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.

Gender Representation Matters: Intervention to Solicit Medical Resident Input to Enable Equity in Leadership in Graduate Medical Education.

PROBLEM: Gender equity in leadership across academic medicine remains a concern. The case of chief resident (CR) offers an opportunity to explore novel strategies in leadership selection in graduate medical education (GME). Means of identifying potential candidates for CR often rely on faculty assessment of resident performance, yet implicit gender bias has the potential to influence this assessment. APPROACH: To diversify the metrics used in CR selection, an intervention was implemented to solicit resident input to identify candidates for CR at 2 U.S. internal medicine residency programs in 2018 and 2019. This involved a simple, cross-sectional survey of residents in which they were asked to identify individual residents as good candidates for consideration for CR. OUTCOMES: There were 298 of 518 internal medicine resident responses to this intervention across sites and years (mean 58.2% response rate). Nomination patterns of residents and program leaders correlated significantly (correlation coefficient 0.62, P < .001). Controlling for site and year, gender was a significant factor associated with who residents nominated for CR (ß-coefficient 0.325, P = .004) with women residents more likely to identify women for CR (odds ratio 1.38, 95% confidence interval 1.11-1.73). Fifty residents nominated themselves for CR, and there was no significant difference by gender (ß-coefficient 0.038, P = .91). NEXT STEPS: Soliciting resident input to identify candidates for CR may enable gender representation of candidates for this position. Influencing candidate choices may be a promising way to impact leadership selection in medicine.

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.

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.

Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review.

BACKGROUND: Case management (CM) is a commonly cited intervention aimed at reducing Emergency Department (ED) utilization by "frequent users," a group of patients that utilize the ED at disproportionately high rates. Studies have investigated the impact of CM on a variety of outcomes in this patient population. OBJECTIVES: We sought to examine the evidence of the effectiveness of the CM model in the frequent ED user patient population. We reviewed the available literature focusing on the impact of CM interventions on ED utilization, cost, disposition, and psychosocial variables in frequent ED users. DISCUSSION: Although there was heterogeneity across the 12 studies investigating the impact of CM interventions on frequent users of the ED, the majority of available evidence shows a benefit to CM interventions. Reductions in ED visitation and ED costs are supported with the strongest evidence. CONCLUSION: CM interventions can improve both clinical and social outcomes among frequent ED users.