Becoming a Doctor Today: by Merit OR Race?
We are entering an existential period for the soul of medicine. For centuries medicine stood for a meritocracy by which physicians would be able to use their distinct knowledge of basic and clinical sciences applied in a humane fashion to cure or alleviate the burden of disease. When death becomes inevitable physicians need the skills to guide the patient/family, alleviating pain and apprehension. But we are now facing a challenge to this core idea, that it be replaced by a form of tribalism under the rubric of diversity, equity, and inclusion.
For over two centuries, the United States was a “melting pot” nation which since the Civil War has with fits and starts strived to be true to the premise, “That all men are created equal”. Great progress has been made, but perfection is an illusory goal.
The legal hedging of a meritocracy in education began in 1978 with a split decision by the U.S. Supreme Court in Regents of the University of California v Bakke, whereby justice Lewis Powell being the sole member of two split decisions decided that race could be used as a “non-predominant” factor in admissions in the interest of “diversity”. The tragedy was that this was to make up for a lack of qualified Hispanic students because of inadequate K-12 education. Instead of dealing with this more difficult issue, the Supreme Court ordered, by the slimmest of a majority, a racial and ethnic solution against the U.S. ideal. In 2003 in Gratz v Bollinger (president U. of Michigan) again in a split decision the Supreme Court found an undergraduate racial point system unconstitutional but at the same time in Grutter v Bollinger upheld the Law School’s use of race as a factor to create a “diverse educational environment”, diverse by outward appearance, NOT of thought.
Then in 2013 & 2015 in Fisher v University of Texas, the Supreme Court after referring the case back to the Fifth Circuit Court found by a narrow 4-3 decision, (one recusal, another jurist had just died), that racist preferences were needed for student body “diversity”. However, the inconsistency of the court regarding race is apparent as in Rice v Cyetano (2000), a voting rights case, when the court stated, “One of the principal reasons race is treated as a forbidden classification is that it demeans the dignity and worth of a person to be judged by ancestry instead of by his or her own merit and essential qualities” (Ref. 1).
These narrow Supreme Court decisions upholding race for admission to educational institutions have created non-meritorious standards for universities and medical schools, which have evolved into an obsession with racism. The Icahn School of Medicine at the Mt. Sinai health care system is an example (Ref.2.) Several years ago, a group of “black & brown” medical students claimed that they were exposed to pervasive racism in the school setting and curriculum. In response the school created The Racism and Bias Initiative stating that ”There is no priority in medical education that is more important than addressing and eliminating racism and bias” (Ref.3). Apparently to this faculty providing the students with the underpinnings of knowledge to alleviate patient suffering from disease and eventual death is no longer the primary mission of a medical school. The Icahn school received monies from the Macy foundation to create the Anti-Racist Transformation in Medical Education program that is now being used at other medical schools (Ref.4,5). Medical school accrediting agencies and medical societies have jumped on board decrying racism in medical school curriculum and demanding change, without ever addressing the purpose of a medical school (Ref.6).
The U.S. Supreme Court has an opportunity to reverse this perversion of the meaning of a “melting pot” nation. We await the finding of Students for Fair Admissions, Inc. v President and Fellows of Harvard College (Ref.7). This could be the end of dividing us by race, causing us to address the inferior education experienced by many children and returning higher education to rigorous learning.
