Skip to main content
main-content
Top

Tip

Swipe om te navigeren naar een ander artikel

Gepubliceerd in: Perspectives on Medical Education 1/2022

Open Access 29-12-2021 | Guidelines

The do’s, don’ts and don’t knows of redressing differential attainment related to race/ethnicity in medical schools

Auteurs: Molly Fyfe, Jo Horsburgh, Julia Blitz, Neville Chiavaroli, Sonia Kumar, Jennifer Cleland

Gepubliceerd in: Perspectives on Medical Education | Uitgave 1/2022

share
DELEN

Deel dit onderdeel of sectie (kopieer de link)

  • Optie A:
    Klik op de rechtermuisknop op de link en selecteer de optie “linkadres kopiëren”
  • Optie B:
    Deel de link per e-mail
insite
ZOEKEN

Abstract

Introduction

Systematic and structural inequities in power and privilege create differential attainment whereby differences in average levels of performance are observed between students from different socio-demographic groups. This paper reviews the international evidence on differential attainment related to ethnicity/race in medical school, drawing together the key messages from research to date to provide guidance for educators to operationalize and enact change and identify areas for further research.

Methods

Authors first identified areas of conceptual importance within differential attainment (learning, assessment, and systems/institutional factors) which were then the focus of a targeted review of the literature on differential attainment related to ethnicity/race in medical education and, where available and relevant, literature from higher education more generally. Each author then conducted a review of the literature and proposed guidelines based on their experience and research literature. The guidelines were iteratively reviewed and refined between all authors until we reached consensus on the Do’s, Don’ts and Don’t Knows.

Results

We present 13 guidelines with a summary of the research evidence for each. Guidelines address assessment practices (assessment design, assessment formats, use of assessments and post-hoc analysis) and educational systems and cultures (student experience, learning environment, faculty diversity and diversity practices).

Conclusions

Differential attainment related to ethnicity/race is a complex, systemic problem reflective of unequal norms and practices within broader society and evident throughout assessment practices, the learning environment and student experiences at medical school. Currently, the strongest empirical evidence is around assessment processes themselves. There is emerging evidence of minoritized students facing discrimination and having different learning experiences in medical school, but more studies are needed. There is a pressing need for research on how to effectively redress systemic issues within our medical schools, particularly related to inequity in teaching and learning.

Definitions of do’s, don’ts and don’t knows

Do’s
Educational activity for which there is evidence of effectiveness
Don’ts
Educational activity for which there is evidence of no effectiveness or of harm (negative effects)
Don’t knows
Educational activity for which there is no evidence of effectiveness

Introduction

In essentially all societies some groups hold more privileges or social resources (power, status, wealth, and opportunity) than others, leading to inequality between groups [1]. Privilege is then maintained and reproduced by norms, assumptions and systems of power. The systematic, or structural, inequity of power and privilege create differential attainment. Differential attainment refers to unexplained variation in average (not individual) levels of performance on educational assessments between students from different societal groups. These students also report different experiences of education (see later for further discussion).
While student socio-demographic characteristics are statistically correlated with differential outcomes, these should not be interpreted as causal. It is the experience of minoritization (defined later) that is likely causally associated with differential attainment, not the socio-demographic characteristics themselves [24]. Interpreting causality based on student demographic characteristics contributes to deficit thinking [2] in which students from lower performing groups are seen as in some way deficient due to their backgrounds, even when acknowledging the social and institutional drivers of minoritization for these identities.
Minoritization occurs in medicine, which privileges some people, cultures and practices above others [35]. As with education generally [68], those who are not from privileged groups are often disadvantaged in their educational experiences and outcomes. Differential attainment in medical education is evidenced across various intersecting characteristics such as ethnicity (and race) [914], age [11, 12], gender [11, 15, 16] and disability/neurodiversity [17, 18]. Differential attainment is observed across multiple types of outcomes, including clinical assessments [10, 14], timely course completion [11], clerkship grades [19], in course grade point average [13], narrative descriptions of student performance [20], multiple-choice exams [14] and honour society inductions [9, 12]. Differential attainment in medical education can hinder individuals’ learning experiences and career progression [14, 21, 22]; limit diversity of the health workforce [2325]; and ultimately impact on patient care [26].
Synthesizing the literature relating to differential attainment in medical education across all minoritized groups was too broad for any one review, particularly given the structures which underpin inequality vary across contexts [27]. We chose instead to focus on differential attainment related to ethnicity/race because of the ongoing crisis of racism: we were preparing these guidelines during a time of turbulence and heightened awareness of systemic racism. The Covid-19 pandemic exacerbated health and other inequalities [28] and the Black Lives Matter movement had increased awareness of racial inequality and white privilege across the globe [29]. This paper was therefore written at a time in which our understanding and awareness of racial inequality was rapidly evolving resulting in increased responsiveness, refined conceptualizations and new terminology. Moreover, the dominant descriptions in the literature were associated with ethnicity/race. Note that race and ethnicity are not causally related to differential attainment, but rather reflect how privilege and discrimination manifest in educational settings and practices [3]. Moreover, race and ethnicity are socially constructed and contested constructs that tend to be defined by those in power in a particular context [27, 30]. The result is that racial and ethnic categories are imprecise and context dependent, shifting over time and between settings [27]. This is reflected in the literature on differential attainment: what groups are minoritized varies between studies and contexts.

Aim

In many countries there is an ethical and legal imperative to address inequalities in medical education [31, 32]. To aid this endeavour, in this paper we review the international evidence on differential attainment related to ethnicity/race in medical school, drawing together the key messages from research to date to provide guidance for educators to operationalize and enact change and identify areas for further research. Specifically, we present evidence-based guidelines for practices in assessment and the learning environment to support equity of experience and attainment at medical school. We preface our interpretation of the literature with a synthesis of how differential attainment is situated in the literature, as a necessary foundation for providing guidelines for its redress.

Methods

These guidelines are based on consensus of expert opinion across medical educators based in five countries, all of whom have published scholarship related to differential attainment [5, 3338]. Authorship opinion identified areas of conceptual importance within differential attainment (learning, assessment, and systems/institutional factors) which were then the focus of a targeted review of the literature on differential attainment in medical education and, where available and relevant, literature from higher education more generally. We utilized an iterative process similar to that outlined in previously published papers for this Guidelines series [39, 40].
Our review of the literature was guided initially by the concept of fair assessment, as articulated by Lucey [41]: “Equity in assessment is present when all students have fair and impartial opportunities to learn, be evaluated, coached, graded, advanced, graduated, and selected for subsequent opportunities based on their demonstration of achievements that predict future success in the field of medicine, and that neither learning experiences nor assessments are negatively influenced by structural or interpersonal bias related to personal or social characteristics of learners or assessors” (p. 599). However, given differential attainment is created by structural inequalities we kept our search broad, to ensure consideration of learning and systems/institutional factors.

Our focus

Our review focused on differential attainment related to ethnicity/race in medical school. Medical school is the first formal stage of medical training and unequal attainment that manifests at this stage underpins a growing chasm of disparities throughout the continuum of medical training and practice [21, 42]. Addressing differential attainment in medical school is thus critical to achieving equity throughout the continuum of medical training and practice.
Selection is positioned as the first assessment of medical school [43] and differential attainment is very relevant to being able to apply for or be accepted to medical school. However, issues related to the fairness of selection processes have been reviewed elsewhere [43]. Our focus in this paper was medical students (that is, those individuals who have been successful in obtaining a place at medical school), and the assessments and learning environment once in medical school.

Terminology

Many different terms are used in the literature to categorize groups from different racial and ethnic backgrounds (e.g., BME [Black and Minority Ethnic], BIPOC [Black, Indigenous and People of Colour]). In this paper, we employ the more contemporary term “minoritized”, defined by Selvarajah et al. [27] as “individuals and populations, including numerical majorities, whose collective cultural, economic, political and social power has been eroded through the targeting of identity in active processes that sustain structures of hegemony.” (p. 3). This term recognizes power imbalance and acknowledges systemic acts of discrimination, exclusion and omission across multiple settings. Differential attainment and minoritization are not the same: rather differential attainment is one of a number of potential consequences of minoritization and can contribute to further minoritization.
A variety of institutional and social factors have been suggested to underpin minoritization and differential attainment in higher education: structural inequalities related to power and race [44, 45], discrimination and microaggressions [44, 46], assessment practices [14, 47], relationships and access to social capital (resources and opportunities) [48, 49] and the nature of the learning environment [44, 50, 51]. Although we present our findings in 13 individual “Do, Don’t and Don’t Know” categories, it is important to note that, for students from minoritized backgrounds, these categories and the structural and systemic factors underpinning differential attainment intersect and overlap [52].
The terms differential awarding instead of differential attainment, and awarding gap rather than attainment gap, have been proposed recently as a way to shift the focus more toward institutional responsibility [21, 53]. However, for the purposes of this paper we kept the arguably more controversial term of differential attainment. Our reasons for doing so were twofold. First, this is the term used widely in the literature reviewed. Second, the message of shifting focus comes out clearly from the Guidelines.

Process

Following agreement upon the topic and the definitions of fairness in assessment and minoritization provided above [41], each author conducted a review of the literature relevant to the topic and definitions discussed above, then used that review to inform a proposal for guidelines. While this is not a systematic review, for transparency we provide an overview of how we identified relevant literature. Searches were conducted in PubMed and Google Scholar, using the terms “assessment”, “medical” in combination with “bias”, “culturally responsive assessment”, “differential attainment”, “disparities”, “diversity”, “ethnicity”, “ethnic minorities” and “fairness”, and combinations thereof. We set no start date to the search. Searches were conducted iteratively between June 2019 and June 2021. Authors also drew on their knowledge of the literature to ensure all relevant papers were included. While we focused on identifying empirical studies (qualitative and quantitative), we also drew on perspective pieces to help identify how differential attainment related to ethnicity/race has been conceptualized in the literature. Our own limitations meant we searched only for English-language papers. Many of the papers were quantitative, particularly those examining assessment practices and processes. However, the papers which focused on educational experiences were more diverse, reflecting quantitative, qualitative and mixed methods approaches. Overall, we drew on 124 papers to develop these guidelines.
MF then compiled an initial list of Do’s, Don’ts and Don’t Knows with input from the wider team. Each author continued to add to and refine this list. Through discussions in person, via email and by Zoom or Skype, the lists were reviewed and refined until we reached consensus on the Do’s, Don’ts and Don’t Knows. We took care to ensure that “Don’ts” were not just the opposite of “Do’s”, and vice-versa. When evidence was lacking or conflicting, an item was allocated to the “Don’t Know” category. This is a valuable category in terms of setting future research agendas.
The paper was developed as a group effort, with each author taking a number of items from the original list, exploring the wider education literature on each of these items, then producing a summary and critique of that literature. These narratives were drawn together in a draft document by MF and JH. All authors then contributed further comments and edits, and reached consensus through discussing the narrative and rating for each guideline (see Table 1). The evolving drafts of the document were edited extensively by JC.
Table 1
Criteria for strength of recommendation
Strong
A large and consistent body of evidence
Moderate
Solid empirical evidence from one or more papers plus consensus of the authors
Tentative
Limited empirical evidence, but clear consensus of the authors

Positionality and reflexivity

This review is a qualitative synthesis of the literature and as such it was important for us to reflect on our backgrounds and social worlds [54], and how these may have shaped our interpretation of the literature. Our identities are nuanced and intersectional in relation to ethnicity, gender, learning experiences and disciplinary backgrounds, research interests and personal life courses [5557]. We are now based in five countries, each of which have different medical education and training systems as well as representing very different contexts in terms of power and privilege, and how access and opportunity are distributed in society [1]. These differences led to lively discussions on the complex topic of differential attainment, as well as (sometimes painful) individual and collective critiques of our own consciousness of structural inequality and biases, convergences and differences [54].

