Association of Gender and Race/Ethnicity with Internal Medicine In-Training Examination Performance in Graduate Medical Education.

BACKGROUND: Disparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern. OBJECTIVE: Examine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity. DESIGN: Longitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014-2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square. PARTICIPANTS: A total of 689 IM residents, including 330 women and URiM residents (48%). MAIN MEASURES: ITE score KEY RESULTS: There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F(2, 1321) 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p<0.001). Women and URiM residents had greater odds of being at potential risk for not passing the ABIM-CE (OR 1.75, 95% CI 1.10 to 2.78) with greatest odds in PGY3 (OR 3.13, 95% CI 1.54 to 6.37). CONCLUSION: Differences in ITE over training were associated with resident gender and race/ethnicity. Women and URiM residents had smaller ITE score gains across PGY translating into greater odds of potentially being seen as at-risk for not passing the ABIM-CE. Differences in ITE over training may reflect differences in experiences of women and URiM residents during training and may lead to further disparities.

Gender Bias in Resident Assessment in Graduate Medical Education: Review of the Literature.

BACKGROUND: Competency-based medical education relies on meaningful resident assessment. Implicit gender bias represents a potential threat to the integrity of resident assessment. We sought to examine the available evidence of the potential for and impact of gender bias in resident assessment in graduate medical education. METHODS: A systematic literature review was performed to evaluate the presence and influence of gender bias on resident assessment. We searched Medline and Embase databases to capture relevant articles using a tiered strategy. Review was conducted by two independent, blinded reviewers. We included studies with primary objective of examining the impact of gender on resident assessment in graduate medical education in the USA or Canada published from 1998 to 2018. RESULTS: Nine studies examined the existence and influence of gender bias in resident assessment and data included rating scores and qualitative comments. Heterogeneity in tools, outcome measures, and methodologic approach precluded meta-analysis. Five of the nine studies reported a difference in outcomes attributed to gender including gender-based differences in traits ascribed to residents, consistency of feedback, and performance measures. CONCLUSION: Our review suggests that gender bias poses a potential threat to the integrity of resident assessment in graduate medical education. Future study is warranted to understand how gender bias manifests in resident assessment, impact on learners and approaches to mitigate this bias.

Reasons for HCV non-treatment in underserved African Americans: implications for treatment with new therapeutics.

BACKGROUND: African Americans are disproportionately affected by hepatitis C (HCV) and are less likely to undergo HCV treatment. Underserved populations are especially at risk for experiencing health disparity. Aim. To identify reasons for HCV non-treatment among underserved African Americans in a large safetynet system. MATERIAL AND METHODS: Medical records of HCV-infected African Americans evaluated at San Francisco General Hospital liver specialty clinic from 2006-2011 who did not receive HCV treatment were reviewed. Treatment eligibility and reasons for non-treatment were assessed. Factors associated with treatment ineligibility were assessed using logistic regression modeling. RESULTS: Among 118 patients, 42% were treatment ineligible, 18% treatment eligible, and 40% were undergoing work-up to determine eligibility. Reasons for treatment ineligibility were medical (54%), non-medical (14%), psychiatric (4%), or combined (28%). When controlling for age and sex, active/recent substance abuse (OR 6.65, p = 0.001) and having two or more medical comorbidities (OR 3.39, p = 0.005) predicted treatment ineligibility. Excluding those ineligible for treatment, 72% of all other patients were lost to follow-up; they were older (55 vs. 48 years, p = 0.01) and more likely to be undergoing work up to determine treatment eligibility (86 vs. 21%, p < 0.0001) than those not lost to follow-up. CONCLUSIONS: Medical comorbidities and substance abuse predicted HCV treatment ineligibility in underserved African Americans. Importantly, the majority of those undergoing work-up to determine HCV treatment eligibility were lost to follow-up. While newer anti-HCV agents may increase treatment eligibility, culturally appropriate interventions to increase compliance with evaluation and care remain critical to HCV management in underserved African Americans.

