The Corruption of Medicine
Tragically, when it comes to the contention that racism is the defining trait of the medical profession and the source of health disparities, opposing views have been ruled out of bounds and are grounds for being purged. The separation of politics and science is no longer seen as a source of empirical strength; it is instead a racist dodge that risks “reinforcing existing power structures.”
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. Predictable tweets called him, inter alia, possibly “the most garbage human being I’ve seen with my own eyes,” and Michael S. Parmacek, chair of the University of Pennsylvania’s Department of Medicine, sent a schoolwide e-mail addressing Goldfarb’s “racist statements.” Those statements had evoked “deep pain and anger,” Parmacek wrote. Accordingly, the school would be making its “entire leadership team” available to “support you,” he said. Parmacek took the occasion to reaffirm that doctors must acknowledge “structural racism.”
That same day, the executive vice president of the University of Pennsylvania for the Health System and the senior vice dean for medical education at the University of Pennsylvania medical school reassured faculty, staff, and students via e-mail that Goldfarb was no longer an active faculty member but rather emeritus. The EVP and the SVD affirmed Penn’s efforts to “foster an anti-racist curriculum” and to promote “inclusive excellence.”
Despite the allegations of faculty racism, disparities in academic performance are the predictable outcome of admissions preferences. In 2021, the average score for white applicants on the Medical College Admission Test was in the 71st percentile, meaning that it was equal to or better than 71 percent of all average scores. The average score for black applicants was in the 35th percentile—a full standard deviation below the average white score. The MCATs have already been redesigned to try to reduce this gap; a quarter of the questions now focus on social issues and psychology.
Yet the gap persists. So medical schools use wildly different standards for admitting black and white applicants. From 2013 to 2016, only 8 percent of white college seniors with below-average undergraduate GPAs and below-average MCAT scores were offered a seat in medical school; less than 6 percent of Asian college seniors with those qualifications were offered a seat, according to an analysis by economist Mark Perry. Medical schools regarded those below-average scores as all but disqualifying—except when presented by blacks and Hispanics. Over 56 percent of black college seniors with below-average undergraduate GPAs and below-average MCATs and 31 percent of Hispanic students with those scores were admitted, making a black student in that range more than seven times as likely as a similarly situated white college senior to be admitted to medical school and more than nine times as likely to be admitted as a similarly situated Asian senior.
Such disparate rates of admission hold in every combination and range of GPA and MCAT scores. Contrary to the AMA’s Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity, blacks are not being “excluded” from medical training; they are being catapulted ahead of their less valued white and Asian peers.
Though mediocre MCAT scores keep out few black students, some activists seek to eliminate the MCATs entirely. Admitting less-qualified students to Ph.D. programs in the life sciences will lower the caliber of future researchers and slow scientific advances. But the stakes are higher in medical training, where insufficient knowledge can endanger a life in the here and now. Nevertheless, some medical schools offer early admissions to college sophomores and juniors with no MCAT requirement, hoping to enroll students with, as the Icahn School of Medicine at Mount Sinai puts it, a “strong appreciation of human rights and social justice.” The University of Pennsylvania medical school guarantees admission to black undergraduates who score a modest 1300 on the SAT (on a 1600-point scale), maintain a 3.6 GPA in college, and complete two summers of internship at the school. The school waives its MCAT requirement for these black students; UPenn’s non-preferred medical students score in the top one percent of all MCAT takers.
According to race advocates, differences in MCAT scores must result from test bias. Yet the MCATs, like all beleaguered standardized tests, are constantly scoured for questions that may presume forms of knowledge particular to a class or race. This “cultural bias” chestnut has been an irrelevancy for decades, yet it retains its salience within the anti-test movement. MCAT questions with the largest racial variance in correct answers are removed. External bias examiners, suitably diverse, double-check the work of the internal MCAT reviewers. If, despite this gauntlet of review, bias still lurked in the MCATs, the tests would underpredict the medical school performance of minority students. In fact, they overpredict it—black medical students do worse than their MCATs would predict, as measured by Step One scores and graduation rates. (Such overprediction characterizes the SATs, too.) Nevertheless, expect a growing number of medical schools to forgo the MCATs, in the hope of shutting down the test entirely and thus eliminating a lingering source of objective data on the allegedly phantom academic skills gap.
Meantime, medical professors need to be reeducated, to ensure that their grading and hiring practices do not provide further evidence of the phantom skills gap. Faculty are routinely subjected to workshops in combating their own racism. On May 3, 2022, the Senior Advisor to the NIH Chief Officer for Scientific Workforce Diversity gave a seminar at the University of Pennsylvania medical school titled “Me, Biased? Recognizing and Blocking Bias.” Senior Advisor Charlene Le Fauve’s mandate at NIH is to “promote diversity, inclusiveness, and equity in the biomedical research enterprise through evidence-based approaches.” Yet her presentation rested heavily on a supposed measure of bias that evidence has discredited: the Implicit Association Test (IAT).The IAT’s own creators have acknowledged that it lacks validity and reliability as a psychometric tool.
Increasing amounts of faculty time are spent on such antiracism activities. On May 16, 2022, the Anti-Racism Program Manager at the David Geffen School of Medicine at the University of California at Los Angeles hosted a presentation from the Director of Strategy and Equity Education Programs at the Icahn School of Medicine at Mount Sinai titled “Anti-Racist Transformation in Medical Education.” Mount Sinai’s Dean for Medical Education and a medical student joined Mount Sinai’s Director of Strategy and Equity Education Programs for the Los Angeles presentation, since spreading the diversity message apparently takes precedence over academic obligations in New York.
Grand rounds is a century-long tradition for passing on the latest medical breakthroughs. (Thomas Eakins’s great 1889 canvas, The Agnew Clinic, portrays an early grand rounds at the University of Pennsylvania.) Rounds are now a conduit for antiracism reeducation. On May 12, 2022, the Vice Chair for Diversity and Inclusion at the University of Pittsburgh’s Department of Medicine gave a grand rounds at the Cleveland Clinic on the topic “In the Absence of Equity: A Look into the Future.” Afterward, attendees would be expected to describe “exclusion from a historical context” and the effects of “hierarchy on health outcomes”; attendance would confer academic credit toward doctors’ continuing-education obligations.