Lots to comment upon. Again, I appreciate the (mostly) constructive and respectful posts from those on all sides of this discussion. Usually, threads like this end up being closed by this time.
As mentioned above, the relative difference in termination rates between races seems quite large, however the absolute difference is very small -- since the vast majority of residents graduate without difficulty. This doesn't mean that it's not a problem, but does impact how we evaluate it. Many have mentioned how this was not a problem in their programs -- which is good news obviously. But a small absolute difference like this isn't going to be noticeable to 99% of people -- you only see it when you look at population statistics.
It is: the black people admitted to medical schools tend to have lower scores than the asian people admitted to medical schools. For this we have pretty compelling objective data.
This is certainly true. Anyone who looks at the AAMC data can see a marked difference in MCAT test score averages -- 506 vs 513 in the latest data comparing Black and white matriculants. Since the standard deviation of both those metrics are 6 (I'm rounding all of these numbers for simplicity), this is a quite significant difference.
However, the MCAT is designed to predict how well people will do in medical school. It's certainly not perfect, some would argue it doesn't work well at all. Just because one group of people have a lower MCAT score than another doesn't necessarily mean that they will inherently do worse in medical school -- although it's also quite possible that they will. Even with this difference, I personally doubt this is the main driver of the difference we see. I realize I have no data to support this -- it's simply my opinion and it's no better than your opinion. My experience has been that USMLE score is a poor predictor of resident quality.
While I cannot answer the bigger question of why black people score lower on tests than asian people, I think it’s pretty obvious why the black people admitted to medical schools score lower than the asians admitted to medical school:
The black people who scored or would have scored as high or higher elected to pursue different fields than medicine. Their reasons for picking other fields may partly be related to a perception that they would face discrimination in the medical field, or possibly they found other paths (tech, finance) more lucrative and interesting.
This is a very interesting supposition. Do you have any data that supports it?
I don't need a double blinded randomized controlled trial to know that I need a parachute when I jump out of a plane.
Conveniently, one of these has been done:
Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial
Spoiler alert: it demonstrated no improved survival of wearing a parachute and jumping from a plane.
I don’t see a plausible explanation for how racism drives lower test scores other than that the URMs who would score higher simply aren’t applying to medical school. But of those that do apply, they clearly have lower knowledge base and lower aptitude as measured by the exams they took. Even if ills of society led to these inequities, it doesn’t alter the fact that the URMs entering med school do so with lower aptitude than others overall.
A common explanation is income. MCAT (and other exam) performance often tracks with familial income. Improved family finances often results in students not being required to work (so more time to study), better study tools. It may also result in an upbringing more supportive of good study habits -- it's really hard to help/support your kids academic goals if you're working 2 full time jobs. Although I'm sure plenty of parents do just that.
This is the conundrum -- we use MCAT as a predictor of performance in medical school, as a way to measure aptitude. If someone's life circumstances lead to a lower score despite an equivalent aptitude, then that seems an unfair process. But if someone's aptitude is in fact lower, then giving them a boost due to their life experiences also seems unfair. And life isn't fair, so there isn't a good way to fix this.
You’re right that the resident dismissals have little to do with test scores - most ent residencies don’t care much about ITE scores at all. I definitely know it wasn’t the issue in the linked article. I do think that it probably impacts the numbers reported by ACGME though, and it would be really easy to control for usmle and mcat scores and see if the attrition rate changes. In some ways, the fact those data are just sitting there and acgme hasn’t analyzed it suggests they probably did but didn’t want to publish what would be a highly unpopular result.
Where I think implicit bias drives attrition is when residents get in trouble. Not only is there the potential for faculty to see them as other, but they often lack the availability of good mentors who can help them remediate. I can think of one URM resident I saw get into hot water as an intern and who has since bounced back beautifully - a key factor was a URM faculty who took him under his wing, gave him assigned reading and met frequently to go over material and get him up to speed. I can imagine if he were in another program without such a faculty member, things may have gone differently.
Agreed on both points. I would like to the the exam metric data for the ACGME data. And it's quite possible that some of the difference we are seeing is that residents of all races get into remediation trouble at equal rates (no way to know this), but end up with a difference in terminations due to the issues you mention. Many would call that "systemic racism" - no one is trying to be racist, but the system is stacked against minorities.
