Medically Clear #23: Gender Bias in Medicine
With our current emphasis on disparities, we are well aware of how the nature and quality of medical care can differ based on race, ethnicity and gender.
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We have come a long way in this regard, but there may be some long-held implicit biases still in play. Consider the Society for Academic Emergency Medicine (SAEM) plenary presentation by Arjun Dayal and Daniel M. O’Connor (both medical students) and Vineet Arora entitled Going the Extra Mile: Predictors of Higher Milestone Achievement in Emergency Medicine Using Longitudinal Multicenter Direct Observation Data.
This study compared 34,758 directly observed resident evaluations collected between 2013–2015 across 359 residents and 8 EDs based on gender (resident and faculty) and experience. The observations were recorded in an app called InstantEval that provides evaluators with an opportunity to record real-time feedback on resident performance and, in particular ACGME-defined “milestone” acquisition over time across 23 sub-competencies. The milestone sub-competencies cover both skills and knowledge and include airway management, patient centered communication, and pharmacotherapy. The study utilized a mixed effects ordinal regression model and, not surprisingly, found that ratings of milestone acquisition were strongly and positively related to resident experience levels. They also found that the gender of the evaluator and the gender pairing of the evaluator/evaluee did not have a significant effect on milestone ranking. While these findings got little attention at SAEM, the additional finding of consistently higher rankings for male residents than female residents, starting in the second year of residency, (p<0.001) definitely did. Several audience comments — including from Dr. Stacey Poznanski, the outgoing president of the Academy for Women in Academic Emergency Medicine — praised the study for being gutsy enough to ask the difficult (and loaded) question of whether there is implicit gender bias in resident evaluations.
Another audience member asked:
“Is it possible that the evaluation pattern captured a true trend — that experienced male residents truly performed better than female?”
The authors thought this was unlikely, for a host of reasons that are summarized in a follow-up written statement by doctor-to-be O’Connor:
“We think it’s likely that the gender differences in our study are at least partially driven by systemic, implicit bias. We found that men and women were evaluated similarly at the beginning of training, suggesting that male and female residents entered training with similar skills and knowledge. However, as women progressed through the same residency programs, they were consistently evaluated lower than their male colleagues. Though disparities related to opportunities or mentoring may have been contributing factors, the relatively equal number of evaluations given to male and female residents suggests that both received similar amounts of direct-observation feedback. By PGY3, women were evaluated lower on all 23 EM sub- competencies. Such a uniform trend, with comparable evaluations at the beginning of residency, strongly implicates bias rather than diminished competency or skill.”
The investigators have a manuscript under preparation and we will see how the methods and findings hold up to peer-review scrutiny. If they do, we can expect an interesting debate about how to correct for implicit bias in our residency programs.
Listen to the podcast here or in iTunes (The Medically Clear Podcast)
Next up, Clarity Re-visited