Results

We drew from the research to gain insight into how differential attainment manifests, how it is experienced by medical students and what strategies, or approaches, can be used to redress inequalities. We first describe how ‘attainment’ is situated in the literature, interrogate how race/ethnicity are conceptualized and operationalized in medical education research, and very briefly summarize the research describing the causes of differential attainment. We then present our guidelines (Do’s and Don’ts) based on evidence for strategies and approaches to redress differential attainment. Lastly, we present our ‘Don’t Knows’ as priority issues needing further development and research.

Attainment

Attainment in education is a broad concept, including performance on educational assessments, achieving a degree, degree outcomes and continuation into postgraduate study and employment [47, 48].
Within medical education, practices of assessment and approaches to research into assessment comes from a variety of epistemic positions. Much of the research that quantifies assessment outcomes and differences in these (differential attainment) is rooted in positivist and post-positivist epistemologies. On the other hand, there is also prevalence of assessment practices that emphasize plurality in views, multiple perspectives, and the validity of subjectivity (e.g. [49, 50]). Within this paper we draw on research from a range of philosophical positions and these guidelines necessarily reflect the philosophical stances of the research on which they are based.

Conceptualization of race and ethnicity in the research on differential attainment

As stated earlier, our focus is the relationship between attainment and ethnicity/race at medical school. The quantitative research on differential attainment in medical education focuses on how students minoritized on the basis of race/ethnicity perform compared with a reference group. Differential attainment between racially/ethnically minoritized and norm groups (see earlier) is reported across multiple types of outcomes, including clinical assessments [10, 14], timely course completion [11], clerkship grades [19], grade point average [13], narrative descriptions of student performance [20], multiple-choice exams [14] and honour society inductions [9, 12]. Although attrition from university programmes is often used as an indicator for differential attainment in university programmes [51], only a few of these studies have looked at course completion as an outcome measure because attrition from medical school is relatively low [10, 13].
Which identities are minoritized in studies varies according to the institutional and societal context. For example, one of the aforementioned studies, from New Zealand, investigated academic outcomes across “Maori”, “Pacific”, and “non-Maori non-Pacific” students [13] while one from the USA used a grouping of “Black or African American, Hispanic, American Indian/Alaska Native, or Native Hawaiian/Pacific Islander” [21]. However, while the groups compared are context-specific, the patterns are common. There is a consistent pattern of minoritized medical students having lower performance on assessments globally (e.g. [915, 20, 21, 36, 48, 51]).
In most studies student assignment into a group is via self-identified race and ethnicity, often through self-selection into pre-determined categories based on skin colour, and geographic or cultural identity (e.g., Black Caribbean). These self-identifications of race are then often amalgamated by researchers into heterogeneous categories, with categories such as “white” or “Western” often used as the norm reference group (e.g. [1315, 37]). The reasons for this are ostensibly statistical: where there are many groups with small numbers, analysis is not possible without re-categorization. While pragmatic, this approach has been criticized for failing to recognize the diversity and intersectionality of student identities and experiences within such broad groupings [47, 50, 56, 57]. Moreover, decisions around assigning a “norm” and “minoritized” groups are not neutral, and likely reflect the positionality of the research team as well as the logistics of a dataset.
As we hope is clear in the introduction to this paper, inequalities and minoritization occur both inside higher education practices and within the wider societies in which medical schools are located. The complexity of institutional (e.g., assessment and teaching approaches) and societal practices (e.g., poverty and longitudinal educational opportunity), norms, privileges and biases that contribute to differential attainment make it challenging to understand the fundamental causes of differential attainment and what actions will effectively redress it. Nevertheless, based on analysis and collation of the literature, we bring our interpretation and understanding of pedagogical practices which seem to contribute and may need to be addressed in relation to differential attainment in minoritized medical students to the guidelines.
A summary of the 13 “Do’s, Don’ts and Don’t Know” guidelines is presented in Table 2. We have teased out how these guidelines individually have influence, but the bigger picture is derived from how they may inter-relate.
Table 2
Summary of guidelines, including strength of evidence and broad area of focus
 
Recommendations
Strength
Area of focus
Do’s
1
Ensure assessments are fair and defensible
Strong
Assessment
2
Use robust and recognized analytic approaches to scrutinize assessments and assessment data
Strong
Assessment
3
Sample broadly across assessment types and assessors to minimize bias
Strong
Assessment
4
Include the concept of ‘cultural validity’ in the design, development and review of assessments
Moderate
Assessment
5
Do recognize unequal privilege and power in the learning environment as causes of differential attainment and take steps to mitigate their negative impacts
Strong
Learning
6
Medical schools must take responsibility for their role in creating and perpetuating differential attainment
Strong
Systems/institutional level
7
Recruit and promote under-represented faculty
Strong
Systems/institutional level
Don’ts
8
Don’t assume that minoritized students will have the same exposure to and familiarity with particular assessment methods as their non-minoritized peers
Tentative
Learning
9
Don’t implement ‘diversity’ practices which place unacknowledged and unrewarded burdens on minoritized faculty and students
Moderate
Systems/institutional level
10
Don’t attribute to the individual what is systematic
Strong
Systems/institutional level
Don’t know’s
11
Are supportive interventions for specific groups effective in respect of assessment outcomes?
Assessment
12
To what extent do professionalism norms and assessments of professionalism discriminate against minoritized students?
Assessment
13
How can formal curricula influence differential attainment?
Learning

Do’s

Guideline 1.
Ensure assessments are fair and defensible (Strong)
Fairness is fundamental to good assessment yet remains elusive to define [5860]. We define fair assessments as those which offer learners similar or equitable opportunity to demonstrate their knowledge, understanding and competence with minimal impact from external factors, such as gender, race or ethnicity. Such external factors might be mediated by the test question context or assumptions in the case of written exams, or by examiner bias (implicit or otherwise) in the case of performance exams. Importantly, fairness does not mean or imply that assessments need to pose a similar challenge to every student; differential knowledge and understanding is a legitimate discriminator [58, 59]. In fair assessments, however, it will be the only significant discriminator.
Proactively ensuring valid and defensible assessments which minimize the impact of extraneous (or “construct-irrelevant”) factors on student performance by paying attention to the basic elements of assessment will be helpful in respect of fairness. Such factors traditionally include design, question writing, peer review, test construction, appropriate scoring and post hoc analysis [59], as well as blueprinting, adequate sampling, careful planning and a programme-level focus [60]. But each of these aspects of assessment carries certain epistemological assumptions and constructed notions which should also be interrogated in determining how fair assessments are, in the same way that discourses of ‘merit’ involve far-reaching assumptions and potential biases [61]. We propose that examination content and underlying assumptions must be routinely analyzed and reviewed to ensure they do not present inappropriate progression barriers for any group.
Guideline 2.
Use robust and recognized analytic approaches to scrutinize assessments and assessment data (Strong)
Assessment data should be routinely analyzed to identify differential attainment. Item response theory (IRT) can provide information about items (e.g., exam questions) which function differently across subgroups [6264]. One IRT approach, Differential Item Functioning (DIF), can be used to see if certain questions in a written or objective structured clinical examination (OSCE)-style examination explain group-level differences in performance [65, 66]. Where test questions discriminate between groups, these items can be revised or removed, and replaced with less biased questions. Recent studies have indicated that another IRT approach, Many Faceted Rasch Modelling (MFRM), can also be used to identify sources of error (e.g., examiner, domain and station) which may influence the student outcome [67]. These statistical approaches are used post hoc, after an assessment, and may offer opportunities to moderate marking. Whether this is possible or not will depend on the wider context. In some countries, information on personal characteristics (e.g., ethnicity, gender) is collected and protected but can be accessed for legitimate purposes which adhere to ethical and governance processes. In other countries, the legal stance is that information on ethnicity and race cannot be collected, thus meaning this type of research is not possible.
Guideline 3.
Sample broadly across assessment types and assessors to minimize bias (Strong)
There is ample evidence that assessor judgements involve a degree of subjectivity particularly in clinical assessments [6870], and examiner variability is a significant source of variability in OSCE scoring [7174]. Many (more positivist) studies have raised the possibility that examiner bias may be a contributing factor to minoritized students performing poorly on assessments [7577]. However, the outcomes of studies looking at examiner bias in medical education are inconclusive. A study in one UK medical school found that student ethnicity did not influence examiners’ scores or feedback [78]. Other studies have suggested that conscious or unconscious assessor biases can impact on the assessment process [79, 80], with one study concluding that “we cannot confidently exclude bias from the examiners in the way that they assessed non-white candidates” [81].
Alternative literature has explored the opposing idea that subjectivity should not and cannot be removed from assessment [8284]. Such literature acknowledges and accepts examiner variability as not only unavoidable, but also as a potential source of greater defensibility and validity of assessment judgements [84].
This perspective promotes the notion of broad sampling in assessment as a guiding principle in assessment systems. Broad sampling involves the conscious use of multiple assessments utilizing different assessors and on multiple occasions. This approach to assessment is a key cornerstone of programmatic assessment [83, 84], and has been shown in one study to reduce ‘ethnicity-related differences in grades’ [81]. While broad sampling cannot be expected to fully reduce any latent examiner bias, the use of multiple assessment moments may also expose discrepancies stemming from those judgements about students’ attainment [80]. Interestingly, we could not find any literature which directly investigated whether “broad sampling” of assessors should deliberately include “diverse assessors.” However, drawing on the literature more broadly indicates the need to do so [85].
Guideline 4.
Include the concept of ‘cultural validity’ in the design, development and review of assessments (Moderate)
This recommendation derives from wider literature which explores the impact of social background on academic attainment, with particular attention to the representation (or not) of minoritized students in assessment activities, and the way minoritized students view and interpret assessment tasks [86]. This guideline is related to Guideline 5 sharing the position that the nature of the students’ experience of the curriculum is central to their learning and attainment but focusing specifically on the nature of the assessment tasks themselves.
The concepts of culturally valid and responsive assessment [87, 88] challenge assumptions that a test designed for and implemented under standardized conditions is inherently fair or appropriate for all learners [89, 90]. Instead, (written and clinical) assessments should reflect the diversity of the test-taking population, minimizing the risk that students might feel excluded or alienated. This can be done by: considering the ethnic characteristics of people represented in assessments and whether there is any stereotyping of minoritized groups (unintended or otherwise); simulated patient and scenario ethnicity; the positioning of minoritized people in relation to majority members; and the inclusivity of the language used [59].
Minoritized students may have different experiences and different ways of viewing the world, or epistemologies, which impact on how they approach learning and respond to assessments [9193]. It is not acceptable to assume that the responsibility lies with minoritized students to exclusively “accommodate” their ways of knowing to assumed “normative” assessment practices [89, 94]. Accordingly, assessment review practices need to consider how items may be viewed from the minoritized perspective, both affectively and cognitively. Involving minoritized students and faculty in assessment planning and review may be one approach to address this issue [89] (but please see Guideline 9 for a caveat).
Guideline 5.
Recognize unequal privilege and power in the learning environment as causes of differential attainment and take steps to mitigate their negative impacts (Strong)
There is a strong and consistent body of literature describing discrimination faced by racially-minoritized medical students. This racism occurs at personal and structural levels.
At a personal level racism is experienced in the form of microaggressions [95, 96], stereotype threat [97] and harassment from peers, patients and faculty [98]. At a structural level, racism operates through biased curricula [99, 100], and knowledge production [3] in which Eurocentric knowledge and practices are valued above others.
Given the discrimination that minoritized students face, we must consider personal and institutional racism within the learning environment as causes of differential attainment. Indeed, a review of 28 studies concluded that minoritized students reported less positive learning environments and were more likely to experience racial harassment compared with non-minoritized students. Across these studies academic achievement was worse and academic progress slower for minoritized students [50]. More recent studies indicate that things have not changed notably in the 10 years since Orom and colleagues completed their review [95, 97].
What can we do differently in the future to lead to improvements? There are some studies exploring what might make a difference. Being part of an established social network and building relationships with faculty are correlated with (positive) medical student experiences and outcomes [101]. Having access to both formal and informal social networks are important building blocks for creating social capital [49, 102] and a sense of belonging [103, 104], a lack of which is also associated with poor achievement and discontinuation of studies [105].
Guideline 6.
Medical schools must take responsibility for their role in creating and perpetuating differential attainment (Strong)
Inequality in the broader societal context can impact on attainment within medical education. Minoritized students often carry a burden of historical disadvantage with them when they enter medical school [41]. Universities may further exacerbate this disadvantage through discriminatory systems and practices [48].
One example of this is “deficit thinking”, where there is an implicit or explicit assumption that minoritized students are in some way deficient and institutions hold minoritized students responsible for the inequalities and challenges they experience [2, 106]. As a starting point to addressing differential attainment, medical schools must seek to recognize and revise systemic deficit thinking, as this will allow them to become aware of and take responsibility for factors in their curricula, policies, learning environments and physical environments that contribute to discrimination and differential attainment [4]. There is, however, little practical guidance on how to do so—we hope these guidelines will go some way to helping medical schools reflect on their practices.
Guideline 7.
Recruit and promote under-represented faculty (Strong)
A diverse faculty can contribute to the creation of equitable inclusive structures and practices that will support equitable student outcomes [42]; bring diverse perspectives to curricula and assessments [48]; and provide representative role models.
The importance of learning from role models has long been recognized within medical education [107109]. Role models are influential in terms of career and specialty choice [110], developing clinical knowledge and skills, as well as understanding the culture of medicine [49, 111]. Students identify more strongly with role models who are similar to them in some way [112, 113] and there is value in having role models from the same ethnic background as students [114, 115]. However, diversity of ethnic backgrounds is often under-represented in faculty, especially in senior positions, giving rise to a paucity of role models for medical students [98, 116120]. We suspect, but do not know, that the lack of representation and role models within the broader learning environment may impact on the learning and performance of minoritized students [78, 121, 122].
Importantly, research shows that under-represented faculty also experience bias and discrimination [123, 124], and greater difficulty in achieving promotion and advancement [125128]. They are also more likely to feel isolated and less satisfied with their career, professional development and networking opportunities [123, 127, 129131]. Medical schools must consider how best to support under-represented faculty via, for example, support from senior leaders [127, 132], peer networking [127, 132], professional skills development [132] and mentoring programmes [112, 133135]. Campbell et al. [135] point out that faculty development initiatives for under-represented faculty must be complemented by initiatives that address inequalities in opportunities and recognition and foster an inclusive culture and environment [126]. Price et al. [131] advocate that institutions undertake a formal assessment of their ‘diversity climate’ in order to better understand and then inform organizational changes.

