Race and Gender Bias in Clerkship Grading.

Phenomenon: Existing literature, as well as anecdotal evidence, suggests that tiered clinical grading systems may display systematic demographic biases. This study aimed to investigate these potential inequities in-depth. Specifically, this study attempted to address the following gaps in the literature: (1) studying grades actually assigned to students (as opposed to self-reported ones), (2) using longitudinal data over an 8-year period, providing stability of data, (3) analyzing three important, potentially confounding covariates, (4) using a comprehensive multivariate statistical design, and (5) investigating not just the main effects of gender and race, but also their potential interaction. Approach: Participants included 1,905 graduates (985 women, 51.7%) who received the Doctor of Medicine degree between 2014 and 2021. Most of the participants were white (n = 1,310, 68.8%) and about one-fifth were nonwhite (n = 397, 20.8%). There were no reported race data for 10.4% (n = 198). To explore potential differential grading, a two-way multivariate analysis of covariance was employed to examine the impact of race and gender on grades in eight required clerkships, adjusting for prior academic performance. Findings: There were two significant main effects, race and gender, but no interaction effect between gender and race. Women received higher grades on average on all eight clerkships, and white students received higher grades on average on four of the eight clerkships (Medicine, Pediatrics, Surgery, Obstetrics/Gynecology). These relationships held even when accounting for prior performance covariates. Insights: These findings provide additional evidence that tiered grading systems may be subject to systematic demographic biases. It is difficult to tease apart the contributions of various factors to the observed differences in gender and race on clerkship grades, and the interactions that produce these biases may be quite complex. The simplest solution to cut through the tangled web of grading biases may be to move away from a tiered grading system altogether.

Factors Associated With Health Care Professionals' Choice to Practice in Rural Minnesota.

Importance: Rural health inequities are due in part to a shortage of health care professionals in these areas. Objective: To determine the factors associated with health care professionals' decisions about where to practice. Design, Setting, and Participants: This prospective, cross-sectional survey study of health care professionals in Minnesota was administered by the Minnesota Department of Health from October 18, 2021, to July 25, 2022. Advanced practice registered nurses (APRNs), physicians, physician assistants (PAs), and registered nurses (RNs) renewing their professional licenses were eligible. Exposures: Individuals' ratings on survey items related to their choice of practice location. Main Outcomes and Measures: Rural or urban practice location as defined by the US Department of Agriculture's Rural-Urban Commuting Area typology. Results: A total of 32 086 respondents were included in the analysis (mean [SD] age, 44.4 [12.2] years; 22 728 identified as female [70.8%]). Response rates were 60.2% for APRNs (n = 2174), 97.7% for PAs (n = 2210), 95.1% for physicians (n = 11 019), and 61.6% for RNs (n = 16 663). The mean (SD) age of APRNs was 45.0 (10.3) years (1833 [84.3%] female); PAs, 39.0 (9.4) years (1648 [74.6%] female); physicians, 48.0 (11.9) years (4455 [40.4%] female); and RNs, 42.6 (12.3) years (14 792 [88.8%] female). Most respondents worked in urban (29 456 [91.8%]) vs rural (2630 [8.2%]) areas. Bivariate analysis suggested that family considerations are the most important determinant of practice location. Multivariate analysis revealed that having grown up in a rural area was the strongest factor associated with rural practice (odds ratio [OR] for APRNs, 3.44 [95% CI, 2.68-4.42]; OR for PAs, 3.75 [95% CI, 2.81-5.00]; OR for physicians, 2.44 [95% CI, 2.18-2.73]; OR for RNs, 3.77 [95% CI, 3.44-4.15]). When controlling for rural background, other associated factors included the availability of loan forgiveness (OR for APRNs, 1.42 [95% CI, 1.19-1.69]; OR for PAs, 1.60 [95% CI, 1.31-1.94]; OR for physicians, 1.54 [95% CI, 1.38-1.71]; OR for RNs, 1.20 [95% CI, 1.12-1.28]) and an educational program that prepared for rural practice (OR for APRNs, 1.44 [95% CI, 1.18-1.76]; OR for PAs. 1.70 [95% CI, 1.34-2.15]; OR for physicians, 1.31 [95% CI, 1.17-1.47]; OR for RNs, 1.23 [95% CI, 1.15-1.31]). Autonomy in one's work (OR for APRNs, 1.42 [95% CI, 1.08-1.86]; OR for PAs, 1.18 [95% CI, 0.89-1.58]; OR for physicians, 1.53 [95% CI, 1.31-1.78]; OR for RNs, 1.16 [95% CI, 1.07-1.25]) and a broad scope of practice (OR for APRNs, 1.46 [95% CI, 1.15-1.86]; OR for PAs, 0.96 [95% CI, 0.74-1.24]; OR for physicians, 1.62 [95% CI, 1.40-1.87]; OR for RNs, 0.96 [95% CI, 0.89-1.03]) were important factors associated with rural practice. Lifestyle and area considerations were not associated with rural practice; family considerations were associated with rural practice for RNs only (OR for APRNs, 0.97 [95% CI, 0.90-1.06]; OR for PAs, 0.95 [95% CI, 0.87-1.04]; OR for physicians, 0.92 [95% CI, 0.88-0.96]; OR for RNs, 1.05 [95% CI, 1.02-1.07]). Conclusions and Relevance: Understanding the interconnected factors involved in rural practice requires modeling relevant factors. The findings of this survey study suggest that loan forgiveness, rural training, autonomy, and a broad scope of practice are factors associated with rural practice for most health care professionals. Other factors associated with rural practice vary by profession, suggesting that there may not be a one-size-fits-all approach to recruitment of rural health care professionals.

