Gaslighting the Racially and Ethnically Minoritized Medical Student: How US Medical School Assessment Practices Perpetuate Systemic Inequities.

Abstract

Introduction: Physicians from racially and ethnically minoritized (REM) populations are woefully under-represented in the medical profession. The consequences of under-representation are far reaching, with profound impacts on social justice efforts and public health. One solution to remedy this crisis involves the aggressive recruitment of students from REM backgrounds. Though medical education programs have advanced in the recruitment of REM students, their outcomes during medical school are worse than for students from non-REM populations. Previously, literature has focused on causes for this disparity including social determinants, biases, and burden. Approach: In this manuscript, we invoke Critical Whiteness Theory (CWT) to argue how the systems of assessment in medical schools are an under-appreciated contributor to disparities, effectively perpetuating inequities by promoting a white supremacist culture. We begin by examining the origins of assessment in medical education, exploring the historical desire to measure attributes of a good doctor, but the tendency to default toward measures of aptitude and rote medical content knowledge that support a white supremacist culture. The Flexner Report and a systemic shift to favor standardized testing are highlighted as major contributors to the foundation of medical school assessment programs. We then describe potential for progress, through a better definition of the good doctor, articulated by the competency-based medical education movement, and advanced further through a justice-oriented assessment program. Findings: Using an illustrative case example and review of the literature, we suggest that progress in admissions and remediation are commonly coupled, and misaligned, with a historical approach to assessment. Resulting from the misalignment, we argue that medical education programs effectively "gaslight" REM students by admitting them into programs poorly equipped to support their success and convincing REM students that their poor outcomes were earned. We share examples from pre-clinical and clinical assessment programs, including a continued reliance on standardized tests, arbitrary grading thresholds, shadow assessment programs, and focus on episodic remediation that results in stigmatization for failures. Insights: We conclude by providing a model for how issues identified through this perspective may be remedied through a justice-oriented approach to assessment. Through that approach, we propose improved alignment in the recruitment and retention of REM students, thereby resulting in better outcomes for patients, improved physician representation, and realization of a diverse and more complete picture of the good doctor.