Don’ts

Guideline 8.
Don’t assume that minoritized students will have the same exposure to and familiarity with particular assessment methods as their non-minoritized peers (Tentative)
This guideline builds on the concept of sampling broadly across assessment types (Guideline 3) and specifically recognizes that educators cannot assume that minoritized students will have had the same exposure to and experience of particular assessment methods as their non-minoritized peers [41]. Differences in prior experience may impact on actual performance, and therefore may contribute to relative underperformance compared with students who are familiar with those methods [80, 120]. Greater use of formative assessments for minoritized students, to both improve familiarity with specific assessment formats and, arguably even more importantly, to alter minoritized students’ sense of agency with particular assessment systems and their own role in the learning process, may be helpful [87, 136].
Guideline 9.
Don’t implement ‘diversity’ practices which place unacknowledged and unrewarded burdens on minoritized faculty and students (Moderate)
Under-represented faculty (i.e., faculty from minoritized groups) are often called upon to work on diversity initiatives, mentor minoritized students and applicants, and serve on equity and diversity committees [132, 137]. Such activities are often not valued in terms of promotion, and time spent on such activities takes faculty away from pursuits which are more beneficial in terms of individual career progression [138]. This often-unacknowledged burden has been described as a ‘minority tax’ [128, 135, 137, 139141]. Minoritized medical students can also experience minority tax, feeling pressure to take part in activities such as mentoring or outreach activities for minoritized students [117]. It is challenging to balance engagement with minority taxation but, as per Guideline 6, change at a systems level is required so these activities are appropriately recognized and rewarded.
Other faculty can also address some of this unbalanced workload by challenging discrimination, supporting under-represented faculty and actively participating in initiatives to address lack of diversity amongst faculty and students [140, 141]. To contribute effectively in this way, faculty development could usefully include: understanding different forms of discrimination such as implicit bias and microaggressions [135]; learning how to challenge racism and examining everyday practices that reinforce existing power structures [103]; and mentoring minoritized students [137], engaging in critical reflection [142] and recognizing when to refer students to others [112].
Guideline 10.
Don’t attribute to the individual what is systematic (Strong)
As per Guideline 7, increasingly, differential attainment is recognized as a systemic issue and not an individual one [2, 106]. That prolonged disadvantage is an issue is unarguable. Yet historically, efforts at redress have too often focused almost exclusively on interventions that target the individual learner. For example, many schools have responded to this academic achievement divide between minoritized and non-minoritized students by establishing premedical school “enrichment”, gateway or pipeline programmes, to bridge the gap for minoritized students [143]. (Consideration of the assumptions of such programmes and how they may perpetuate deficit models is beyond the remit of this paper). However, as we hope is obvious so far, the past few decades have moved this conversation on to recognize that minoritization within medicine is itself an independent predictor of exam success. Therefore, systematic and structural changes need to take place, rather than merely focusing on individual student success. The terms differential awarding instead of differential attainment, and awarding gap rather than attainment gap have been proposed recently as a way to shift the focus more toward institutional responsibility [21, 53].

Don’t knows

Guideline 11.
Are supportive interventions for specific groups effective in respect of assessment outcomes?
Some educators and researchers argue for targeted interventions for specific groups to address differential attainment [79]. This is an approach which is relatively underutilized in medical education and training (see [144] for an exception) but is reported more extensively in the wider education literature. For example, studies have examined the efficacy of self-affirmation interventions in relation to assessment performance in ethnic minority groups [145, 146]. Another approach reported as effective in terms of addressing differential attainment is that of enhancing goal-directed conceptualization and action [147]. This approach aims to support minoritized students in challenging learning environments to enhance their motivation and self-regulation [148]. Again, however, while promising and encouragingly well-grounded in theoretical principles, neither self-affirmation nor goal-directed approaches/interventions have been tested empirically in minoritized medical students.
More generally, the onus is on medical schools to scrutinize routine assessment and other data to develop targeted strategies in areas of particular concern [149]. Extrapolating from Cleland et al. [150], it is then crucial to evaluate the impact of additional support for specific groups of students to identify what works, from whom and why in terms of assessment support.
Guideline 12.
To what extent do professionalism norms and assessments of professionalism discriminate against minoritized students?
As described earlier, there is growing evidence that cultural norms and values are embedded in assessment design and practice. If these reflect only the norms of the privileged group, this can result in biased assessments that lack cultural validity and may contribute to differential attainment. In particular, the assessment of professionalism in examinations is likely to reflect culturally embedded values about the practice of medicine [121]. For example, medical educators may have a white Eurocentric view of what clinical communication looks like or how empathy is expressed [116].
Although ethnicity is acknowledged to be a part of one’s personal identity [151], the understanding of the influence of race and ethnicity on the process of professional identity formation (PIF) and its impact on the assessment of professionalism is largely absent from published literature [141, 152154]. The wider literature suggests areas for further research. For example, socialization is critical in PIF [155]. Given minoritized students have less extensive peer and faculty networks (see Guidelines 6 and 8), it would be worth exploring if and how these may impact on their PIF and progression from student to physician. In trying to make sense of their race or ethnicity and becoming a member of an apparently “white” profession, minoritized students may struggle to see how they can conform to this stereotyped image of a doctor [156, 157] and may conceal or repress aspects of their racial or ethnic identity [138, 158] and/or experience tensions in trying to reconcile these and a new professional identity [159]. Conversely, if dominant professional norms are rejected in this process of PIF, this could have an impact on attainment and progression through medical education and training. Direct evidence is lacking, but in many countries doctors from minority groups tend to receive disproportionately more sanctions or warnings than those identifying as from the dominant group [160, 161]. Retrospective and prospective studies which examine patterns of performance and explore underlying reasons for differential attainment are needed.
Research is also needed to understand how aspects of student identity relate to experiences of minoritization within medical education [162], and how this in turn relates to differential attainment.
Guideline 13.
How can formal curricula influence differential attainment?
Research from higher education posits that curricula are important to redressing differential attainment [48]. Inclusive pedagogies and curricula are theorized to combat the centrality of whiteness and thus experiences of minoritization within higher education [3, 4, 163]. Two particular approaches are being implemented within medical education: inclusive curricula and removing racism from curricula.
Inclusive curriculum strategies aim to make curricula accessible and acceptable for all students [4]. These include “decolonizing” curricula by bringing different voices and knowledge sources into courses (epistemic pluralism) [4]. Some medical schools are actively undertaking work to ensure previously unheard voices (voices that legitimize issues of gender, race and class) within their curricula and to address issues such as ethnic biases in cases and teaching materials [34, 99, 164167]. Future research could examine the processes of strategy implementation [168] and strategy impact on the learning environment, student experience and differential attainment.
Throughout their curricula, medical schools teach directly and indirectly about race, ethnicity and health. Race-based medicine positions race as a biological variable that influences physiological functioning and thus becomes a basis for differential clinical care [169]. Biological conceptualizations of race, which are deeply embedded in medical education [99], contribute to institutional racism impacting on student learning, and ultimately racial health inequalities [99, 170]. “Anti-racist” curricula shift teaching about race as a biological variable to that of a social construct, thus prompting explanations about health inequalities that focus on equity and discrimination rather than spurious genetic explanations [99, 164, 171173]. There is the potential for anti-racist curricula to re-frame conceptions and misconceptions of race and racism, that impact on values, cultures and norms [163].
However, empirical evidence as to the effectiveness of curricular strategies to redress differential attainment is currently lacking.