- John B. Daukas, Racial Preferences and the Fainthearted Supreme Court: For 45 years, the justices have tried to set strict limits and colleges have ignored them. It’s time for a bright-line ruling that discrimination is unlawful, WSJ, January 13, 2023, available at: https://www.wsj.com/articles/racial-preferences-and-the-fainthearted-supreme-court-harvard-unc-bakke-race-diversity-title-vi-roberts-11673642764 (accessed January 14, 2023)
- Icahn School of Medicine at Mount Sinai, available at: https://icahn.mssm.edu/ (accessed January 18, 2023)
- Leona Hess, Ann-Gel Palermo, David Muller, Addressing and Undoing Racism and Bias in the Medical School Learning and Work Environment, Academic Medicine, 2020, available at: https://journals.lww.com/academicmedicine/Fulltext/2020/12001/Addressing_and_Undoing_Racism_and_Bias_in_the.8.aspx(accessed January 14, 2023)
- Icahn School of Medicine at Mount Sinai, Anti-Racist Transformation in Medical Education, 2023, available at: https://icahn.mssm.edu/education/medical/anti-racist-transformation (accessed January 14, 2023)
- John Sailer, How DEI Is Supplanting Truth as the Mission of American Universities, The Free Press, January 9, 2023, available at: https://www.thefp.com/p/how-dei-is-supplanting-truth-as-the (assessed January 12, 2023)
- Richard D. deShazo, Craig J. Hoesley, Selwyn M. Vickers, Ending Racial Bias in American Medicine: A Call for Help from the AMA, NMA, AAMC, and the Rest of Us. American Journal of Medicine, 2021, available at: https://www.amjmed.com/article/S0002-9343(20)31103-7/fulltext (accessed January 18, 2023)
- Scott Jaschik, Supreme Court Takes Affirmative Action Cases, Inside Higher Ed, January 31, 2022, available at: https://www.insidehighered.com/admissions/article/2022/01/31/supreme-court-will-hear-harvard-and-unc-affirmative-action-cases(accessed January 18, 2023)
Pat, Thank you for your scholarly response to Natalie. Ken
Ken, the irony in your commentary is believing that when medical school was full of nothing but White males, they were admitted based on merit when there were certainly women and POC who were highly qualified and were rejected on gender/race alone. It wasn’t all that long ago. We will never know the numbers because they were rejected. When Flexner’s Report was brought to fruition, 5/7 Black medical schools were shut down. Of course they were never going to measure up to the predominantly White schools academically as they never received the same governmental funding, if any, because they were Black schools. With money comes more quality, that should be evident. But somehow, over the decades, you want to believe that the industrialized racism that was ubiquitous in medicine has somehow dissipated. It hasn’t. It has simply become more sophisticated. Because human beings have no ability to be objective and leave their personal s**t at home.
It’s easy to state that one needs to measure up to the “standards” but who set the standards in the first place? You know that K-12 education for Blacks, Hispanics and Native Americans was never equivalent for hundreds of years until Brown vs the Board of Education. But that law did not equalize education. It permitted integration so Black students would have a chance to have the same access as Whites to a quality education. And we were not welcomed with open arms. That integration also did not happen overnight. It is not a coincidence that medical school remains predominantly White. There will always be White leaders in medical school and medicine who discriminate because they can. They are the legacy that continues to perpetuate this nonsense.
What I find most offensive about your commentary is the presumption that because Black people or other POC don’t get admitted to med school, they must not be qualified and that the White people who get accepted are qualified. Name one medical school that has allowed so many POC that the Whites are in the minority. This resentment and stereotyping of the few POC who do get admitted is absurd. I was accepted to med school and paid for it under the Health Professions Scholarship Program(HPSP). A White male classmate who came in under the same program had the audacity to say to my face that it was easier for me to get in because I was Black. Despite the fact that our class was 85% White. I was not admitted under any “special” program–he just presumed I could not have gotten in under my own merits because I’m Black. All of my education was public and/or through the Department of Defense. Overwhelmingly predominantly White schools so I was well-prepared to go to college.
Here’s the bottom line. If the White men who were in charge of admitting medical students had admitted people based on merit in the first place, we would not be in this mess. They chose not to do the right thing and rejected others based on race, gender, physical disability and veteran status. And that s**t still goes occurs. And it won’t change until we get people representing all of those demographics in positions of leadership. Frankly, we cannot depend on White men in leadership to do the right thing. They had decades to do it and they didn’t, they had to be forced.
Natalie, with sincere respect, you make some valid historical arguments, but it is equally unfair to state “There will always be White leaders in medical school and medicine who discriminate because they can.” That is an unprovable assumption.
