C.R. Lucey is executive vice dean/vice dean for education and professor of medicine, University of California, San Francisco, School of Medicine, San Francisco, California.
K.E. Hauer is professor of medicine, University of California, San Francisco, School of Medicine, San Francisco, California.
Acad Med. 2020 Dec;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S98-S108. doi: 10.1097/ACM.0000000000003717.
Despite a lack of intent to discriminate, physicians educated in U.S. medical schools and residency programs often take actions that systematically disadvantage minority patients. The approach to assessment of learner performance in medical education can similarly disadvantage minority learners. The adoption of holistic admissions strategies to increase the diversity of medical training programs has not been accompanied by increases in diversity in honor societies, selective residency programs, medical specialties, and medical school faculty. These observations prompt justified concerns about structural and interpersonal bias in assessment. This manuscript characterizes equity in assessment as a "wicked problem" with inherent conflicts, uncertainty, dynamic tensions, and susceptibility to contextual influences. The authors review the underlying individual and structural causes of inequity in assessment. Using an organizational model, they propose strategies to achieve equity in assessment and drive institutional and systemic improvement based on clearly articulated principles. This model addresses the culture, systems, and assessment tools necessary to achieve equitable results that reflect stated principles. Three components of equity in assessment that can be measured and evaluated to confirm success include intrinsic equity (selection and design of assessment tools), contextual equity (the learning environment in which assessment occurs), and instrumental equity (uses of assessment data for learner advancement and selection and program evaluation). A research agenda to address these challenges and controversies and demonstrate reduction in bias and discrimination in medical education is presented.
尽管没有歧视的意图，但在美国医学院校和住院医师培训项目中接受教育的医生，往往会采取一些系统地使少数族裔患者处于不利地位的行动。医学教育中学生学习成绩评估的方法也可能使少数族裔学习者处于不利地位。为了增加医学培训项目的多样性，采用整体招生策略，但荣誉学会、选择性住院医师培训项目、医学专业和医学院教师的多样性并没有随之增加。这些观察结果引发了人们对评估中的结构性和人际偏见的合理担忧。本文将评估中的公平性描述为一个具有内在冲突、不确定性、动态紧张和易受环境影响的“棘手问题”。作者回顾了评估中不公平的潜在个体和结构性原因。他们使用组织模型，提出了在评估中实现公平性的策略，并基于明确阐述的原则推动机构和系统的改进。该模型解决了实现反映既定原则的公平结果所需的文化、系统和评估工具。可以衡量和评估以确认成功的评估公平性的三个组成部分包括内在公平性（评估工具的选择和设计）、背景公平性（评估发生的学习环境）和工具公平性（评估数据用于学习者进步以及选择和项目评估）。提出了一个研究议程，以解决这些挑战和争议，并证明医学教育中的偏见和歧视有所减少。