Conclusion

Differential attainment is a complex, systemic problem reflective of unequal norms and practices within broader society and evident throughout assessment practices, the learning environment and student experiences at medical school linked to systems/institutional factors (Table 2). This paper summarizes what we currently know from the published literature and our own knowledge and experiences of differential attainment. These guidelines reflect the core values of education, highlighting the importance of fair and transparent educational policies, practices and structures, as well as our societal responsibility to learners and patients.
It is clear that the most convincing evidence is that around assessment processes themselves, arguably because this is the most tangible area to focus on in respect of addressing differential attainment. However, there are issues with some of this (mostly quantitative) research in terms of how learners are categorized, limiting granularity and knowledge. The evidence on minoritized students (and faculty) facing discrimination in their environment and different experiences is emerging, but more studies are needed and there is a pressing need for research on how to address systemic issues. We also suggest that further research should focus on those areas where the evidence for the recommendations is not strong or has not been researched over the longer term, where intuitively recommendations seem sensible, but have not been fully substantiated and explored, or those areas which have been identified as “Don’t Knows”.
The good news is that, as medical educators, we have increasing awareness of and expertise in practices that can address differential attainment and minoritization. Differential attainment is not just an issue for those involved in assessment: it must be tackled at an institutional level. Ultimately, decisions about differential attainment reflect institutional values and, therefore, clarifying those values is critical. Indeed, our intention is that this summary of the current state of differential attainment research will enable individuals, institutions and the medical profession to make more informed choices about how to support all learners. There is no simple way of doing so but we suggest that these guidelines can be the basis of critically examining (both quantitatively and reflexively) whether certain practices and structures privilege certain groups. The trajectory of reflection which will result from this exercise can be used to question “the given”, and by doing so “interrupt” complicity and ongoing reproduction of differential attainment and minoritization.
This is a growing area of research—there are far fewer studies on differential attainment in medical education than there are studies in, for example, remediation [39] or feedback [40] and thus and key questions remain unanswered. It is also important to note that we identified very few studies from low- and middle-income countries [110, 115] and all empirical studies on differential attainment originated from the USA, the UK, Canada, Europe and Australia. This may have been due at least to some extent to our search being limited to English-language publications but there does seem to be a global gap: medical schools in lower-income countries are either not publishing on differential attainment in medical education, not publishing in English and/or not publishing in journals listed in mainstream databases. This absence in the literature is important in terms of “how we construct the field of health professions education research: what we include or exclude, what we count or not, what we believe to be true or false, what we do or do not read, who speaks and who is silenced” (Paton et al., 2021, p. 6. [174]). The global medical education community knows little about differential attainment practices and ideals in low- and middle-income countries, and there is no opportunity to learn from different ways of thinking and doing.
However, we are optimistic that wider societal drivers, such as Black Lives Matter, are increasing awareness within medical education globally, and this increased awareness will lead to action and evaluation so that an update of this review in 10 years’ time will be able to synthesize many more studies. With change will come the need to evaluate change—not just in terms of outcomes for particular minoritized groups, but also to ensure we understand the processes of change and can monitor for any unintended consequences for certain individuals or groups. We make a plea for research approaches that capture the complexity and nuance of intersecting identities and how these may influence the experience of education and assessment.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
share
DELEN

Deel dit onderdeel of sectie (kopieer de link)