Demographics of carotid atherosclerotic plaque features imaged by computed tomography.

OBJECTIVES: This was a prospective, cross-sectional study to evaluate the risk factors and symptoms associated with specific carotid wall and atherosclerotic plaque features as seen on computed tomography-angiography (CTA) studies. MATERIALS AND METHODS: A total of 120 consecutive consenting patients admitted to the emergency department with suspected cerebrovascular ischemia, and receiving standard-of-care CTA of the brain and neck on a 64-slice CT scanner, were prospectively enrolled in the study. The carotid wall features observed on CT were quantitatively analyzed with customized software using different radiodensities for contrast-phase acquisition of the carotids. Clinical datasets, including a complete medical history and examination, were obtained by research physicians or specially trained associates blinded to any findings on CT. Univariate and multivariate analyses were performed to assess the degree of association between clinical indicators and quantitative CT features of carotid atherosclerotic plaques. RESULTS: Men tended to have increased carotid lumen (coefficient: 608.7; 95% CI: 356.9-860.6; P<0.001) and wall volumes (209.2; 54.5-364.0; P=0.008), and hypertension was associated with increased wall volume (260.6; 88.7-432.6; P=0.003). Advanced age was associated with increases in maximum wall thickness (0.02; 0.003-0.05; P=0.029), fibrous cap thickness (0.005; 0.001-0.008; P=0.016) and number of calcium voxels (2.7; 1.25-4.2; P<0.001), and the presence of a carotid bruit was associated with carotid stenosis length (21.0; 5.38-37.8; P=0.009). Exercise was inversely related to the number of calcium (-37.1; -71.5 - -2.7; P=0.035) and lipid (-7.9; -15.1 - -0.7; P=0.032) voxels. ACE inhibitor use was associated with fibrous cap thickness (0.1; 0.04-0.23; P=0.005). CONCLUSION: Significant associations were found between clinical descriptors and carotid atherosclerotic plaque features as revealed by CT. Future studies are needed to validate our findings, and to continue investigations into whether CT features of carotid plaques can be used as biomarkers to quantify the impact of strategies aiming to correct vascular risk factors.

Life in plastic, it's not fantastic: Sublethal effects of polyethylene microplastics ingestion throughout amphibian metamorphosis.

Microplastics (MP) are an abundant, long-lasting, and widespread type of environmental pollution that is of increasing concern as it might pose a serious threat to ecosystems and species. However, these threats are still largely unknown for amphibians. Here, we used the African clawed frog (Xenopus laevis) as a model species to investigate whether polyethylene MP ingestion affects amphibian growth and development and leads to metabolic changes across two consecutive life stages (larvae and juveniles). Furthermore, we examined whether MP effects were more pronounced at higher rearing temperatures. Larval growth, development, and body condition were recorded, and standard metabolic rate (SMR) and levels of stress hormone (corticosterone, CORT) were measured. We determined variation in size, morphology, and hepatosomatic index in juveniles to identify any potential consequences of MP ingestion across metamorphosis. In both life stages, MP accumulation in the body was assessed. MP ingestion was found to result in sublethal effects on larval growth, development, and metabolism, to lead to allometric carry-over effects on juvenile morphology, and to accumulate in the specimens at both life stages. In larvae, SMR and developmental rate increased in response to MP ingestion; there additionally was a significant interaction of MP ingestion and temperature on development. CORT levels were higher in larvae that ingested MP, except at higher temperature. In juveniles, body was wider, and extremities were longer in animals exposed to MP during the larval stage; a high rearing temperature in combination with MP ingestion counteracted this effect. Our results provide first insights into the effects of MP on amphibians throughout metamorphosis and demonstrate that juvenile amphibians may act as a pathway for MP from freshwater to terrestrial environments. To allow for generalizations across amphibian species, future experiments need to consider the field prevalence and abundance of different MP in amphibians at various life stages.

