U.S.This could indicate that students who grew up in the U.S. are comfortable within U.S. academic culture regardless of whether their parents were immigrants.
Bronfenbrenner's Environmental Satisfaction model offers an important lens with which to interpret these findings 15 .This model suggests that belonging is determined by the degree of satisfaction one has with their interactions with others and their environment.First-generation students may be dissatisfied with interactions between themselves and their peers as illustrated by survey items that reflect perceived likeability ("Other students here like me the way I am.") and interests in these students by others ("Other students in this school seem interested in my opinions, ideas, and questions related to coursework.").Correspondingly, the Identity-Proximity model suggests that positive relationships with "other" groups determine belonging 21 .First-generation students may feel inhibited by or be dissatisfied with classroom culture, specifically with respect to their comfort speaking up ("I feel comfortable asking a question in class.")or asking for help ("I would feel comfortable asking a professor for help if I did not understand course-related material.").This is unsurprising as agency in the classroom has been shown to increase belongingness 21 .
Institutional support has also been associated with student belongingness in non-U.S.medical schools 22 .Among our participants, first-generation students may experience barriers to access or be dissatisfied with available institutional resources, particularly career counseling ("I can find career planning support services.")and tutoring resources ("I can find tutoring support services.").Conversely, items regarding inclusive personal care ("I can find health and wellness support services.")had little or no difference between groups.
First-generation students knew how to access health services but found other services less accessible such as counseling, career services, or tutoring.
Importantly, we did not detect statistical difference for the item, "The professors here respect me."This suggests that first-generation students feel respected in school even when they might not feel as though they belong.However, respect from faculty members alone is clearly insufficient when first-generation students experience poor relationships with peers, lack of agency in the classroom, and inadequate institutional support.
It is critical that first-generation students are adequately supported to meet the national demand for a more diverse physician workforce 23 .Lack of belonging not only threatens the success of first-generation medical students but also their recruitment, wellness, and ongoing professional development 24 .
The implications are broad and involve numerous stakeholders in medical education that include faculty, administration, alumni, donors, and the students themselves.To further diversify medicine, targeted efforts to address social integration and identify the necessary support to facilitate belongingness amongst first-generation students is imperative.

Potential interventions
Based on our findings and the theoretical frameworks we described, two types of interventions might improve belongingness: the first focuses on changing the individual's perception of how they belong; and the second involves tailoring the social environment of the learner to stimulate belonging 25  who then wrote letters to future medical students after reflecting on the videos.This proved to decrease social isolation scores, which were associated with low belongingness, especially among Black medical students 26 .Another intervention involved helping students reframe ambiguous experiences, such as constructive criticism, in a manner that encouraged a growth mindset instead of a fixed mindset 27 .Furthermore, it can be helpful to have students focus on their in-group identities when feeling low levels of belonging instead of emphasizing their out-group identities 28 .For medical students, Brown et al. created a social media handle, @FirstGenDocs, to facilitate an online community and enhance in-group identities for first-generation student physicians 29 .
Positive educational experiences can improve medical student belongingness.Longitudinal exposure to teaching physicians during clinical rotations as a senior medical student improved the students' "in-group fit" and sense of belonging during the transition from student to practitioner 30,31 .Longitudinal integrated clerkships in rural medicine increased students' senses of belonging in rural communities and their likelihood to practice there after training 32 .More specifically, educational experiences in primary care increased students' senses of belonging and their choice to enter primary care specialties 33 .Thus, optimizing the learning environment for medical students is especially important because their success and wellbeing is strongly associated with their professional identities and performance 17 .
Coaching programs and guided reflective practices have been used successfully to improve student enculturation and social belonging in medical school [34][35][36] .Other interventions that change the social environment include students adopting a set of mutually agreed upon classroom goals and norms; ranking their priorities within the classroom; comparing their priorities to the teacher's; supporting students while still allowing an appropriate sense of autonomy; and emphasizing dialogue within the learning environment 25 .
Our study suggests that important interventions might include normalization of differences rather than "otherness" as well as intentionally cultivating an inclusive classroom environment 37

Limitations
There are several important limitations to these findings.Notably, the Ingram survey instrument has only been published in dissertation form, but it has been cited and used in a number of other studies and, thus, appears to be an accepted method in this field.Additionally, we modified the Ingram survey instrument by removing questions to reduce survey fatigue.We limited the effect of these changes by removing questions with low factor loading or low correlation with belongingness.However, we did not perform an independent analysis of the validity of the modified instrument.There is also risk of response biases, as with all survey studies, such as extreme response bias, acquiescence bias, and social desirability bias.These may have affected the results given the personal and potential emotional nature of the survey content.
Lastly, we conducted this study at only one institution, and it is limited by a response rate of 20%, which affects the generalizability of these findings to other medical schools.We also chose not to control for other demographic factors (e.g., socioeconomic status, race, ethnicity, gender, sexuality, disability status) in an effort to preserve anonymity due to the small number of expected participants.There is a need for larger investigations across many schools to properly identify disparities in belongingness between medical student populations.Qualitative studies may better uncover the sources of disparities and describe in more depth how they impact students during medical school.

