Implicit gender bias has long been suspected in many medical
training programs, but until recently has been difficult to study
objectively. Now, for the first time, a nationally standardized
milestone evaluation system for emergency medicine residents is shining a
light on these potential biases.
In study published today in JAMA Internal Medicine
researchers found that although male and female emergency medicine
specialists start off residency on an equal playing field, by the end of
the three-year training program male residents, on average, received
higher evaluations on all 23 emergency medicine training categories -
including medical knowledge, patient safety, team management, and
‘Female residents in emergency medicine receive lower scores than males across all sub-competencies implicates bias rather than a deficit in specific skills or knowledge.’
During the first year of training, female residents actually scored
slightly higher than males on 15 of the 23 areas, with notably higher
scores in accountability, multitasking, and diagnosis. However, by the
end of the third and final year of residency, males had gained higher
scores in all 23 categories and had a 13% higher rate of
milestone attainment per year - the equivalent of three to four months of
additional training by graduation.
"We are concerned that the disparity we discovered in evaluations
may point to an implicit bias," said co-lead author Daniel O'Connor, a
student in the Perelman School of Medicine at the University of
Pennsylvania. "Our finding, that female residents in emergency medicine
receive lower scores than males across all sub-competencies really
implicates bias rather than a deficit in specific skills or knowledge."
O'Connor and researchers from the University of Chicago Pritzker
School of Medicine collected 33,456 "milestone" evaluations, from 359
emergency medicine residents over a two-year period. One-third (122) of
the residents were female; two-thirds (237) were male. The training
programs studied represent a mix of rural, suburban, and urban hospitals
and included small, medium and large academic as well as community
About a third of the faculty physicians who evaluated the trainees
were female (91) and two-thirds were male (194). Male and female faculty
members evaluated residents similarly, consistently giving female
residents lower scores throughout residency years two and three.
Although senior residents, for example, are expected to display
stereotypically male characteristics such as assertiveness and
independence, female residents who display such qualities may incur a
penalty, even among their female role models, for violating customary
"One way to interpret our findings is that a widening gender gap is
attributable to the cumulative effects of repeated disadvantages and
biases that become increasingly pronounced at the more senior levels of
training," the authors wrote.
In light of recent national discussions calling for formalized
competency demonstrations before residents can graduate in their
specialty, this implicit bias could have long-term implications for
"Based on our results," O'Connor said, "this would mean female
residents could be required to complete additional training to graduate
at the same level as their male counterparts."