Medical Education: Racial, Gender Disparities Persist at All Levels

Diana Phillips

March 07, 2017

Pervasive racial and gender disparities persist in medical education among both students and faculty, according to three studies published online March 6 in JAMA Internal Medicine. The findings lead to calls for new approaches to increase opportunities for underrepresented minorities and women.

Each of the studies considers participants at a different step in education. One study looks at the influence of race/ethnicity on medical students' election into the Alpha Omega Alpha (ΑΩΑ) honor society. The second study assesses perceived performance differences among male and female emergency medicine residents. And the third study considers gender representation among grand rounds speakers.

Honor Society Membership

To determine race/ethnicity representation among medical students who had achieved membership into the ΑΩA, which has been linked to future success in academic medicine, Dowin Boatright, MD, MBA, a postdoctoral fellow at the Yale School of Medicine in New Haven, Connecticut, and colleagues conducted a retrospective analysis of a cohort of medical students who applied for residency positions at Yale Medical Center for the 2014-2015 academic year using data from the Electronic Residency Application Service.

Overall, 4655 US medical students from 123 medical schools with an AΩA chapter applied to 12 distinct residency programs. Of those, 2605 (56.0%) were white, 276 (5.9%) were black, 186 (4.0%) were Hispanic, and 1170 (25.1%) were Asian.

Among the applicants, 966 (20.8%) were elected into the AΩA. The absolute proportion of AΩA members differed by race/ethnicity: 691 (71.5%) white, 7 (0.7%) black, 27 (2.8%) Hispanic, and 168 (17.4%) Asian.

After controlling for variables that could influence AΩA selection, including self-reported community service hours, self-reported time dedicated to leadership activities, additional degrees, Gold Humanism Honor Society membership, US Medical Licensing Examination (USMLE) Step 1 scores, and number of research publication/presentations, the investigators observed that black medical students were nearly six times less likely than white students to be inducted into the AΩA (adjusted odds ratio [aOR], 0.16; 95% confidence interval [CI], 0.07-0.37). Asian students were half as likely as whites (aOR, 0.52; 95% CI, 0.42-0.65) to be AΩA members.

Of the potentially influential variables, "the USMLE Step 1 scores demonstrated a strong association with AΩA membership," the authors report. They note, however, that the wide confidence interval (top quartile: OR, 105.57; 95% CI, 63.95-174.28) contributes to uncertainty about the true effect size of the scores on AΩA membership.

"In addition, we found a statistically significant interaction between race/ethnicity and USMLE Step 1 scores when treating these scores as a binary variable," the authors write. They note that in a model that included only students who did not rank in the top USMLE Step 1 score quartile, black, Hispanic, and Asian medical students were still less likely than their white peers to be AΩA members.

In a model restricted to students ranking in the top quartile of USMLE Step 1 scores, "Asian students remained less likely than white students to be AΩA members (OR, 0.55; 95% CI, 0.41-0.76), and black applicants were also less likely than white applicants to be AΩA members; however, the association for black applicants did not reach statistical significance (OR, 0.38; 95% CI, 0.13-1.07)," they report.

No significant differences were observed in community service or leadership hours between society members and nonmembers, suggesting that those factors "are not being strongly weighed in election to the society," the authors write.

The findings of this study — the first to describe a racial disparity in the receipt of academic awards at the level of undergraduate medical education that is similar to the disparity that has been reported among minority faculty with respect to promotions and National Institutes of Health] funding in academic settings — "suggest that individual medical schools might benefit from internal review of their AΩA membership profiles with specific attention to differences by race/ ethnicity."

Residency program directors and the national AΩA society should also take note of the findings to ensure that their interview and application review processes do not reflect systemic bias, the authors write. They also suggest that the national AΩA society should consider regularly collecting and disseminating member characteristics across the country. "Although publicly available data could be presented in aggregate, this database would provide AΩA with the ability to internally benchmark trends in member demographic data over time," they write.

Resident Evaluations Uneven

Meanwhile, in a longitudinal, retrospective analysis, Arjun Dayal, from the Pritzker School of Medicine at the University of Chicago, and colleagues compared faculty evaluations regarding milestone achievements of male vs female emergency medicine (EM) residents from eight EM training programs between July 1, 2013, and July 1, 2015.

During the study period, the investigators collected 33,456 direct-observation evaluations of 359 EM residents, including 237 men (66.0%) and 122 women (34.0%), by 285 faculty members (194 men [68.1%] and 91 women [31.9%]).

"In the first year of residency, male and female residents were evaluated comparably, with female residents receiving higher evaluations in subcompetencies, such as multitasking, diagnosis, and accountability," the authors report. "For [postgraduate year 3] residents, men were evaluated higher on all 23 subcompetencies."