Conclusion
Medical students who are first in their families to attend college or medical school report lower belongingness than their peers.Peer relationships and institutional support play an important role in belongingness.To meet the need for a more diverse physician workforce, interventions must be designed to better address belongingness for these students.Ongoing efforts to assess belongingness, the effectiveness of existing interventions, and quality of innovations and improvements are warranted.
results imply that parents who have had similar educational experiences might be able to better prepare and support their children for the unique stressors experienced in medical school."Based on your survey items, I am not sure that you can draw these conclusions.Your data supports that higher parental education is associated with higher levels of belonging but does not provide insight into whether that is because their parent's education allows them to better prepare or support their children for the unique stressor of medical school.I would also argue that it is unclear whether these parents' educational experiences were similar (a parent who took one course at a community college would be very different to the experience of medical school).You also note, "This suggests that the capacity to experience meaningful relationships with peers and access adequate support through institutional resources play significant roles in determining belongingness in medical school."Your survey questions explore one's abilities though not capacity.This conflates skill with potential.

○
The first sentence of your conclusion reads "medical students who are first in their families to attend college or medical school report lower belongingness than their peers."However, your data did not stratify those who were first in their family to go to medical school, only graduate school.

○
While the study focuses on first generation students, much of the introduction focuses on the importance of achieving greater diversity in the physician workforce though does not delineate how first-generation students contribute to this diversity.I would consider expanding on this.Particularly expanding on any literature that gives data on the demographics of first-generation students.

○
In the introduction, you note that studies show that first-generation students lack a sophisticated knowledge of the medical school "admissions game."More information about what you mean by "admissions game" would be helpful.Additionally, the articles you cite to support this are all out of the UK though your study is focused on American medical students.Perhaps exploring the literature on hidden curriculum and URiM students would yield more support to your argument.

○
Please define first generation medical student (first student to attend medical school, to attend higher education, etc.) and ensure that your use of the term matches that in the literature that you cite.

○
In the introduction, you mention that those underrepresented in medicine include firstgeneration medical students which is discordant with the AAMC definition (racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population).Subsequently you discuss first-generation American, college, and graduate school though do not discuss first generation medical student.
○ I appreciate the discussion on the importance of positive opportunities (especially positive longitudinal opportunities) and how this increases a sense of in-group fit.However, you transitioned the discussion to how working in a rural community increased the sense of belonging in that community, which, while important, does not necessarily correlate with a student's sense of belonging in their medical school.Similarly, I was confused about your discussion about the desire to enter primary care and how this related to one's sense of belonging in medical school.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?I cannot comment.A qualified statistician is required.

Have any limitations of the research been acknowledged? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: bias in assessment, lactation support for trainees, responding to patient initiated harassment We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

David Kirtchuk
Brighton And Sussex Medical School, Brighton, UK Francesca Hall BSMS, Brighton and Sussex Medical School, Brighton, Sussex, UK I applaud the work here which is necessary as medical education literature needs to explore how belongingness is experienced in diverse student groups.
I believe this article should be approved with reservations.
There are a few areas of the paper that could benefit from greater exploration, whilst also using language that reflects the limitations of this type of research.This is particularly the case when it comes to understanding cause and effects of the findings.

1.
Grouping students based on a single attribute is complicated and does not mean the 2.
students are homogenous in nature.A lack of a demographic breakdown of both groups makes any assumptions from the findings challenging to interpret if one is attempting to identify the drivers of a sense of lack of belonging.This raises the issue of confounders as no other demographics are controlled for and thus extrapolating cause and effect of the differences identified in the paper are limited.There is a large pool of existing literature regarding student belongingness and we feel more could be done in the discussion portion to explore where these findings sit within the literature.For example, in the discussion segment a comment is made regarding a strong association with parental education and belonging.Whilst this may be true I think it is hard to be certain what factors drive this.A note should be made in the limitations to make this explicit.We are not convinced your findings imply that parental education status is directly linked to belonging as these parents are less well placed to support their children.Belongingness is far more complex and nuanced an issue.Is parental education a proxy for class/financial/cultural capital?

3.
There could be some attention given to intersectionality and how it influences the issues you discuss.By removing the term 'woman' from your survey instrument, there is a lost opportunity to see if students in that particular group have a different experience.Consider Bourdieu's theories regarding this as a potential source to explore?The work of Costello may offer some understanding within your cultural context.

