The National Academies of Sciences urge affirmative action in med-school admissions

April 26, 2023 • 11:30 am

I present yet another example of a scientific organization engaged in political/ideological advocacy. In this case the organization is the august body of the National Academies of Science, an organization that admits only the most accomplished of America’s scientists. It also publishes the Proceedings of the National Academies of Sciences (PNAS), a pretty well respected journal though not of the quality of Science or Nature.

In the latest issue, three authors from Harvard (and Mass General Hospital) argue, well, you can see the claim themselves from the title screenshot below. It’s a political argument, not a scientific one, and is a reaction to the likely dismantling this year of of race-based preferential admission (“affirmative action”) by the Supreme Court. The Justices have already heard a case that began in 2014, arguing that both Harvard and The University of North Carolina violated both the Constitution (the “equal protection clause” of the Fourteenth Amendment) and—for the private university of Harvard—the Title VI provision of the Civil Rights Act of 1964. (Private universities can also be sued for discrimination if they receive federal funding.)

There’s little doubt in my mind that PNAS agrees wholly with this op-ed, since it rarely publishes articles like this and also itself has a “progressive” ideological slant. I’m confident in arguing that this is probably the National Academies’ view as well as the authors’ view.

The issue here is that the paper takes an expressly ideological stance by favoring one political outcome (“equity” among doctors) over what is possibly a negative side of that outcome: worsening quality of medical care in America. This is because affirmative action in medical school had led to a substantial gap between the admissions credentials of whites and Asians on the one hand, and Hispanics and blacks on the other. And if admission credentials have ANYTHING to do with the quality of a doctor, then lowering the bar in the way that Aaron et al. suggest—achieving “equity,” or ethnic representation among doctors equal to the proportion of groups in the population—will inevitably result in the decline of the average quality of doctors.

You may, I suppose, suggest that if people have doctors who “look like them”, or if doctors treat patients who “look more like them” better, then increased equity might increase overall health quality. But that is a supposition only, and one with no empirical basis (there’s no need to mention the “dead baby” issue, which has substantial problems). It also doesn’t tell us how far we must lower the bar to achieve equity, and whether lowering the admissions bar that much can counteract any positive effect on healthcare caused by the supposed “looks like me” issue.

As I’ve said, I do favor some form of affirmative action for admission to colleges and medical schools, but more and more it’s taking the form of favoring minority candidates when you’re faced with deciding between candidates who are both qualified and nearly equally qualified. My thinking on this is evolving. But the difference in qualifications among ethnic groups among med-school applicants as well as those who are admitted is sufficiently large that my brand of affirmative action would never come close to producing equity.

Click to read (it’s free):

The paper begins with a flawed argument: that by forcing universities to not discriminate among races, the Supreme Court is practicing unwarranted “judicial intrusion into medicine” (my emphasis)

Given the likelihood that the Supreme Court will end affirmative action, medical institutions must plan how to further diversity without incurring liability. More broadly, the cases follow a pattern of judicial intrusion into the affairs of medicine and health. As with abortion, contraception, health insurance, and COVID-19, the Supreme Court has encroached on the field of medicine, denying expert guidance on what is required in order to achieve a healthy and equitable society. The affirmative action cases are emblematic of a high court intent on opposing racial progress and other forms of social change.

This is bogus. Yes, some Justices may “oppose racial progress”, but what they’ll do if they rule against affirmative action is simply enforce the law and the Constitution.  That is, they will interpret the law as saying that one cannot discriminate among by race, regardless of which races are at issue.  But to say that this denies doctors “expert guidance” to achieve a healthy and equitable society” is mere carping, and beside the point, for you could use the same argument to justify any sort of race-based discrimination, especially if you think feel that “equity” is an outcome more desirable than application of settled law. I find the argument for retaining “expert guidance” risible, for experts are going to differ about what societal outcome is “healthy and equitable”. What they’re really saying is that the Supreme Court is overreaching itself by disallowing discrimination on the basis of race.

Now, about the differences in qualifications of candidates. Here’s what the article says:

As of 2015, there is estimated to be a deficit of about 114,000 Black and 81,000 Hispanic doctors compared to what one would expect from proportions of the US population. This dearth is at least partially historical: Racial and ethnic minorities were excluded from attending medical school and joining medical organizations, such as the American Medical Association (AMA). In 1900, 11.6% of the US population was Black, compared with 1.3% of physicians. In 2018, 12.8% of the population was Black, but only 5.4% of physicians. Over 120 years, then, the fraction of Black physicians has increased by only 4 percentage points. This lack of representation emphasizes why the fate of affirmative action is essential to securing a racially and ethnically diverse physician body in the United States.

