Assessment of a revolution: “How can we alleviate bias in test items?”

As we prioritize the critical revolution that’s happening in assessment science, addressing biases has to be one of the concepts that rises to the top with the science itself.

Science, like all means of understanding the world around us, is informed by those that create it. If the people holding power — leading the advancement of science — hold discriminatory biases, wouldn’t those biases show up in the science itself? The long history of discrimination in medicine, college admissions, and access to health care, amongst other things, says yes.

Reena Karani, MD, MHPE, treasurer for the NBME Board of Directors and Director of the Institute for Medical Education at the Icahn School of Medicine at Mount Sinai, agrees. “So much of what we learned in medicine is predicated on incredibly discriminatory biases and systems of racism and oppression. NBME and faculty across health professions’ schools recognize the critical work we have ahead of us.”

In the effort to right these wrongs, students and patients are leading the charge. While most medical education faculty and leaders believe in the importance of addressing these biases and dismantling racism, many may feel overwhelmed about where to start.

Although the task may seem daunting, it’s important to understand that change at this scale doesn’t always happen overnight; unlearning is a process that takes commitment and sustained effort. Plus, knowledge available on the social determinants of health is growing at an unprecedented rate. By using this knowledge to strengthen understanding of bias and structural racism, collaborate across disciplines, and challenge outdated paradigms of the past, physicians and educators are able to center the work of dismantling bias and championing equity within what they teach, assess, and practice every day.

“As we prioritize the critical revolution that’s happening in assessment science, addressing biases has to be one of the concepts that rises to the top with the science itself,” Dr. Karani said.

Advocating for better assessment

So, what is NBME’s role in this work as an assessment organization? A huge one, says Dr. Karani.

“Organizations like NBME set the standard for the industry. We have no shortage of areas to work on. There are so many levels to this work, from nomenclature to assessing skills in the structural determinants of health. How do we assess those critical skills? That’s what we’re figuring out.”

The United States Medical Licensing Examination® (USMLE®), a program co-sponsored by NBME and the Federation of State Medical Boards (FSMB), formed the Patient Characteristics Advisory Panel (PCAP) to tackle these exact issues. They aim to review representation across exams, inform item development practices related to the inclusion of patient characteristics, and provide feedback to USMLE governance on global recommendations, like ensuring that exam blueprints remain aligned with current diversity, equity, and inclusion (DEI) best practice.

Dr. Karani affirms that the panel has taken on a “whatever is needed, we want to play a role” perspective, and is not shy about speaking up. They’re focused on change within NBME’s walls, as well as outside — support for both NBME and external professionals leading test development and exam review is their top priority.

NBME Test Development has since implemented PCAP recommendations that include understanding race as a social construct not linked to biology or susceptibility to disease, and that patient characteristics should be based on patient self-report. On the more granular level, they’ve introduced processes to ensure that definitions of race, ancestry, ethnicity, and other social and cultural signifiers are clarified and subsequently checked in all test items.

Additionally, the importance of updating the NBME® Item-Writing Guide to provide guidance on incorporating patient characteristics into test items cannot be understated. “The work related to patient characteristics becomes increasingly critical to review and vet regularly. We have to ask our faculty, ‘are you using this guide?’ ‘How is it helping you?’” Dr. Karani said.

Outside NBME, PCAP is also looking to improve item writing and exam taking for all involved. It’s not just USMLE they’re focusing on — they’re advocating to expand professional development opportunities for faculty who write items, and better NBME products and services for medical schools across the country.

Fostering change is everyone’s work

Dr. Karani has a few tips for medical educators and organizations moving through this work. First and foremost is reflecting humility at every step. If someone flags a problematic question, don’t run away from it. Thank them for raising that flag and then let it inform a new perspective.

Also paramount is internalizing the urgency felt by the people this affects the most — patients and historically marginalized communities.

“For NBME, we know we can’t use the old excuse of ‘everything takes time.’ This work has to be a priority,” Dr. Karani explained. “Remove items that promote biases and stereotypes and build questions that test key skills and knowledge relevant to the structural determinants of health and health disparities.”

There’s no more “this isn’t my job, it’s theirs”; it’s everyone’s work because of what’s at stake when we don’t take this work seriously — the health of patients.

“How do the voices who have been historically excluded galvanize a movement? Maybe we have to find new ways to center this work. It’s been awe-inspiring to watch.”

Whatever those ways are, there’s no doubt they all start here. At PCAP meetings, in the halls of medical schools, among the pages of scientific journals — in all these places, not tomorrow, but today.

Medical education needs to support the advancement of skills and behaviors alongside knowledge, so students can develop as complete physicians, ready to take on patient care. We’re rethinking measurement to facilitate this evolution, but we can’t do it without new perspectives and ideas.