Female Residents From Underrepresented Groups Face Assessment Bias

Female residents in emergency medicine who are also from underrepresented minorities score worse on performance assessments than their white male counterparts, according to a new study published in JAMA Network Open.

Investigators studied assessments of nearly 2700 emergency medicine residents and found disparities between female residents from groups underrepresented in medicine (URM). The disparities are considered discrimination, preventing minority trainees from advancing in their careers, study authors wrote.

The study highlights the need to address the "ongoing and pernicious problem of assessment bias in graduate medical education," said co-author Eric Holmboe, MD, an adjunct professor of medicine at Yale University.

The findings may explain why there are fewer women, people of color, and people from marginalized communities in leadership roles in medicine, said Diana Lautenberger, MA, director of Gender Equity Initiatives at the American Association of Medical Colleges (AAMC).

Conversations about bias often overlook how assessments impact residents' careers, she said. "We often think of ‘bias' interpersonally but pay less attention to evaluations. Yet the evaluation has a dramatic and profound impact on the progress of one's career."

Expanding on Past Research

Previous studies showed racial and gender disparities in standardized resident milestone assessments for internal medicine and emergency medicine, with female or URM residents "consistently rated as less skilled than their male and non-URM counterparts," study authors write. But those studies addressed racial and gender disparities separately.

The authors of the current study used the Accreditation Council for Graduate Medical Education (ACGME) Milestones data for academic years 2014-2015 through 2017-2018 to research "sex-specific ethnoracial discrimination" in assessments of emergency medicine residents.

The ratings were based on standardized Milestones linked to resident demographic data, including ethnoracial identity, binary sex, and Step 2 CK United States Medical License Examination scores that AAMC provided to ACGME. Milestone assessments in EM are conducted twice during the academic year and are grouped into six core ACGME competency areas: patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonally and communication skills.

The study involved 128 ACGME-accredited programs with more than 16,000 assessments and 2708 emergency medicine residents. Of the residents, about 70% were in 3-year programs and nearly 30% in 4-year programs.

The residents in the study were divided into three ethnoracial groups: Asian, URM, and White. Most residents were White (74%), followed by Asian (18%), Hispanic or Latino (8%), and African American or Black (6%). About 35% were women and 14% URM.

Compared with White male residents, URM female residents consistently received lower assessment scores with the difference in scores increasing over time. All minority residents, except for White female residents, experienced progressively lower ratings midway through the second postgraduate year, regardless of whether they were in 3- or 4-year programs, the study showed.

Implications for the Future

The study findings come as no surprise to Sacha Sharp, PhD, assistant professor of medicine and adjunct assistant professor of the Program of Africana Studies at Indiana University School of Medicine (IUSM).

"The culture of medicine often benefits White men over other demographic categories," Sharp, a medical education specialist and co-chair of the IUSM Diversity Council, told Medscape.

"When researchers evaluate disparity, they often prioritize gender or race, thus ignoring individuals with intersectional identities such as Black women or trans women," she said. As a result, the barriers that prevent those from minority groups from achieving academic success in medical education remain in place, Sharp added.

"No longer can the small sample size be blamed, and real concerns be overlooked."

The study findings may be a warning of future attrition, according to Carol Lin, MD, assistant professor of orthopedics at Cedars Sinai in Los Angeles. She co-authored another study published in JAMA Surgery earlier this year showing that the risk for attrition is significantly elevated for surgery residents who are female and from underrepresented minorities compared to White and male residents.

"When I read these findings in context of our paper on surgical attrition," Lin said, "I realize that if [URM residents] are working as hard as their peers, with academic credentials strong enough to match into the same programs but are getting poorer ratings, and already have a feeling of 'otherness' based on race, sex, and ethnicity, that might be associated with future attrition and a parallel process might be going on in surgical specialties as was shown here in emergency medicine."

The JAMA Network Open study received grants from the US National Institutes of Health and the Emergency Medicine Foundation. Holmboe reported textbook royalties from Elsevier oversight of the Milestones initiative during the conduct of the study. The other authors' disclosures are listed on the original paper. Lautenberger, Sharp, and Lin declare no relevant financial relationships.

JAMA Netw Open. Published online September 21, 2023. Full text

Batya Swift Yasgur, MA, LSW is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).