Affirmative action helps compensate for systemic inequities throughout childhood and young adulthood that impede the significant steps required to apply to and be admitted to medical school. The current biggest gatekeeper to medical school admission is the Medical College Admission Test® (MCAT®), whose notable racial and ethnic disparities are well documented (57). As of 2022, Black and American Indian/Alaska Native medical school applicants have an average MCAT® score of 497.4 and 498.7, respectively, which is about one standard deviation below the average score for White applicants of 507.9. Although these disparities do not mean that the test makers intentionally discriminate by race, they reflect the systematic disadvantage facing racial and ethnic minorities applying to medical school.

Note the claim that there is “systematic disadvantage”, which to many means “structural disadvantage”: something about the tests themselves that give racial and ethnic minorities a disadvantage. If it’s social circumstances: poverty, poor education, and so on, then that’s a different matter, though one that still must be considered. This is symptomatic of the whole failure of the authors to see the dimensionality of the problem.

What holds for MCAT scores (still required for nearly all med school admissions) also holds for grade-point averages. These recent data come from an admissions consulting service, Shemassian, which notes that race certainly does matter when applying for medical school: 

And data on those who matriculate among four racial groups divided by MCAT scores and grade point averages. The differential rates of acceptance among groups is striking.  Asians in particular have a hard time getting in, being accepted at only about 10% the rate of blacks in the leftmost category.

This is from the American Enterprise Institute (couldn’t they use skin-pigment neutral colors for the bars?):

Now one could argue that one standard deviation in MCAT scores doesn’t mean that, on average, a lower-scoring individual is less qualified to be a good doctor than a higher-scoring one. But if that’s the case, why use scores at all for determining who’s qualified? And if qualifications have any correlation with quality of medical care dispensed later in life, then they could have titled the article, invidiously, “Attacks on affirmative action threatens quality in medicine.”

To me, qualifications for medical school are like qualifications for being an airline pilot in one way: once you make it, you’d better be good, as you’ll have a whole lot of lives in your hands over your whole career. If you say we should lower the bar for going to med school, would you say the same thing for pilot training? If not, why not?

At any rate, the main issue with the article is that it doesn’t even discuss the possible tradeoff between the quality of American healthcare and ethnic equity among American doctors. Perhaps they feel that equity among doctors will, as I said, outweigh any bad effects of lowering the bar for med-school applicants. Or perhaps they feel that equity in a profession even outweighs the concrete benefits that the profession is supposed to confer on society. (That is, equity among doctors is more important for society than the overall quality of healthcare.) One could make both of these arguments, but the problem is the authors don’t. They simply feel that affirmative action is an affront to medical care and to American society, and that equity is a virtue that’s above American law. Indeed, opposing affirmative action is equated, throughout this article, as identical to endorsing white supremacy:

But because the Supreme Court may now deem consideration of race itself to be discrimination—even when it would benefit a racial group and society as a whole—the Supreme Court may stipulate a rule with far-reaching effects across the US healthcare industry. This would not be the first Roberts Court decision to re-interpret civil rights laws as protective of White people, as opposed to the subordinated groups these laws were meant to protect. For example, in Parents Involved in Community Schools v. Seattle School District (2007), the Supreme Court held that voluntary school desegregation plans in Seattle, WA, and Louisville, KY, violated the Equal Protection Clause. Although this clause was created to help remedy racial discrimination after the Civil War, the Supreme Court used it to impede efforts to address systemic racism. In this case, Chief Justice Roberts famously quipped, “The way to stop discrimination on the basis of race is to stop discriminating on the basis of race,” thereby imparting a “color-blind” reading on a clause aimed at racial progress. The Roberts Court’s belief that color-blindness will end racism overlooks the more structural and systemic forms of racism that are likely the biggest propagators of disadvantage today. At the same time, the color-blind approach invalidates policies aimed at racial progress like affirmative action, thus entrenching the benefits of Whiteness.

