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

Abstract

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.

Figure 1

Mean adjusted standardized core competency scores for underrepresented in medicine (URiM) and not underrepresented in medicine (non-URiM) residents in a study of the association between resident race/ethnicity and assessment scores, 2016–2017. Mean adjusted standardized scores, standard errors, and P values were obtained from cross-classified random-intercept mixed models adjusted for resident gender, postgraduate year, and baseline Internal Medicine In-Training Examination percentile rank; rotation time of year (July–September, October–December, January–March, April–June) and setting (university, Veterans Administration, community or public hospital); and faculty gender, academic rank (assistant professor/instructor/ chief resident, associate professor, professor, no rank/clinical associate), and specialty (general medicine, hospital medicine, subspecialty).

Figure 2

Mean adjusted standardized core competency scores by resident race/ethnicity in a study of the association between resident race/ethnicity and assessment scores, 2016–2017. Mean adjusted standardized scores, standard errors, and P values were obtained from cross-classified random-intercept mixed models adjusted for resident gender, postgraduate year, and baseline Internal Medicine In-Training Examination percentile rank; rotation time of year (July–September, October–December, January–March, April–June) and setting (university, Veterans Administration, community or public hospital); and faculty gender, academic rank (assistant professor/instructor/chief resident, associate professor, professor, no rank/clinical associate), and specialty (general medicine, hospital medicine, subspecialty). Abbreviations: URiM, underrepresented in medicine; non-URiM, not underrepresented in medicine.

Figure 3

Mean adjusted standardized core competency scores for underrepresented in medicine (URiM) and not underrepresented in medicine (non-URiM) residents by faculty gender in a study of the association between resident race/ethnicity and assessment scores, 2016–2017. Mean adjusted standardized scores, standard errors, and P values were obtained from cross-classified random-intercept mixed models adjusted for resident gender, postgraduate year, and baseline Internal Medicine In-Training Examination percentile rank; rotation time of year (July–September, October–December, January–March, April–June) and setting (university, Veterans Administration, community or public hospital); and faculty academic rank (assistant professor/instructor/chief resident, associate professor, professor, no rank/clinical associate) and specialty (general medicine, hospital medicine, subspecialty).