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

PURPOSE: To assess the association between internal medicine (IM) residents' race/ethnicity and clinical performance assessments. METHOD: The 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), systems-based 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. CONCLUSIONS: Resident 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.

Introduction to the medical professions through an innovative medical student-run pipeline program.

Underrepresented minorities (URMs) make up a disproportionately small percentage of medical school applicants, matriculants, and physicians relative to the general US population. Preprofessional pipeline programs may help introduce URMs to careers in the medical field. MiniMeds was developed as a paracurricular enrichment program that targeted URM students. The curriculum was designed and administered by medical students, and 2 trials of this program were conducted. Data were collected pre and post program through a survey that assessed knowledge of medical concepts and knowledge of and interest in careers in medicine. Attendance at program sessions correlated with baseline knowledge about medical professions. Knowledge about medical concepts increased significantly from baseline to follow-up for boys, a group significantly represented by URMs in our cohort. Median scores for knowledge of medical careers increased significantly from baseline to followup for URMs as well as for boys and girls. Preprofessional pipeline programs such as MiniMeds are able to engage and develop medical knowledge in URM students at a critical developmental age. Further evaluation and implementation of programs that incorporate medical students to actively develop and lead pipeline programs are warranted.

Avoiding the Virtual Pitfall: Identifying and Mitigating Biases in Graduate Medical Education Videoconference Interviews.

Public health concerns related to the COVID-19 pandemic are leading many residency and fellowship programs to transition from in-person to videoconference interviews (VCIs). The magnitude and speed of the shift to VCIs, the lack of existing research around bias and VCIs, and the underlying stress on all involved related to the pandemic put programs at risk of implementing virtual interviews without fully exploring their implications for diversity and equity. VCIs can promote diversity efforts by reducing the need for travel, making interviews more convenient and cost effective for applicants. However, VCIs may also introduce new biases and amplify existing biases in recruitment. VCIs introduce a dependence on technology to conduct the interview process, which may amplify systemic inequities in access to broadband internet and high-quality hardware. Communication delays due to technology challenges may negatively affect interview scores. Additionally, users experience increased cognitive load when participating in videoconferences, which can activate implicit biases. Exposure to cues in the interviewee's personal living situation previously unavailable to interviewers may lead to unconscious assumptions by interviewers, which may also influence scoring. Graduate medical education programs committed to maintaining equitable recruitment processes must be able to recognize potential biases in VCIs and implement strategies to mitigate them. This article identifies some of the biases VCIs can introduce to the recruitment process and offers strategies for programs to mitigate them. These include making interviewers aware of potential technology-based inequities, encouraging interviewers to minimize multitasking, and offering guidance on use of standardized backgrounds. The authors also recognize the limitations of offering behavioral strategies to mitigate systemic inequities and suggest that structural changes are needed to ensure equitable access to technology.

Carotid atherosclerosis does not predict coronary, vertebral, or aortic atherosclerosis in patients with acute stroke symptoms.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether significant atherosclerotic disease in the carotid arteries predicts significant atherosclerotic disease in the coronary arteries, vertebral arteries, or aorta in patients with symptoms of acute ischemic stroke. METHODS: Atherosclerotic disease was imaged using CT angiography in a prospective study of 120 consecutive patients undergoing emergent CT evaluation for symptoms of stroke. Using a comprehensive CT angiography protocol that captured the carotid arteries, coronary arteries, vertebral arteries, and aorta, we evaluated these arteries for the presence and severity of atherosclerotic disease. Significant atherosclerotic disease was defined as >50% stenosis in the carotid, coronary, and vertebral arteries, or >or=4 mm thickness and encroaching in the aorta. Presence of any and significant atherosclerotic disease was compared in the different types of arteries assessed. RESULTS: Of these 120 patients, 79 had CT angiography examinations of adequate image quality and were evaluated in this study. Of these 79 patients, 33 had significant atherosclerotic disease. In 26 of these 33 patients (79%), significant disease was isolated to 1 type of artery, most often to the coronary arteries (N=14; 54%). Nonsignificant atherosclerotic disease was more systemic and involved multiple arteries. CONCLUSIONS: Significant atherosclerotic disease in the carotid arteries does not predict significant atherosclerotic disease in the coronary arteries, vertebral arteries, or aorta in patients with symptoms of acute ischemic stroke. Significant atherosclerotic disease is most often isolated to 1 type of artery in these patients, whereas nonsignificant atherosclerotic disease tends to be more systemic.