Two more points. First, the authors reply on the deeply flawed Implicit Bias Test, one that’s been rejected by most psychologists as not measuring anything meaningful and even as counterproductive in reducing bias:

Affirmative action’s loss may result in medicine and healthcare that look substantially less diverse. And any loss of diversity could be self-perpetuating. Through their presence and contributions, racial and ethnic minorities help make spaces more accommodating and inclusive to people from differing backgrounds. For example, testing of implicit bias using the well-validated Implicit Association Test has revealed that African-American physicians have far less implicit bias than White physicians  Racial and ethnic prejudice, prolific throughout medicine, impact physician–patient communication, treatment decisions, and patient outcomes. A less racially diverse pool of providers could bring heightened bias toward racial and ethnic minorities, leading to a spiral effect, in which medical spaces become less varied across the board.

That, of course, is purely speculative.  And remember that when affirmative action was first implemented in the Sixties, it was supposed to be a temporary expedient—a few decades at most. In the Grutter v. Bollinger decision in 2003, in which (by a 5-4 vote) the Supreme Court allowed some consideration of race in college admissions, liberal justice Sandra Day O’Connor said this:

“Finally, race-conscious admissions policies must be limited in time. The Court takes the Law School at its word that it would like nothing better than to find a race-neutral admissions formula and will terminate its use of racial preferences as soon as practicable. The Court expects that 25 years from now, the use of racial preferences will no longer be necessary to further the interest approved today.”

Note that she later clarified that she didn’t mean to set a firm deadline. But I think we know now, from the institutionalization of both affirmative action and DEI programs in colleges, that affirmative action and “racial preferences” will—are intended to—last forever. 

Finally, the authors suggest the obvious: that medical schools should start trying to find ways around the upcoming changes in law to maintain a diverse medical profession:

The affirmative action cases before the Supreme Court raise serious questions about the future of a diverse medical profession and the integrity of healthcare itself. In advance of the decision, medical programs that value diversity and accept federal funds (or are government institutions) would be wise to consider alternative paths to create a racially diverse student body without explicitly considering race. With some strategizing, they can preserve some racial diversity while keeping to the letter of the law.

I’m trying to be charitable here, but it sounds like me that they want to circumvent the law in some way by “strategizing,” but that might not be possible if the Supreme Court rules that you can’t use correlates of race as proxy data for admissions. But the authors don’t like even that strategy!:

Many medical schools will be driven to alternative metrics, or proxies, to attain racial diversity. Such proxies could include family history, experiences of discrimination, socioeconomic status, and geography. However, proxies are limited for at least two reasons. First, they may poorly approximate race. For example, experiences of discrimination may seem to correlate with race, but they have frequently been claimed by White applicants, including in the Supreme Court’s historical affirmative action cases. And, second, the upcoming decision may prohibit not only consideration of race, but also similar metrics.

So what do we do if we want the body of physicians to “look like America”? My view is not to lower standards or devalue merit, but invest in giving minorities and other disadvantaged people equal opportunities to achieve. And, as I always say, that’s a much harder task than just lowering merit bars . Sadly, throwing money at schools doesn’t seem to work. Reducing income inequality might, but we all know that Americans don’t want that. Right now I don’t know what the solution is; perhaps all we can do is call attention to the problem and hope that better minds can create equal opportunities. (Even that won’t work, of course, because so long as there is inherited wealth, there will be inherited privilege.) 

But back to the article. I conclude that it is not a contribution to solving the problem. It neglects important issues, brings up irrelevant ones, makes unstated assumptions, and, above all, injects ideology into science.

28 thoughts on “The National Academies of Sciences urge affirmative action in med-school admissions

  1. Such a trend is very troubling indeed, but this kind of highly ideological language is now pervasive in scientific organizations, in museums, and in universities; one can read, for example, on Harvard’s website that the Harvard Library “is becoming one of the campus leaders in advancing equity, diversity, inclusion, belonging, and antiracism.”

  2. Sandra Day O’Connor was a conservative justice, although she sometimes voted with the liberals. Wikipedia puts it this way:

    Initially, O’Connor’s voting record aligned closely with the conservative William Rehnquist (voting with him 87% of the time her first three years at the Court).[56] From that time until 1998, O’Connor’s alignment with Rehnquist ranged from 93.4% to 63.2%, hitting above 90% in three of those years.[57] In nine of her first sixteen years on the Court, O’Connor voted with Rehnquist more than with any other justice.[57]

    Later on, as the Court’s make-up became more conservative (e.g., Anthony Kennedy replacing Lewis Powell, and Clarence Thomas replacing Thurgood Marshall), O’Connor often became the swing vote on the Court. However, she usually disappointed the Court’s more liberal bloc in contentious 5–4 decisions: from 1994 to 2004, she joined the traditional conservative bloc of Rehnquist, Antonin Scalia, Anthony Kennedy, and Thomas 82 times; she joined the liberal bloc of John Paul Stevens, David Souter, Ruth Bader Ginsburg, and Stephen Breyer only 28 times.