No one can give an objective value for “diversity,” yet people fall all over themselves to demonstrate it. You and Ken have both made some real points – my question is, how do genuine, thinking physicians like those engaged here move forward past all of this to make things better for all of us?
Pat, Agree our goal should be the ideal, “That all men are created equal”, and that medical schools job is to prepare students to be qualified physicians. That does not diminish that there have been gross deficiencies in the past, but the ideal remains and we should not stop pursuing it because of past sins. Ken
Pat, I have always respected you and your perspective, even if I don’t necessarily agree with all of your viewpoints. It is important to me to always keep my eyes and ears open to hear and see other perspectives. I don’t do well in echo chambers because I stagnate.
You said racism does not exist in med school and hasn’t for a long time. How have you proved that? My lived experience begs to differ. Of course from your point of view you would never see it. The legacy of White America is what it is. Institutionalized racism did not simply dissipate due to the goodness of men, that is how I can make my sweeping statement regarding White leaders in medicine. Because many are culpable for the persistent racist issues. I would love to have just one year of my life not to have to deal with that s**t. Just one. How do you expect us to move forward when you don’t even believe racism exists in medical school? I’m a physician advocate and frankly I’m tired of the emails I get from Black students struggling in their programs. We know what racism is. We don’t need to be “overly” sensitive. The only difference between today and the past is the racism is more sophisticated. Students in their clinical years are left at the mercy of mostly White attendings who are just people. People with biases. The same people are responsible for subjective evaluations on performance. I’m here to tell you that my f**k-ups were magnified compared to my White male counterparts, even if the f**k-ups were exactly the same. White men identify with White men so the empathy is there. Why the f**k would they have empathy for me when they don’t even view me as a person and more of an irritant? It is well-known in the Black community that we have to be 10X better in our performances just to be considered equal.
Why does there need to be an objective value for diversity? Racism is a social construct that is not objective. The counter is diversity. Mix the s**t up a little so everyone has equal opportunity. But we will never have genuine diversity because there will always be racism in people who hold positions of power. Always. The best we can do RIGHT NOW are statutes, guidelines and policies, which is bulls**t. Long-term solution? Native Americans on reservations should have the same quality of K-12 education that a White student in Great Neck, NY gets. That will take decades, if ever, to happen. So all we have left are policies. Because human beings just won’t do the right f***ing thing on their own.
Natalie, I hope you noticed that in the essay I pointed out that improving schools for minority children is essential for a society to include ALL its citizens equally and that is a much more difficult task than assigning quotas. To me the goal is that every citizen be treated equally. Certainly that has NOT been true in the past, but that should not stop us in trying to reach the ideal. Secondly I tried to point out that the goal of a medical school is to prepare its students to alleviate the burden of disease and to be able to help when death is inevitable.
I want to thank you for your input in this most highly charged difficult issue. I am confident that with open discussion we can agree on what our long term goals should be. Ken
I read everything you wrote. How do I interpret your solution? You’re telling POC and other disadvantaged demographics
to wait. And do it right. Or what you perceive as right. So how long do we wait Ken? Do you think POC have not been patient for long enough? When left to the devices of fallible human beings, nothing get’s done so change has to almost always occur legislatively. It’s easy to tell people who are being affected to wait–when it is not you. It’s not about the solution being difficult, it’s ignoring the conditions that brought about the issue in the first place. That means something transformational has to occur from within for one to acknowledge it is people who brought about the issues. Most people are incapable of such transformation because doing so means giving up inherent privilege. You are speaking as if these issues are in the past. They are my present. They have not gone anywhere and why would they? What’s the incentive to change? The opportunity to improve conditions always existed, so why hasn’t it happened? Because, IMO, some people will just not do the right thing if it presents an inconvenience or a threat to them. And that has caused us to remain stuck.