Does an endocrinology subspecialty residency rotation enhance resident endocrine clinical knowledge?

BACKGROUND: Internal Medicine (IM) programs offer elective subspecialty rotations in which residents may enroll to supplement the experience and knowledge obtained during general inpatient and outpatient rotations. Objective evidence that these rotations provide enhanced subspecialty specific knowledge is lacking. The purpose of this study was to determine whether exposure to an endocrinology subspecialty rotation enhanced a resident's endocrinology-specific knowledge beyond that otherwise acquired during IM residency. METHODS: Data were collected on internal medicine resident scores on the American College of Physicians Internal Medicine In-Training Examinations (IM-ITE) for calendar years 2012 through 2018 along with enrollment data as to whether residents had completed an endocrinology subspecialty rotation prior to sitting for a given IM-ITE. Three hundred and six internal medicine residents in the University of Minnesota Internal Medicine residency program with 664 scores total on the IM-ITE for calendar years 2012 through 2018. Percentage of correct answers on the overall and endocrine subspecialty content areas on the IM-ITE for each exam were determined and the association between prior exposure to an endocrinology subspecialty rotation and percentage of correct answers in the endocrinology content area was analyzed using generalized linear mixed-effects models. RESULTS: Two hundred and thirty-three residents (76%) completed an endocrinology subspecialty rotation at some point during their residency; 121 (40%) residents had at least one IM-ITE both before and after exposure to an endocrine subspecialty rotation. Exposure to an endocrinology subspecialty rotation exhibited a positive association with the expected IM-ITE percent correct on the endocrinology content area (5.5% predicted absolute increase). Advancing year of residency was associated with a predicted increase in overall IM-ITE score but did not improve the predictive model for endocrine subspecialty score. CONCLUSIONS: Completion of an endocrinology subspecialty elective was associated with an increase in resident endocrine specific knowledge as assessed by the IM-ITE. These findings support the value of subspecialty rotations in enhancing a resident's subspecialty specific medical knowledge.

Impact of the Rural Physician Associate Program on Workforce Outcomes.

BACKGROUND AND OBJECTIVES: The Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School (UMMS) is a 9-month rural longitudinal integrated clerkship (LIC) for third-year medical students built on a foundation of family medicine. The purpose of this study was to examine the relationships between participation in the RPAP program and the desired workforce outcomes of practice in Minnesota, primary care specialty (particularly family medicine), and rural practice. METHODS: We analyzed workforce outcomes for UMMS graduates who completed postgraduate training between 1975 and 2017, comparing RPAP participants (n=1,217) to noparticipants (n=7,928). We identified graduates through internal UMMS databases linked to the American Medical Association (AMA) Physician Masterfile and the National Provider Identifier (NPI) registry. We identified workforce outcomes of rural practice, practice in Minnesota, primary care specialty, and family medicine specialty based on practice specialty and practice location data available through the AMA and NPI data sets. RESULTS: Proportionally, more RPAP graduates practice in state (65.7% vs 54.4%, P<.01), in primary care (69.0% vs 33.4%, P<.01), in family medicine (61.1% vs 17.3%, P<.01), and rurally (41.2% vs 13.9%, P<.01) than non-RPAP graduates. CONCLUSIONS: We demonstrate a significant association between participation in RPAP and a career in family medicine, rural practice, and primary care, all outcomes that promote meeting urgent rural workforce needs.

