U.S.-Born Black Medical Residents Continue to Face Bias in Medical Education
New study finds bias against other marginalized groups receded once a new evaluation method was adopted
https://www.acpjournals.org/doi/10.7326/M23-1588
Philadelphia, December 26, 2023 – Black, Latino and Asian physicians in residency training suffered large bias in residency knowledge ratings prior to the adoption of the Milestone ratings system in 2013. A new study published in The Annals of Internal Medicine reports that there was a substantial decline in bias after implementation of Milestone ratings, yet significant bias toward U.S.-born Black residents persisted.
“The Adoption of Internal Medicine Milestone Ratings and Changes in Bias Against Black, Latino and Asian Internal Medicine Residents,” authored by researchers from the American Board of Internal Medicine (ABIM), the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, the University of California San Francisco and Harvard University, found that bias was “large” against Black, Latino and U.S.-born Asian residents in the pre-Milestones period of 2008–2013.
For example, results of the study imply that a U.S.-born Black resident who should have been in the 50th percentile in clinical knowledge—as measured objectively by their performance on the ABIM Certification exam—would have been rated as being in the 32nd percentile prior to the implementation of the Milestones. The study also showed U.S.-born Black residents were half as likely to receive a top rating compared to U.S.-born non-Latino White residents prior to when the Milestone ratings system was implemented.
After the adoption of the new ratings system—which incorporated competency committees that replaced ratings made solely by program directors as well as more explicit and detailed rating scales—bias dropped significantly across the board. However, substantial bias still persists for U.S.-born Black residents in terms of both overall bias and receiving a top rating.
To account for underlying medical knowledge when comparing ratings between race/ethnicity groups, the study used an objective, unbiased, blind measure of knowledge, namely ABIM internal medicine certification exam scores, which have been associated with better quality of care.
“As a U.S.-born Black medical student and internal medicine resident, I witnessed firsthand what I thought was evaluator rater bias. It was really jarring to me when I was a medical student,” said co-author Robert O. Roswell, MD, Associate Dean for Diversity, Equity and Inclusion and Professor of Cardiology and Science Education at the Zucker School of Medicine at Hofstra/Northwell and Chair-Elect of the ABIM Board of Directors. “ABIM and ACGME are to be commended for implementing a fairer resident assessment rating. Although the assessment is fairer, more research is needed to guide medical educators on how to reduce bias against U.S.-born Black residents. At the very least, increasing awareness of implicit bias among medical educators is imperative.”
The study sample included 59,835 internal medicine residents who completed an internal medicine residency program and received their last residency rating in the 2008–2013 (pre-Milestones) period or the 2015–2020 (post-Milestones) period. Residents whose last rating was in 2014 were excluded from the analysis because it was a transition year between rating systems.
“The significant bias we found pre-Milestones both suggests that there exists large underlying evaluation bias against the minoritized groups we studied and provides an explanation as to why these groups are vastly underrepresented in academic medicine and other leadership positions,” said Bradley Gray, Ph.D., lead author and Senior Health Services Researcher for ABIM. “The fact that large bias persists for U.S.-born Black residents relative to their non-U.S. born counterparts is troubling and suggests that there is a cultural history deeply seated in racism in the United States that specifically affects bias against Black Americans.”
Marcella Alsan, MD, Harvard University Kennedy School of Government Professor of Public Policy and a co-author, added: “The good news of this research is that systemic changes that make review less discretionary can indeed narrow inequitable gaps in residency evaluation. However, it also highlights that much more needs to be done to increase the numbers of and reduce the bias against U.S.-born Black physicians.”
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Contact: Lisa Finnegan
American Board of Internal Medicine
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