Guardians of the profession discard merit in order to alter the demographics of their field
By Heather Mac Donald - August 10, 2022
The post–George Floyd racial reckoning has hit the field of medicine like an earthquake. Medical education, medical research, and standards of competence have been upended by two related hypotheses: that systemic racism is responsible both for racial disparities in the demographics of the medical profession and for racial disparities in health outcomes. Questioning those hypotheses is professionally suicidal. Vast sums of public and private research funding are being redirected from basic science to political projects aimed at dismantling white supremacy. The result will be declining quality of medical care and a curtailment of scientific progress.
Virtually every major medical organization—from the American Medical Association (AMA) and the American Association of Medical Colleges (AAMC) to the American Association of Pediatrics—has embraced the idea that medicine is an inequity-producing enterprise. The AMA’s 2021 Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity is virtually indistinguishable from a black studies department’s mission statement. The plan’s anonymous authors seem aware of how radically its rhetoric differs from medicine’s traditional concerns. The preamble notes that “just as the general parlance of a business document varies from that of a physics document, so too is the case for an equity document.” (Such shaky command of usage and grammar characterizes the entire 86-page tome, making the preamble’s boast that “the field of equity has developed a parlance which conveys both [sic] authenticity, precision, and meaning” particularly ironic.)
Thus forewarned, the reader plunges into a thicket of social-justice maxims: physicians must “confront inequities and dismantle white supremacy, racism, and other forms of exclusion and structured oppression, as well as embed racial justice and advance equity within and across all aspects of health systems.” The country needs to pivot “from euphemisms to explicit conversations about power, racism, gender and class oppression, forms of discrimination and exclusion.” (The reader may puzzle over how much more “explicit” current “conversations” about racism can be.) We need to discard “America’s stronghold of false notions of hierarchy of value based on gender, skin color, religion, ability and country of origin, as well as other forms of privilege.”
A key solution to this alleged oppression is identity-based preferences throughout the medical profession. The AMA strategic plan calls for the “just representation of Black, Indigenous and Latinx people in medical school admissions as well as . . . leadership ranks.” The lack of “just representation,” according to the AMA, is due to deliberate “exclusion,” which will end only when we have “prioritize[d] and integrate[d] the voices and ideas of people and communities experiencing great injustice and historically excluded, exploited, and deprived of needed resources such as people of color, women, people with disabilities, LGBTQ+, and those in rural and urban communities alike.”
According to medical and STEM leaders, to be white is to be per se racist; apologies and reparations for that offending trait are now de rigueur. In June 2020, Nature identified itself as one of the culpably “white institutions that is responsible for bias in research and scholarship.” In January 2021, the editor-in-chief of Health Affairs lamented that “our own staff and leadership are overwhelmingly white.” The AMA’s strategic plan blames “white male lawmakers” for America’s systemic racism.
And so medical schools and medical societies are discarding traditional standards of merit in order to alter the demographic characteristics of their profession. That demolition of standards rests on an a priori truth: that there is no academic skills gap between whites and Asians, on the one hand, and blacks and Hispanics, on the other. No proof is needed for this proposition; it is the starting point for any discussion of racial disparities in medical personnel. Therefore, any test or evaluation on which blacks and Hispanics score worse than whites and Asians is biased and should be eliminated.
The U.S. Medical Licensing Exam is a prime offender. At the end of their second year of medical school, students take Step One of the USMLE, which measures knowledge of the body’s anatomical parts, their functioning, and their malfunctioning; topics include biochemistry, physiology, cell biology, pharmacology, and the cardiovascular system. High scores on Step One predict success in a residency; highly sought-after residency programs, such as neurosurgery and radiology, use Step One scores to help select applicants.
Black students are not admitted into competitive residencies at the same rate as whites because their average Step One test scores are a standard deviation below those of whites. Step One has already been modified to try to shrink that gap; it now includes nonscience components such as “communication and interpersonal skills.” But the standard deviation in scores has persisted. In the world of antiracism, that persistence means only one thing: the test is to blame. It is Step One that, in the language of antiracism, “disadvantages” underrepresented minorities, not any lesser degree of medical knowledge.
The Step One exam has a further mark against it. The pressure to score well inhibits minority students from what has become a core component of medical education: antiracism advocacy. A fourth-year Yale medical student describes how the specter of Step One affected his priorities. In his first two years of medical school, the student had “immersed” himself, as he describes it, in a student-led committee focused on diversity, inclusion, and social justice. The student ran a podcast about health disparities. All that political work was made possible by Yale’s pass-fail grading system, which meant that he didn’t feel compelled to put studying ahead of diversity concerns. Then, as he tells it, Step One “reared its ugly head.” Getting an actual grade on an exam might prove to “whoever might have thought it before that I didn’t deserve a seat at Yale as a Black medical student,” the student worried.
The solution to such academic pressure was obvious: abolish Step One grades. Since January 2022, Step One has been graded on a pass-fail basis. The fourth-year Yale student can now go back to his diversity activism, without worrying about what a graded exam might reveal. Whether his future patients will appreciate his chosen focus is unclear.
Every other measure of academic mastery has a disparate impact on blacks and thus is in the crosshairs.
In the third year of medical school, professors grade students on their clinical knowledge in what is known as a Medical Student Performance Evaluation (MSPE). The MSPE uses qualitative categories like Outstanding, Excellent, Very Good, and Good. White students at the University of Washington School of Medicine received higher MSPE ratings than underrepresented minority students from 2010 to 2015, according to a 2019 analysis. The disparity in MSPEs tracked the disparity in Step One scores.
The parallel between MSPE and Step One evaluations might suggest that what is being measured in both cases is real. But the a priori truth holds that no academic skills gap exists. Accordingly, the researchers proposed a national study of medical school grades to identify the actual causes of that racial disparity. The conclusion is foregone: faculty bias. As a Harvard medical student put it in Stat News: “biases are baked into the evaluations of students from marginalized backgrounds.”
A 2022 study of clinical performance scores anticipated that foregone conclusion. Professors from Emory University, Massachusetts General Hospital, and the University of California at San Francisco, among other institutions, analyzed faculty evaluations of internal medicine residents in such areas as medical knowledge and professionalism. On every assessment, black and Hispanic residents were rated lower than white and Asian residents. The researchers hypothesized three possible explanations: bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment. University of Pennsylvania professor of medicine Stanley Goldfarb tweeted out a fourth possibility: “Could it be [that the minority students] were just less good at being residents?”
Goldfarb had violated the a priori truth. Punishment was immediate . . .
[SNIP]
