How Small Differences in Assessed Clinical Performance Amplify to Large Differences in Grades and Awards: A Cascade With Serious Consequences for Students Underrepresented in Medicine

Abstract

While students entering medical schools are becoming more diverse, trainees in residency programs in competitive specialties and academic medicine faculty have not increased in diversity. As part of an educational continuous quality improvement process at the University of California, San Francisco, School of Medicine, the authors examined data for the classes of 2013-2016 to determine whether differences existed between underrepresented in medicine (UIM) and not-UIM students' clinical performance (clerkship director ratings and number of clerkship honors grades awarded) and honor society membership-all of which influence residency selection and academic career choices.This analysis demonstrated differences that consistently favored not-UIM students. Whereas the size and magnitude of differences in clerkship director ratings were small, UIM students received approximately half as many honors grades as not-UIM students and were three times less likely to be selected for honor society membership.The authors use these findings to illustrate the amplification cascade, a phenomenon in which small differences in assessed performance lead to larger differences in grades and selection for awards. The amplification cascade raises concerns about opportunities for UIM students to compete successfully for competitive residency programs and potentially enter academic careers. Using a fishbone diagram, a continuous quality improvement root cause analysis tool, the authors contextualize their institutional results. They describe potential causes of group differences, drawing from the education disparities literature, and propose interventions and future research. They also share countermeasures adopted at their institution and encourage other medical schools to consider similar exploration of their institutional data.

Differences in Narrative Language in Evaluations of Medical Students by Gender and Under-represented Minority Status

“…Research on performance assessments suggests that small differences in assessment can result in larger differences in grades and awards received-a phenomenon referred to as the Bamplification cascade.^Teherani et al illustrate the presence of this phenomenon among URM and non-URM students in undergraduate medical education. 38 The amplification cascade holds major implications for residency selection and ultimately career progression that can disproportionately affect students from underrepresented groups. Our study has limitations.…”

Interrupting Microaggressions in Health Care Settings: A Guide for Teaching Medical Students

“…The root causes of this cascade include experiences such as exposure to microaggressions from peers, faculty, and patients, as well as racism. [10][11][12][13] A curricular forum for UIM learners to discuss experiences of discrimination may benefit their wellbeing. Krieger and Sidney found that "individuals belonging to groups subjected to discrimination may be at lower risk of elevated blood pressure if they are able to articulate, rather than internalize, their experiences of discrimination."…”

Racial Privilege and Medical Student Awards: Addressing Racial Disparities in Alpha Omega Alpha Honor Society Membership

“…This type of investigation was recently completed by the University of California, San Francisco School of Medicine (UCSF), which found that racial/ethnic minority medical students were not only historically less likely than White students to be selected as AOA members, but that racial/ethnic minority students were less likely to receive ratings of honors on their clinical clerkship performance evaluations. 27 Similar studies have shown that racial/ethnic minority medical students are described less favorably than their White peers in the written comments on performance evaluations, even when controlling for standardized measures of academic performance. [28][29][30] Third, chapters could ensure their leadership is appropriately diverse to reduce bias when choosing and mentoring members.…”