Ethnic bias and the hidden curriculum: The impact of routine inclusion of ethnicity in medical education assessment

Suzanne Pitama; Jenni Manuel; Tim Wilkinson; Mike Tweed; Jessica Cuddy; Tania Huria; Cameron Lacey

doi:10.11157/fohpe.v25i3.777

Authors

Suzanne Pitama University of Otago, New Zealand
Jenni Manuel University of Otago, New Zealand
Tim Wilkinson University of Otago, New Zealand
Mike Tweed University of Otago, New Zealand
Jessica Cuddy University of Otago, New Zealand
Tania Huria University of Otago, New Zealand
Cameron Lacey University of Otago, New Zealand

DOI:

https://doi.org/10.11157/fohpe.v25i3.777

Keywords:

Indigenous, Māori, assessment, medical education, bias

Abstract

Introduction: In 2012, the University of Otago Medical School in New Zealand amended high stakes examination questions to routinely include ethnicity. This policy change was prompted by the assessment committee, including the Māori subcommittee. This study aimed to examine the portrayal of Māori patients and to explore the impact of routine inclusion of ethnicity.

Methods: A quantitative description of demographic variables of examination questions and responses (role-model answers, multiple-response preferred answer, guidelines for markers) from a pre policy (2009–2011), post policy (2012–2013) and follow-up period (2018–2019) was undertaken. A qualitative content analysis of Māori examination questions was conducted with consideration of trends over time.

Results: The majority (98%) of examination questions did not report ethnicity prior to the 2012 policy, whereas around 80% of cases did post policy implementation. Three themes were identified: the non-adherent Māori patient, determinants of health and the patient assigned Māori ethnicity. Examination questions and responses that portrayed Māori as being non-adherent were more common prior to the implementation of the policy. Post policy, many questions did not require students to consider the relevance of ethnicity but presented an increase in social and cultural contextual information of the patient over time.

Conclusion: Policy implementation by the assessment committee led to less racist stereotyping and “othering” of Māori patients and prompted further refinement of social and cultural determinants of health over time. Future recommendations include increasing representation of Māori as a reflection of the increased burden of disease alongside representing intersectionality using other socio-cultural indicators.

References

Bowen, G. A. (2009). Document analysis as a qualitative research method. Qualitative Research Journal, 9(2), 27–40. https://doi.org/10.3316/QRJ0902027

Braun, V., & Clarke, V. (2012). Thematic analysis. In H. Cooper, P. M. Camic, D. L. Long, A. T. Panter, D. Rindskopf, & K. J. Sher (Eds.), APA handbook of research methods in psychology, Vol 2. Research designs: Quantitative, qualitative, neuropsychological, and biological (pp. 57–71). American Psychological Association. https://doi.org/10.1037/13620-004

Colorafi, K. J., & Evans, B. (2016). Qualitative descriptive methods in health science research. HERD: Health Environments Research & Design Journal, 9(4), 16–25 https://doi.org/10.1177/1937586715614171

Cormack, D., Harris, R., Stanley, J., Lacey, C., Jones, R., & Curtis, E. (2018). Ethnic bias amongst medical students in Aotearoa/New Zealand: Findings from the Bias and Decision Making in Medicine (BDMM) study. PLoS ONE, 13(8), Article e0201168. https://doi.org/10.1371/journal.pone.0201168

Cram, F., McCreanor, T., Smith, L., Nairn, R., & Johnstone, W. (2006). Kaupapa Maori research and Pakeha social science: Epistemological tensions in a study of Maori health. Hulili, 3(1), 41–68. https://kamehamehapublishing.org/wp-content/uploads/sites/38/2020/09/Hulili_Vol3_5.pdf

Ewen, S., Mazel, O., & Knoche, D. (2012). Exposing the hidden curriculum influencing medical education on the health of Indigenous people in Australia and New Zealand: The role of the critical reflection tool. Academic Medicine, 87(2), 200–205.

