Bias in Medicine: An Elephant in the Room

My mentor told me, “You must be twice as qualified to get a promotion compared to your White male peers.” I appreciated his transparent feedback as he did not hold back from making me conscious of my race or skin color. Why is a person who is not White held to different expectations and standards? One word instantly came to my mind: bias. Every human being has some sort of bias, whether we admit it or not. When I typed “bias in medicine” into a search engine, the results were astonishing. Confronting bias is a significant challenge that demands proactive measures to counteract its unconscious and detrimental effects. Specifically, evaluation bias poses a threat to efforts aimed at achieving health equity and promoting diversity by hindering the advancement and retention of trainees who are underrepresented in medicine (URiM). A study analyzed letters of recommendation (LORs) for internal medicine residency program applicants, focusing on those from underrepresented groups (including Black and Latino people and women) versus nonunderrepresented applicants (1). It found that regardless of whether LORs adhered to the Alliance for Academic Internal Medicine guidelines, underrepresented applicants were more frequently described with communal and doubt-raising language along with career trajectory bias.

The introduction of the Milestone evaluation system was an attempt to address shortcomings in residency assessment and feedback methods, particularly subjectivity, reliance on single decision makers, and the use of non–competency-based assessment strategies (2). The Clinical Competency Committee and descriptive Milestone rating categories aimed to standardize the trainee assessment approach to reduce assessment bias. The important question remains: Does racial bias persist in assessments despite the adoption of the Milestone rating system?

A study published in Annals of Internal Medicine shed some light on this crucial question (3). This study analyzed evaluation bias toward Asian, Black, and Latino residents by comparing the periods before and after the Milestone rating system was introduced. It used data on 59,835 allopathic internal medicine residents, sourced from the American Board of Internal Medicine and the Association of American Medical Colleges. The study assessed medical knowledge ratings for Asian, Black, and Latino residents, both U.S.-born and non–U.S.-born, across 2 periods: before the Milestone implementation (2008–2013) and after (2015–2020). It compared these ratings with those of U.S.-born non-Latino White residents, who served as the benchmark group. The evaluation analyzed residents’ medical knowledge scores from the pre-Milestone Resident Annual Evaluation Summary and Milestone evaluations for overall clinical knowledge. Pre-Milestone bias estimates were highest among Black residents, followed by non–U.S.-born Latino and non–U.S.-born Asian residents. The introduction of the Milestone rating system has successfully reduced biases in medical knowledge assessments against URiM and Asian residents, marking a positive step toward equity. However, the bias estimate remained substantially higher for U.S.-born Black residents.

There are disparate numbers of Black physicians in the physician workforce compared with the U.S. population. In addition, Black, Latino, and Asian groups are vastly underrepresented in academic leadership (2). Training programs should ensure that trainees are assessed with intentionally designed systems that provide accurate, competency-based information based on observations from multiple trained assessors. To build a sustainable health care workforce, we need to be aware of bias and its impact at both personal and organizational levels.

References

1. Zhang N, Blissett S, Anderson D, et al. Race and gender bias in internal medicine program director letters of recommendation. J Grad Med Educ. 2021;13:335-344. [PMID: 34178258] doi:10.4300/JGME-D-20-00929.1
2. Anderson A, Onumah C. Does racial bias play a role in internal medicine resident knowledge evaluations? [Editorial]. Ann Intern Med. 2024;177:95-96. [PMID: 38145567] doi:10.7326/M23-3141
3. Gray BM, Lipner RS, Roswell RO, et al. Adoption of internal medicine milestone ratings and changes in bias against Black, Latino, and Asian internal medicine residents. Ann Intern Med. 2024;177:70-82. [PMID: 38145569] doi:10.7326/M23-1588

Farzana Hoque, MD

Dr. Farzana Hoque is an academic hospitalist and an associate professor of medicine at Saint Louis University School of Medicine. She serves as the codirector of the Internal Medicine Acting Internship and the inaugural medical director of Bordley Tower at SSM Health Saint Louis University Hospital. Dr. Hoque is a fellow of the Royal College of Physicians of the United Kingdom and the President of the Society of Hospital Medicine St. Louis Chapter.