  • Optie A:
    Klik op de rechtermuisknop op de link en selecteer de optie “linkadres kopiëren”
  • Optie B:
    Deel de link per e-mail
Literatuur
1.
go back to reference Tajfel H. Differentiation between social groups: Studies in the social psychology of intergroup relations. London: Academic Press; 1978. Tajfel H. Differentiation between social groups: Studies in the social psychology of intergroup relations. London: Academic Press; 1978.
3.
go back to reference Paton M, Naidu T, Wyatt T, et al. Dismantling the master’s house: new ways of knowing for equity and social justice in health professions education. Adv Health Sci Educ. 2020;25:1107–26. Paton M, Naidu T, Wyatt T, et al. Dismantling the master’s house: new ways of knowing for equity and social justice in health professions education. Adv Health Sci Educ. 2020;25:1107–26.
4.
go back to reference Wong S, Gishen F, Lokugamage A. ‘Decolonising the Medical Curriculum’: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness. Lond Rev Educ. 2021;19:1–22. Wong S, Gishen F, Lokugamage A. ‘Decolonising the Medical Curriculum’: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness. Lond Rev Educ. 2021;19:1–22.
5.
go back to reference Chiavaroli N, Blitz J, Cleland J. When I say …. diversity. Med Educ. 2020;54:876–7. Chiavaroli N, Blitz J, Cleland J. When I say …. diversity. Med Educ. 2020;54:876–7.
6.
go back to reference Arday J, Mirza HS, editors. Dismantling race in higher education: Racism, whiteness and decolonising the academy. Berlin, Heidelberg, New York: Springer; 2018. Arday J, Mirza HS, editors. Dismantling race in higher education: Racism, whiteness and decolonising the academy. Berlin, Heidelberg, New York: Springer; 2018.
7.
go back to reference Li Y. Unequal returns: higher education and access to the salariat by ethnic groups in the UK. Basingstoke: Palgrave Macmillan; 2018. Li Y. Unequal returns: higher education and access to the salariat by ethnic groups in the UK. Basingstoke: Palgrave Macmillan; 2018.
8.
go back to reference Smith D. Diversity’s promise for higher education: Making it work. JHU Press; 2020. Smith D. Diversity’s promise for higher education: Making it work. JHU Press; 2020.
9.
go back to reference Boatright D, Ross D, O’Connor P, Moore E, Nunez-Smith M. Racial disparities in medical student membership in the alpha omega alpha honor society. JAMA Intern Med. 2017;177:659–65. Boatright D, Ross D, O’Connor P, Moore E, Nunez-Smith M. Racial disparities in medical student membership in the alpha omega alpha honor society. JAMA Intern Med. 2017;177:659–65.
10.
go back to reference Stegers-Jager K, Steyerberg E, Cohen-Schotanus J, Themmen A. Ethnic disparities in undergraduate pre-clinical and clinical performance. Med Educ. 2012;46:575–85. Stegers-Jager K, Steyerberg E, Cohen-Schotanus J, Themmen A. Ethnic disparities in undergraduate pre-clinical and clinical performance. Med Educ. 2012;46:575–85.
11.
go back to reference Stegers-Jager K, Themmen A, Cohen-Schotanus J, Steyerberg E. Predicting performance: Relative importance of students’ background and past performance. Med Educ. 2015;49:933–45. Stegers-Jager K, Themmen A, Cohen-Schotanus J, Steyerberg E. Predicting performance: Relative importance of students’ background and past performance. Med Educ. 2015;49:933–45.
12.
go back to reference Wijesekera T, Kim M, Moore E, Sorenson O, Ross D. All other things being equal: exploring racial and gender disparities in medical school honor society induction. Acad Med. 2019;94:562–9. Wijesekera T, Kim M, Moore E, Sorenson O, Ross D. All other things being equal: exploring racial and gender disparities in medical school honor society induction. Acad Med. 2019;94:562–9.
13.
go back to reference Wilkaire E, Curtis E, Cormack D, et al. Predictors of academic success for Māori, Pacific and non-Māori non-Pacific students in health professional education: a quantitative analysis. Adv Health Sci Educ. 2017;22:299–326. Wilkaire E, Curtis E, Cormack D, et al. Predictors of academic success for Māori, Pacific and non-Māori non-Pacific students in health professional education: a quantitative analysis. Adv Health Sci Educ. 2017;22:299–326.
14.
go back to reference Woolf K, Potts H, McManus I. Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ. 2011;342:d901. Woolf K, Potts H, McManus I. Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ. 2011;342:d901.
15.
go back to reference Haq I, Higham J, Morris R, Dacre J. Effect of ethnicity and gender on performance in undergraduate medical examinations. Med Educ. 2005;39:1126–8. Haq I, Higham J, Morris R, Dacre J. Effect of ethnicity and gender on performance in undergraduate medical examinations. Med Educ. 2005;39:1126–8.
16.
go back to reference King J Jr, Angoff N, Forrest J Jr, Justice A. Gender disparities in medical student research awards: A 13-year study from the Yale School of Medicine. Acad Med. 2018;93:911–9. King J Jr, Angoff N, Forrest J Jr, Justice A. Gender disparities in medical student research awards: A 13-year study from the Yale School of Medicine. Acad Med. 2018;93:911–9.
17.
go back to reference Asghar Z, Williams N, Denney M, Siriwardena A. Performance in candidates declaring versus those not declaring dyslexia in a licensing clinical examination. Med Educ. 2019;53:1243–52. Asghar Z, Williams N, Denney M, Siriwardena A. Performance in candidates declaring versus those not declaring dyslexia in a licensing clinical examination. Med Educ. 2019;53:1243–52.
18.
go back to reference Hutchinson K, Ricketts W, Maxwell S, Ng F. Candidates registered for reasonable adjustments underperform compared to other candidates in the national undergraduate prescribing safety assessment: Retrospective cohort analysis (2014–2018). Br J Clin Pharmacol. 2021;87:946–54. Hutchinson K, Ricketts W, Maxwell S, Ng F. Candidates registered for reasonable adjustments underperform compared to other candidates in the national undergraduate prescribing safety assessment: Retrospective cohort analysis (2014–2018). Br J Clin Pharmacol. 2021;87:946–54.
19.
go back to reference Lee K, Vaishnavi S, Lau S, Andriole D, Jeffe D. “Making the grade:” Noncognitive predictors of medical students’ clinical clerkship grades. J Natl Med Assoc. 2007;99:1138–50. Lee K, Vaishnavi S, Lau S, Andriole D, Jeffe D. “Making the grade:” Noncognitive predictors of medical students’ clinical clerkship grades. J Natl Med Assoc. 2007;99:1138–50.
20.
go back to reference Ross D, Boatright D, Nunez-Smith D, Jordan A, Chekroud A, Moore E. Differences in words used to describe racial and gender groups in medical student performance evaluations. PLoS ONE. 2017;12:e181659. Ross D, Boatright D, Nunez-Smith D, Jordan A, Chekroud A, Moore E. Differences in words used to describe racial and gender groups in medical student performance evaluations. PLoS ONE. 2017;12:e181659.
21.
go back to reference Teherani A, Hauer K, Fernandez A, King T Jr, Lucey C. 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. Acad Med. 2018;93:1286–92. Teherani A, Hauer K, Fernandez A, King T Jr, Lucey C. 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. Acad Med. 2018;93:1286–92.
22.
go back to reference Woolf K, Rich A, Viney R, Rigby M, Needleman S, Griffin A. Fair training pathways for all: understanding experiences of progression. UCL Medical School: General Medical Council; 2016. Woolf K, Rich A, Viney R, Rigby M, Needleman S, Griffin A. Fair training pathways for all: understanding experiences of progression. UCL Medical School: General Medical Council; 2016.
23.
go back to reference Cantor J, Miles E, Baker L, Barker D. Physician service to the underserved: implications for affirmative action in medical education. Inquiry. 1996;33:167–80. Cantor J, Miles E, Baker L, Barker D. Physician service to the underserved: implications for affirmative action in medical education. Inquiry. 1996;33:167–80.
25.
go back to reference Rabinowitz H, Diamond J, Veloski J, Gayle J. The impact of multiple predictors on generalist physicians’ care of underserved populations. Am J Public Health. 2000;90:1225–8. Rabinowitz H, Diamond J, Veloski J, Gayle J. The impact of multiple predictors on generalist physicians’ care of underserved populations. Am J Public Health. 2000;90:1225–8.
26.
go back to reference Shen M, Peterson E, Costas-Muniz R, et al. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. J Racial Ethn Health Disparities. 2018;5:117–40. Shen M, Peterson E, Costas-Muniz R, et al. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. J Racial Ethn Health Disparities. 2018;5:117–40.
27.
go back to reference Selvarajah S, Deivanayagam T, Lasco G, et al. Categorisation and Minoritisation. BMJ. 2020;5(12):e4508. Selvarajah S, Deivanayagam T, Lasco G, et al. Categorisation and Minoritisation. BMJ. 2020;5(12):e4508.
28.
go back to reference Devakumar D, Selvarajah S, Shannon G, et al. Racism, the public health crisis we can no longer ignore. Lancet. 2020;395:e112–3. Devakumar D, Selvarajah S, Shannon G, et al. Racism, the public health crisis we can no longer ignore. Lancet. 2020;395:e112–3.
29.
go back to reference Krieger N. ENOUGH: COVID-19, structural racism, police brutality, plutocracy, climate change—And time for health justice, democratic governance, and an equitable, sustainable future. Am J Public Health. 2020;110:1620–3. Krieger N. ENOUGH: COVID-19, structural racism, police brutality, plutocracy, climate change—And time for health justice, democratic governance, and an equitable, sustainable future. Am J Public Health. 2020;110:1620–3.
30.
go back to reference DiAngelo R. White fragility: Why it’s so hard for white people to talk about racism. Beacon Press; 2018. DiAngelo R. White fragility: Why it’s so hard for white people to talk about racism. Beacon Press; 2018.
31.
go back to reference General Medical Council. Outcomes for graduates. 2018. General Medical Council. Outcomes for graduates. 2018.
32.
go back to reference Gonzaga A, Appiah-Pippim J, Onumah C, Yialamas M. A framework for inclusive graduate medical education recruitment strategies: Meeting the ACGME standard for a diverse and inclusive workforce. Acad Med. 2020;95:710–6. Gonzaga A, Appiah-Pippim J, Onumah C, Yialamas M. A framework for inclusive graduate medical education recruitment strategies: Meeting the ACGME standard for a diverse and inclusive workforce. Acad Med. 2020;95:710–6.
34.
go back to reference Dutta N, Maini A, Afolabi F, et al. Promoting cultural diversity and inclusion in undergraduate primary care education. Educ Prim Care. 2021;29:1–6. Dutta N, Maini A, Afolabi F, et al. Promoting cultural diversity and inclusion in undergraduate primary care education. Educ Prim Care. 2021;29:1–6.
35.
go back to reference Fyfe M, Kumar S, Maini A, Horsburgh J, Golding B. Widening participation: moving from diversity to inclusion. BMJ. 2020;368:M966. Fyfe M, Kumar S, Maini A, Horsburgh J, Golding B. Widening participation: moving from diversity to inclusion. BMJ. 2020;368:M966.
36.
go back to reference Kumwenda B, Cleland J, Walker K, Lee A, Greatrix R. The relationship between school type and academic performance at medical school: a national, multi-cohort study. BMJ Open. 2017;7(8):e16291. Kumwenda B, Cleland J, Walker K, Lee A, Greatrix R. The relationship between school type and academic performance at medical school: a national, multi-cohort study. BMJ Open. 2017;7(8):e16291.
37.
go back to reference Kumwenda B, Cleland JA, Prescott GJ, Walker KA, Johnston PW. Relationship between sociodemographic factors and specialty destination of UK trainee doctors: a national cohort study. BMJ Open. 2019;9:e26961. Kumwenda B, Cleland JA, Prescott GJ, Walker KA, Johnston PW. Relationship between sociodemographic factors and specialty destination of UK trainee doctors: a national cohort study. BMJ Open. 2019;9:e26961.
38.
go back to reference McElwee S, Fyfe M, Grant K. The consequences of biomedical admissions testing on individuals, institutions and society. Cambridge: Cambridge University Press; 2017. McElwee S, Fyfe M, Grant K. The consequences of biomedical admissions testing on individuals, institutions and society. Cambridge: Cambridge University Press; 2017.
39.
go back to reference Chou C, Kalet A, Costa M, Cleland J, Winston K. Guidelines: The dos, don’ts and don’t knows of remediation in medical education. Perspect Med Educ. 2019;8:322–38. Chou C, Kalet A, Costa M, Cleland J, Winston K. Guidelines: The dos, don’ts and don’t knows of remediation in medical education. Perspect Med Educ. 2019;8:322–38.
40.
go back to reference Lefroy J, Watling C, Teunissen P, Brand P. Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education. Perspect Med Educ. 2015;4:284–99. Lefroy J, Watling C, Teunissen P, Brand P. Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education. Perspect Med Educ. 2015;4:284–99.
41.
go back to reference Lucey C, Hauer K, Boatright D, Fernandez A. Medical education’s wicked problem: achieving equity in assessment for medical learners. Acad Med. 2020;95:S98–S108. Lucey C, Hauer K, Boatright D, Fernandez A. Medical education’s wicked problem: achieving equity in assessment for medical learners. Acad Med. 2020;95:S98–S108.
42.
go back to reference Kaplan S, Raj A, Carr P, Terrin N, Breeze J, Freund K. Race/ethnicity and success in academic medicine: findings from a longitudinal multi-institutional study. Acad Med. 2018;93:616. Kaplan S, Raj A, Carr P, Terrin N, Breeze J, Freund K. Race/ethnicity and success in academic medicine: findings from a longitudinal multi-institutional study. Acad Med. 2018;93:616.
43.
go back to reference Patterson F, Knight A, Dowell J, Nicholson S, Cousans F, Cleland J. How effective are selection methods in medical education? A systematic review. Med Educ. 2016;50:36–60. Patterson F, Knight A, Dowell J, Nicholson S, Cousans F, Cleland J. How effective are selection methods in medical education? A systematic review. Med Educ. 2016;50:36–60.