  3. And if admission credentials have ANYTHING to do with the quality of a doctor, then lowering the bar in the way that Aaron et al. suggest—achieving “equity,” or ethnic representation among doctors equal to the proportion of groups in the population—will inevitably result in the decline of the average quality of doctors.

    And worse than that, patients will have an easy way of discerning which doctors are the ones likely to have benefitted from lowered standards. And any rational patient would avoid them. Is this a future people want?

    Note, of course, that demands for equal representation in admissions will be followed shortly by demands for equal representation in graduation rates.

    Far better, surely, to have lower representation from some groups, but have confidence that doctors from those groups have indeed met the same high standards.

    1. I’ve had this discussion so many times recently, Coel. I will be *more* likely to seek out a white, male doctor knowing that the hurdles he had to overcome to gain admittance. I want to trust my doctor, regardless of skin color, but the DEI initiatives are taking that away from us. A physician friend who teaches explained recently that medicine is planning to make the boards pass/fail; historically, the top scorers could do their residencies at the best schools, but now the best opportunities are set to be distributed based on “diversity” criteria. Credentialing for something as critical as medicine should be based on merit.

      An example of discrimination in action: a friend has applied to medical school that last few cycles, and despite being top of the class with thousands of clinic hours, leadership roles, etc., he was explicitly told into two interviews that, while his application was impressive, they had to focus on diversity. Apparently, permanently disabled and living below the poverty line don’t qualify as “diverse” if you’re a straight, white male. It’s a sad state of affairs.

  4. Percent and percentages are widely misunderstood and abused, and that statistic referring to the increase in minority doctors as “only” 4 percentage points is a mendacious classic. It could equally well be described as a 400% increase, but that would not convey the intended message.

  5. The enterprise of science (not of all scientists, of course) has gathered centuries of well-earned credibility, so much so that the word “science” has become synonymous in the minds of many with the effective pursuit of objective knowledge. By making “science” complicit in an anti-scientific ideology, that ideology is draining that credibility. The most apt term I can think of for this type of relationship is “parasitism”. This word also describes the relationship of that ideology to media platforms with earned credibility such as the nation’s paper of record, erstwhile credible science journals such as Scientific American, large segments of higher education, and so forth. Like the tapeworm, wokism is a parasitic organism consisting mainly of just a mouth, a gut, an anus, and reproductive organs. Oh, and a venomous sting.

  6. The basic dishonesty (undoubtedly deliberate) behind the PNAS article’s argument is perfectly revealed in the following excerpt.. ” In 1900, 11.6% of the US population was Black, compared with 1.3% of physicians. In 2018, 12.8% of the population was Black, but only 5.4% of physicians. Over 120 years, then, the fraction of Black physicians has increased by only 4 percentage points.” The puny 4 percentage point increase which the article dismisses is a 4.15-fold increase.

    As for the trade-off between engineered equal representation and physician capability, some expert guidance on this matter is available in a hard-hitting book by Dr. Stanley Goldfarb, a nephrologist and former associate dean of the U, Penn SOM: “Take Two Aspirins and Call Me By My Pronouns” (2022).

  7. [ Sigh of agreement…]

    I just add three important pieces I know of on this topic in no particular order, all caps is because I am in haste:

    William G. Bowen and Derek Bok
    1998 Princeton University Press

    2. Affirmative Action
    Around the World
    An Empirical Study
    Thomas Sowell

    …. I’ll just leave it at that, though I’d like to note this case as it pertains to medical school :
    … especially the consequences, which Sowell discusses.

  8. “In 1900, 11.6% of the US population was Black, compared with 1.3% of physicians. In 2018, 12.8% of the population was Black, but only 5.4% of physicians. Over 120 years, then, the fraction of Black physicians has increased by only 4 percentage points.”

    The enumeracy of people writing on behalf of the NAS is disappointing. If the representation of black physicians had increased to 12.8% of the population by 2018, would the authors say it “has increased by only 11 percentage points”?

    Instead one could rejoice that representation *tripled* during the 20th century. This is progress.

    And one could address the problem that too many black kids (and other kids!) don’t graduate high school and couldn’t qualify as any kind of medical professional.

    [edit] whoops Richard@4 beat me to it!