Association of Gender With Learner Assessment in Graduate Medical Education.

Importance: Gender bias may affect assessment in competency-based medical education. Objective: To evaluate the association of gender with assessment of internal medicine residents. Design, Setting, and Participants: This multisite, retrospective, cross-sectional study included 6 internal medicine residency programs in the United States. Data were collected from July 1, 2016, to June 30, 2017, and analyzed from June 7 to November 6, 2019. Exposures: Faculty assessments of resident performance during general medicine inpatient rotations. Main Outcomes and Measures: Standardized scores were calculated based on rating distributions for the Accreditation Council for Graduate Medical Education's core competencies and internal medicine Milestones at each site. Standardized scores are expressed as SDs from the mean. The interaction of gender and postgraduate year (PGY) with standardized scores was assessed, adjusting for site, time of year, resident In-Training Examination percentile rank, and faculty rank and specialty. Results: Data included 3600 evaluations for 703 residents (387 male [55.0%]) by 605 faculty (318 male [52.6%]). Interaction between resident gender and PGY was significant in 6 core competencies. In PGY2, female residents scored significantly higher than male residents in 4 of 6 competencies, including patient care (mean standardized score [SE], 0.10 [0.04] vs 0.22 [0.05]; P = .04), systems-based practice (mean standardized score [SE], -0.06 [0.05] vs 0.13 [0.05]; P = .003), professionalism (mean standardized score [SE], -0.04 [0.06] vs 0.21 [0.06]; P = .001), and interpersonal and communication skills (mean standardized score [SE], 0.06 [0.05] vs 0.32 [0.06]; P < .001). In PGY3, male residents scored significantly higher than female patients in 5 of 6 competencies, including patient care (mean standardized score [SE], 0.47 [0.05] vs 0.32 [0.05]; P = .03), medical knowledge (mean standardized score [SE], 0.47 [0.05] vs 0.24 [0.06]; P = .003), systems-based practice (mean standardized score [SE], 0.30 [0.05] vs 0.12 [0.06]; P = .02), practice-based learning (mean standardized score [SE], 0.39 [0.05] vs 0.16 [0.06]; P = .004), and professionalism (mean standardized score [SE], 0.35 [0.05] vs 0.18 [0.06]; P = .03). There was a significant increase in male residents' competency scores between PGY2 and PGY3 (range of difference in mean adjusted standardized scores between PGY2 and PGY3, 0.208-0.391; P ≤ .002) that was not seen in female residents' scores (range of difference in mean adjusted standardized scores between PGY2 and PGY3, -0.117 to 0.101; P ≥ .14). There was a significant increase in male residents' scores between PGY2 and PGY3 cohorts in 6 competencies with female faculty and in 4 competencies with male faculty. There was no significant change in female residents' competency scores between PGY2 to PGY3 cohorts with male or female faculty. Interaction between faculty-resident gender dyad and PGY was significant in the patient care competency (ß estimate [SE] for female vs male dyad in PGY1 vs PGY3, 0.184 [0.158]; ß estimate [SE] for female vs male dyad in PGY2 vs PGY3, 0.457 [0.181]; P = .04). Conclusions and Relevance: In this study, resident gender was associated with differences in faculty assessments of resident performance, and differences were linked to PGY. In contrast to male residents' scores, female residents' scores displayed a peak-and-plateau pattern whereby assessment scores peaked in PGY2. Notably, the peak-and-plateau pattern was seen in assessments by male and female faculty. Further study of factors that influence gender-based differences in assessment is needed.

