What A Recent Study Reveals About Implicit Bias In Medical Education

Is it possible that you have implicit bias?

Implicit bias (also known as unconscious bias) refers to unconscious attitudes or sterotypes about underrepresented minorities (URM), and/or unconscious sexism toward women. A recently published study in the Journal of the American Medical Association Internal Medicine offers some eye-opening insights on the potential impact of implicit bias in medical education.

Hill and colleagues say the objective of the study was “to examine the association between mistreatment and medical student sex, race/ethnicity, and sexual orientation."¹ The study was based upon survey responses from a total of 27,504 students who graduated from allopathic medical schools in 2016 and 2017. The demographic breakdown of study participants included:

• 13,351 female respondents(48.5 percent);
• 16,521 Caucasian respondents (60.1 percent);
• 5,641 Asian respondents (20.5 percent);
• 2,433 URM respondents (8.8 percent);
• 2,376 multiracial respondents (8.6 percent);
• 25,763 heterosexual respondents (93.7 percent); and 
• 1,463 lesbian, gay, or bisexual (LGB) (5.3 percent).¹

The Association of American Medical Colleges defines URM as meaning, “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”² In the JAMA article above, the authors did not specify their definition of URM.

The study authors and others describe the mistreatment of medical trainees as "a spectrum of abusive behaviors, including discrimination, assault, verbal abuse, and sexual harassment, and has been associated with burnout, depression, alcohol abuse, increased cynicism, and medical school attrition.”^1,3-5

The results from the study by Hill and coworkers reinforce that the journey toward our professional and societal ideals remains unfinished. 

Over 28 percent of female students reported discrimination based on gender in comparison to 9.4 percent of male students.¹ 

Over 23 percent of URM students, 15.7 percent of Asian students and 11.8 percent of multiracial students reported discrimination based on race/ethnicity in comparison to 3.8 percent of Caucasian students.¹ 

Over 23 percent of LGB students reported discrimination based on sexual orientation in comparison to 1 percent of heterosexual students.¹

Nearly 41 percent of female students experienced at least one episode of mistreatment in comparison to 25.2 percent of male students.¹ There was also a higher proportion of female students (17.8 percent) who had two or more episodes of mistreatment in comparison to 7 percent of male students.

Thirty-eight percent of URM students, nearly 33 percent of multiracial students and nearly 32 percent of Asian students noted at least one episode of mistreatment in comparison to 24 percent of Caucasian students.¹ Two or more episodes of mistreatment were reported by 16.3 percent of URM respondents, 11.3 percent of multiracial students, 10.7 percent of Asian students and 4.9 percent of Caucasian students. 

In comparing the experience of LGB students to heterosexual students, researchers found that 43.5 percent of LBG students had at least one episode of mistreatment in comparison to 23.6 percent of heterosexual students.¹ Two or more episodes of mistreatment were cited by 16.4 percent of LGB students in comparison to 3.6 percent of their male, white and heterosexual counterparts.

Taking A Closer Look At The Potential Of ‘Near-Peer’ Mentoring

Practical measures to recognize and address implicit bias in medical education (including podiatric medical education) are essential "to promote diversity, equity, and inclusion in medical education.”¹ 

Youmans and colleagues presented a measure to address implicit bias in medical education through near-peer mentorship.⁶ The lead author Quentin R. Youmans, MD, an internal medicine resident at the time, initiated the Student to Resident Institutional Vehicle for Excellence (STRIVE) at the Northwestern University (NU) Feinberg School of Medicine (FSM) in 2016. This school educates approximately 650 medical students and trains 1,200 residents and fellows each year. The STRIVE mentorship program consists "of 3 pillars of programming: medical school curriculum review sessions, panel discussions, and social events for medical students."⁶

After three years, the program's evaluation consisted of a seven-item survey with 35 of 151 eligible (23 percent) URM residents participating as mentors for an average of 50 of 110 eligible (45 percent) URM medical students annually.⁶ According to the study authors, 20 out of 32 (63 percent) eligible resident mentors completed the program’s evaluation survey. The study authors reported that “Ninety-five percent (19 of 20) of survey respondents agreed that STRIVE made them a better mentor; 90 percent (18 of 20) reported that they would have appreciated an equivalent program during their medical school training, and 75 percent (15 of 20) agreed that the program helped them address the challenges of underrepresentation in medicine."⁶

Could a near-peer mentoring program for podiatric medical students be a valuable resource to URM and women? Would an unintended consequence from such a program be professional URM and female leaders' development during their residency program by serving as mentors? What if a mentorship training component for those participating in the program could further elevate their leadership skills? What effect would a profession-wide program like STRIVE have on student recruitment? How profound would the impact of such a program be on the podiatric profession at large?

Final Notes

Recognition of the existence of implicit bias is the first step. Listening to those affected is the second step. An action plan with defined goals and metrics is the third step. Finally, a retrospective analysis of such a program to build upon strengths and correct weakness is how we, as a collective family, ascend to a higher standard.

Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, and a Fellow of the American College of Foot and Ankle Pediatrics. Dr DeHeer is also a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.

References

1. Hill KA, Samuels EA, Gross CP, et al. Assessment of the prevalence of medical student mistreatment by sex, race/ethnicity, and sexual orientation. JAMA Int Med. 2020;180(5):653-665.
2. American Association of Medical Colleges. Underrepresented in medicine definition. Available at: https://www.aamc.org/what-we-do/mission-areas/diversity-inclusion/underrepresented-in-medicine . Accessed October 22, 2020.
3. Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The prevalence of medical student mistreatment and its association with burnout. Acad Med. 2014;89(5):749-754.
4. Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and correlates of reported medical student abuse. JAMA. 1992;267(5):692-694. 
5. Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin Jr DC. A pilot study of medical student "abuse": student perceptions of mistreatment and misconduct in medical school. JAMA. 1990;263(4): 533-537. 
6. Youmans QR, Adrissi JA, Akhetuamhen A, et al. "The STRIVE Initiative: A Resident-Led Mentorship Framework for Underrepresented Minority Medical Students." J Grad Med Ed. 2020;12(1):74-79.