4.
The paper opens by describing Stanford as attracting a 'diverse student body'.However, it is internationally recognised as an elite institution.Later in in paper, a considerable part of the article is devoted to explaining to the support that students could expect to receive as a first generation student.There is a slight sense of discord between your suggestions that Stanford has a diverse population, but that support is required.

5.
Therefore, of the un examined social characteristics acknowledged in the paper, I would suggest social class to be a key missing possibly explanatory factor influencing 'belongingness'.Reay and others consider this in from a UK perspective.[1]   6.
We believe the major conclusion that can be drawn from the findings in this paper is that a difference exists but the study was not designed to be able to explore this in greater detail.Therefore, discussion statements need to consider the degree of extrapolation drawn from the results.

7.
There are a few minor points that could be clarified.
Are students who responded to the survey over-representative of first generation students compared to the overall cohort of students at the medical school?Is there data held by the admissions team at the school to compare with?This would help understand whether the results are more likely to be biased? 1.
Were there differences across year groups?Pre-clinical vs clinical attachments?Or was there insufficient data to extrapolate this?There are a number of groups that students are expected to belong to during the course of becoming a doctor; higher education student, medical student and doctor amongst others.These identities change over time and 'belongingness' to one group may not signify the same sense to all groups. 2.
Results -The comparator group is a bit unclear in the results section.Table 1 numbers add up to 68 (what happened to the other 14 respondents?Why were they not included?Was this because they met the criteria for first generation students but not based on parent immigration?)

3.
How much cross over is there between the 3 groups of first generational students?How does that likely impact the findings?

4.
We think additional comments regarding the need to understand what is meant by belonging and what this does to students from first in family populations.The suggestions for potential interventions seem to focus on how to make students belong but don't consider the need for medical institutes to reflect on the learning environment and culture that exists and how their policies contribute to it.I.e. the balance between students from diverse backgrounds having to adapt to belong and the degree to which the institutional culture needs to develop and adapt.

5.
We wonder whether the section which describes what Stanford does to support students could instead be uses to orientate the research within the existing literature as that would provide much needed context for the results.

Minor Concerns:
There was a reference to the social media handle @FirstGenDocs.The #FirstGenDocs online community and social media movement was created by Lamesha Brown, Raven Cokeley, and Jason Wallace.This community wasn't created for medical students specifically.It was created to serve and create community for first-generation Ph.D. students.This information should either be updated in the article or removed.Consider using the IG account "FoosinMedicine" instead.Very popular social media handle that follows two firstgeneration students in medical school. 1.
Consider adding some data/metrics to your examples in the potential interventions section of the article.For example, the article mentions that educational experience in primary care increased students' sense of belonging and their choice to enter primary specialties.By what percentage did it increase? 2.
In the Stanford School of Medicine section, it discussed the first-generation student interest group of medical students and its possible impact on student belongingness but wasn't 3.
sure of this and didn't include concrete data or information.You may want to consider removing this or providing some metrics about the impact.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes

Have any limitations of the research been acknowledged? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: First-Generation College Access and Success, First-Generation Student Mental Health and Wellness, Development and Implementation of First-Generation Programming, Education Access and Success for Rural Black First-Generation Students, Intersectionality and the First-Generation Student Identity I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Thank you for the opportunity to review this manuscript.I commend the authors for engaging in this work as wellbeing, belongingness, and academic performance -among many other factorsare critical elements for success in medical school.While I recommend approval for this manuscript, I have some concerns that I believe can be addressed in a potential revision.I've noted them below, divided into major and minor concerns:

Major Concerns
The premise of the front-end relies on recruiting medical students from diverse backgrounds so they can then go on to practice in underserved areas.Is this not the responsibility of all medical students?I find it problematic that underrepresented medical students, if you will, are the "fix" for serving and practicing in areas that are arguably the most challenging, most under-resourced, least retained, and least compensated? 1.
Could there be differences between the classes at Stanford?In other words, could an MS4 report on belongingness differently than an MS2?I imagine the latter's experiences are a bit more intense since everything is relatively new and they haven't yet experienced clerkships.Moreover, an MS3 may likely experience belongingness much differently than an MS2 given the vast literature on the clerkship experience.I say all this to question whether it would be worth disaggregating the sample by cohort.

2.
I think there are serious concerns about the tweaks made to the instrument.It is unclear how this impacts validity evidence of the instrument.By combining factors and removing single items, it is difficult to determine if and how these constructs still measure for the intended domains.This deserves a bit more real estate in the limitations and perhaps in the results (as a caveat to the findings).Additionally, is there a case to interpret individual items (versus the constructs)?If so, does removing items from the instrument impact this interpretation? 3.
Are first generation Americans, first generation college students, and first generation graduate students one and the same?I suspect they are different and nuanced but it seems like the manuscript combines all of these together as one group.The front end seems to refer to first generation college students and I wonder if the authors can expound on if, and how, first generation college students might differ from Americans and graduate students? 4.
I also have concerns about the response rate and the sample size of some of the groups reported (comparing 19 vs 63 in Table 2).Perhaps the authors can include power indices and/or effect sizes?