Fahy, K., Lee, A., & Milne, B. J. (2017). New Zealand socio-economic index 2013. https://www.stats.govt.nz/assets/Uploads/Retirement-of-archive-website-project-files/Research/New-Zealand-socio-economic-index-2013/New-Zealand-socio-economic-index-2013.pdf

Graham, R., & Masters‐Awatere, B. (2020). Experiences of Māori of Aotearoa New Zealand's public health system: A systematic review of two decades of published qualitative research. Australian and New Zealand Journal of Public Health, 44(3), 193–200. https://doi.org/10.1111/1753-6405.12971

Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L., Iezzoni, L. I., & Banaji, M. R. (2007). Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. Journal of General Internal Medicine, 22(9), 1231–1238. https://doi.org/10.1007/s11606-007-0258-5

Hafferty, F. W. (1998). Beyond curriculum reform: Confronting medicine's hidden curriculum. Academic Medicine, 73(4), 403–407. https://doi.org/10.1097/00001888-199804000-00013

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. American Journal of Public Health, 105(12), e60–e76. https://doi.org/10.2105/AJPH.2015.302903

Harris, R., Tobias, M., Jeffreys, M., Waldegrave, K., Karlsen, S., & Nazroo, J. (2006). Effects of self-reported racial discrimination and deprivation on Māori health and inequalities in New Zealand: Cross-sectional study. The Lancet, 367(9527), 2005–2009. https://doi.org/10.1016/S0140-6736(06)68890-9

Hudson, M., Milne, M., Reynolds, P., Russell, K., & Smith, B. (2010). Te Ara Tika guidelines for Māori research ethics: A framework for researchers and ethics committee members. https://www.hrc.govt.nz/sites/default/files/2019-06/Resource%20Library%20PDF%20-%20Te%20Ara%20Tika%20Guidelines%20for%20Maori%20Research%20Ethics_0.pdf

Huria, T., Palmer, S., Beckert, L., Lacey, C., & Pitama, S. (2017). Indigenous health: Designing a clinical orientation program valued by learners. BMC Medical Education, 17(1), Article 180. https://doi.org/10.1186/s12909-017-1019-8

Jones, R. G., Crowshoe, L., Reid, P., Calam, B., Curtis, E., Green, M., Huria, T., Jacklin, K., Kamaka, M., & Lacey, C. (2019). Educating for Indigenous health equity: An international consensus statement. Academic Medicine, 94(4), 512–519. https://doi.org/10.1097/ACM.0000000000002476

Jones, R. G., Henning, M. A., Pinncok, R., Shulruf, B., & Hawken, S. J. (2013). Medical students' and clinical teachers' perceptions of Māori health teaching. The New Zealand Medical Journal, 126(1377), 41–50.

Marjadi, B., Chiavaroli, N., Sorinola, O., Milos Nymberg, V., Joyce, C., Parsons, C., & Ryan, A. (2023). Diversity audit of medical school examination questions. Teaching and Learning in Medicine, 1–9. https://doi.org/10.1080/10401334.2023.2240776

Ministry of Health New Zealand. (2015). Mortality and demographic data 2012. Ministry of Health. https://www.health.govt.nz/publication/mortality-and-demographic-data-2012

Monrouxe, L. V. (2010). Identity, identification and medical education: Why should we care? Medical Education, 44, 40–49. https://doi.org/10.1111/j.1365-2923.2009.03440.x

Nash, J. C. (2008). Re-thinking intersectionality. Feminist Review, 89(1), 1–15. https://doi.org/10.1057/fr.2008.4

Pitama, S., Palmer, S. C., Huria, T., Lacey, C., & Wilkinson, T. (2018). Implementation and impact of Indigenous health curricula: A systematic review. Medical Education, 52(9), 898–909. https://doi.org/10.1111/medu.13613

Sabin, J. A., & Greenwald, A. G. (2012). The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: Pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. American Journal of Public Health, 102(5), 988–995. https://doi.org/10.2105/AJPH.2011.300621

Sandelowski, M. (2010). What's in a name? Qualitative description revisited. Research in Nursing & Health, 33(1), 77–84. https://doi.org/10.1002/nur.20362

Smith, L. (1999). Decolonizing methodologies. University of Otago Press.

Statistics New Zealand. (2019). New Zealand as a villiage of 100 people: 2018 Census. Statistics New Zealand.

https://www.stats.govt.nz/infographics/new-zealand-as-a-village-of-100-people-2018-census-data

Taylor, J. S. (2003). Confronting “culture” in medicine's “culture of no culture”. Academic Medicine, 78(6), 555–559. https://journals.lww.com/academicmedicine/Fulltext/2003/06000/Confronting__Culture__in_Medicine_s__Culture_of_No.3.aspx

Turbes, S., Krebs, E., & Axtell, S. (2002). The hidden curriculum in multicultural medical education: The role of case examples. Academic Medicine, 77(3), 209–216. https://doi.org/10.1097/00001888-200203000-00007

Viruell-Fuentes, E. A., Miranda, P. Y., & Abdulrahim, S. (2012). More than culture: Structural racism, intersectionality theory, and immigrant health. Social Science & Medicine, 75(12), 2099–2106. https://doi.org/10.1016/j.socscimed.2011.12.037