Association Between Resident Race and Ethnicity and Clinical Performance Assessment Scores in Graduate Medical Education

Abstract

PurposeTo assess the association between internal medicine (IM) residents' race/ ethnicity and clinical performance assessments. MethodThe authors conducted a cross-sectional analysis of clinical performance assessment scores at 6 U.S. IM residency programs from 2016 to 2017. Residents underrepresented in medicine (URiM) were identified using self-reported race/ ethnicity. Standardized scores were calculated for Accreditation Council for Graduate Medical Education core competencies. Cross-classified mixed-effects regression assessed the association between race/ethnicity and competency scores, adjusting for rotation time of year and setting; resident gender, postgraduate year, and IM In-Training Examination percentile rank; and faculty gender, rank, and specialty. Results Data included 3,600 evaluations by 605 faculty of 703 residents, including 94 (13.4%) URiM residents. Resident race/ethnicity was associated with competency scores, with lower scores for URiM residents (difference in adjusted standardized scores between URiM and non-URiM residents, mean [standard error]) in medical knowledge (−0.123 [0.05], P = .021), systemsbased practice (−0.179 [0.05], P = .005), practice-based learning and improvement (−0.112 [0.05], P = .032), professionalism (−0.116 [0.06], P = .036), and interpersonal and communication skills (−0.113 [0.06], P = .044).Translating this to a 1 to 5 scale in 0.5 increments, URiM resident ratings were 0.07 to 0.12 points lower than non-URiM resident ratings in these 5 competencies. The interaction with faculty gender was notable in professionalism (difference between URiM and non-URiM for men faculty −0.199 [0.06] vs women faculty −0.014 [0.07], P = .01) with men more than women faculty rating URiM residents lower than non-URiM residents. Using the 1 to 5 scale, men faculty rated URiM residents 0.13 points lower than non-URiM residents in professionalism. ConclusionsResident race/ethnicity was associated with assessment scores to the disadvantage of URiM residents. This may reflect bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment.

Racial and Ethnic Differences in Internal Medicine Residency Assessments

“…These results build on prior evidence showing differences in IM performance evaluations between URiM and non-URiM residents at 6 residency programs. 17 Our findings advance this work by demonstrating racial inequities in Milestone assessments for all trainees from racial and ethnic groups that have been historically marginalized in medicine, including Asian residents. In addition, our study furthers this research by examining assessments in a sample of more than 9000 trainees from 2 successive cohorts of IM residents.…”

“…The Milestone system was designed to support formative assessment, bolster professional development, and enhance the quality of assessments. 15,16 However, a recent study 17 of ACGME's Milestone assessment system reported differences in assessment by race and ethnicity, suggesting that the Milestone assessment system may be vulnerable to bias. This study 17 was limited in cohort size and the number of included GME training sites; therefore, it is unclear whether these findings are generalizable.…”

“…15,16 However, a recent study 17 of ACGME's Milestone assessment system reported differences in assessment by race and ethnicity, suggesting that the Milestone assessment system may be vulnerable to bias. This study 17 was limited in cohort size and the number of included GME training sites; therefore, it is unclear whether these findings are generalizable. To address this important knowledge gap, we examined Milestone ratings across all clinical competency domains for racial and ethnic differences among a national cohort of IM residents.…”

Resculpting Professionalism for Equity and Accountability

“…In particular, men faculty rated racially minoritized residents 0.13 points lower than White residents in professionalism competencies. 23 These findings highlight the unconscious imbuement of racialized and gendered standards in assessment of professionalism.…”

Contextualizing the Landscape of Diversity, Equity, and Inclusion in Dermatology

“…In letters of recommendation, URM applicants are more likely to be described using grindstone words to highlight effort as compared with White applicants who are more likely to be described with standout descriptors that highlight achievement . A hidden curriculum prevails, in which certain characteristics of racial and ethnic or cultural identity, such as dress, hair, and speech, are seen as examples of unprofessional behavior because they do not conform to the broader and historic norms . These inequitable metrics and biases serve to disadvantage or exclude already historically marginalized groups.…”