A Study of the Validity of the New MCAT Exam.

PURPOSE: To conduct a study of the validity of the new Medical College Admission Test (MCAT). METHOD: Deidentified data for first- and second-year medical students (185 women, 54.3%; 156 men, 45.7%) who matriculated in 2016 and 2017 to the University of Minnesota Medical School-Twin Cities were included. Of those students, 220 (64.5%) had taken the new MCAT exam and 182 (53.4%) had taken the old MCAT exam (61 [17.9%] had taken both). The authors calculated descriptive statistics and Pearson product moment correlations (r) between new and old MCAT section scores. They conducteda regression analysis of MCAT section scores with Step 1 scores and with preclerkship course performance. They also conducted an exploratory factor analysis (principal component analysis with varimax rotation) of MCAT scores, undergraduate grade point average, Step 1 scores, and course performance. RESULTS: The new MCAT exam section mean score percentiles ranged from 72 to 78 (mean composite score percentile of 80). The old MCAT exam section mean score percentiles ranged from 84 to 88 (mean composite score percentile of 83). The pattern of correlations among and between new and old MCAT exam section scores (range of r: 0.03-0.67; P < .01) provided evidence of both divergent and convergent validities. Backward multiple regression of new MCAT exam section scores and Step 1 scores resulted in a multiple R of .440; the same analysis with Human Behavior course performance as the dependent variable provided a similar solution with the expected sections of the new MCAT exam (multiple R = .502). The factor analysis resulted in 4 cohesive, theoretically meaningful factors: biomedical knowledge, basic science concepts, cognitive reasoning, and general achievement. CONCLUSIONS: This study provided empirical evidence of multiple types of validity for the new MCAT exam.

Building a Medical Education Outcomes Center: Development Study.

BACKGROUND: Medical education outcomes and clinical data exist in multiple unconnected databases, resulting in 3 problems: (1) it is difficult to connect learner outcomes with patient outcomes, (2) learners cannot be easily tracked over time through the education-training-practice continuum, and (3) no standard methodology ensures quality and privacy of the data. OBJECTIVE: The purpose of this study was to develop a Medical Education Outcomes Center (MEOC) to integrate education data and to build a framework to standardize the intake and processing of requests for using these data. METHODS: An inventory of over 100 data sources owned or utilized by the medical school was conducted, and nearly 2 dozen of these data sources have been vetted and integrated into the MEOC. In addition, the American Medical Association (AMA) Physician Masterfile data of the University of Minnesota Medical School (UMMS) graduates were linked to the data from the National Provider Identifier (NPI) registry to develop a mechanism to connect alumni practice data to education data. RESULTS: Over 160 data requests have been fulfilled, culminating in a range of outcomes analyses, including support of accreditation efforts. The MEOC received data on 13,092 UMMS graduates in the AMA Physician Masterfile and could link 10,443 with NPI numbers and began to explore their practice demographics. The technical and operational work to expand the MEOC continues. Next steps are to link the educational data to the clinical practice data through NPI numbers to assess the effectiveness of our medical education programs by the clinical outcomes of our graduates. CONCLUSIONS: The MEOC provides a replicable framework to allow other schools to more effectively operate their programs and drive innovation.

Treating and teaching: using publicly available data to explore the relationship between student and patient evaluations of teaching hospitals.

Introduction: Treating patients and teaching medical students are parallel activities that occur at teaching hospitals. However, the relationship between these activities is poorly understood. There have been multiple calls for assessing the quality of medical education by examining publicly available clinical data but there is minimal evidence linking these variables. Method: In this proof-of-principle study, the authors examined publicly available Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS)Ⓡ data collected during Calendar Year 2013 to explore the relationship between patient evaluations of their hospital experience and medical student evaluations of the educational experience at that site. Results: Pearson product-moment correlation coefficients were calculated for multiple variables. Patient ratings of doctor-patient communication correlated with student ratings of organization (R=0.882, p=0.048), educational value (R=0.882, p=0.048), teaching (R=0.963, p=0.008), and evaluation and feedback (R=0.920, p=0.027). Conclusion: These findings provide preliminary evidence for a relationship between patient experiences and the quality of education at that site. Further studies linking clinical and education outcomes are needed to explore this relationship in more depth. The contributions of specific hospital locations, providers, or clerkships need to be evaluated. Studies examining these relationships have the potential to improve both patient care and medical education.

