Longitudinal comparison of the academic performances of Asian-American and white medical students

Ethnic minority GP trainees at risk for underperformance assessments: a quantitative cohort study

BACKGROUND

Recent studies suggest that ethnic minority students underperform in standardised assessments commonly used to evaluate their progress. This disparity seems to also hold for postgraduate medical students and GP trainees, and may affect the quality of primary health care, which requires an optimally diverse workforce.

AIMS

To address the following: 1) to determine to what extent ethnic minority GP trainees are more at risk of being assessed as underperforming than their majority peers; 2) to investigate whether established underperformance appears in specific competence areas; and 3) to explore first- and second-generation ethnic minority trainees' deviations.

DESIGN & SETTING

Quantitative retrospective cohort design in Dutch GP specialty training (start years: 2015-2017).

METHOD

In 2020-2021, the authors evaluated files on assessed underperformance of 1700 GP trainees at seven Dutch GP specialty training institutes after excluding five opt-outs and 165 incomplete datasets (17.4% ethnic minority trainees). Underperformance was defined as the occurrence of the following, which was prompted by the training institute: 1) preliminary dropout; 2) extension of the educational pathway; and/or 3) mandatory coaching pathways. Statistics Netherlands (CBS) anonymised the files and added data about ethnic group. Thereafter, the authors performed logistic regression for potential underperformance analysis and χ² tests for competence area analysis.

RESULTS

Ethnic minority GP trainees were more likely to face underperformance assessments than the majority group (odds ratio [OR] 2.41, 95% confidence interval [CI] = 1.67 to 3.49). Underperformance was not significantly nested in particular competence areas. First-generation ethnic minority trainees seemed more at risk than their second-generation peers.

CONCLUSION

Ethnic minority GP trainees seem more at risk of facing educational barriers than the majority group. Additional qualitative research on underlying factors is essential.

Preparing for the MD: How Long, at What Cost, and With What Outcomes?

PURPOSE

To assess educational and professional outcomes of an accelerated combined bachelor of science-doctor of medicine (BS-MD) program using data collected from 1968 through 2018.

METHOD

Participants of this longitudinal study included 2,235 students who entered medical school between 1968 and 2014: 1,134 in the accelerated program and 1,101 in the regular curriculum (control group)-matched by year of entrance to medical school, gender, and Medical College Admission Test (MCAT) scores. Outcome measures included performance on medical licensing examinations, academic progress, satisfaction with medical school, educational debt, first-year residency program directors' ratings on clinical competence, specialty choice, board certification, and faculty appointments.

RESULTS

The authors found no practically important differences between students in the accelerated program and those in the control group on licensing examination performance, academic progress, specialty choice, board certification, and faculty appointments. Accelerated students had lower mean educational debt (P < .01, effect sizes = 0.81 and 0.45 for, respectively, their baccalaureate debt and medical school debt), lower satisfaction with their second year of medical school (P < .01, effect size = 0.21), and lower global satisfaction with their medical school education (P < .01, effect size = 0.35). Residency program directors' ratings in 6 postgraduate competency areas showed no practically important differences between the students in the accelerated program and those in the control group. The proportion of Asian students was higher among program participants (P < .01, effect size = 0.43).

CONCLUSIONS

Students in the accelerated program earned BS and MD degrees at a faster pace and pursued careers that were comparable to students in a matched control who were in a regular MD program. Findings indicate that shortening the length of medical education does not compromise educational and professional outcomes.

They Don't See a Lot of People My Color: A Mixed Methods Study of Racial/Ethnic Stereotype Threat Among Medical Students on Core Clerkships

PURPOSE

Stereotype threat is an important psychological phenomenon in which fear of fulfilling negative stereotypes about one's group impairs performance. The effects of stereotype threat in medical education are poorly characterized. This study examined the prevalence of racial/ethnic stereotype threat amongst fourth-year medical students and explored its impact on students' clinical experience.

METHOD

This was an explanatory sequential mixed methods study at 2 institutions in 2019. First, the authors administered the quantitative Stereotype Vulnerability Scale (SVS) to fourth-year medical students. The authors then conducted semistructured interviews among a purposive sample of students with high SVS scores, using a qualitative phenomenographic approach to analyze experiences of stereotype threat. The research team considered reflexivity through group discussion and journaling.

RESULTS

Overall, 52% (184/353) of students responded to the survey. Collectively, 28% of students had high vulnerability to stereotype threat: 82% of Black, 45% of Asian, 43% of Latinx, and 4% of White students. Eighteen students participated in interviews. Stereotype threat was a dynamic, 3-stage process triggered when students experienced the workplace through the colored lens of race/ethnicity by standing out, reliving past experiences, and witnessing microaggressions. Next, students engaged in internal dialogue to navigate racially charged events and workplace power dynamics. These efforts depleted cognitive resources and interfered with learning. Finally, students responded and coped to withstand threats. Immediate and deferred interventions from allies reduced stereotype threat.

CONCLUSIONS

Stereotype threat is common, particularly among non-White students, and interferes with learning. Increased minority representation and developing evidence-based strategies for allyship around microaggressions could mitigate effects of stereotype threat.

Student perspectives on barriers to performance for black and minority ethnic graduate-entry medical students: a qualitative study in a West Midlands medical school

OBJECTIVE

To explore graduate-entry medical students experiences of undergraduate training in the context of academic underperformance of medical students from ethnic minority backgrounds.

DESIGN

Qualitative study using semi-structured focus groups.

SETTING

A West Midlands medical school.

PARTICIPANTS

24 graduate-entry MBChB students were recruited using volunteer and snowball sampling; all students self-identified as being from Black and Minority Ethnic (BME) backgrounds.

RESULTS

BME students reported facing a range of difficulties, throughout their undergraduate medical training, that they felt impeded their learning and performance. Their relationships with staff and clinicians, though also identified as facilitators to learning, were also perceived to have hindered progress, as many students felt that a lack of BME representation and lack of understanding of cultural differences among staff impacted their experience. Students also reported a lack of trust in the institution's ability to support BME students, with many not seeking support. Students' narratives indicated that they had to mask their identity to fit in among their peers and to avoid negative stereotyping. Although rare, students faced overt racism from their peers and from patients. Many students reported feelings of isolation, reduced self-confidence and low self-esteem.

CONCLUSIONS

BME students in this study reported experiencing relationship issues with other students, academic and clinical staff, lack of trust in the institution and some racist events. Although it is not clear from this small study of one institution whether these findings would be replicated in other institutions, they nevertheless highlight important issues to be considered by the institution concerned and other institutions. These findings suggest that all stakeholders of graduate-entry undergraduate medical education should reflect on the current institutional practices intended to improve student-peer and student-staff relationships. Reviewing current proposals intended to diversify student and staff populations as well as evaluating guidance on tackling racism is likely to be beneficial.

Ethnic and social disparities in different types of examinations in undergraduate pre-clinical training

Medical schools are increasingly faced with a more diverse student population. Generally, ethnic minority students are reported to underperform compared with those from the ethnic majority. However, there are inconsistencies in findings in different types of examinations. Additionally, little is known about the performance of first-generation university students and about performance differences across ethnic minority groups. This study aimed to investigate underperformance across ethnic minority groups and by first-generation university students in different types of written tests and clinical skills examinations during pre-clinical training. A longitudinal prospective cohort study of progress on a 3-year Dutch Bachelor of Medicine course was conducted. Participants included 2432 students who entered the course over a consecutive 6-year period (2008-2013). Compared with Dutch students, the three non-Western ethnic minority groups (Turkish/Moroccan/African, Surinamese/Antillean and Asian) underperformed in the clinical problem solving tests, the language test and the OSCEs. Findings on the theoretical end-of-block tests and writing skills tests, and results for Western minority students were less consistent. Age, gender, pre-university grade point average and additional socio-demographic variables (including first-generation university student, first language, and medical doctor parent) could explain the ethnicity-related differences in theoretical examinations, but not in language, clinical and writing skills examinations. First-generation university students only underperformed in the language test. Apparently, underperformance differs both across ethnic subgroups and between different types of written and clinical examinations. Medical schools should ensure their assessment strategies create a level playing field for all students and explore reasons for underperformance in the clinical and writing skills examinations.

Student performance in and perceptions of a high structure undergraduate human anatomy course

Human anatomy has usually been taught in a didactic fashion in colleges and universities. However, recent calls from United States governmental agencies have called for the transformation of undergraduate life sciences education to include active learning in the classroom. In addition, high structure courses have been shown to increase student engagement both in and out of the classroom and to improve student performance. Due to these reform efforts and the evidence on the benefits of these student-centered pedagogies, the goal of this study was to develop and assess a high structure college undergraduate human anatomy course with a lecture and laboratory component. The course was taught using a systems anatomy approach that required students to read the textbook and complete assignments before class, actively participate in class, and complete review quizzes after class. Results showed that teaching with high structure methods did not negatively affect any student groups (based on gender, ethnicity, or major) as measured by performance on lecture examinations and laboratory practical examinations. Students reported that reading the textbook and working with anatomical models were the most important towards helping them learn the course material and students' confidence in achieving the course goals significantly increased at the end of the course. The successful development and implementation of this course suggests that it is possible to teach human anatomy using active learning and high structure. Future studies can now be conducted to determine the contributions of specific course components to student success in high structure human anatomy courses. Anat Sci Educ 9: 516-528. © 2016 American Association of Anatomists.

How well do doctors think they perform on the General Medical Council's Tests of Competence pilot examinations? A cross-sectional study

OBJECTIVE

To investigate how accurately doctors estimated their performance on the General Medical Council's Tests of Competence pilot examinations.

DESIGN

A cross-sectional survey design using a questionnaire method.

SETTING

University College London Medical School.

PARTICIPANTS

524 medical doctors working in a range of clinical specialties between foundation year two and consultant level.

MAIN OUTCOME MEASURES

Estimated and actual total scores on a knowledge test and Observed Structured Clinical Examination (OSCE).

RESULTS

The pattern of results for OSCE performance differed from the results for knowledge test performance. The majority of doctors significantly underestimated their OSCE performance. Whereas estimated knowledge test performance differed between high and low performers. Those who did particularly well significantly underestimated their knowledge test performance (t (196)=-7.70, p<0.01) and those who did less well significantly overestimated (t (172)=6.09, p<0.01). There were also significant differences between estimated and/or actual performance by gender, ethnicity and region of Primary Medical Qualification.

CONCLUSIONS

Doctors were more accurate in predicating their knowledge test performance than their OSCE performance. The association between estimated and actual knowledge test performance supports the established differences between high and low performers described in the behavioural sciences literature. This was not the case for the OSCE. The implications of the results to the revalidation process are discussed.

Ethnic disparities in undergraduate pre-clinical and clinical performance

CONTEXT

Research from numerous medical schools has shown that students from ethnic minorities underperform compared with those from the ethnic majority. However, little is known about why this underperformance occurs and whether there are performance differences among ethnic minority groups.

OBJECTIVES

This study aimed to investigate underperformance across ethnic minority groups in undergraduate pre-clinical and clinical training.

METHODS

A longitudinal prospective cohort study of progress on a 6-year undergraduate medical course was conducted in a Dutch medical school. Participants included 1661 Dutch and 696 non-Dutch students who entered the course over a consecutive 6-year period (2002-2007). Main outcome measures were performance in Year 1 and in the pre-clinical and clinical courses. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre-university grade point average (pu-GPA), additional socio-demographic variables (first-generation immigrant, urban background, first-generation university student, first language, medical doctor as parent) and previous performance at medical school.

RESULTS

Compared with Dutch students, Surinamese and Antillean students specifically underperformed in the Year 1 course (pass rate: 37% versus 64%; adjusted OR 0.40, 95% CI 0.27-0.60) and the pre-clinical course (pass rate: 19% versus 41%; adjusted OR 0.57, 95% CI 0.35-0.93). On the clinical course all non-Dutch subgroups were less likely than Dutch students to receive a grade of ≥ 8.0 (at least three of five grades: 54-77% versus 88%; adjusted ORs: 0.17-0.45).

CONCLUSIONS

Strong ethnic disparities exist in medical school performance even after adjusting for age, gender, pu-GPA and socio-demographic variables. More subjective grading cannot be ruled out as a cause of lower grades in clinical training, but other possible explanations should be studied further to mitigate the disparities.

The mediators of minority ethnic underperformance in final medical school examinations

BACKGROUND

UK-trained medical students and doctors from minority ethnic groups underperform academically. It is unclear why this problem exists, which makes it difficult to know how to address it.

AIM

To investigate whether demographic and psychological factors mediate the relationship between ethnicity and final examination scores.

SAMPLE

Two consecutive cohorts of Year 5 (final year) UCL Medical School students (n= 703; 51% minority ethnic). A total of 587 (83%) had previously completed a questionnaire in Year 3.

METHODS

Participants were administered a questionnaire in 2005 and 2006 that included a short version of the NEO-PI-R, the Study Process Questionnaire, and the General Health Questionnaire (GHQ) as well as socio-demographic measures. Participants were then followed up to final year (2007-2010). White and minority ethnic students' questionnaire responses and final examination grades were compared using univariate tests. The effect of ethnicity on final year grades after taking into account the questionnaire variables was calculated using hierarchical multiple linear regression.

RESULTS

Univariate ethnic differences were found on age, personality, learning styles, living at home, first language, parental factors, and prior education. Minority ethnic students had lower final exam scores, were more likely to fail, and less likely to achieve a merit or distinction in finals. Multivariate analyses showed ethnicity predicted final exam scores even after taking into account questionnaire factors.

CONCLUSIONS

Ethnic differences in the final year performance of two cohorts of UCL medical students were not due to differences in psychological or demographic factors, which suggests alternative explanations are responsible for the ethnic attainment gap in medicine.

The effect of a brief social intervention on the examination results of UK medical students: a cluster randomised controlled trial

BACKGROUND

Ethnic minority (EM) medical students and doctors underperform academically, but little evidence exists on how to ameliorate the problem. Psychologists Cohen et al. recently demonstrated that a written self-affirmation intervention substantially improved EM adolescents' school grades several months later. Cohen et al.'s methods were replicated in the different setting of UK undergraduate medical education.

METHODS

All 348 Year 3 white (W) and EM students at one UK medical school were randomly allocated to an intervention condition (writing about one's own values) or a control condition (writing about another's values), via their tutor group. Students and assessors were blind to the existence of the study. Group comparisons on post-intervention written and OSCE (clinical) assessment scores adjusted for baseline written assessment scores were made using two-way analysis of covariance. All assessment scores were transformed to z-scores (mean = 0 standard deviation = 1) for ease of comparison. Comparisons between types of words used in essays were calculated using t-tests. The study was covered by University Ethics Committee guidelines.

RESULTS

Groups were statistically identical at baseline on demographic and psychological factors, and analysis was by intention to treat [intervention group EM n = 95, W n = 79; control group EM n = 77; W n = 84]. As predicted, there was a significant ethnicity by intervention interaction [F(4,334) = 5.74; p = 0.017] on the written assessment. Unexpectedly, this was due to decreased scores in the W intervention group [mean difference = 0.283; (95% CI = 0.093 to 0.474] not improved EM intervention group scores [mean difference = -0.060 (95% CI = -0.268 to 0.148)]. On the OSCE, both W and EM intervention groups outperformed controls [mean difference = 0.261; (95%CI = -0.047 to -0.476; p = 0.013)]. The intervention group used more optimistic words (p < 0.001) and more "I" and "self" pronouns in their essays (p < 0.001), whereas the control group used more "other" pronouns (p < 0.001) and more negations (p < 0.001).

DISCUSSION

Cohen et al.'s finding that a brief self-affirmation task narrowed the ethnic academic achievement gap was replicated on the written assessment but against expectations, this was due to reduced performance in the W group. On the OSCE, the intervention improved performance in both W and EM groups. In the intervention condition, participants tended to write about themselves and used more optimistic words than in the control group, indicating the task was completed as requested. The study shows that minimal interventions can have substantial educational outcomes several months later, which has implications for the multitude of seemingly trivial changes in teaching that are made on an everyday basis, whose consequences are never formally assessed.

Evaluation and treatment of students with difficulties passing the Step examinations

PURPOSE

The author designed this retrospective case series study both to systematically examine characteristics of individuals referred for treatment after multiple failures on the United States Medical Licensing Examinations (USMLE) Step 1 or 2 administered by the National Board of Medical Examiners and to evaluate treatment effectiveness in a uniform sample.

METHOD

Six medical students referred to rehabilitation psychology met selection criteria. All students completed the requisite neuropsychological, academic, and psychological testing to identify cognitive and emotional strengths and weaknesses. All six underwent individualized cognitive rehabilitation (CR) with a primary focus on reading fluency and accuracy.

RESULTS

All participants improved on a quantitative measure of reading speed and accuracy, and five of the six passed their next USLME Step examination in spite of past failures.

CONCLUSIONS

Medical students with identified difficulties on reading fluency, but no history of a learning disability, may benefit from systematic CR that addresses cognitive weaknesses related to test-taking abilities. The strong relationships between language and reading skills and the USMLE Step examinations suggest that some students may fail these examinations because of a relative weakness in language processing and reading fluency that may prohibit their successful completion of the Step examinations.

Impact of preadmission variables on USMLE step 1 and step 2 performance

PURPOSE

To examine the predictive ability of preadmission variables on United States Medical Licensing Examinations (USMLE) step 1 and step 2 performance, incorporating the use of a neural network model.

METHOD

Preadmission data were collected on matriculants from 1998 to 2004. Linear regression analysis was first used to identify predictors of performance on step 1 and step 2. A generalized regression neural network (GRNN) as well as a feed forward neural network (FFNN) was then developed in an effort to more accurately predict step 1 and step 2 scores from these preadmission data.

RESULTS

Statistically significant predictors for step 1 and step 2 included science grade point average (SGPA), the biologic science (BS) section of the Medical College Admissions Test (MCAT), college selectivity, race, and age of the applicant. Neural networks were found to predict a significant portion of the variance, and the FFNN demonstrated some superiority over that obtained with linear regression models as well as the GRNN.

CONCLUSIONS

The results have implications that could impact the selection of applicants to medical school and the neural networks that we developed could be used in a prospective manner.

Exploring the underperformance of male and minority ethnic medical students in first year clinical examinations

Evidence shows that medical students from Minority Ethnic (ME) backgrounds and male medical students underperform in undergraduate examinations. Our study confirmed these findings in first year clinical (year 3) medical students, and further explored this disparity in performance. We conducted a series of meta-analyses to measure the effects of sex and ethnic group on the written examination and Objective Structured Clinical Examination (OSCE) scores of three groups of year 3 medical students at two London UK medical schools (n = 1,051; 46.0% male; 48.7% White). Male and ME students scored lower on written and OSCE assessments. Both assessments were statistically significantly correlated (mean r = 0.45) and therefore the effects of sex and ethnic group were measured on each exam after being adjusted for the effect of the other. Although sex and ethnic differences remained on the OSCE when adjusted for written performance, these differences disappeared on the written when it was adjusted for OSCE performance. These findings may reflect a relative deficit in practical clinical knowledge in male and ME year 3 students. Results were unlikely to be due to examiner bias, as the machine-marked unadjusted written exam results showed significant sex and ethnic differences.

Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study

OBJECTIVE

To explore ethnic stereotypes of UK medical students in the context of academic underachievement of medical students from ethnic minorities.

DESIGN

Qualitative study using semistructured one to one interviews and focus groups.

SETTING

A London medical school.

PARTICIPANTS

27 year 3 medical students and 25 clinical teachers, purposively sampled for ethnicity and sex.

METHODS

Data were analysed using the theory of stereotype threat (a psychological phenomenon thought to negatively affect the performance of people from ethnic minorities in educational contexts) and the constant comparative method.

RESULTS

Participants believed the student-teacher relationship was vital for clinical learning. Teachers had strong perceptions about "good" clinical students (interactive, keen, respectful), and some described being aggressive towards students whom they perceived as quiet, unmotivated, and unwilling. Students had equally strong perceptions about "good" clinical teachers (encouraging, interested, interactive, non-aggressive). Students and teachers had concordant and well developed perceptions of the "typical" Asian clinical medical student who was considered over-reliant on books, poor at communicating with patients, too quiet during clinical teaching sessions, and unmotivated owing to being pushed into studying medicine by ambitious parents. Stereotypes of the "typical" white student were less well developed: autonomous, confident, and outgoing team player. Direct discrimination was not reported.

CONCLUSIONS

Asian clinical medical students may be more likely than white students to be perceived stereotypically and negatively, which may reduce their learning by jeopardising their relationships with teachers. The existence of a negative stereotype about their group also raises the possibility that underperformance of medical students from ethnic minorities may be partly due to stereotype threat. It is recommended that clinical teachers be given opportunities and training to encourage them to get to know their students as individuals and thus foster positive educational relationships with them.

Effect of medical students' ethnicity on their attitudes towards consultation skills and final year examination performance

AIM

The study had two aims. The first aim was to examine the relationship between final year medical students' ethnicity and their attitudes towards consultation skills. The second aim was to investigate the relationship between ethnicity and final year performance.

METHOD

A cross-sectional study was undertaken of all final year medical students in 1995 and 1996, both before and after their attachment through the Department of General Practice at Monash University, Australia. A questionnaire was designed to assess students' attitudes (views of importance and confidence) towards consultation skills. Also, records of final year performance were obtained from the University.

RESULTS

Five clusters of consultation skills were formed through factor analysis: communication skills, difficult consultations, traditional diagnostic methods, routine management and life threatening conditions. There were no significant differences in students' attitudes towards these consultation skills based on country of birth, language, or student status preattachment. The only significant postattachment difference was that students born in non-Western countries placed a significantly higher importance on communication skills and the traditional diagnostic method than students born in Western countries. There were significant differences in final year performance between students across all three parameters of ethnic diversity. Non-Western born students performed worse than Western born students. Students who preferred using a language other than English also performed worse than those students preferring English. International students performed worse than students with Australian citizenship or permanent residency.,

CONCLUSIONS

The only significant difference regarding attitudes to consultation skills was that non-Western born students placed significantly greater importance on communication skills and the traditional diagnostic method postattachment than Western born students. No significant differences were found in attitudes preattachment. There were significant differences in performance, with students of ethnic background performing consistently poorer in all the final year assessment parameters analysed.

Validity of admissions measures in predicting performance outcomes: the contribution of cognitive and non-cognitive dimensions

BACKGROUND

Admissions committees face the daunting task of selecting a small number of candidates who are most likely to succeed in medical school from a large pool of seemingly suitable applicants. While numerous studies have shown moderate correlations among measures of academic performance, predictors of the non-cognitive domain (e.g. interpersonal, communication, ethical) remain elusive, in part because of the absence of a sound criterion measure.

PURPOSE

We examined the utility of several cognitive and non-cognitive criteria used in the admissions processes in predicting both cognitive and non-cognitive dimensions of the licencing examinations of the Medical Council of Canada (LMCC).

METHODS

Predictors included: undergraduate GPA, undergraduate science GPA, an autobiographical letter, scores from a simulated tutorial, a personal interview and the MCAT. Of specific interest was the relation between measures of communication and problem-exploration skills as assessed during the admissions process and Part II of the LMCC Examination, a multi-station OSCE.

RESULTS

Undergraduate GPAs were found to have the most utility in predicting both academic and clinical performance. Scores derived from the simulated tutorial did not predict future performance. The MCAT Verbal Reasoning score and the personal interview were found to be useful in predicting communication skills on the LMCC Part II.

CONCLUSIONS

The results have implications for any school that uses the interview as an admissions tool.

Library use and academic achievement among medical students

Many factors play a part in determining the performance of students in examinations, but the extent to which students use library facilities does not appear to have been recently considered as a factor, in medicine or in any other academic subject. In this study, the number of books borrowed from the library by undergraduate medical students was used as a simple measure of library use, and significant differences in book-borrowing levels were found between students in different years of the medical course, students from different regions of the world, and men and women students. In the first year of the course, students who borrowed most also performed best in their end-of-year examinations, and this association was only partly explained by regional differences. No such association was found among final-year students, suggesting different study habits and different assessment criteria in the clinical years of the course.