Intersectional disparities in performance assessment of emergency medicine residents

By Tarun Sai LomteSep 25 2023Reviewed by Lily Ramsey, LLM

A recent study published in JAMA Network Open evaluated intersectional ethnoracial disparities in emergency medicine (EM) resident assessments.

Study: Intersectional Disparities in Emergency Medicine Residents’ Performance Assessments by Race, Ethnicity, and Sex. Image Credit: Ground Picture/Shutterstock.com

Background

Health equity is a paramount priority for national healthcare bodies. Yet, achieving a diverse healthcare workforce representative of populations is challenging.

The advantages of a representative workforce are improved care access for economically disadvantaged people and those from minoritized ethnoracial groups, which become significant in the emergency room where complex socio-structural factors determine who is disproportionately represented.

EM physicians provide safety-net care to those who may have been neglected or excluded by the healthcare system, such as patients experiencing homelessness and those with comorbid psychiatric illnesses and substance/alcohol use disorders.

Performance assessment disparities represent a form of discrimination. Studies have shown that female residents and those underrepresented in medicine (URM) were consistently rated less skilled than male and non-URM counterparts.

About the study

In the present study, researchers assessed intersectional sex-specific ethnoracial disparities in EM resident assessments using the Accreditation Council for Graduate Medical Education (ACGME) Milestones data from 2014-15 to 2017-18. Ratings were linked to demographic data of residents provided by the Association of American Medical Colleges (AAMC).

AAMC and ACGME data were merged; residents whose records were not present in both data sources and those with missing ethnoracial data were excluded.

Further, EM programs without at least one URM and one Asian trainee were excluded. EM residents were assessed two times (midyear and year-end). EM residents were categorized as White, Asian, and URM.

The team estimated disparities in Milestone scores using linear mixed-effects models. The primary outcomes were the average scores for six core competencies (patient care, systems-based practice, medical knowledge, communication and interpersonal skills, professionalism, and practice-based learning and improvement).

Separate models were fit for three- and four-year programs and each model included fixed effects for the time, sex, and ethnoracial group.

Findings

The study included 2,708 EM residents; 1,913 and 795 were in three- and four-year programs, respectively. Nearly 75% of EM residents were White, 17.6% were Asian, 7.95 were Hispanic/Latino, and 5.9% were Black.

Around 34.6% were females, and 14.3% were URM residents. Sixty programs did not have URM or Asian residents in training. Residents in four-year programs were rated lower than those in three-year programs at midyear assessment in the first post-graduate year (PGY1).

However, competency scores varied by sex, program length, and ethnoracial group. URM female residents in four-year programs had the highest scores in all core competencies except in medical knowledge at PGY1 midyear.

Disparities emerged in PGY2, as URM and Asian residents of both sexes had the lowest ratings than White males at year-end.

The largest disparities were noted in medical knowledge, especially between White male and URM male residents at PGY3 year-end in three-year programs and between White male and URM female residents at PGY2 year-end in four-year programs. In adjusted models, disparities worsened for minoritized EM residents, except for White females.

URM residents of both sexes in three-year programs initially had ratings comparable to White male residents; nonetheless, they were lower than White males in three competencies (medical knowledge, learning and improvement, and patient care) by PGY3 year-end. Similar patterns were evident in four-year programs but only in URM female residents.

Further, Asian males had lower communication and interpersonal skills scores than White males by PGY-3 year-end in three-year programs.

The average overall assessment scores showed similar patterns at the PGY1 midyear assessment and throughout the period. Minoritized residents, except White females, had progressively lower ratings by PGY2 midyear.

The adjusted models revealed no differences in overall scores between White males and minoritized residents from PGY1 midyear to PGY2 midyear in three- and four-year programs.

By PGY3 year-end, Asian females and URM residents in three-year programs had lower ratings than White males. In four-year programs, URM females had lower scores than White males from PGY3 midyear to PGY4 year-end.

Conclusions

The researchers found significant evidence of sex-specific ethnic and racial disparities in performance assessments throughout training.

The disparities were particularly severe for URM and Asian female residents and URM male residents than White males. Eliminating sex-specific ethnic and racial disparities in assessments will help contribute to equitable healthcare and facilitate diversity in the emergency physician workforce.