The association between United States Medical Licensing Examination scores and clinical performance in medical students.

Purpose: United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) scores are frequently used to evaluate applicants to residency programs. Recent literature questions the value of USMLE scores for evaluation of residency applicants, in part due to a lack of evidence supporting a relationship with clinical performance. This study explored the relationship between USMLE scores and medical students' clinical performance, as measured by the count of honors grades received in core clinical clerkships. Methods: USMLE Step 1 and Step 2 CK scores and number of honors grades per student in seven core clinical clerkships were obtained from 1,511 medical students who graduated in 2013-2017 from two medical schools. The relationships between variables were analyzed using correlation coefficients, independent-samples t-tests, and hierarchical multiple regression. Results: Count of honors grades correlated with both Step 1 (R=0.480, P<0.001) and Step 2 CK (R=0.542, P<0.001). After correcting for gender, institution, and test-taking ability (using MCAT scores as a proxy for test-taking ability) in a hierarchical multiple regression model, Step 1 and Step 2 CK scores together explained 22.2% of the variance in count of honors grades. Conclusion: USMLE Step 1 and Step 2 CK scores moderately correlate with the number of honors grades per student in core clinical clerkships. This relationship is maintained even after correcting for gender, institution, and test-taking ability. These results indicate that USMLE scores have a positive linear association with clinical performance as a medical student.

Relationships of demographic variables to USMLE physician licensing exam scores: a statistical analysis on five years of medical student data.

INTRODUCTION: The purpose of this study was to determine the associations of the demographic variables of gender, state of legal residency, student age, and undergraduate major with scores on the Medical College Admissions Test (MCAT) and the United States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge. METHODS: The researchers collected and analyzed exam scores and demographic student data from participants of five graduating classes of students at the University of Minnesota Medical School (N = 1,067). RESULTS: Significant differences (p < 0.05) were found for traditional-aged (defined as < 25 years old at matriculation) versus nontraditional-aged students on USMLE Step 1 scores (t[1065] = 2.91, p = 0.004) and USMLE Step 2 scores (t[1061] = 4.39, p < 0.001), both in favor of traditional-aged students. Significant differences were found for males versus females on MCAT Composite scores (t[1063] = 6.53, p < 0.001) and USMLE Step 1 scores (t[1065] = 5.14, p < 0.001), both in favor of males. There were no significant differences between science and nonscience majors or between Minnesota legal residents and nonresidents. CONCLUSION: Traditional age and male gender were associated with higher exam scores, although patterns differed between tests, whereas undergraduate major and state of legal residency were not associated with higher exam scores.

Association between the Medical College Admission Test scores and Alpha Omega Alpha Medical Honors Society membership.

INTRODUCTION: Medical schools worldwide are faced with the challenge of selecting from among many qualified applicants. One factor that might help admissions committees identify future exceptional medical students is scores on standardized entrance exams. The purpose of this study was to determine the association between scores on the most commonly used standardized medical school entrance exam in the USA, the Medical College Admission Test (MCAT), and election to the US medical honors society, Alpha Omega Alpha (AOA). METHOD: MCAT scores and AOA membership data were analyzed for all the students pursuing Doctor of Medicine degrees at the University of Minnesota Medical School and who graduated between 2012-2016 (n=1,309). RESULTS: An independent-samples t-test found a significant difference (t=6.132, p<0.001) in MCAT scores between those who were elected to AOA (n=179) and those who were not (n=1,130). On average, students who were elected to AOA had composite MCAT scores of 1.65 points higher than those who were not. Percentages of students elected to AOA gradually but inconsistently increased with MCAT score. No student who scored <27 on the MCAT was elected to AOA. Among students with MCAT scores at the 99th percentile or above (scores of ≥38), 13 of 48 (27.1%) were elected to AOA. DISCUSSION: Election to AOA during medical school was significantly associated with higher MCAT scores. Admissions committees should carefully consider the role of standardized entrance exam scores, in the context of a holistic review, when selecting for exceptional medical students.

