November 2019

posted in: 2019 Journal Clubs | 0

Racial bias in clinical grading

Racial/Ethnic Disparities in Clinical Grading in Medical School. Low D, Pollack SW, et al.  Teaching and Learning in Medicine 2019; 31(5), 487-496



Reviewed by Randy Rockney



What was the study question?

Can the association between race/ethnicity and measures of clinical performance be accounted for by disparities in standardized exam scores or are other potentially unrecognized factors influencing the association of race/ethnicity with measures of clinical performance?

How was the study done?

At the University of Washington School of Medicine, MSPE summary words, in this instance Outstanding, Excellent, Very Good and Good (n=892); and core clerkship final grades, Honors, High Pass, and Pass/Fail (n=6,474), were studied as a function of students’ self-selected race/ethnicity.

What were the results?

The highest proportion of students receiving Outstanding as the MSPE summary word were White students (71%) followed by non-URM minority students (13%) with only 3% of URM students receiving Outstanding as the MSPE summary word. White students received the highest percentage of Honors grades across all clerkships (34%-46%) followed by non-URM minority students (29%-39%) and URM students (16%-40%). Men and older students were less likely to receive a higher category summary word than women. Some of the race/ethnicity differences in clerkship grades disappeared after accounting for test scores though the racial/ethnicity disparities persisted in the grades from four of the six required clerkships. After accounting for all available confounding variables, grading disparities favored white students.

What are the implications?

Clinical performance measures like MSPE summary words and final clerkship grades are associated with AOA membership, residency selection and overall career advancement. The authors posit that physician evaluators hold implicit and explicit biases favoring white students and link that phenomenon to other manifestations of increased discrimination experienced by minority medical faculty like a lesser likelihood of promotion and NIH funding. The authors are especially alarmed by the fact that clerkship grades, MSPE summary words, and AOA membership have profound influence over the career trajectory of medical students.

Editor’s Note: We all should be alarmed.   It is fair to say that most clinician- educators value clinical performance over performance on a multiple-choice test and want to reward students who excel in clinical settings over those with their nose in the board prep books.  But we need to find a way to do so without reinforcing societal biases that disadvantage minority students (JG).



Curric’ing together

Student engagement in medical education: A mixed-method study on medical students as module co-directors in curriculum development.

Milles, LS., Hitzblech T., Drees S., Wurl W., Arends P., Peters H. Medical Teacher 2019. 41(10):1143-1150.

Reviewed by Erin Peebles

What was the study question?

What are the perceptions of student and faculty module co-directors regarding the role, function and effect of student involvement as module co-directors in curriculum development?

How was the study done?

This was a mixed-methods study of student and faculty module co-directors. Students and faculty were surveyed using quantitative and qualitative methods on the role, function and competencies of student module co-directors in the process of curricular quality improvement. A focus group was also conducted with student module co-directors. Quantitative data were analyzed descriptively, and the narrative components and focus group data were analyzed using an inductive approach.

What were the results?

23 out of 25 student and 81 of 107 faculty co-directors participated in the survey portion. The majority of student module co-directors felt that they had influence on curricular change, that the curriculum benefited from their work and that they were equal partners with the other module directors. They did tend to agree that student evaluation could differ from their ideas. Faculty co-directors felt strongly that the curriculum benefitted from student involvement, and students were equal contributors to curriculum development. Faculty also rated that student co-directors were competent in knowledge of the curriculum, interpretation of student evaluations, communication and assessment of the quality of classes but not in assessing discipline related content.  Data from the focus groups revealed that students felt they brought unique knowledge and gave students a voice.  They also felt it was important to be prepared, take on laborious but strategic tasks and support each other. They gained experience dealing with hierarchy and valuable learning regarding the negotiation process for curriculum delivery.

What are the implications of these findings?

Students were able to make mutually beneficial contributions to curriculum design. Both faculty and students felt the curriculum was strengthened from their involvement, and students learned important lessons in curriculum design. This is a model of curriculum design that could be implemented to increase student engagement. An appendix outlines the “how to” of the student involvement.

Editor’s Comments: Students as co-directors for modules represents a shift from reactive involvement of students (i.e. evaluating the curriculum that has been taught), to students taking on a pro-active role and both faculty and students recognize value in this collaboration. How might you consider active engagement of students in your educational setting? (KFo)



The difficult patient

What Do Medical Students Do and Want When Caring for “Difficult Patients”?

Steinauer JE, Teherani A, PreskIll F et al. Teaching and Learning in Medicine. 2019;31(3):238-249.

Reviewed by Michele Haight

What was the study question?

What strategies do students use when interacting with difficult patients and what curricular supports are available for these interactions?

How was the study done?

Two faculty members interviewed twenty-six fourth year medical students entering diverse specialties. Student responses were then analyzed using directed content analysis. Student responses to two questions formed the basis for the analysis. For a given negative patient interaction: 1. Describe the strategies you used, including how you sought support from your team. 2. How do you think the medical school curriculum has prepared you for such interactions?  Student responses were then mapped to Stalmeijer et al.’s depiction of cognitive apprenticeship methods, which include modeling, coaching, scaffolding, articulation, reflection and exploration. The responses were also aligned with traditional teaching techniques.

What were the results?

In general, students reported that they did not know how to handle these types of emotional interactions with difficult patients Students’ responses yielded five strategy themes for dealing with difficult patients: finding empathy, using learned communication approaches, seeking support, thinking of the interaction as an opportunity for more responsibility and anticipating challenging interactions. Students identified the following pedagogical supports as useful: short talks or longer didactics on topics that elicit strong emotions from patients, small group and team clinical debriefings, clinical “prebriefs” and one on one interactions with attendings or non-evaluating faculty. The students also identified a need for faculty development to train faculty and residents to serve as role models and supports for difficult patient interactions.

What are the implications of these findings?

Students desire more direct guidance and support in dealing with emotional patient interactions. Providing formal and informal curricular opportunities throughout medical school to help guide medical students to identify, reflect upon and explore their emotions is recommended. Integrating a Social Behavioral Sciences curriculum across all four years of medical student training is a curricular strategy recommended by the IOM.

Editor’s note: Difficult patients are difficult for all of us no matter whether we are seasoned practitioners or medical students just starting out. While there is no perfect remedy for this circumstance, a multimodal and longitudinal approach that emphasizes attention to the difficult interaction in the moment or just after makes the most sense. (RR)