In recent years, we have witnessed how the content and structure of clerkship education changes in response to societal and patient needs.1.,2 Examples of such adaptations include pedagogical redesign,3 early immersion in patient care,4 competency-based medical education,5,6 and longitudinal integrated clerkships.7,8 More recently, many learners and educators have turned their attention to structural racism in medicine9,10 and the parallels between disparities in health care and disparities in access to education and opportunity within medicine. Educational equity is now recognized as a core principle of undergraduate medical education.11, 12, 13 Many learners from racial and ethnic groups underrepresented (URG) in medicine face inequities in the clerkship learning environment that lead to social isolation, job dissatisfaction,14, 15, 16 and eventual attrition of URG learners and faculty. These negative outcomes are particularly concerning because diversity among learners, health care workforce, and teams is important for health equity,17, 18, 19 enhances the learning environment, promotes culturally responsive care, improves access to care for underserved communities, and can improve health outcomes.20, 21, 22, 23
A thorough analysis of disparities in medical school is critical to creating a learning environment that is equitable, particularly in the clerkship year when assessment of student performance can have long-term ramifications on a career trajectory.24, 25, 26 URG learners face multiple pressures and inequities that affect their lived experiences and assessments in the clerkship setting,14,27, 28, 29 including heightened scrutiny from physicians and patients, stereotype threat when facing faculty and resident assessors,14 “covering” (concealing or reducing the prominence of a trait),30 differential expectations in the classroom,31 and imposter syndrome.14 Although many of these phenomena occur in interpersonal relationships, structural barriers are also woven into clerkship assessment, evaluation, and grading. Clerkship students are observed, assessed, evaluated and, at many institutions, graded. They receive formative feedback meant to foster their growth and summative evaluations to determine their performance based on clerkship objectives and rubrics. Grades or narrative summaries serve to communicate their level of achievement or competence to internal and external stakeholders. In most Liaison Committee on Medical Education (LCME)-accredited medical schools, individual clinical performance evaluations, standardized tests, and standardized patient examinations remain the foundation of student clerkship assessment,32 yet there is evidence of inequity in these assessments and the grading process.26,33,34
In this perspective, we summarize evidence-based recommendations to address inequities focusing on the clerkship grading process. We aim to guide clerkship directors through an exploration and potential redesign of current assessment and grading systems using an equity lens. Although we focus on strategies that internal medicine clerkship leaders can use, we believe these strategies can be applied to other specialty clerkships seeking to create a more equitable grading process.
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-Chavon M. Onumah, MD 1, Cindy J. Lai, MD 1, Diane Levine, MD, Nadia Ismail, MD, Amber T. Pincavage, MD, Nora Y. Osman, MD
