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Dussault N, Nickolopoulos E, Henderson K, Hemming P, Cho A, Ma JE. Internal Medicine Resident Barriers to Advance Care Planning in the Primary Care Continuity Clinic. Am J Hosp Palliat Care 2023; 40:1205-1211. [PMID: 36722713 DOI: 10.1177/10499091231154606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background: While primary care providers regularly engage in Advance Care Planning (ACP) conversations, it is not well known what challenges resident physicians face to achieving this core competency. Objectives: We aimed to assess resident perceptions of barriers and potential interventions to outpatient ACP. Methods: We distributed an electronic survey to Internal Medicine and Medicine-Psychiatry residents at our institution in 2022. Questions addressed outpatient ACP barriers and potential interventions in several domains: structural issues, personal knowledge, and communication skills. We reported results using descriptive statistics and Wilcoxon rank-sum tests, comparing responses by residency year (interns vs upperyears). Likert-scale responses were dichotomized to a "not at all or slightly" vs "moderate or extreme" barrier or helpful intervention. Results: Of 149 residents, 71 completed the survey (48%). Highest scoring barriers were structural, including 1) lack of clinic time (99%), 2) need to prioritize other medical problems (94%), and 3) lack of patient continuity (62%). Highest scoring interventions included the ability to schedule dedicated ACP visits with themselves (96%) or another clinician (82%). Interns were statistically significantly less confident in their ability to conduct ACP, and more likely to report lack of knowledge (i.e., not understanding ACP, patient prognosis, or how to complete paperwork, P < .05). Conclusions: Residents report significant structural barriers to outpatient ACP, including limitations in time, continuity, and competing medical priorities, that may warrant greater program attention to interventions such as clinic schedules and work-flow. Additional trainings may be most beneficial if targeted to the beginning of intern year.
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Affiliation(s)
- Nicole Dussault
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Elissa Nickolopoulos
- Division of Clinical Social Work, Department of Case Management, Duke University Health System, Durham, NC, USA
| | - Katherine Henderson
- Department of Chaplain Services and Education, Duke University Health System, Durham, NC, USA
| | - Patrick Hemming
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Alex Cho
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jessica E Ma
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research Education and Clinical Center, Durham VA Health System, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Huh DD, Yamazaki K, Holmboe E, Bartley GB, Schnabel SD, Levine RB, Srikumaran D. Gender Bias and Ophthalmology Accreditation Council for Graduate Medical Education Milestones Evaluations. JAMA Ophthalmol 2023; 141:982-988. [PMID: 37707837 PMCID: PMC10502694 DOI: 10.1001/jamaophthalmol.2023.4138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/24/2023] [Indexed: 09/15/2023]
Abstract
Importance Women remain underrepresented in ophthalmology and gender-based disparities exist in salary, grant receipt, publication rates, and surgical volume throughout training and in practice. Although studies in emergency medicine and general surgery showed mixed findings regarding gender differences in Accreditation Council for Graduate Medical Education (ACGME) Milestones ratings, limited data exist examining such differences within ophthalmology. Objective To examine gender differences in ophthalmology ACGME Milestones. Design, Setting, and Participants This was a retrospective cross-sectional study of postgraduate year 4 (PGY-4) residents from 120 ophthalmology programs graduating in 2019. Main Outcomes and Measures PGY-4 midyear and year-end medical knowledge (MK) and patient care (PC) ratings and Written Qualifying Examination (WQE) scaled scores for residents graduating in 2019 were included. Differential prediction techniques using Generalized Estimating Equations models were performed to identify differences by gender. Results Of 452 residents (median [IQR] age, 30.0 [29.0-32.0] years), 275 (61%) identified as men and 177 (39%) as women. There were no differences in PC domain average between women and men for both midyear (-0.07; 95% CI, -0.11 to 0; P =.06) and year-end (-0.04; 95% CI, -0.07 to 0.03; P =.51) assessment periods. For the MK domain average in the midyear assessment period, women (mean [SD], 3.76 [0.50]) were rated lower than men (mean [SD], 3.88 [0.47]; P = .006) with a difference in mean of -0.12 (95% CI, -0.18 to -0.03). For the year-end assessment, however, the average MK ratings were not different for women (mean [SD], 4.10 [0.47]) compared with men (mean [SD], 4.18 [0.47]; P = .20) with a difference in mean of -0.08 (95% CI, -0.13 to 0.03). Conclusions and Relevance Results suggest that ACGME ophthalmology Milestones in 2 general competencies did not demonstrate major gender bias on a national level at the time of graduation. There were, however, differences in MK ratings at the midyear mark, and as low ratings on evaluations and examinations may adversely affect career opportunities for trainees, it is important to continue further work examining other competencies or performance measures for potential biases.