There were no statistically significant differences in the scores given by male and female faculty members, "indicating that faculty members of both sexes evaluated female residents lower," the authors state.

The performance on first-year evaluations suggest that men and women entered training with similar skills and knowledge. "However, as women progressed through the same residency programs, they were consistently evaluated lower than their male colleagues," the authors write.

The EM subcompetencies for which they were evaluated include "the potentially more objective procedural subcompetencies and potentially more subjective nonprocedural subcompetencies," the authors note. "Such a uniform trend may suggest implicit bias rather than diminished competency or skill, especially considering that men and women began residency with similar skills and knowledge."

It is possible that the gap may reflect "disparate opportunities in accessing mentorship, practicing skills, and obtaining meaningful feedback," the authors suggest.

Women may be disadvantaged in certain clinical practice domains. For example, the authors write, "We found larger differences between men and women in certain subcompetencies, such as airway management and general approach to procedures."

Incongruity with respect to gender expectations may also be a factor, they explain. They note that certain behaviors and attributes are considered more traditionally male — such as assertiveness and certain leadership traits — and thus may not be judged as positively when exhibited by female residents.

Based on their findings, the authors stress the need for more research into the drivers of these trends in order to design solutions that promote gender equality. In addition, the results highlight the need for increased awareness of gender bias in residency training, the implementation of focused communication and evaluation techniques, recruitment and training efforts to narrow the gender and mentorship gaps, and implicit bias training.

Further, because residents' milestone evaluations may one day influence their training time under a competency-based education system, "it is imperative that the evaluation system be rigorously validated and investigated for any possible bias."

Grand Rounds Speakers Rarely Women

In the third study, Julie Boiko, MD, a resident in the department of pediatrics at the University of California, San Francisco, and colleagues looked at women's representation as grand rounds speakers to determine whether the gender mix is reflective of that seen in the academic medical workforce.

The investigators analyzed grand rounds speaker series for nine specialities for 2014 and determined that, among the sessions delivered by faculty or other nontrainees, 19.6% to 53.3% (median 26.2%) were delivered by women.

"Compared with national academic medical workforces, the percentages of nontrainee female speakers were uniformly significantly lower than the female composition of the resident workforces, and lower than the female composition of the faculty workforces in all specialties except obstetrics/gynecology and surgery," the authors write.

"This finding suggests that audiences are not typically exposed to presenter line-ups resembling their demographic gender profiles," Dr Boiko and colleagues continue. This may be because senior speakers are often invited to deliver grand rounds but "academic medicine's 'leaky pipeline' leaves few women among the full professor ranks."

The link between grand rounds gender representation and retention of women in academic medicine warrants further study, the authors note. "Representation of women at [grand rounds] podiums reflects and potentially contributes to limited female retention in academic medicine."

Collective Findings Challenge the Community

The collective findings of the three studies "challenge us to address equity within our profession as well as beyond it," Molly Cooke, MD, professor of medicine at the University of California San Francisco, writes in an invited commentary.

Medical education can play a role in eliminating the harmful effects of bias in healthcare, according to Dr Cooke. She offers these suggestions for leaders in academic medicine:

  • Identify one's own implicit biases, which is "the first step in recognizing our own ideas of what a doctor looks like," and which can influence ideas and decisions about residents' and other physicians' performance and progress.

  • Track the performance of processes that are meant to be data-driven and gender- and race-neutral.

"We must insist that our profession and the processes that our trainees encounter along the way treat them fairly and reflect the diversity of the patients we serve," Dr Cooke concludes.

JAMA Intern Med. Published online March 6, 2017. Full text

JAMA Intern Med. Published online March 6, 2017. Full text

JAMA Intern Med. Published online March 6, 2017. Full text

JAMA Intern Med. Published online March 6, 2017. Full text

The Yale race/ethnicity study was supported by funds from Rosemarie Fisher, MD, associate dean of graduate medical education at the Yale School of Medicine and designated institutional official for Yale-New Haven Hospital.

Two of the study authors report being cofounders of Scutmonkey Consulting LLC.

The study of gender bias in emergency residency evaluations was supported by a grant from the National Center for Advancing Translational Sciences of the National Institutes of Health. Additional funding was provided by a University of Chicago Diversity Research and Small Grants Program.

Two of the study authors, Arjun Dayal and Daniel O'Connor, reported codeveloping InstantEval, which was used to collect the evaluation data used in this study.

Dr Boiko and coauthors of the grand rounds study have disclosed no relevant financial relationships.

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