44.
go back to reference Burke P. Trans/forming pedagogical spaces: Race, belonging and recognition in higher education. Basingstoke: Palgrave Macmillan; 2018. Burke P. Trans/forming pedagogical spaces: Race, belonging and recognition in higher education. Basingstoke: Palgrave Macmillan; 2018.
45.
go back to reference Pilkington A. The rise and fall in the salience of race equality in higher education. Basingstoke: Palgrave Macmillan; 2018. Pilkington A. The rise and fall in the salience of race equality in higher education. Basingstoke: Palgrave Macmillan; 2018.
46.
go back to reference Johnson A, Joseph-Salisbury R. ‘Are you supposed to be in here?’ Racial microaggressions and knowledge production in Higher Education. Basingstoke: Palgrave Macmillan; 2018. Johnson A, Joseph-Salisbury R. ‘Are you supposed to be in here?’ Racial microaggressions and knowledge production in Higher Education. Basingstoke: Palgrave Macmillan; 2018.
47.
go back to reference Frings D, Gleibs I, Ridley A. What moderates the attainment gap? The effects of social identity incompatibility and practical incompatibility on the performance of students who are or are not black, asian or minority ethnic. Soc Psychol Educ. 2020;23:171–88. Frings D, Gleibs I, Ridley A. What moderates the attainment gap? The effects of social identity incompatibility and practical incompatibility on the performance of students who are or are not black, asian or minority ethnic. Soc Psychol Educ. 2020;23:171–88.
48.
go back to reference Mountford-Zimdars A, Sabri D, Moore J, Sanders J, Jones S, Higham L. Causes of differences in student outcomes. Higher Education Funding Council for England; 2015. Mountford-Zimdars A, Sabri D, Moore J, Sanders J, Jones S, Higham L. Causes of differences in student outcomes. Higher Education Funding Council for England; 2015.
49.
go back to reference Vaughan S, Sanders T, Crossley N, O’Neill P, Wass V. Bridging the gap: the roles of social capital and ethnicity in medical student achievement. Med Educ. 2015;49:114–23. Vaughan S, Sanders T, Crossley N, O’Neill P, Wass V. Bridging the gap: the roles of social capital and ethnicity in medical student achievement. Med Educ. 2015;49:114–23.
50.
go back to reference Orom H, Semalulu T, Underwood W III. The social and learning environments experienced by underrepresented minority medical students: a narrative review. Acad Med. 2013;88:1765–77. Orom H, Semalulu T, Underwood W III. The social and learning environments experienced by underrepresented minority medical students: a narrative review. Acad Med. 2013;88:1765–77.
51.
go back to reference Richardson J. Understanding the under-attainment of ethnic minority students in UK higher education: The known knowns and the known unknowns. Basingstoke: Palgrave Macmillan; 2018. Richardson J. Understanding the under-attainment of ethnic minority students in UK higher education: The known knowns and the known unknowns. Basingstoke: Palgrave Macmillan; 2018.
52.
go back to reference Crenshaw K. Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Rev. 1991;43:1241–99. Crenshaw K. Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Rev. 1991;43:1241–99.
53.
go back to reference Godbold R, Brathwaite B. Minding the gap. Improving the black asian and minority ethnic student awarding gap in pre-registration adult nursing programmes by decolonizing the curriculum. Nurse Educ Today. 2021;98:104667. Godbold R, Brathwaite B. Minding the gap. Improving the black asian and minority ethnic student awarding gap in pre-registration adult nursing programmes by decolonizing the curriculum. Nurse Educ Today. 2021;98:104667.
54.
go back to reference Lichterman P. Interpretive reflexivity in ethnography. Ethnography. 2017;18:35–45. Lichterman P. Interpretive reflexivity in ethnography. Ethnography. 2017;18:35–45.
55.
go back to reference Giele J, Elder G. Methods of life course research: Qualitative and quantitative approaches. Thousand Oaks: SAGE; 1998. Giele J, Elder G. Methods of life course research: Qualitative and quantitative approaches. Thousand Oaks: SAGE; 1998.
56.
go back to reference Monrouxe L. When I say… intersectionality in medical education research. Med Educ. 2015;49:21–2. Monrouxe L. When I say… intersectionality in medical education research. Med Educ. 2015;49:21–2.
58.
go back to reference Eva K. Moving beyond childish notions of fair and equitable. Med Educ. 2015;49:1–3. Eva K. Moving beyond childish notions of fair and equitable. Med Educ. 2015;49:1–3.
59.
go back to reference Zieky M. Fairness in test design and development. New York: Routledge; 2016. Zieky M. Fairness in test design and development. New York: Routledge; 2016.
60.
go back to reference van der Vleuten C, Schuwirth L. Assessing professional competence: from methods to programmes. Med Educ. 2005;39:309–17. van der Vleuten C, Schuwirth L. Assessing professional competence: from methods to programmes. Med Educ. 2005;39:309–17.
61.
go back to reference Razack S, Risør T, Hodges B, Steinert Y. Beyond the cultural myth of medical meritocracy. Med Educ. 2020;54:46–53. Razack S, Risør T, Hodges B, Steinert Y. Beyond the cultural myth of medical meritocracy. Med Educ. 2020;54:46–53.
62.
go back to reference Champlain A. A primer on classical test theory and item response theory for assessments in medical education. Med Educ. 2010;44:109–17. Champlain A. A primer on classical test theory and item response theory for assessments in medical education. Med Educ. 2010;44:109–17.
63.
go back to reference Downing S. Item response theory: applications of modern test theory in medical education. Med Educ. 2003;37:739–45. Downing S. Item response theory: applications of modern test theory in medical education. Med Educ. 2003;37:739–45.
64.
go back to reference Hope D, Adamson K, McManus I, Chis L, Elder A. Using differential item functioning to evaluate potential bias in a high stakes postgraduate knowledge based assessment. BMC Med Educ. 2018;18:64. Hope D, Adamson K, McManus I, Chis L, Elder A. Using differential item functioning to evaluate potential bias in a high stakes postgraduate knowledge based assessment. BMC Med Educ. 2018;18:64.
65.
go back to reference Clauser B, Mazor K. Using statistical procedures to identify differentially functioning test items. Educ Meas Issues Pract. 1998;17:31–44. Clauser B, Mazor K. Using statistical procedures to identify differentially functioning test items. Educ Meas Issues Pract. 1998;17:31–44.
66.
go back to reference Swaminathan H, Rogers H. Detecting differential item functioning using logistic regression procedures. J Educ Meas. 1990;27:361–70. Swaminathan H, Rogers H. Detecting differential item functioning using logistic regression procedures. J Educ Meas. 1990;27:361–70.
67.
go back to reference Tavakol M, Pinner G. Using the Many-Facet Rasch Model to analyse and evaluate the quality of objective structured clinical examination: a non-experimental crosssectional design. BMJ Open. 2019;9:e29208. Tavakol M, Pinner G. Using the Many-Facet Rasch Model to analyse and evaluate the quality of objective structured clinical examination: a non-experimental crosssectional design. BMJ Open. 2019;9:e29208.
68.
go back to reference Gingerich A, Kogan J, Yeates P, Govaerts M, Holmboe E. Seeing the ‘Black Box’ differently: Assessor cognition from three research perspectives. Med Educ. 2014;48:1055–68. Gingerich A, Kogan J, Yeates P, Govaerts M, Holmboe E. Seeing the ‘Black Box’ differently: Assessor cognition from three research perspectives. Med Educ. 2014;48:1055–68.
69.
go back to reference Tavares W, Eva K. Exploring the impact of mental workload on rater-based assessments. Adv Health Sci Educ Theory Pract. 2013;18:291–303. Tavares W, Eva K. Exploring the impact of mental workload on rater-based assessments. Adv Health Sci Educ Theory Pract. 2013;18:291–303.
70.
go back to reference Williams R, Klamen D, McGaghie W. Cognitive, social and environmental sources of bias in clinical performance ratings. Teach Learn Med. 2003;15:270–92. Williams R, Klamen D, McGaghie W. Cognitive, social and environmental sources of bias in clinical performance ratings. Teach Learn Med. 2003;15:270–92.
71.
go back to reference Chesser A, Cameron H, Evans P, Cleland J, Boursicot K, Mires G. Sources of variation in performance on a shared OSCE station across four UK medical schools. Med Educ. 2009;43:526–32. Chesser A, Cameron H, Evans P, Cleland J, Boursicot K, Mires G. Sources of variation in performance on a shared OSCE station across four UK medical schools. Med Educ. 2009;43:526–32.
72.
go back to reference Fuller R, Homer M, Pell G, Hallam J. Managing extremes of assessor judgment within the OSCE. Med Teach. 2017;39:58–66. Fuller R, Homer M, Pell G, Hallam J. Managing extremes of assessor judgment within the OSCE. Med Teach. 2017;39:58–66.
73.
go back to reference Hope D, Cameron H. Examiners are most lenient at the start of a two-day OSCE. Med Teach. 2015;37:81–5. Hope D, Cameron H. Examiners are most lenient at the start of a two-day OSCE. Med Teach. 2015;37:81–5.
74.
go back to reference Yeates P, Moreau M, Eva K. Are examiners’ judgments in OSCE Style assessments influenced by contrast effects? Acad Med. 2015;90:975–80. Yeates P, Moreau M, Eva K. Are examiners’ judgments in OSCE Style assessments influenced by contrast effects? Acad Med. 2015;90:975–80.
75.
go back to reference Greenwald A, Banaji M. Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychol Rev. 1995;102:4–27. Greenwald A, Banaji M. Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychol Rev. 1995;102:4–27.
76.
go back to reference Harasym P, Woloschuk W, Cunning L. Undesired variance due to examiner stringency/leniency effect in communication skill scores assessed in OSCEs. Adv Health Sci Educ Theory Pract. 2008;13:617–32. Harasym P, Woloschuk W, Cunning L. Undesired variance due to examiner stringency/leniency effect in communication skill scores assessed in OSCEs. Adv Health Sci Educ Theory Pract. 2008;13:617–32.
77.
go back to reference Mirza H. Racism in higher education: ‘What then, can be done?’. Basingstoke: Palgrave Macmillan; 2018. Mirza H. Racism in higher education: ‘What then, can be done?’. Basingstoke: Palgrave Macmillan; 2018.
79.
go back to reference Stegers-Jager K, Brommet F, Themmen A. Ethnic and social disparities in different types of examinations in undergraduate pre-clinical training. Adv Health Sci Educ. 2016;21:1023–46. Stegers-Jager K, Brommet F, Themmen A. Ethnic and social disparities in different types of examinations in undergraduate pre-clinical training. Adv Health Sci Educ. 2016;21:1023–46.
80.
go back to reference van Andel C, Born M, Themmen A, Stegers-Jager K. Broadly sampled assessment reduces ethnicity-related differences in clinical grades. Med Educ. 2019;53:264–75. van Andel C, Born M, Themmen A, Stegers-Jager K. Broadly sampled assessment reduces ethnicity-related differences in clinical grades. Med Educ. 2019;53:264–75.
81.
go back to reference Esmail A, Roberts C. Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: analysis of data. BMJ. 2013;347:f5662. Esmail A, Roberts C. Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: analysis of data. BMJ. 2013;347:f5662.
82.
go back to reference Gingerich A, van der Vleuten CP, Eva KW, Regehr G. More consensus than idiosyncrasy: Categorizing social judgments to examine variability in Mini-CEX ratings. Acad Med. 2014;89:1510–9. Gingerich A, van der Vleuten CP, Eva KW, Regehr G. More consensus than idiosyncrasy: Categorizing social judgments to examine variability in Mini-CEX ratings. Acad Med. 2014;89:1510–9.
83.
go back to reference Hodges B. Assessment in the post-psychometric era: learning to love the subjective and collective. Med Teach. 2013;35:564–8. Hodges B. Assessment in the post-psychometric era: learning to love the subjective and collective. Med Teach. 2013;35:564–8.
84.
go back to reference Ten Cate O, Regehr G. The power of subjectivity in the assessment of medical trainees. Acad Med. 2019;94:333–7. Ten Cate O, Regehr G. The power of subjectivity in the assessment of medical trainees. Acad Med. 2019;94:333–7.
85.
go back to reference Denney M, Freeman A, Wakeford R. MRCGP clinical skills assessment: are the examiners biased, favouring their own by sex, ethnicity and degree source? Br J Gen Pract. 2013;63:e718–e25. Denney M, Freeman A, Wakeford R. MRCGP clinical skills assessment: are the examiners biased, favouring their own by sex, ethnicity and degree source? Br J Gen Pract. 2013;63:e718–e25.
86.
go back to reference Singer-Freeman K, Hobbs H, Robinson C. Theoretical matrix of culturally relevant assessment. Assess Update. 2019;31:1–16. Singer-Freeman K, Hobbs H, Robinson C. Theoretical matrix of culturally relevant assessment. Assess Update. 2019;31:1–16.
87.
go back to reference Montenegro E, Jankowski N. Equity and assessment: Moving towards culturally responsive assessment. Occasional paper no., Vol. 29. Urbana: University of Illinois and Indiana University, National Institute for Learning Outcomes Assessment (NILOA); 2017. Montenegro E, Jankowski N. Equity and assessment: Moving towards culturally responsive assessment. Occasional paper no., Vol. 29. Urbana: University of Illinois and Indiana University, National Institute for Learning Outcomes Assessment (NILOA); 2017.
88.
go back to reference Suzuki L, Lyon-Thomas J. Culturally responsive assessment. Thousand Oaks: SAGE; 2012. Suzuki L, Lyon-Thomas J. Culturally responsive assessment. Thousand Oaks: SAGE; 2012.
89.
go back to reference Solano-Flores G. Assessing the cultural validity of assessment practices: an introduction. London: Routledge; 2011. Solano-Flores G. Assessing the cultural validity of assessment practices: an introduction. London: Routledge; 2011.
90.