Resident Physician Experiences With and Responses to Biased Patients.

Importance: Biased patient behavior negatively impacts resident well-being. Data on the prevalence and frequency of these encounters are lacking and are needed to guide the creation of institutional trainings and policies to support trainees. Objective: To evaluate the frequency of resident experiences with and responses to a range of biased patient behaviors. Design, Setting, and Participants: A retrospective survey was sent via email to 331 second- and third-year internal medicine residents from 3 academic medical centers in California and North Carolina. First-year residents were excluded owing to their limited interactions with patients at the time of participant recruitment. Data were collected from August 21 to November 25, 2019. Main Outcomes and Measures: Descriptive statistics were used to report the frequency of experience of various types of biased patient behavior, residents' responses, the factors impeding residents' responses, and residents' experiences and beliefs regarding training and policies. Results: Overall, 232 of 331 residents (70%) participated; 116 (50%) were women; 116 of 247 (47%) were White (participants had the option of selecting >1 race/ethnicity); and 23 (10%) identified as lesbian, gay, bisexual, transgender, or queer. The frequency of resident-reported experience of types of biased patient behaviors varied. The most common behaviors-belittling comments and assumption of nonphysician status-were reported to be experienced 1 or more times per week by 14% of residents (32 of 231) and 17% of residents (38 of 230), respectively. Women, Black or Latinx, and Asian residents reported experiencing biased behavior more frequently. Forty-five percent of Black or Latinx residents (17 of 38) encountered instances of explicit epithets or rejection of care. All 70 Asian residents reported experiencing inquiries into their ethnic origins. Most women residents (110 of 115 [96%]) experienced role questioning behaviors, and 87% (100 of 115) experienced sexual harassment. The need to prioritize clinical care and a sense of futility in responding were the most common factors (cited by 34% of residents [76 of 227] and 25% of residents [56 of 227], respectively) significantly impeding responses to biased behaviors. Eighty-five percent of residents (191 of 226) never reported incidents to their institution. Eighty-nine percent of residents (206 of 232) identified training and policies as necessary or very necessary. Conclusions and Relevance: This survey study suggests that biased patient behavior is experienced frequently by internal medicine residents. Non-White and women residents reported experiencing a disproportionate burden of these incidents. Residents' responses rarely included institutional involvement. Residency programs and health care systems should prioritize training and policies to address biased patient behavior and support affected residents.

Semi-automated computer assessment of the degree of carotid artery stenosis compares favorably to visual evaluation.

OBJECTIVE: To validate a semi-automated computer approach for the assessment of the degree of carotid artery luminal narrowing by comparing it to the visual evaluation by a neuroradiologist. STUDY DESIGN AND MAIN OUTCOME MEASURES: In a retrospective cross-sectional study, consecutive emergency department patients who underwent computed tomography angiography (CTA) of the carotid arteries were identified. CTA studies were reviewed by a neuroradiologist, and also independently processed with a computer algorithm that automatically measures the degree of luminal narrowing at the level of the internal carotid artery bulb. The findings of the neuroradiologist and computer assessment were compared using Chi2 tests/kappa calculations and linear regression for categorical and continuous measurements of carotid stenosis, respectively. RESULTS: The study population consisted of 125 patients (74 no stroke/TIA, 18TIA, and 33 stroke). 201 carotid arteries showed no significant stenosis; 33 showed > or =70% stenosis, 5 showed 95-99% stenosis, and 11 showed complete occlusion. There was excellent agreement between the neuroradiologist's visual assessment and the automated computer evaluation of the category of carotid stenosis (kappa=0.918, p<0.001). CONCLUSION: The automated computer algorithm for quantifying the degree of carotid stenosis is reliable and shows high concordance with the interpretation of an experienced neuroradiologist.