Racial Bias on the Emergency Medicine Standardized Letter of Evaluation

Introduction: Racial discrimination is widespread throughout medicine and studies of the assessment of medical students continue to show evidence of racial bias. Matching into EM residency is significantly influenced by the rankings a student achieves on the Standardized Letter of Evaluation (SLOE). This study aims to determine whether there is a difference in scores on the EM SLOE between UIM (underrepresented in medicine) and non-UIM applicants and to examine whether differences persist after controlling for other factors in the residency application. Methods: The population consists of medical students who applied to EM residency during the 2019 application season. We compared rankings between UIM and non-UIM students, and rankings between students of each individual race and white students. Results: UIM students received significantly lower rankings on all three SLOE variables compared to non-UIM students, p<.05. After controlling for applicant characteristics, non-UIM students were significantly more likely to be ranked higher than UIM students on RAP (rank against peers), OR 1.46 (95% CI 1.03-2.07) and grade OR 1.46 (95% CI 1.05-2.04). White students were significantly more likely to be ranked higher than Asian and Black students on RAP, OR 1.46 (95% CI 1.00-2.13) and OR 1.81 (1.15-2.83), respectively. White students were significantly more likely to be ranked higher than Asian students on RLP (rank list prediction), OR 1.49 (95% CI 1.04-2.15). White students were significantly more likely to receive a higher grade than Black students, OR 1.65 (95% CI 1.08-2.25). Discussion: Our results demonstrate significant racial bias on the EM SLOE, which persist even after controlling for other performance predictors. This finding is similar to those on other assessments and supports the conclusion that the bias in assessment is likely due to systemic racial inequalities and social determinants of education. Approaching this systemic problem through an anti-racism lens may help lessen the disparity in assessment.