The association of USMLE Step 1 and Step 2 CK scores with residency match specialty and location.

BACKGROUND: For future physicians, residency programs offer necessary extended training in specific medical specialties. Medical schools benefit from an understanding of factors that lead their students to match into certain residency specialties. One such factor, often used during the residency application process, is scores on the USA Medical Licensing Exam (USMLE). OBJECTIVES: To determine the relationship between USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores and students' residency specialty match, and the association between both USMLE scores and state of legal residency (Minnesota) at the time of admission with students staying in-state or leaving the state for residency program. DESIGN: USMLE scores and residency match data were analyzed from five graduating classes of students at the University of Minnesota Medical School (N = 1054). RESULTS: A MANOVA found significant differences (p < 0.001) between residency specialties and both USMLE Step 1 and Step 2 CK scores, as well as the combination of the two. Students who matched in Dermatology had the highest mean USMLE scores overall, while students who matched in Family Medicine had the lowest mean scores. Students who went out of state for residency had significantly higher Step 1 scores (p = 0.027) than students who stayed in-state for residency, while there was no significant difference between the groups for Step 2 scores. A significant positive association was found between a student who applied as a legal resident of Minnesota and whether the student stayed in Minnesota for their residency program. CONCLUSIONS: Residency specialty match was significantly associated with USMLE Step 1 and USMLE Step 2 CK scores, as was staying in-state or leaving the state for residency. Students who were legal residents of the state at the time of application were more likely to stay in-state for residency, regardless of USMLE score. ABBREVIATIONS: CK: Clinical knowledge; COMLEX: Comprehensive Osteopathic Medical Licensing Examination; GME: Graduate medical education; NRMP: National Resident Matching Program; UME: Undergraduate medical education; USMLE: United States Medical Licensing Examination.

Do MCAT scores predict USMLE scores? An analysis on 5 years of medical student data.

INTRODUCTION: The purpose of this study was to determine the associations and predictive values of Medical College Admission Test (MCAT) component and composite scores prior to 2015 with U.S. Medical Licensure Exam (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) scores, with a focus on whether students scoring low on the MCAT were particularly likely to continue to score low on the USMLE exams. METHOD: Multiple linear regression, correlation, and chi-square analyses were performed to determine the relationship between MCAT component and composite scores and USMLE Step 1 and Step 2 CK scores from five graduating classes (2011-2015) at the University of Minnesota Medical School (N=1,065). RESULTS: The multiple linear regression analyses were both significant (p<0.001). The three MCAT component scores together explained 17.7% of the variance in Step 1 scores (p<0.001) and 12.0% of the variance in Step 2 CK scores (p<0.001). In the chi-square analyses, significant, albeit weak associations were observed between almost all MCAT component scores and USMLE scores (Cramer's V ranged from 0.05 to 0.24). DISCUSSION: Each of the MCAT component scores was significantly associated with USMLE Step 1 and Step 2 CK scores, although the effect size was small. Being in the top or bottom scoring range of the MCAT exam was predictive of being in the top or bottom scoring range of the USMLE exams, although the strengths of the associations were weak to moderate. These results indicate that MCAT scores are predictive of student performance on the USMLE exams, but, given the small effect sizes, should be considered as part of the holistic view of the student.

Gestalt principle use in college students, children with autism, toddlers (Homo sapiens), and cotton top tamarins (Saguinus oedipus).

The use of Gestalt principles of proximity, similarity, and closure to recognize objects by configural superiority was examined in college students, low- and high-functioning children with autism, toddlers, and adult cotton top tamarin monkeys. At issue was whether the monkeys showed differences from humans in perceptual processing and whether they showed any similarities with clinical or developmental groups. The method required a pointing response to discriminate an odd item in a 4-item visual display. All subjects were trained to a high accuracy to point to the odd item before being tested with graphic stimuli that differentiated feature changes based on configural superiority. The results were that college students and high-functioning children with autism responded faster and more accurately to trials in which the odd item was easily noticed by the use of Gestalt principles and configural superiority. Toddlers also responded more accurately to the Gestalt trials, but without being faster at making the response. Low-functioning children with autism and tamarins showed no advantage to Gestalt trials but exhibited different processing styles. The implications of these findings to track the evolution of human perception and to develop a primate model for the perceptual deficits of autism are discussed.