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Affiliation(s)
- Dana D. Huh
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kenji Yamazaki
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Eric Holmboe
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - George B. Bartley
- American Board of Ophthalmology, Doylestown, Pennsylvania
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | | | - Rachel B. Levine
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Divya Srikumaran
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Lett E, Tran NK, Nweke N, Nguyen M, Kim JG, Holmboe E, McDade W, Boatright D. Intersectional Disparities in Emergency Medicine Residents' Performance Assessments by Race, Ethnicity, and Sex. JAMA Netw Open 2023; 6:e2330847. [PMID: 37733347 PMCID: PMC10514741 DOI: 10.1001/jamanetworkopen.2023.30847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/19/2023] [Indexed: 09/22/2023] Open
Abstract
Importance Previous studies have demonstrated sex-specific disparities in performance assessments among emergency medicine (EM) residents. However, less work has focused on intersectional disparities by ethnoracial identity and sex in resident performance assessments. Objective To estimate intersectional sex-specific ethnoracial disparities in standardized EM resident assessments. Design, Setting, and Participants This retrospective cohort study used data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education Milestones (Milestones) assessments to evaluate ratings for EM residents at 128 EM training programs in the US. Statistical analyses were conducted in June 2020 to January 2023. Exposure Training and assessment environments in EM residency programs across comparison groups defined by ethnoracial identity (Asian, White, or groups underrepresented in medicine [URM], ie, African American/Black, American Indian/Alaska Native, Hispanic/Latine, and Native Hawaiian/Other Pacific Islander) and sex (female/male). Main Outcomes and Measures Mean Milestone scores (scale, 0-9) across 6 core competency domains: interpersonal and communications skills, medical knowledge, patient care, practice-based learning and improvement, professionalism, and system-based practice. Overall assessment scores were calculated as the mean of the 6 competency scores. Results The study sample comprised 128 ACGME-accredited programs and 16 634 assessments for 2708 EM residents of which 1913 (70.6%) were in 3-year and 795 (29.4%) in 4-year programs. Most of the residents were White (n = 2012; 74.3%), followed by Asian (n = 477; 17.6%), Hispanic or Latine (n = 213; 7.9%), African American or Black (n = 160; 5.9%), American Indian or Alaska Native (n = 24; 0.9%), and Native Hawaiian or Other Pacific Islander (n = 4; 0.1%). Approximately 14.3% (n = 386) and 34.6% (n = 936) were of URM groups and female, respectively. Compared with White male residents, URM female residents in 3-year programs were rated increasingly lower in the medical knowledge (URM female score, -0.47; 95% CI, -0.77 to -0.17), patient care (-0.18; 95% CI, -0.35 to -0.01), and practice-based learning and improvement (-0.37; 95% CI, -0.65 to -0.09) domains by postgraduate year 3 year-end assessment; URM female residents in 4-year programs were also rated lower in all 6 competencies over the assessment period. Conclusions and Relevance This retrospective cohort study found that URM female residents were consistently rated lower than White male residents on Milestone assessments, findings that may reflect intersectional discrimination in physician competency evaluation. Eliminating sex-specific ethnoracial disparities in resident assessments may contribute to equitable health care by removing barriers to retention and promotion of underrepresented and minoritized trainees and facilitating diversity and representation among the emergency physician workforce.
