Paucity of Diversity and Representation of Minoratized Individuals in Educational Questions in Gastroenterology

Introduction: In the wake of racial reckoning in the USA and heightened awareness of health disparities that minoritized individuals face on a daily basis, the AAMC guidelines advocate for integrating diversity, equity, and inclusion (DEI) competencies throughout the medical education continuum. We aimed to assess the extent of representation in graduate medical education in gastroenterology/ hepatology by investigating the extent to which there is diverse representation in clinical cases in 3 large question banks published by major scientific GI societies. Methods: We reviewed the DDSEP+ question bank from AGA, the 2022 self-assessment test from ACG and GESAPX from ASGE offered for ABIM GI certification exam preparation. We only included questions pertaining to clinical cases in our analysis. We collected data on age, and socio-demographics (SD) such as gender identity, race, nationality physical and mental ability, job status, educational level, immigration status, sexual orientation, and marital or dating status (Table 1). Results: We reviewed a total of 1,602 questions. Once we excluded theoretical review questions, our study cohort included a final number of 1,544 clinical questions. 1,440 (93.3%) were adult patients. Median age was 48 years and ranged from 2 days to 98 years. 48.9% (n=753) were identified as women with she/her pronouns. 19 (1.2%) patients did not carry any gender identity. In total, 11.1% (N=171) cases included a description of any SD factors. In these instances, the correct answer was 85% more likely to be associated with these factors, whenever mentioned in the question stem, compared to questions that did not specify any SD (RR: 1.85 [95% CI= 1.51 – 2.27]). Conclusion: Despite AAMC DEI competency guidelines, GI board review questions continue to lack diverse patient representation. Failing to include diverse SD in clinical cases creates a non-authentic perception of our society. Addressing representation within medical educational cases will more fully portray the diversity of the patients we treat, and better prepare future providers to treat diverse patient populations. Stereotyping becomes more striking when the correct answer is usually associated with any of the rare instances a SD factor is mentioned in the stem of the question. In an effort to provide equitable care, we call on the major GI societies to ensure that their educational resources include DEI related competency-driven content in their board examination review questions and clinical scenarios. Table 1. - Characteristics of patients from clinical cases Characteristics N (%) ALL SAT 2022 DDSEP+ GESAP X Patients 1,544 293 808 443 Adults 1,440(93.3%) 292 (99.7%) 748 (92.8%) 400 (90.9%) Median age [range] 48 years [2 days – 98 years] 50 years [2 – 90 years] 45 years [2 days – 98 years] 54 years [4 weeks – 89 years] Gender identity Men with he/his pronouns 771 (50.1%) 146 (49.8%) 381 (47.2%) 244 (55.1%) Women with she/her pronouns 753 (48.9%) 146 (49.8%) 416 (51.5%) 191 (43.1%) Genderless 19 (1.2%) 1 (0.3%) 10 (1.2%) 8 (1.8%) Non-binary 1 (0.06%) 0 1 (0.1%) 0 Cisgender specified 0 0 0 0 Transgender specified 0 0 0 0 Race/Nationality/Ethnicity 54 (3.5%) 8 (2.7%) 28 (3.5%) 18 (4.1%) Black 15 (1.0%) 4 (1.4%) 8 (1.0%) 3 (0.7%) White 15 (0.1%) 0 6 (0.7%) 9 (2.0%)(incl. 5 Caucasians) Hispanic ethnicity 3 (0.2%) 0 1 (0.3%) 2 (0.4%) Has a job 37 (2.4%) 9 (3.1%) 21 (2.6%) 7 (1.6%) Immigrants 16 (1.0%) 0 12 (1.5%) 4 (0.9%) Educational level 11 (0.7%) 0 6 (0.7%) 5 (1.1%) Veterans 3 (0.2%) 3 (1.0%) 0 0 Prisoner 0 0 1 (0.1%) 0 Marital status Opposite-sex marriage 10 (0.6%) 2 (0.7%) 8 (1.0%) 2 (0.4%) Same-sex marriage 0 0 0 0 Opposite-sex dating 1 (0.1%) 0 1 (0.1%) 0 Same-sex dating 1 (0.1%) 1 (0.3%) 0 0 Spouse/partner of unspecified gender 4 (0.3%) 1 (0.3%) 2 (0.2%) 1 (0.2%) Sexual orientation 2 (0.1%) 0 1 Bisexual (0.1%) 1 Homosexual (0.2%) Sexual practices 2 (0.1%) 0 1 Penetrative and receptive anal sex 1 Anal receptive intercourse (0.2%) Physical or mental ability 4 (0.3%) 0 2 on mental ability (0.2%) 2 on mental ability (0.4%) Insurance type, housing, or language proficiency 0 0 0 0