go back to reference Stobart G. Fairness in multicultural assessment systems. Assess Educ Princ Policy Pract. 2005;12:275–87. Stobart G. Fairness in multicultural assessment systems. Assess Educ Princ Policy Pract. 2005;12:275–87.
91.
go back to reference Carjuzaa J, Ruff W. When western epistemology and an indigenous worldview meet: Culturally responsive assessment in practice. J Scholarsh Teach Learn. 2010;10:68–79. Carjuzaa J, Ruff W. When western epistemology and an indigenous worldview meet: Culturally responsive assessment in practice. J Scholarsh Teach Learn. 2010;10:68–79.
92.
go back to reference Nortvedt G, Wiese E, Brown M, et al. Aiding culturally responsive assessment in schools in a globalising world. Educ Asse Eval Acc. 2020;32:5–27. Nortvedt G, Wiese E, Brown M, et al. Aiding culturally responsive assessment in schools in a globalising world. Educ Asse Eval Acc. 2020;32:5–27.
94.
go back to reference Meyer L. Editorial—Research on tertiary assessment policy and practices. High Educ Q. 2010;64:226–30. Meyer L. Editorial—Research on tertiary assessment policy and practices. High Educ Q. 2010;64:226–30.
95.
go back to reference Chisholm L, Jackson R, Davidson H, Churchwell A, Fleming A, Drolet B. Evaluation of racial microaggressions experienced during medical school training and the effect on medical student education and burnout: a validation study. J Natl Med Assoc. 2021;113:310–4. Chisholm L, Jackson R, Davidson H, Churchwell A, Fleming A, Drolet B. Evaluation of racial microaggressions experienced during medical school training and the effect on medical student education and burnout: a validation study. J Natl Med Assoc. 2021;113:310–4.
96.
go back to reference Espaillat A, Panna D, Goede D, Gurka M, Novak M, Zaidi Z. An exploratory study on microaggressions in medical school: What are they and why should we care? Perspect Med Educ. 2019;8:143–51. Espaillat A, Panna D, Goede D, Gurka M, Novak M, Zaidi Z. An exploratory study on microaggressions in medical school: What are they and why should we care? Perspect Med Educ. 2019;8:143–51.
97.
go back to reference Bullock J, Lockspeiser T, del Pino-Jones A, Richards R, Teherani A, Hauer K. They don’t see a lot of people my color: A mixed methods study of racial/ethnic stereotype threat among medical students on core clerkships. Acad Med. 2020;95:S58–S66. Bullock J, Lockspeiser T, del Pino-Jones A, Richards R, Teherani A, Hauer K. They don’t see a lot of people my color: A mixed methods study of racial/ethnic stereotype threat among medical students on core clerkships. Acad Med. 2020;95:S58–S66.
98.
go back to reference Kmietowicz Z. Are medical schools turning a blind eye to racism? BMJ. 2020;368:m420. Kmietowicz Z. Are medical schools turning a blind eye to racism? BMJ. 2020;368:m420.
99.
go back to reference Lim G, Sibanda Z, Erhabor J, Bandyopadhyay S. Students’ perceptions on race in medical education and healthcare. Perspect Med Educ. 2021;10:130–4. Lim G, Sibanda Z, Erhabor J, Bandyopadhyay S. Students’ perceptions on race in medical education and healthcare. Perspect Med Educ. 2021;10:130–4.
100.
go back to reference Ulloa J, Talamantes E, Moreno G. Microaggressions during medical training. JAMA. 2016;316:1113–4. Ulloa J, Talamantes E, Moreno G. Microaggressions during medical training. JAMA. 2016;316:1113–4.
101.
go back to reference Woolf K, McManus I, Potts H, Dacre J. The mediators of minority ethnic underperformance in final medical school examinations. Br J Educ Psychol. 2013;83:135–59. Woolf K, McManus I, Potts H, Dacre J. The mediators of minority ethnic underperformance in final medical school examinations. Br J Educ Psychol. 2013;83:135–59.
102.
go back to reference Nicholson S, Cleland J. “It’s making contacts”: Notions of social capital and implications for widening access to medical education. Adv Health Sci Educ. 2017;22:477–90. Nicholson S, Cleland J. “It’s making contacts”: Notions of social capital and implications for widening access to medical education. Adv Health Sci Educ. 2017;22:477–90.
103.
go back to reference Beagan B. Is this worth getting into a big fuss over? Everyday racism in medical school. Med Educ. 2003;37:852–60. Beagan B. Is this worth getting into a big fuss over? Everyday racism in medical school. Med Educ. 2003;37:852–60.
104.
go back to reference Beagan B. Everyday classism in medical school: Experiencing marginality and resistance. Med Educ. 2005;39:777–84. Beagan B. Everyday classism in medical school: Experiencing marginality and resistance. Med Educ. 2005;39:777–84.
105.
go back to reference Christenson S, Reschly A, Wylie C. Handbook of research on student engagement. New York: Springer; 2012. Christenson S, Reschly A, Wylie C. Handbook of research on student engagement. New York: Springer; 2012.
106.
go back to reference Tekian A, Han Y, Hruska L, Krainik A. Do underrepresented minority medical students differ from nonminority students in problem-solving ability? Teach Learn Med. 2001;13:86–91. Tekian A, Han Y, Hruska L, Krainik A. Do underrepresented minority medical students differ from nonminority students in problem-solving ability? Teach Learn Med. 2001;13:86–91.
107.
go back to reference Jochemsen-van der Leeuw R, van Dijk N, van Etten-Jamaludin F, Wieringa-de Waard M. The attributes of the clinical trainer as a role model: a systematic review. Acad Med. 2012;88:26–34. Jochemsen-van der Leeuw R, van Dijk N, van Etten-Jamaludin F, Wieringa-de Waard M. The attributes of the clinical trainer as a role model: a systematic review. Acad Med. 2012;88:26–34.
108.
go back to reference Park J, Woodrow S, Reznick R, Beales J, MacRae H. Observation, reflection, and reinforcement: surgery faculty members’ and residents’ perceptions of how they learned professionalism. Acad Med. 2010;85:134–9. Park J, Woodrow S, Reznick R, Beales J, MacRae H. Observation, reflection, and reinforcement: surgery faculty members’ and residents’ perceptions of how they learned professionalism. Acad Med. 2010;85:134–9.
109.
go back to reference Passi V, Johnson S, Peile E, Wright S, Hafferty F, Johnson N. Doctor role modelling in medical education: BEME Guide No. 27. Med Teach. 2013;35:e1422–36. Passi V, Johnson S, Peile E, Wright S, Hafferty F, Johnson N. Doctor role modelling in medical education: BEME Guide No. 27. Med Teach. 2013;35:e1422–36.
110.
go back to reference Sawatsky A, Parekh N, Muula A, Mbata I, Bui T. Cultural implications of mentoring in sub-Saharan Africa: A qualitative study. Med Educ. 2016;50:657–69. Sawatsky A, Parekh N, Muula A, Mbata I, Bui T. Cultural implications of mentoring in sub-Saharan Africa: A qualitative study. Med Educ. 2016;50:657–69.
111.
go back to reference Cruess S, Cruess R, Steinert Y. Role modelling—Making the most of a powerful teaching strategy. BMJ. 2008;336:718–21. Cruess S, Cruess R, Steinert Y. Role modelling—Making the most of a powerful teaching strategy. BMJ. 2008;336:718–21.
112.
go back to reference Wright S, Carrese J. Serving as a physician role model for a diverse population of medical learners. Acad Med. 2003;78:623–8. Wright S, Carrese J. Serving as a physician role model for a diverse population of medical learners. Acad Med. 2003;78:623–8.
113.
go back to reference Wyatt T, Rockich-Winston N, Taylor T, White D. What does context have to do with anything? A study of professional identity formation in physician-trainees considered underrepresented in medicine. Acad Med. 2020;95:1587–93. Wyatt T, Rockich-Winston N, Taylor T, White D. What does context have to do with anything? A study of professional identity formation in physician-trainees considered underrepresented in medicine. Acad Med. 2020;95:1587–93.
114.
go back to reference McLean M. Is culture important in the choice of role models? Experiences from a culturally diverse medical school. Med Teach. 2004;26:142–9. McLean M. Is culture important in the choice of role models? Experiences from a culturally diverse medical school. Med Teach. 2004;26:142–9.
115.
go back to reference Parekh N, Sawatsky A, Muula A, Mbata I, Bui T. Malawian impressions of expatriate physicians: a qualitative study. Malawi Med J. 2016;28:43–7. Parekh N, Sawatsky A, Muula A, Mbata I, Bui T. Malawian impressions of expatriate physicians: a qualitative study. Malawi Med J. 2016;28:43–7.
116.
go back to reference Claridge H, Stone K, Ussher M. The ethnicity attainment gap among medical and biomedical science students: a qualitative study. BMC Med Educ. 2018;18:1–12. Claridge H, Stone K, Ussher M. The ethnicity attainment gap among medical and biomedical science students: a qualitative study. BMC Med Educ. 2018;18:1–12.
117.
go back to reference Dickins K, Levinson D, Smith S, Humphrey H. The minority student voice at one medical school: Lessons for all? Acad Med. 2013;88:73–9. Dickins K, Levinson D, Smith S, Humphrey H. The minority student voice at one medical school: Lessons for all? Acad Med. 2013;88:73–9.
119.
go back to reference Lemp H. Medical-school culture. Oxon: Routledge; 2009. Lemp H. Medical-school culture. Oxon: Routledge; 2009.
120.
go back to reference Odom K, Roberts L, Johnson R, Cooper L. Exploring obstacles to and opportunities for professional success among ethnic minority medical students. Acad Med. 2007;82:146–53. Odom K, Roberts L, Johnson R, Cooper L. Exploring obstacles to and opportunities for professional success among ethnic minority medical students. Acad Med. 2007;82:146–53.
121.
go back to reference Dave A, Bhatti N, Grover J, et al. Does a narrow definition of medical professionalism lead to systemic bias and differential outcomes? Sushruta J Health Policy. 2021;14:1–12. Dave A, Bhatti N, Grover J, et al. Does a narrow definition of medical professionalism lead to systemic bias and differential outcomes? Sushruta J Health Policy. 2021;14:1–12.
122.
go back to reference Woolf K. Differential attainment in medical education and training. BMJ. 2020;368:m339. Woolf K. Differential attainment in medical education and training. BMJ. 2020;368:m339.
123.
go back to reference Peterson N, Friedman R, Ash A, Franco S, Carr P. Faculty self reported experience with racial and ethnic discrimination in academic medicine. J Gen Intern Med. 2004;19:259–65. Peterson N, Friedman R, Ash A, Franco S, Carr P. Faculty self reported experience with racial and ethnic discrimination in academic medicine. J Gen Intern Med. 2004;19:259–65.
124.
go back to reference Pololi L, Evans A, Gibbs B, Krupat E, Brennan R, Civian J. The experience of minority faculty who are underrepresented in medicine, at 26 representative US medical schools. Acad Med. 2013;88:1308–14. Pololi L, Evans A, Gibbs B, Krupat E, Brennan R, Civian J. The experience of minority faculty who are underrepresented in medicine, at 26 representative US medical schools. Acad Med. 2013;88:1308–14.
125.
go back to reference Anderson H, Lang J. The long term retention and attrition of underrepresented medical school faculty. Washington: Association of American Medical Colleges; 2008. Anderson H, Lang J. The long term retention and attrition of underrepresented medical school faculty. Washington: Association of American Medical Colleges; 2008.
126.
go back to reference Guevara J, Adanga E, Avakame E, Carthon M. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310:2297–304. Guevara J, Adanga E, Avakame E, Carthon M. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310:2297–304.
127.
go back to reference Hassouneh D, Lutz K, Beckett A, Junkins E Jr., Horton L. The experiences of underrepresented minority faculty in schools of medicine. Med Educ Online. 2014;19:24768. Hassouneh D, Lutz K, Beckett A, Junkins E Jr., Horton L. The experiences of underrepresented minority faculty in schools of medicine. Med Educ Online. 2014;19:24768.
128.
go back to reference Sullivan L, Mittman I. The state of diversity in the health professions a century after Flexner. Acad Med. 2010;85:246–53. Sullivan L, Mittman I. The state of diversity in the health professions a century after Flexner. Acad Med. 2010;85:246–53.
129.
go back to reference Mahoney M, Wilson E, Odom K, Flowers L, Adler S. Minority faculty voices on diversity in academic medicine: Perspectives from one school. Acad Med. 2008;83:781–5. Mahoney M, Wilson E, Odom K, Flowers L, Adler S. Minority faculty voices on diversity in academic medicine: Perspectives from one school. Acad Med. 2008;83:781–5.
130.
go back to reference Nivet M, Taylor V, Butts G, et al. Diversity in academic medicine no. 1 case for minority faculty development today. Mt Sinai J Med. 2008;75:491–8. Nivet M, Taylor V, Butts G, et al. Diversity in academic medicine no. 1 case for minority faculty development today. Mt Sinai J Med. 2008;75:491–8.
131.
go back to reference Price E, Powe N, Kern D, Golden S, Wand G, Cooper L. Improving the diversity climate in academic medicine: faculty perceptions as a catalyst for institutional change. Acad Med. 2009;84:95–105. Price E, Powe N, Kern D, Golden S, Wand G, Cooper L. Improving the diversity climate in academic medicine: faculty perceptions as a catalyst for institutional change. Acad Med. 2009;84:95–105.
132.
go back to reference Daley S, Broyles S, Rivera L, Brennan J, Lu E, Reznik V. A conceptual model for faculty development in academic medicine: The underrepresented minority faculty experience. J Natl Med Assoc. 2011;103:816–21. Daley S, Broyles S, Rivera L, Brennan J, Lu E, Reznik V. A conceptual model for faculty development in academic medicine: The underrepresented minority faculty experience. J Natl Med Assoc. 2011;103:816–21.
133.
go back to reference Beech B, Calles-Escandon J, Hairston K, Langdon S, Latham-Sadler B, Bell R. Mentoring programs for underrepresented minority faculty in academic medical centers: a systematic review of the literature. Acad Med. 2013;88:541–9. Beech B, Calles-Escandon J, Hairston K, Langdon S, Latham-Sadler B, Bell R. Mentoring programs for underrepresented minority faculty in academic medical centers: a systematic review of the literature. Acad Med. 2013;88:541–9.
