Influence of Race, Ethnicity, and Gender on Clinical Performance Assessments in Graduate Medical Education

Evidence suggests disparities associated with race and ethnicity (R&E) in assessment in graduate medical education (GME). How these disparities manifest across competencies and training time and intersect with disparities associated with other factors such as gender is unclear.

Examine the association of R&E and gender with clinical performance assessment in GME.

Longitudinal analysis of resident clinical performance assessments.

Assessment data of residents at seven internal medicine (IM) residency programs, 2014 to 2019 (9346 evaluations of 664 residents). Residents underrepresented in medicine (URiM) were identified using self-reported R&E.

Standardized scores were calculated for the Accreditation Council for Graduate Medical Education competencies (patient care [PC], medical knowledge [MK], practice-based learning and improvement [PBLI], systems-based practice [SBP], professionalism [PROF], and interpersonal communication and skills [ICS]). Cross-classified mixed effects regression assessed differences in standardized competency ratings with R&E over time and the interaction of R&E and gender while controlling for time of year and setting; resident gender, post-graduate year (PGY), and IM in-training examination percentile rank; and faculty gender, educational role, specialty, rank, and years of experience.

URiM resident scores were lower than non-URIM residents across competencies (difference in standardized scores between URiM and non-URiM residents [se] PC - 0.126 [0.035], p < 0.001; MK - 0.118 [0.035], p < 0.001; PBLI - 0.122 [0.042], p = 0.004; SBP - 0.128 [0.034], p < 0.001; PROF - 0.075 [0.036], p = 0.036; ICS - 0.124 [0.039], p = 0.002). The interaction between resident R&E, gender, and PGY was significant in PBLI (estimate - 0.15 [0.06], p = 0.02) and SBP (- 0.11 [0.05], p = 0.04) indicating smaller gains over time for URiM women.

There were significant differences associated with R&E with lower scores for URiM residents across competencies. There was a significant interaction with resident gender and R&E over time in PBLI and SBP. Findings may reflect bias in faculty assessment, effects of non-inclusive learning environments, or structural inequities in assessment.