Year ago, during the affirmative action era, mostly White men would call the affirmative action statutes “reverse discrimination”, not realizing they were tacitly admitting that they knew discrimination existed in the first place. It was only when they began to experience a scintilla of what marginalized communities had experienced for hundreds of years that it became a problem. Suddenly the conversations became about merit, much like your commentary now. When it was never about and never has been about merit. It has always been about privilege and entitlements.
I swear the Flexner Report is like a Rorschach test. Was Flexner addressing a problem of shoddy for-profit medical schools, or a bigot trying to drive minorities and women out of medicine? Depends on one’s outlook……..to some degree. At the same time, there is evidence Flexner had the same “progressive” attitude toward blacks that, say, Margaret Sanger professed about the same time.
Dave, A society that does not ensure high quality education for all children will see troubles that far exceed what the cost would be to provide that education for all. Certainly true in the U.S. today. Ken
arf, I agree it is difficult to separate the thoughts of a gentleman in the early 20th century about medical school quality of education. We have in this nation a idealistic goal of “All men are created equal”. That does not mean it is going to be easy, but I believe we should do everything we can to set our sights on that ideal. Ken
Dave, Thanks for the comment, certainly the supreme Court has NOT helped in this matter. Ken
I agree it is a great summary. However times have changed. Many of us who went to school back in those old litiginous days would look at the future and wonder if it was worth it……in today’s climate. Is the time, effort, expense, physical and emotional pain WORTH IT??? Does society value us any more? Why do I read about inflation all the time, yet I see my insurance reimbursement falling and my patients are expecting more of me?
Gary, I agree these are tough times for our profession, our leaders, deans of medical schools, medical society executives have become pawns in a government driven debacle. I believe there is a solution, change the funding stream, put the $$ into the patients’ control and they would have the means to direct their own care. Ken
“Medical school accrediting agencies and medical societies have jumped on board decrying racism in medical school curriculum and demanding change…”
This is an invented problem, created by grifters, and embraced by idiot academicians and university administrators terrified of protests and lawsuits. There is no racism in medical school, has not been for a long time, and no one can define any objective value or worth of “diversity.”
This is a financial scam, and darker, a larger Marxist trend of indoctrinating would-be health techs into unquestioning, unthinking collectivist servitude.
Pat, No doubt this drive for DIE is pure folly. Thanks, Ken
Pat, racism still exists in medical school. For it not to you have to believe that every human being involved with educating medical students either has no biases or has a remarkable ability to restrain themselves from exhibiting those biases. You wouldn’t know if racism still exists if you haven’t walked in a victim’s shoes or you don’t mentor any of the students experiencing it. I know I certainly experienced it and I graduated in the mid-90’s. For racism to not exist in medicine would require transformative leadership that begins way before med school. And for that to occur one has to have significant self-reflection to be able to accomplish that kind of transformation. Most racists will not commit to that. It’s too ugly.
Natalie, I love your phrase “a remarkable ability to restrain themselves from exhibiting those biases…”. I have to restrain my biases against drug use, stupidity, apathy, and laziness every single shift I work. Wasn’t being able to keep our prejudices in check part of medical training?
Your experience in training is certainly not what I witnessed in any alway at my med school in the mid-Nineties, quite the opposite. Nor do I question your experience or sincerity, not at all. I do not however accept the premise that not personally experiencing something invalidates a contrary view.
If this is so, then either one side is irredeemably naive with no right to an opinion, and they are permanently damned by their circumstances…
And/or the other side has every reason to be permanently suspicious and resentful, again resulting in irreparable division.
If this is so, then no one, black, white, or otherwise should want anything to with such a toxic, divisive field, and medicine really is not worth saving.
My own experiences have taught me to mistrust and fear collective solutions, into which hopes for “transformative leadership” I observe typically devolve. This is such a sad, tragic topic that I want to end on a positive note, (hopefully not received as a pointless bromide), and will sign off with a quote from my favorite author, John D. MacDonald:
“The only thing in the world worth a damn is the strange, touching, pathetic, awesome nobility of the individual human spirit.”
Great summary! The problems with education definitely stem from well before the realm of higher education.