Posted November 26, 2019

Mitigating bias and eliminating unjustified patient stereotypes are important initiatives in teaching, learning and assessment. Concerns about bias have been raised in the academic literature, the media, among students and faculty at schools of medicine, and by patients. The USMLE program remains cognizant of these topics. Characteristics of a patient such as age, sex, gender identity, and occupation are sometimes mentioned within the case vignettes in test items. Some patient characteristics may be important inputs into the diagnostic reasoning process. Others may lead to incorrect conclusions and misdiagnoses. Among the latter are characteristics associated with harmful patient stereotypes.

The USMLE program treats race as a social construct not linked to biology or susceptibility to disease. This is similarly true of ethnicity and “culture” or heritage. Ancestry, if known, may be biologically important, and thus may be relevant to factors relating to health and disease. In addition, when and if these characteristics are to be considered they should be considered on the basis of patient self-report, not the assumption of a health care provider. The USMLE program views patients as individuals, just as medical practice should and does. 

Accurate diagnosis is the goal

Test items and cases on USMLE exams are carefully designed to measure accurate diagnosis, not assumptions, bias, or stereotypes. When examinees select the correct diagnosis, they are given credit because they are demonstrating what the examination item is designed to measure.

The USMLE assessments have evolved significantly since their introduction in 1992, thanks to the more than 400 volunteers who contribute to USMLE each year. The individual faculty members and clinicians who write USMLE test items and cases today follow guidelines that encourage thoughtful consideration of patient characteristics, while at the same time striving to promote diversity and present patients that reflect the US population. 

Ongoing test item review

The USMLE program is reviewing the entirety of its exam content to eliminate questions and cases that may reflect biases or perpetuate stereotypes. We are committed to this thorough review as part of the shared goal of eliminating the biases in clinical practice and the disparities in healthcare access and health outcomes experienced by vulnerable populations. Given the scope of the USMLE’s item and case pool, this full review is ongoing and will take some time, likely 3 to 4 years. 

In the meantime, the end-of examination survey for each computer-based Step examination seeks examinee feedback on whether any patient or physician portrayals in the test promoted stereotypes in medicine. We will track survey responses to this question as a critical part of our review process. Examinees will also begin to notice that certain characteristics, specifically those that relate to social factors such as race, ethnicity, and heritage, if presented within a test item, will be described as self-reported by the patient. The USMLE program intends to share annual updates on progress.

These are important issues for all of us in healthcare as well as in health professions education and assessment. We look forward to completing this work and to continuing our ongoing collaborations with others in the house of medicine in support of equity and outstanding patient care.