78 Does Applicant Sex Have an Effect on Standardized Letters of Evaluations Obtained During Medical Student Emergency Medicine Rotations?

Abstract

Implicit bias in regards to sex and gender has been suspected in the different phases of medical training. A recent study has demonstrated sex bias in emergency medicine residency training as evidenced by a higher rate of milestone achievement in male residents versus female residents. The objective of our study was to assess for sex bias even earlier in the EM training process. The first formal component of an emergency medicine career is the emergency medicine rotation performed in the final year of medical school. A standardized letter of evaluation (SLOE) is written by the institution with whom the student rotated. Over 90 percent of emergency medicine program directors use the SLOE as the most important factor in selecting candidates for their program. This study compared male versus female medical students’ SLOE scores. We performed a retrospective study using SLOEs from 2015 and 2016 that were submitted to a large urban, academic emergency medicine program in southern California. Sex was determined as reported on the student’s residency application. The quantitative measure of SLOE score was determined by a composite score of the 2 components of the global assessment: comparative rank to other rotators and position on institution’s rank list. A perfect score (top 10% on both categories) would be a 2 and the worst score possible is a 9. Each rotation number (either first, second, or third) was compared between male and female applicants using an independent samples t test. 1040 applications were identified with 2,146 total SLOEs. 686 (66%) were male and 354 (34%) were female. Applications came from each region of the country (25% northeast, 24% south, 23% midwest, and 28% west). 933 of the SLOEs were from home institutions and 1213 were from away institutions. The minimum number of SLOEs per student was 1, the maximum was 3, and the mean was 2.1. Male students scored better on their first (4.9 versus 4.6 p<.05), second (5.1 versus 4.7 p<.05), and third rotations (4.9 versus 4.6 p=.14), with the first and second differences being statistically significant. Male applicants also performed better on the USMLE Step 1 exam than female applicants (231.8 versus 228.3 p<.05). However, on the USMLE Step 2 Clinical Knowledge exam, female applicants outperformed male applicants (243.7 versus 241.7 p<.05). Our results indicate that the sex gap that has been identified in emergency medicine residency training exists even earlier than residency. These results further emphasize the need to correct this widespread disparity in training. Several mechanisms for this disparity are proposed and should be addressed. Faculty and evaluators need to be aware of any potential implicit biases they may carry when educating and evaluating students. Access to mentorship for female students needs to be improved.