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Affiliation(s)
- Elle Lett
- Health Systems and Population Health, University of Washington School of Public Health, Seattle
- Center for Anti-Racism and Community Health, University of Washington School of Public Health, Seattle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nguyen Khai Tran
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Palo Alto, California
| | - Nkemjika Nweke
- St George’s University School of Medicine, St George, Grenada
| | | | - Jung G. Kim
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Eric Holmboe
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - William McDade
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Dowin Boatright
- Ronald O. Perelman Department of Emergency Medicine, New York University, New York
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Hauer KE, Park YS, Bullock JL, Tekian A. "My Assessments Are Biased!" Measurement and Sociocultural Approaches to Achieve Fairness in Assessment in Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S16-S27. [PMID: 37094278 DOI: 10.1097/acm.0000000000005245] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Assessing learners is foundational to their training and developmental growth throughout the medical education continuum. However, growing evidence shows the prevalence and impact of harmful bias in assessments in medical education, accelerating the urgency to identify solutions. Assessment bias presents a critical problem for all stages of learning and the broader educational system. Bias poses significant challenges to learners, disrupts the learning environment, and threatens the pathway and transition of learners into health professionals. While the topic of assessment bias has been examined within the context of measurement literature, limited guidance and solutions exist for learners in medical education, particularly in the clinical environment. This article presents an overview of assessment bias, focusing on clinical learners. A definition of bias and its manifestations in assessments are presented. Consequences of assessment bias are discussed within the contexts of validity and fairness and their impact on learners, patients/caregivers, and the broader field of medicine. Messick's unified validity framework is used to contextualize assessment bias; in addition, perspectives from sociocultural contexts are incorporated into the discussion to elaborate the nuanced implications in the clinical training environment. Discussions of these topics are conceptualized within the literature and the interventions used to date. The article concludes with practical recommendations to overcome bias and to develop an ideal assessment system. Recommendations address articulating values to guide assessment, designing assessment to foster learning and outcomes, attending to assessment procedures, promoting continuous quality improvement of assessment, and fostering equitable learning and assessment environments.
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Affiliation(s)
- Karen E Hauer
- K.E. Hauer is associate dean for competency assessment and professional standards, and professor, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0002-8812-4045
| | - Yoon Soo Park
- Y.S. Park is associate professor and associate head, Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, Illinois; ORCID: http://orcid.org/0000-0001-8583-4335
| | - Justin L Bullock
- J.L. Bullock is a fellow, Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Seattle, Washington; ORCID: http://orcid.org/0000-0003-4240-9798
| | - Ara Tekian
- A. Tekian is professor and associate dean for international education, Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, Illinois; ORCID: http://orcid.org/0000-0002-9252-1588
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Klein R, Koch J, Snyder ED, Volerman A, Simon W, Jassal SK, Cosco D, Cioletti A, Ufere NN, Burnett-Bowie SAM, Palamara K, Schaeffer S, Julian KA, Thompson V. Association of Gender and Race/Ethnicity with Internal Medicine In-Training Examination Performance in Graduate Medical Education. J Gen Intern Med 2022; 37:2194-2199. [PMID: 35710653 PMCID: PMC9296734 DOI: 10.1007/s11606-022-07597-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/30/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Robin Klein
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Emory University School of Medicine, 49 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA.
