Influence of Race, Ethnicity, and Gender on Clinical Performance Assessments in Graduate Medical Education.

Background: Evidence suggests disparities associated with race and ethnicity (R&E) in assessment in graduate medical education (GME). How these disparities manifest across competencies and training time and intersect with disparities associated with other factors such as gender is unclear.

Objective: Examine the association of R&E and gender with clinical performance assessment in GME.

Methods: Longitudinal analysis of resident clinical performance assessments. Methods: Assessment data of residents at seven internal medicine (IM) residency programs, 2014 to 2019 (9346 evaluations of 664 residents). Residents underrepresented in medicine (URiM) were identified using self-reported R&E. Methods: Standardized scores were calculated for the Accreditation Council for Graduate Medical Education competencies (patient care [PC], medical knowledge [MK], practice-based learning and improvement [PBLI], systems-based practice [SBP], professionalism [PROF], and interpersonal communication and skills [ICS]). Cross-classified mixed effects regression assessed differences in standardized competency ratings with R&E over time and the interaction of R&E and gender while controlling for time of year and setting; resident gender, post-graduate year (PGY), and IM in-training examination percentile rank; and faculty gender, educational role, specialty, rank, and years of experience.

Results: URiM resident scores were lower than non-URIM residents across competencies (difference in standardized scores between URiM and non-URiM residents [se] PC - 0.126 [0.035], p < 0.001; MK - 0.118 [0.035], p < 0.001; PBLI - 0.122 [0.042], p = 0.004; SBP - 0.128 [0.034], p < 0.001; PROF - 0.075 [0.036], p = 0.036; ICS - 0.124 [0.039], p = 0.002). The interaction between resident R&E, gender, and PGY was significant in PBLI (estimate - 0.15 [0.06], p = 0.02) and SBP (- 0.11 [0.05], p = 0.04) indicating smaller gains over time for URiM women.

Conclusions: There were significant differences associated with R&E with lower scores for URiM residents across competencies. There was a significant interaction with resident gender and R&E over time in PBLI and SBP. Findings may reflect bias in faculty assessment, effects of non-inclusive learning environments, or structural inequities in assessment.