Improving Cultural Sensitivity in Preclinical Exam Questions

To the Editor: When reading a clinical vignette on a preclinical exam, a student struggles to correctly diagnose the "young African American boy with constant fatigue, scleral icterus, and leg pain." The student selects "sickle cell disease" and moves to the next question, struggling to avoid conflating ethnic origin with a socially constructed racial classification. Although the student understands the importance of separating the 2 in clinical practice, they concede to lumping the 2 together for the purpose of completing the exam. Recently, some of our classmates noticed that several exam questions in their preclinical organ sequences were insensitive toward cultural and social issues. Concerns related to cultural appropriation, stereotyping, race-based diagnoses, and implicit biases in question stems were observed and brought to the attention of staff and faculty on our medical school's Evaluation and Assessment Committee. The feedback was met with immediate support and prompted further discussion about how to rigorously evaluate these questions for future classes of students. While these topics have been long-standing within medical education, our current social and political climate necessitates engaging in critical dialogue around these issues and bringing them to the forefront of our educational training. Traditionally, preclinical exam questions serve the purpose of assessing students' knowledge of pathophysiology, pharmacology, and diagnostic reasoning. However, at times, these questions are contextualized within clinical vignettes that include information on certain characteristics, such as age, gender, race, ethnicity, or occupation. While some of these characteristics are important identifiers for clinical reasoning, others may be harmful and rely on unjustified and incorrect stereotypes. To better evaluate and improve such questions, we developed a set of tools and frameworks that aligned with the principles of diversity, equity, and inclusion. 1–3 These tools and frameworks consist of evidence-based guidelines for developing inclusive language, preferred terminology, and visual content to be used in preclinical assessments. We used these tools and frameworks to critically review nearly 6,000 medical school year 1 exam questions for cultural humility and provide constructive feedback and formal recommendations to faculty exam writers. It is necessary for medical schools and their respective evaluation and assessment committees to rigorously examine their test questions to improve assessments of students' diagnostic reasoning and recognize where implicit biases impact health outcomes. We believe that medical education must continue to challenge itself to analyze and remove content that perpetuates stereotypical and antiquated relationships between disease and socially constructed identities. This is a pivotal step to move toward developing trainees who are equipped to dismantle and ameliorate health disparities. Acknowledgments: The authors thank Dr. Karri Grob, Dean Seetha Monrad, Dr. Suzy McTaggart, and the University of Michigan Medical School Evaluation and Assessment Committee for guiding and supporting students in this process. The authors also thank the first-year medical students whose experiences helped inspire this work.