| | - Jennifer Koch
- Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Erin D Snyder
- Department of Medicine, University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Anna Volerman
- Departments of Medicine and Pediatrics, University of Chicago, Chicago, IL, USA
| | - Wendy Simon
- Department of Medicine, University of California, Los Angeles, Los Angeles, USA
| | - Simerjot K Jassal
- Department of Medicine, VA San Diego Healthcare System, University of California, San Diego, San Diego, USA
| | - Dominique Cosco
- Department of Medicine, Washington University St. Louis, St. Louis, USA
| | - Anne Cioletti
- Department of Medicine, University of Utah, Salt Lake City, USA
| | - Nneka N Ufere
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kerri Palamara
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah Schaeffer
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Katherine A Julian
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Vanessa Thompson
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Andrews J, Chartash D, Hay S. Gender bias in resident evaluations: Natural language processing and competency evaluation. MEDICAL EDUCATION 2021; 55:1383-1387. [PMID: 34224606 DOI: 10.1111/medu.14593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Research shows that female trainees experience evaluation penalties for gender non-conforming behaviour during medical training. Studies of medical education evaluations and performance scores do reflect a gender bias, though studies are of varying methodology and results have not been consistent. OBJECTIVE We sought to examine the differences in word use, competency themes and length within written evaluations of internal medicine residents at scale, considering the impact of both faculty and resident gender. We hypothesised that female internal medicine residents receive more negative feedback, and different thematic feedback than male residents. METHODS This study utilised a corpus of 3864 individual responses to positive and negative questions over the course of six years (2012-2018) within Yale University School of Medicine's internal medicine residency. Researchers developed a sentiment model to assess the valence of evaluation responses. We then used natural language processing (NLP) to evaluate whether female versus male residents received more positive or negative feedback and if that feedback focussed on different Accreditation Council for Graduate Medical Education (ACGME) core competencies based on their gender. Evaluator-evaluatee gender dyad was analysed to see how it impacted quantity and quality of feedback. RESULTS We found that female and male residents did not have substantively different numbers of positive or negative comments. While certain competencies were discussed more than others, gender did not seem to influence which competencies were discussed. Neither gender trainee received more written feedback, though female evaluators tended to write longer evaluations. CONCLUSIONS We conclude that when examined at scale, quantitative gender differences are not as prevalent as has been seen in qualitative work. We suggest that further investigation of linguistic phenomena (such as context) is warranted to reconcile this finding with prior work.
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Affiliation(s)
- Jane Andrews
- Department of Internal Medicine, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX, USA
| | - David Chartash
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, USA
| | - Seonaid Hay
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Weber DE, Kinnear B, Kelleher M, Klein M, Sall D, Schumacher DJ, Zhang N, Warm E, Schauer DP. Effect of resident and assessor gender on entrustment-based observational assessment in an internal medicine residency program. MEDEDPUBLISH 2021. [DOI: 10.12688/mep.17410.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Implicit gender bias leads to differences in assessment. Studies examining gender differences in resident milestone assessment data demonstrate variable results. The purpose of this study was to determine if observational entrustment scores differ by resident and assessor gender in a program of assessment based on discrete, observable skills. Methods: We analyzed overall entrustment scores and entrustment scores by Accreditation Council for Graduate Medical Education (ACGME) core competency for 238 residents (49% female) from 396 assessors (38% female) in one internal medicine residency program from July 2012 to June 2019. We conducted analyses at 1-12 months, 1-36 months, 1-6 months, 7-12 months, and 31-36 months. We used linear mixed-effect models to assess the role of resident and assessor gender, with resident-specific and assessor-specific random effect to account for repeated measures. Results: Statistically significant interactions existed between resident and assessor gender for overall entrustment at 1-12 months (p < 0.001), 1-36 months (p< 0.001), 1-6 months (p<0.001), 7-12 months (p=0.04), and 31-36 months (p<0.001). However, group differences were not statistically significant. In several instances an interaction was significant between resident and assessor gender by ACGME core competency, but there were no statistically significant group differences for all competencies at any time point. When applicable, subsequent analysis of main effect of resident or assessor gender independently of one another revealed no statistically significant differences. Conclusions: No significant differences in entrustment scores were found based on resident or assessor gender in our large, robust entrustment-based program of assessment. Determining the reasons for our findings may help identify ways to mitigate gender bias in assessment.
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