134.
go back to reference Bonifacino E, Ufomata E, Farkas A, Turner R, Corbelli J. Mentorship of underrepresented physicians and trainees in academic medicine: a systematic review. J Gen Intern Med. 2021;36:1023–34. Bonifacino E, Ufomata E, Farkas A, Turner R, Corbelli J. Mentorship of underrepresented physicians and trainees in academic medicine: a systematic review. J Gen Intern Med. 2021;36:1023–34.
135.
go back to reference Campbell K, Hudson B, Tumin D. Releasing the net to promote minority faculty success in academic medicine. J Racial Ethn Health Disparities. 2020;7:202–6. Campbell K, Hudson B, Tumin D. Releasing the net to promote minority faculty success in academic medicine. J Racial Ethn Health Disparities. 2020;7:202–6.
136.
go back to reference Vergel J, Quintero GA, Isaza-Restrepo A, Ortiz-Fonseca M, Latorre-Santos C, Pardo-Oviedo J. The influence of different curriculum designs on students’ dropout rate: a case study. Med Educ Online. 2018;23:1432963. Vergel J, Quintero GA, Isaza-Restrepo A, Ortiz-Fonseca M, Latorre-Santos C, Pardo-Oviedo J. The influence of different curriculum designs on students’ dropout rate: a case study. Med Educ Online. 2018;23:1432963.
137.
go back to reference Rodriguez J, Campbell K, Pololi L. Addressing disparities in academic medicine: What of the minority tax? BMC Med Educ. 2015;15:1–5. Rodriguez J, Campbell K, Pololi L. Addressing disparities in academic medicine: What of the minority tax? BMC Med Educ. 2015;15:1–5.
138.
go back to reference Osseo-Asare A, Balasuriya L, Huot S, et al. Minority resident physicians’ views on the role of race/ethnicity in their training experiences in the workplace. Med Educ. 2018;1:e182723. Osseo-Asare A, Balasuriya L, Huot S, et al. Minority resident physicians’ views on the role of race/ethnicity in their training experiences in the workplace. Med Educ. 2018;1:e182723.
139.
go back to reference Campbell K, Rodriguez J. Addressing the minority tax: Perspectives from two diversity leaders on building minority faculty success in academic medicine. Acad Med. 2019;94:1854–7. Campbell K, Rodriguez J. Addressing the minority tax: Perspectives from two diversity leaders on building minority faculty success in academic medicine. Acad Med. 2019;94:1854–7.
140.
go back to reference Cyrus K. Medical education and the minority tax. JAMA. 2017;317:1833–4. Cyrus K. Medical education and the minority tax. JAMA. 2017;317:1833–4.
141.
go back to reference Wyatt T, Rockich-Winston N, White D, Taylor T. “Changing the narrative”: A study on professional identity formation among Black/African American physicians in the U.S. Adv Health Sci Educ. 2020;26:183–98. Wyatt T, Rockich-Winston N, White D, Taylor T. “Changing the narrative”: A study on professional identity formation among Black/African American physicians in the U.S. Adv Health Sci Educ. 2020;26:183–98.
142.
go back to reference Sawatsky A, Beckman T, Hafferty F. Cultural competency, professional identity formation and transformative learning. Med Educ. 2017;51:462–4. Sawatsky A, Beckman T, Hafferty F. Cultural competency, professional identity formation and transformative learning. Med Educ. 2017;51:462–4.
143.
go back to reference Shields P. A survey and analysis of student academic support programs in medical schools focus: Underrepresented minority students. J Natl Med Assoc. 1994;86:373–7. Shields P. A survey and analysis of student academic support programs in medical schools focus: Underrepresented minority students. J Natl Med Assoc. 1994;86:373–7.
144.
go back to reference Woolf K, McManus I, Gill D, Dacre J. The effect of a brief social intervention on the examination results of UK medical students: A cluster randomised controlled trial. BMC Med Educ. 2009;9:1–15. Woolf K, McManus I, Gill D, Dacre J. The effect of a brief social intervention on the examination results of UK medical students: A cluster randomised controlled trial. BMC Med Educ. 2009;9:1–15.
145.
go back to reference Cohen G, Sherman D. The psychology of change: self-affirmation and social psychological intervention. Annu Rev Psychol. 2014;65:333–71. Cohen G, Sherman D. The psychology of change: self-affirmation and social psychological intervention. Annu Rev Psychol. 2014;65:333–71.
146.
go back to reference Hanselman P, Rozek C, Grigg J, Borman G. New evidence on self-affirmation effects and theorized sources of heterogeneity from large-scale replications. J Educ Psychol. 2017;109:405–24. Hanselman P, Rozek C, Grigg J, Borman G. New evidence on self-affirmation effects and theorized sources of heterogeneity from large-scale replications. J Educ Psychol. 2017;109:405–24.
148.
go back to reference Zimmerman B, Schunk D. Self-regulated learning and academic achievement: Theoretical perspectives. London: Routledge; 2001. Zimmerman B, Schunk D. Self-regulated learning and academic achievement: Theoretical perspectives. London: Routledge; 2001.
149.
go back to reference Panesar L. Academic support and the BAME attainment gap: using data to challenge assumptions. Spark UAL Creat Teach Learn J. 2017;2:45–9. Panesar L. Academic support and the BAME attainment gap: using data to challenge assumptions. Spark UAL Creat Teach Learn J. 2017;2:45–9.
150.
go back to reference Cleland J, Leggett H, Sandars J, Costa M, Patel R, Moffat M. The remediation challenge: Theoretical and methodological insights from a systematic review. Med Educ. 2013;47:242–51. Cleland J, Leggett H, Sandars J, Costa M, Patel R, Moffat M. The remediation challenge: Theoretical and methodological insights from a systematic review. Med Educ. 2013;47:242–51.
151.
go back to reference Cruess S, Cruess R, Boudreau J, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: A guide for medical educators. Acad Med. 2015;90:718–25. Cruess S, Cruess R, Boudreau J, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: A guide for medical educators. Acad Med. 2015;90:718–25.
152.
go back to reference Crampton P, Afzali Y. Professional identity formation, intersectionality and equity in medical education. Med Educ. 2021;55:140–2. Crampton P, Afzali Y. Professional identity formation, intersectionality and equity in medical education. Med Educ. 2021;55:140–2.
153.
go back to reference Volpe R, Hopkins M, Haidet P, Wolpaw D, Adams N. Is research on professional identity formation biased? early insights from a scoping review and metasynthesis. Med Educ. 2019;53:119–32. Volpe R, Hopkins M, Haidet P, Wolpaw D, Adams N. Is research on professional identity formation biased? early insights from a scoping review and metasynthesis. Med Educ. 2019;53:119–32.
154.
go back to reference Wyatt T, Balmer D, Rockich-Winston N, Chow C, Richards J, Zaidi Z. ‘Whispers and shadows’: A critical review of the professional identity literature with respect to minority physicians. Med Educ. 2020;55:148–58. Wyatt T, Balmer D, Rockich-Winston N, Chow C, Richards J, Zaidi Z. ‘Whispers and shadows’: A critical review of the professional identity literature with respect to minority physicians. Med Educ. 2020;55:148–58.
155.
go back to reference O’Doherty D, Culhane A, O’Doherty J, et al. Medical students and clinical placements—A qualitative study of the continuum of professional identity formation. Educ Prim Care. 2021;32:202–10. O’Doherty D, Culhane A, O’Doherty J, et al. Medical students and clinical placements—A qualitative study of the continuum of professional identity formation. Educ Prim Care. 2021;32:202–10.
156.
go back to reference Fergus K, Teale B, Sivapragasam M, Mesina O, Stergiopoulos E. Medical students are not blank slates: Positionality and curriculum interact to develop professional identity. Perspect Med Educ. 2018;7:5–7. Fergus K, Teale B, Sivapragasam M, Mesina O, Stergiopoulos E. Medical students are not blank slates: Positionality and curriculum interact to develop professional identity. Perspect Med Educ. 2018;7:5–7.
157.
go back to reference Frost H, Regehr G. I am a doctor: Negotiating the discourses of standardization and diversity in professional identity construction. Acad Med. 2013;88:1570–7. Frost H, Regehr G. I am a doctor: Negotiating the discourses of standardization and diversity in professional identity construction. Acad Med. 2013;88:1570–7.
158.
go back to reference Morrison N, Machado M, Blackburn C. Student perspectives on barriers to performance for black and minority ethnic graduate-entry medical students: a qualitative study in a West Midlands medical school. BMJ Open. 2019;9:e32493. Morrison N, Machado M, Blackburn C. Student perspectives on barriers to performance for black and minority ethnic graduate-entry medical students: a qualitative study in a West Midlands medical school. BMJ Open. 2019;9:e32493.
159.
go back to reference AbdelHameid D. Professionalism 101 for black physicians. N Engl J Med. 2020;383:e34. AbdelHameid D. Professionalism 101 for black physicians. N Engl J Med. 2020;383:e34.
160.
go back to reference Archibong U, Kline R, Eshareturi C, McIntosh B. Disproportionality in NHS disciplinary proceedings. Br J Healthc Manag. 2019;25:1–7. Archibong U, Kline R, Eshareturi C, McIntosh B. Disproportionality in NHS disciplinary proceedings. Br J Healthc Manag. 2019;25:1–7.
161.
go back to reference Rogers P. Demographics of disciplinary action by the medical board of California (2003–2013). California Research Bureau; 2017. Rogers P. Demographics of disciplinary action by the medical board of California (2003–2013). California Research Bureau; 2017.
162.
go back to reference Balloo K, Winstone N. A primer on gathering and analysing multi-level quantitative evidence for differential student outcomes in higher education. Front Learn Res. 2021;9:121–44. Balloo K, Winstone N. A primer on gathering and analysing multi-level quantitative evidence for differential student outcomes in higher education. Front Learn Res. 2021;9:121–44.
163.
go back to reference Arday J, Belluigi D, Thomas D. Attempting to break the chain: reimaging inclusive pedagogy and decolonising the curriculum within the academy. Educ Philos Theory. 2021;53:298–313. Arday J, Belluigi D, Thomas D. Attempting to break the chain: reimaging inclusive pedagogy and decolonising the curriculum within the academy. Educ Philos Theory. 2021;53:298–313.
164.
go back to reference Chohan N, Arzoky Z, Khan N. Twelve tips for incorporating migrant and ethnic minorities in the medical curriculum and healthcare. Med Teach. 2021;43:1122–6. Chohan N, Arzoky Z, Khan N. Twelve tips for incorporating migrant and ethnic minorities in the medical curriculum and healthcare. Med Teach. 2021;43:1122–6.
166.
go back to reference Nazar M, Kendall K, Day L, Nazar H. Decolonising medical curricula through diversity education: Lessons from students. Med Teach. 2015;37:385–93. Nazar M, Kendall K, Day L, Nazar H. Decolonising medical curricula through diversity education: Lessons from students. Med Teach. 2015;37:385–93.
167.
go back to reference Nieblas-Bedolla E, Christophers B, Nkinsi N, Schumann P, Stein E. Changing how race is portrayed in medical education: recommendations from medical students. Acad Med. 2020;95:1802–6. Nieblas-Bedolla E, Christophers B, Nkinsi N, Schumann P, Stein E. Changing how race is portrayed in medical education: recommendations from medical students. Acad Med. 2020;95:1802–6.
169.
go back to reference Cerdena J, Plaisime M, Tsai J. From race-based to race-conscious medicine: How anti-racist uprisings call us to act. Lancet. 2020;396:1125–8. Cerdena J, Plaisime M, Tsai J. From race-based to race-conscious medicine: How anti-racist uprisings call us to act. Lancet. 2020;396:1125–8.
170.
go back to reference Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race matters? Examining and rethinking race portrayal in preclinical medical education. Acad Med. 2016;91:916–20. Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race matters? Examining and rethinking race portrayal in preclinical medical education. Acad Med. 2016;91:916–20.
171.
go back to reference Dogra N, Reitmanova S, Carter-Pokras O. Twelve tips for teaching diversity and embedding it in the medical curriculum. Med Teach. 2009;31:990–3. Dogra N, Reitmanova S, Carter-Pokras O. Twelve tips for teaching diversity and embedding it in the medical curriculum. Med Teach. 2009;31:990–3.
172.
go back to reference Dogra N, Bhatti F, Ertubey C, et al. Teaching diversity to medical undergraduates: Curriculum development, delivery and assessment. AMEE GUIDE No. 103. Med Teach. 2016;38:323–37. Dogra N, Bhatti F, Ertubey C, et al. Teaching diversity to medical undergraduates: Curriculum development, delivery and assessment. AMEE GUIDE No. 103. Med Teach. 2016;38:323–37.
173.
go back to reference Ona F, Amutah-Onukagha N, Asemamaw R, Schlaff A. Struggles and tensions in antiracism education in medical school: lessons learned. Acad Med. 2020;95:S163–8. Ona F, Amutah-Onukagha N, Asemamaw R, Schlaff A. Struggles and tensions in antiracism education in medical school: lessons learned. Acad Med. 2020;95:S163–8.
174.
go back to reference Paton M, Kuper A, Paradis E, Feilchenfeld Z, Whitehead CR. Tackling the void: the importance of addressing absences in the field of health professions education research. Adv Health Sci Educ. 2021;26:5–18. Paton M, Kuper A, Paradis E, Feilchenfeld Z, Whitehead CR. Tackling the void: the importance of addressing absences in the field of health professions education research. Adv Health Sci Educ. 2021;26:5–18.
Metagegevens
Titel
The do’s, don’ts and don’t knows of redressing differential attainment related to race/ethnicity in medical schools
Auteurs
Molly Fyfe
Jo Horsburgh
Julia Blitz
Neville Chiavaroli
Sonia Kumar
Jennifer Cleland
Publicatiedatum
29-12-2021
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Perspectives on Medical Education / Uitgave 1/2022
Print ISSN: 2212-2761
Elektronisch ISSN: 2212-277X
DOI
https://doi.org/10.1007/s40037-021-00696-3