Even if URMs are being admitted with worse MCAT scores/GPA it also begs the question whether or not they're receiving adequate support to "catch" up to their peers with higher MCAT/GPAs. Not to mention URMs usually having a different "cultural mindset" that might not match their usually white PD/attending expectations. This is one of the reasons they encourage minorities into leadership/mentorship positions so they can provide their own "cultural viewpoints" into the mix
This is also a very interesting point / issue. It also raises the question of how much deficiency residency programs should need to remediate. If a new intern is quickly discovered to be "worse than a 4th year sub I" in their performance, is it our ethical responsibility to remediate that? Or can we demand some minimum level of performance in our trainees / employees and hold them to that standard? And how to we measure success? Let's say the intern mentioned above, 6 months into internship, is now caught up to where an intern would be expected to be on day 1. Is that success? Should we extend them for a whole 6 months or even a year? Or do we decide they just don't meet our standards? There is no correct answer, and I expect programs will differ in their viewpoints -- and the impact of this on co-residents may be very different in programs of varying sizes and specialties
We will have to agree to disagree. One person in power can absolutely unilaterally make a case for dismissing someone. The due process requirements are non existant. This isnt a criminal trial. Residency is a contract, you give enough notice, I do not have to give you a reason why I am firing you. Residency programs abuse this. Try reporting your hours accurately and see if you dont get ****-canned. Classic cases of retaliation. I am not saying your examples do not exist. There are absolute sociopaths that need to be dismissed but my examples exist not infrequently.
I would encourage you to read through any program’s handbook and policies from their ACGME office about the process for terminating a resident. There is absolutely a due process, just different from that of the criminal justice system. There are some offenses that trump due process, but most things require some kind of written notice, remediation, etc.
I’m sure some retaliation has happened, but it’s exceedingly rare. No matter how much one person hates a resident, you still have to justify your decisions to all your fellow faculty. If you try to can someone they all think is great, it could backfire and you might find yourself having a meeting with your chairman.
It also creates a big risk for your program as too many firings will dissuade top applicants from applying for a few cycles. Privately I’ve heard this from a few faculty that they started dropping lower on their rank list after terminating a couple residents.
I'm going to agree that firing a resident, although not easy, also isn't all that impossible. Once a resident is placed under closer scrutiny (which is often required due to patient safety concerns), addiitional errors and problems are almost certain to be found. This would be true of anyone. Programs that want to get rid of residents can compile these reports and work with HR towards termination. The due process of GME is almost always a review of the "process" -- did you give the resident an adequate warning and chance to improve. It's very difficult for the GME office or other PD's (whom are usually called upon to staff any appeal / grievance process) to assess clinical skills. If the surgery PD says the resident is a klutz in the OR, and they have examples, there is no way for me to assess the validity of that.
My opinion is this is a multifactorial issue. Med school/residency is hard some laggards will drop out.
1. From a stats standpoint, under represented minorities tend to have lower hard stat numbers
2. There is racism in isolated instances by not so nice people but I highly doubt there is systemic racism. So yes, they have to deal with this.
3. Growing up under represented, they have dealt with racism thus more hypersensitive when the situation pop up that was not intended to be racism.
4. They typically grew up in a less educated family and an economically lower rung thus adding to the stress of med school/residency. Try going through med school when you have to take the bus to class b/c you can not afford a car or your car breaks down all the time.
5. You have less that looks, acts, grew up like you thus there will be a level of isolation. Its life, people tend to hang around people who are similar.
Add this all together and a few more minor stuff, then you get a higher failure rate.
There were many times when the attendings, upper levels got on me. I am sure I have had things said that could very well been perceived as racist if I were an URM.
Interestingly, in #2, you state that you "highly doubt" systemic racism is at play.
#3-#5 are what I would consider "systemic racism". As mentioned earlier in this thread, this is a common point of disagreement. Systemic racism, by most definitions, does not mean "lots of people are racist in the system". It means that despite well meaning people in the system, the rules / processes / culture of the system impacts minorities in a negative way. Black residents having a lack of good mentors is a classic example of systemic racism.
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The ACGME data presented is interesting, but doesn't "prove" anything. Most likely the difference is due to a mixture of factors, many mentioned on this thread. It's worth exploring further to see. No amount of further exploration is going to definitively determine the cause of the difference, but it may shed more light on it.
There may be other explanations. The ACGME data is not actually on residents whom were terminated / fired. We simply report to the ACGME residents who left training before completion. It's possible that Black residents choose to change specialties of their own volition more than while residents. Although I doubt this is the explanation (mainly because of my own experience), I realize that my experience is too small to see a population difference like this. Perhaps because Black residents have less mentors / role models, as they progress with training and get exposed to more people they see a different career pathway more frequently.
In the end, I worry that the actual cause is as above -- that minority residents when placed in a remediation plan may end up in a "death spiral" more frequently than white residents. There are all sorts of reasons this may be -- less mentors / someone willing to take them under their wing, they may on average be of lower socioeconomic means which might impact their ability to perform (i.e. may have increased distractions outside of work), or implicit bias in those in leadership positions. Someone gave
@VA Hopeful Dr an extra chance. The decision to do so is very subjective, and our inherent implicit biases may impact these types of decisions. Realizing this may help fix the problem -- programs asking themselves "why is this resident struggling?", and trying to assess resident performance as a group which helps mitigate against biases.
