Implicit Bias and the Association of Redaction of Identifiers With Residency Application Screening Scores

Abstract

IMPORTANCE Diversity in the ophthalmology profession is important when providing care for an increasingly diverse patient population. However, implicit bias may inadvertently disadvantage underrepresented applicants during resident recruitment and selection.OBJECTIVE To evaluate the association of the redaction of applicant identifiers with the review scores on ophthalmology residency applications as an intervention to address implicit bias. DESIGN, SETTING, AND PARTICIPANTSIn this quality improvement study, 46 faculty members reviewed randomized sets of 462 redacted and unredacted applications from a single academic institution during the 2019-2020 ophthalmology residency application cycle.INTERVENTIONS Applications electronically redacted for applicant identifiers, including name, sex or gender, race and ethnicity, and related terms. MAIN OUTCOMES AND MEASURESThe main outcome was the distribution of scores on redacted and unredacted applications, stratified by applicant's sex, underrepresentation in medicine (URiM; traditionally comprising American Indian or Alaskan Native, Black, and Hispanic individuals) status, and international medical graduate (IMG) status; the application score β coefficients for redaction and the applicant and reviewer characteristics were calculated. Applications were scored on a scale of 1 to 9, where 1 was the best score and 9 was the worst score. Scores were evaluated for a significant difference based on redaction among female, URiM, and IMG applicants. Linear regression was used to evaluate the adjusted association of redaction, self-reported applicant characteristics, and reviewer characteristics with scores on ophthalmology residency applications. RESULTSIn this study, 277 applicants (60.0%) were male and 71 (15.4%) had URiM status; 32 faculty reviewers (69.6%) were male and 2 (0.4%) had URiM status. The distribution of scores was similar for redacted vs unredacted applications, with no difference based on sex, URiM status, or IMG status. Applicant's sex, URiM status, and IMG status had no association with scores in multivariable analysis (sex, β = -0.08; 95% CI, -0.32 to 0.15; P = .26; URiM status, β = -0.03; (95% CI, -0.36 to 0.30; P = .94; and IMG status, β = 0.39; 95% CI, -0.24 to 1.02; P = .35). In adjusted regression, redaction was not associated with differences in scores (β = −0.06 points on a 1-9 scale; 95% CI, -0.22 to 0.10 points; P = .48). Factors most associated with better scores were attending a top 20 medical school (β = −1.06; 95% CI, -1.37 to -0.76; P < .001), holding an additional advanced degree (β = −0.86; 95% CI, -1.22 to -0.50; P < .001), and having a higher United States Medical Licensing Examination Step 1 score (β = −0.35 per 10-point increase; 95% CI, -0.45 to -0.26; P < .001). CONCLUSIONS AND RELEVANCEThis quality improvement study did not detect an association between the redaction of applicant characteristics on ophthalmology residency applications and the application review scores among underrepresented candidates at this institution. Although the s...

Black Physicians’ Experiences with Anti-Black Racism in Healthcare Systems Explored Through An Attraction-Selection-Attrition Lens

“…The most significant increases were among Black physicians selected to be interviewed. Similarly, Pershing et al (2021) found that with a holistic approach, the redaction of racial identifiers (e.g., names) was not associated with a difference in application scores for interviews between Black physicians and White physicians.…”

“…Additionally, all interviewers should use rating forms, a set of clearly defined job performance-related questions (to avoid illegal questions), and standardized performance-based criteria with a scoring rubric (Consul et al, 2021;Gardner et al, 2018). We also suggest blinding reviewers to academic metrics and photographs prior to the interview to ensure the risk of bias is reduced (Capers, 2020;Pershing et al, 2021). Capers et al, (2018) saw a significant increase in the number of Black physicians selected after implementing the strategies outlined above.…”

Gender bias in academic medicine: a resumé study

“…However, anonymising job applications can have unpredictable effects, with some studies finding that the practice resulted in increasing women’s chances of interview, and others finding a reduced chance [ 21 , 22 ]. An investigation of the effects of anonymisation on recruitment to an ophthalmology residency programme found no significant effect on applicant scores overall or specifically for female candidates [ 16 ]. When applications are anonymised, reviewers can seek implicit signals to categorise applicants according to gender, and in doing so, use stereotypes of employment patterns and communications styles, thus activating biases which the anonymisation procedure sought to suppress [ 21 ].…”

“…Gender-blinding is an attractive strategy because it removes the source of bias, and does not disadvantage other groups of candidates [ 14 ]. This strategy has been shown to be successful in fields such as astronomy and music [ 14 , 15 ], but other studies in ophthalmology and molecular biology have found no effect [ 16 , 17 ] and overall, evidence is limited [ 18 ]. We sought to investigate its effectiveness in recruitment to an early career training programme for junior doctors, the Academic Internship Track (AIT).…”

Beyond Implicit Bias to Explicit Action

“…Diversifying residency training programs must come with departmental prioritization and commitment to diversity, equity, and inclusion. In this issue of JAMA Ophthalmology , Pershing et al present data on implicit bias and the association of redaction with review scores on residency application screening. Faculty reviewed randomized sets of redacted and unredacted applications and found no significant differences in review scores of redacted vs unredacted applications based on applicants’ sex, underrepresented in medicine (URiM) status, or international medical graduate status.…”