Racial Bias in Test Performance:

We applaud the efforts of Wang et al to address systemic racism in their paper on racial differences in family medicine residency, in-training exam scores.1 However, we were disappointed the researchers did not address the differences in exam performance of test takers using English as a second language (ESL). Primary language has long been shown to be an important factor when taking timed exams in English.2 Test takers using ESL have been found to have particular difficulty with lengthy clinical vignettes.3 International medical graduates made up over 30% of the sample and were found to have lower overall initial exam scores and more rapid improvement during residency. Even if the current data collection does not include primary language or ESL, the ABFM does collect data on respondents’ use of languages other than English for care delivery.4 This could be a valuable proxy measure for ESL and might help sort out the differential impact of language versus race/ethnicity on exam performance. Extending the time allowed for test completion has also been found to improve scores for those taking a knowledge test in a second language.5 We caution the authors in anchoring on exam performance as the measure of resident knowledge acquisition without acknowledging the development of skills and other competencies that are less concretely assessed. Diversity has been shown to improve the quality of patient care.6 STFM has set forth a strategic plan to increase diversity in family medicine educators and model “antiracism, health equity, and social justice themes in their materials” for learners and educators.7 We recommend that STFM collaborates with the ABFM and other external organizations to also explore resident assessment using an equity lens. It is imperative that the ABFM determines a way to adequately assess the progression of medical knowledge of family medicine residents from diverse backgrounds. In the final paragraph, the authors equate exam performance with knowledge. We challenge this assumption and hope the ABFM will consider more holistic evaluation. The assessment of language and its impact on test performance would be an excellent first step.