5.
Of the respondents, how many reported being a first generation American, a first generation college student, AND a first generation graduate student?I'm wondering if there's any sort of compounding effect here.In other words, does being first generation for each of these phases mitigate negative effects of belongingness?Or somehow exacerbate them? 6.

Minor Concerns
The authors speak to the lack of statistical significance of the professor-respect item.However, the tables indicate that these items trend lower for the first-gen group.I wonder if it might be worth softening the language here and speaking to the trends being observed.
In other words, with more power, could these differences have been significant?1.
Belongingness does not occur in a vacuum and I was hoping to read more about how this weaves into existing literature about professional identity formation and wellbeing.The 2.
authors nod very briefly to this when speaking to possible interventions but I believe this deserves a bit more focus when stepping back and interpreting these findings in the bigger picture.
Is the work clearly and accurately presented and does it cite the current literature?Yes Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes

Have any limitations of the research been acknowledged? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Health professions education; wellbeing; assessment and validity I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Table 1 . Responses to each survey question and composite values by whether the respondent was the a first-generation American. Survey items (Q1-16) First-generation American status p value b First-gen n = 32 Non-first-gen n = 36
Q11.I would feel comfortable asking a professor for help if I did not understand course-related material.3.3 (1.0) 3.4 (0.9) 0.826 Q12.I can find resource center support services for individuals like me.3.1 (1.0) 2.9 (1.1) 0.471 Q13.I can find counseling support services.a Values are given as mean (standard deviation).Responses were on a scale of 1 (Strongly disagree) to 5 (Strongly agree) b Mann-Whitney U test.Red boxes indicate p<0.01, pink boxes indicate p<0.05.

Table 2 . Responses to each survey question and composite values by whether the respondent was the first generation to attend college. Survey items (Q1-16) First-generation to college status p value b
Q2. Students at this medical school are friendly with me.2.6 (.09) 3.5 (0.8) 0.0001 Q3.I feel I belong at this medical school.2.1 (1.1) 3.2 (1.1) 0.0003 Q4.It has been easy for me to make friends in medical school.1.6 (1.2) 2.8 (1.2) 0.0007 Q5.I can really be myself at this medical school.1.7 (1.2) 2.8 (1.3) 0.0009

Table 3 . Responses to each survey question and composite values by whether the respondent was the first generation to attend graduate school. Survey items (Q1-16) First-generation to graduate school status p value b First-gen n = 34 Non-first-gen n = 48
Q8.I feel comfortable asking a question in class.2.5 (1.5) 3.1 (0.9) 0.0589 Q9.I feel comfortable contributing to class discussions.2.7 (1.3) 3.3 (0.8) 0.0488 Q10.The professors here respect me.3.0 (1.0) 3.4 (0.8) 0.0673 Q11.I would feel comfortable asking a professor for help if I did not understand course-related material.a Values are given as mean (standard deviation).Responses were on a scale of 1 (Strongly disagree) to 5 (Strongly agree) b Mann-Whitney U test.Red boxes indicate p<0.01, pink boxes indicate p<0.05.

Survey items (Q1-16) First-generation to graduate school status p value b
. For example, in a program called "Build & Belong," senior medical students at one school created video messages about belongingness for junior medical students, a Values are given as mean (standard deviation).Responses were on a scale of 1 (Strongly disagree) to 5 (Strongly agree) b Mann-Whitney U test.Red boxes indicate p<0.01, pink boxes indicate p<0.05.
. Identifying cause and effect could further inform the design of these interventions to enhance belonging.Research is needed to evaluate interventions for medical students, and interventions may need to be tailored differently for preclinical classrooms and clinical learning environments.

Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Have any limitations of the research been acknowledged? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests:
1. Reay D, Crozier G, Clayton J: 'Fitting in' or 'standing out': Working-class students in UK higher education.British Educational Research Journal.2010; 36 (1): 107-124 Publisher Full Text No competing interests were disclosed.

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Georgia Tech University, Atlanta, GA, USA Thank you for the opportunity to review this article.I applaud the authors for writing this article about the importance of belongingness among first-generation students in medical school.It is a © 2024 Troy C. topic that is not widely covered in the literature and I am excited to see it.Sense of belonging is a key factor in the success of a first-generation student's experience, both inside and outside of the classroom.I recommend approval of this article with revisions.I have a couple of concerns that can be addressed in a revision.Below are my concerns:Major Concerns: I would like to see more detail in this article about their mentoring program at Stanford.I don't think that it gives enough context about the program and how it can contribute to the importance of the study.Some of the detail in this section could include: