The Long Shadow: A Historical Perspective on Racism in Medical Education

Advancing health professions education: a review of holistic admissions and competency-based admissions practices

In this review, we gathered information about competency-based admissions and holistic admissions related to healthcare education to understand current practices better and offer recommendations within the healthcare education field. A literature search was conducted to gather peer-reviewed articles detailing information related to competency-based admissions and holistic admissions that have been implemented in healthcare education, including medical schools, nursing schools, dental schools, and other allied health fields. After screening and the addition of articles through ancestral search, 166 articles were included in this systematic review. The articles were coded for information related to definitions of competency-based admissions and holistic admissions, specific desired competencies, procedures to evaluate these competencies, outcomes of these practices, and the success of admitting well-prepared students using these practices. Results show there is wide variation in established definitions and desired competencies. Similarly, there was some variation in methods for evaluating these competencies with some common practices identified. Lastly, little evidence demonstrates the effectiveness of admitting students who are well-prepared for their programs when competency-based or holistic admissions are employed. There is a need for future research to establish a standard definition for both competency-based admissions and holistic admissions. Desired competencies should be established based on the program's mission and vision statements for what type of students they want to admit. Lastly, future research needs to focus on the long-term outcomes of implementing these practices.

On Seeing Long Shadows: Is Academic Medicine at its Core a Practice of Racial Oppression?

Suggestions that academic medicine is systemically racist are increasingly common in the medical literature. Such suggestions often rely upon expansive notions of systemic racism that are deeply controversial. The author argues for an empirical concept of systemic racism and offers a counter argument to a recent suggestion that academic medicine is systemically racist in its treatment of medical trainees: Anderson et al.'s (Academic Medicine, 98(8S), S28-S36, 2023) "The Long Shadow: a Historical Perspective on Racism in Medical Education." Contra the authors of "The Long Shadow," the author argues that racial performance disparities in medical education cannot be validly attributed to racism without careful empirical confirmation; he further argues that standards of assessment in medical education cannot be properly deemed racist merely because minority trainees are disproportionately disadvantaged by them. Furthermore, the history of medicine and society in the Anglo-European West is not, as argued by the authors of "The Long Shadow," best viewed as one long tale of racial oppression culminating in the present day pervasive racism of academic medicine in the United States. Racism is a deplorable stain on our history and our present but it is not the historical essence of Christianity, European civilization, Western medicine, or contemporary academic medical institutions.

Recommendations to address and research systemic bias in assessment: perspectives from directors of research in medical education

INTRODUCTION

Addressing systemic bias in medical school assessment is an urgent task for medical education. This paper outlines recommendations on topic areas for further research on systemic bias, developed from a workshop discussion at the 2023 annual meeting of the Society of Directors of Research in Medical Education.

MATERIALS AND METHODS

During the workshop, directors engaged in small-group discussions on guidelines to address bias in assessment practices following a proposed categorization of 'Do's,' 'Don'ts,' and 'Don't knows' and listed their insights using anonymous sticky notes, which were shared and discussed with the larger group of participants. The authors performed a content analysis of the notes through deductive and inductive coding. We reviewed and discussed our analysis to reach consensus.

RESULTS

The workshop included 31 participants from 28 institutions across the US and Canada, generating 51 unique notes. Participants identified 23 research areas in need of further study. The inductive analysis of proposed research areas revealed four main topics: 1) The role of interventions, including pre-medical academic interventions, medical-education interventions, assessment approaches, and wellness interventions; 2) Professional development, including the definition and assessment of professionalism and professional identity formation; 3) Context, including patient care and systemic influences; and 4) Research approaches.

DISCUSSION

While limited to data from a single workshop, the results offered perspectives about areas for further research shared by a group of directors of medical education research units from diverse backgrounds. The workshop produced valuable insights into the need for more evidence-based interventions that promote more equitable assessment practices grounded in real-world situations and that attenuate the effects of bias.

The need for critical and intersectional approaches to equity efforts in postgraduate medical education: A critical narrative review

BACKGROUND

Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training.

METHODS

We conducted a critical narrative review of EDI literature from 2009-2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform.

RESULTS

Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI-related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power.

DISCUSSION

Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners.

"Where are you really from?": a qualitative study of Asian American medical provider experiences

The COVID-19 pandemic highlighted how racially minoritized patients and clinicians have suffered racial discrimination. It also made visible the ways in which Asians across the globe experience racial hate and illuminated that the experiences of Asians in medicine are not often spotlighted. In the United States specifically, Asian Americans are not viewed as minoritized in medicine, yet their professional experiences are rarely highlighted. Informed by the discourses of the model minority, the forever foreigner, and ethnic lumping, we used Asian critical theory to explore how Asian American medical providers in Utah understand racial and ethnic identity and how these identities and experiences of racialization inform their professional identities. Using a case study approach, we identified and interviewed 23 physicians, physician assistants, and nurse practitioners (during spring 2022) who live in and practice medicine in Utah. Transcribed interviews were coded using reflective thematic analysis. Findings were organized into three themes: (1) feeling different, (2) experiences with discrimination, and (3) wrestling with the model minority myth. While Asian American medical providers experience not belonging, they also have the agency to disrupt discrimination and stereotypes. Asian American medical providers' racial and ethnic identities influence their professional interactions. Understanding the intersections of their social and professional identities are important to providing support for Asian medical providers, within the United States and beyond.

Validity in the Next Era of Assessment: Consequences, Social Impact, and Equity

Validity has long held a venerated place in education, leading some authors to refer to it as the "sine qua non" or "cardinal virtue" of assessment. And yet, validity has not held a fixed meaning; rather it has shifted in its definition and scope over time. In this Eye Opener, the authors explore if and how current conceptualizations of validity fit a next era of assessment that prioritizes patient care and learner equity. They posit that health profession education's conceptualization of validity will change in three related but distinct ways. First, consequences of assessment decisions will play a central role in validity arguments. Second, validity evidence regarding impacts of assessment on patients and society will be prioritized. Third, equity will be seen as part of validity rather than an unrelated concept. The authors argue that health professions education has the agency to change its ideology around validity, and to align with values that predominate the next era of assessment such as high-quality care and equity for learners and patients.

How Did Black and Hispanic Orthopaedic Applicants and Residents Compare to General Surgery Between 2015 and 2022?

BACKGROUND

Despite the heavy demand for and knowledge of the benefits of diversity, there is a persistent lack of racial, ethnic, and gender diversity in orthopaedic surgery. Since the implementation of diversity initiatives, data have shown that general surgery has been one of the top competitive surgical fields and has demonstrated growth in racial, ethnic, and gender diversity, making general surgery a good point of reference and comparison when analyzing racial and ethnic growth in orthopaedic surgery.

QUESTIONS/PURPOSES

(1) What were the growth rates for Black and Hispanic orthopaedic residency applicants and residents between 2015 and 2022? (2) How did the growth rates of Black and Hispanic individuals in orthopaedic surgery compare with those of general surgery? (3) How did applicant recruitment and resident acceptance differ between Black and Hispanic people in orthopaedic surgery?

METHODS

Applicant data were obtained from historical specialty-specific data from the Association of American Medical Colleges Electronic Residency Application Service Statistics database between 2018 and 2022, and resident data were obtained from the Accreditation Council of Graduate Medical Education Data Resource Book between 2015 and 2021. Between 2018 and 2022, the number of residency applicants totaled 216,677, with 17,912 Black residency applicants and 20,413 Hispanic residency applicants. Between 2015 and 2021, the number of active residents totaled 977,877, with 48,600 Black residents and 62,605 Hispanic residents. Because the applicant and resident data do not overlap throughout all years of observation, a sensitivity analysis of overlapping years (between 2018 and 2021) was conducted to ensure observed trends were consistent and valid throughout the study. All datasets obtained were used to establish the different racial and ethnic proportions of Black and Hispanic residency applicants and residents in four nonsurgical primary care specialties and four surgical subspecialties. A reference slope was created using data from the Association of American Medical Colleges and Accreditation Council of Graduate Medical Education to represent the growth rate for total residency applicants and residents, independently, across all residency specialties reported in each database. This slope was used for comparison among the resident and applicant growth rates for all eight selected specialties. Datapoints were placed into a scatterplot with regression lines, using slope equations to depict rate of growth and R 2 values to depict linear fit. Applicant growth corresponded to applicant recruitment and resident growth corresponded to resident acceptance. Chi-square tests were used to compare residents and residency applicants for the Black and Hispanic populations, separately. Two-way analysis of variance with a time-by-specialty interaction term (F-test) was conducted to determine differences between growth slopes.

RESULTS

There was no difference in the growth rate of Black orthopaedic surgery applicants between 2018 and 2022, and there was no difference in the growth rate of Hispanic orthopaedic surgery applicants (R 2 = 0.43; p = 0.23 and R 2 = 0.63; p = 0.11, respectively). However, there was a very slight increase in the growth rate of Black orthopaedic surgery residents between 2015 and 2021, and a very slight increase in the growth rate of Hispanic orthopaedic surgery residents (R 2 = 0.73; p = 0.02 and R 2 = 0.79; p = 0.01, respectively). There were no differences in orthopaedic and general surgery rates of growth for Black applicants between 2018 and 2022 (0.004 applicants/year versus -0.001 applicants/year; p = 0.22), and no differences were found in orthopaedic and general surgery rates of growth for Black residents between 2015 and 2021 (0.003 residents/year versus 0.002 residents/year; p = 0.59). Likewise, Hispanic orthopaedic applicant growth rates did not differ between 2018 and 2022 from the rates of general surgery (0.004 applicants/year versus 0.005 applicants/year; p = 0.68), and there were no differences in orthopaedic and general surgery rates of growth for Hispanic residents (0.007 residents/year versus 0.01 residents/year; p = 0.35). Furthermore, growth rate comparisons between Black orthopaedic applicants and residents between 2018 and 2021 showed applicant growth was larger than resident growth, illustrating that the recruitment of Black applicants increased slightly more rapidly than resident acceptance. Growth rate comparisons between Hispanic applicants and residents showed a larger rate of resident growth, illustrating Hispanic resident acceptance increased slightly faster than applicant recruitment during that time.

CONCLUSION

We found low acceptance of Black residents compared with the higher recruitment of Black applicants, as well as overall low proportions of Black and Hispanic applicants and residents. Future studies might explore the factors contributing to the higher acceptances of Hispanic orthopaedic residents than Black orthopaedic residents.

CLINICAL RELEVANCE

We recommend that more emphasis should be placed on increasing Black and Hispanic representation at the department level to ensure cultural considerations remain at the forefront of applicant recruitment. Internal or external reviews of residency selection processes should be considered, and more immersive, longitudinal orthopaedic surgery clerkships and research mentorship experiences should be targeted toward Black and Hispanic students. Holistic reviews of applications and selection processes should be implemented to produce an increased racially and ethnically diverse applicant pool and a diverse residency work force, and implicit bias training should be implemented to address potential biases and diversity barriers that are present in residency programs and leadership.