  9. I’m a white male and the last time I had a doctor that looked like me was 20 years ago. That’s fine with me.

    1. Me too. Now I’m on the other end of the business, I don’t care what my doctors look like, but I do like to know that they are there because they earned it by showing they were the best candidates for the medical school/residency place, and I know what that takes. When dealing with a lethal diagnosis it becomes more important than ever that your doctor knows exactly what he or she is doing. My hematologist is currently a very nice and knowledgeable graduate of the University of Cairo. I get excellent care from him.
      And whilst I’m being cosmopolitan, I have just passed my second anniversary post-transplant and have been put in touch with my donor, a nice 23 year old from Bavaria who gave me his stem cells. Just think, I literally have German blood! I’ll refrain from puerile jokes, but it does amuse me to wonder what my father would say (he had much respect for most of the men and boys who fought against him—so I guess he would be tickled pink.)

  10. I fear that an unintended consequence of this will be to cause patients of all ethnicities to trust black clinicians less than white clinicians, other things being equal (they never are, of course), just as it would for making customers more wary of black airline pilots. If my son required surgery for brain cancer, and it were well known that blacks receive preferential treatment in their education, I would- to my own sorrow- take that into consideration in my decision. It will also likely disadvantage black clinicians and pilots of high talent who worked hard for their education.

    1. In addition to being disadvantaged, some black clinicians who are well qualified will come to doubt themselves for the same reason others will be wary of them. I’ve seen this happen to young academics who experience affirmative action and wonder whether they merited their positions. Admittedly imposter syndrome is common in universities, maybe physicians are less susceptible to it.

      1. Don’t you believe it. Every physician will sometimes find himself out of his depth, but obliged to cope, sometimes with no help or backup. How can you do that without having some self-confidence that you are going to do as good a job as anyone can in the circumstances? Will you get through it, or will you give up if you are aware that the rest of your class was smarter than you and you have a suspicion you got in because you ticked a box? That’s not fair on the patient, nor on the physician.

  11. Personally, I think the Sokal hoax – and possibly the Grievance Studies affair – stimulated a come-uppance from humanities/post-modernist scholars, and this is a sign that it worked.

  12. Just one more :

    In addition to the list of things a place of higher education is not (a club, a political party – as asserted properly in the Kalven report), I’d posit :

    The university/college is not the United Nations, or even the United States House of Representatives.

  13. Surely by now there must be enough evidence to show whether female doctors treat femal patients differently than male doctors (treat female patients, for those who don’t like NYT headlines).

  14. Does making the medical profession look like the population mean that patients get to be treated by doctors who look like them? Never mind if it’s a Good Thing. Is it even logically true?

    Let’s posit for sake of argument that there is actual social value in cosmetic diversity of skin pigment and all the social baggage that goes along with that. Let’s further posit that you manage, through non-competitive race-selective admission to medical schools for a few decades, to get the black proportion of the medical profession up to 12% (or make it 20% as reparations for past wrongs.) Does this mean that a black patient will, at long last, be treated by a doctor who looks like her*?

    No, it doesn’t. Because you can’t assume that black MD grads will want to practice in heavily black neighbourhoods just because they themselves are black. This is an especially insulting assumption if the black grad is black because his parents immigrated from Nigeria or Ghana and he wants nothing to do with legacy black American culture. What happens during med school is a Great Sort that culminates on Match Day where grads rank the residency programs they want to do and the programs rank the applicants. Without putting too fine a point on it, programs that lead a trainee to working in poorly remunerated primary care practices made up of fundamentally unremediable social problems in violent neighbourhoods don’t attract the best and the brightest other than the odd activist saint. Many of these training positions go unfilled unless they take the grads that no other program wanted, which is what they do. When there are only a few black students in the national class, these kids at the bottom of the barrel aren’t all black, by any stretch.

    If the more competitive programs are unable to be sure that everyone who graduated from med school at least had the right stuff coming in, they will avoid people who are most likely to have got in on the basis of race. Unless they have truly stellar track records in med school to overcome the affirmative action stigma, black grads will be sorted into those uncompetitive programs and yes they will end up looking after black patients. The competitive programs will make the same rational choice as Esoterica says “competitive” (i.e. choosy, insured, informed) patients of all races will do: avoid black doctors.

    Remember the residency programs are much more afraid of taking in people who can’t do the work than med schools are. Residents have graduated responsibilities for direct patient care including surgery and critical care at night under the supervision — the length of the leash varies according to the trainee’s progress and the nature of the work — of faculty doctors in whose lap the buck stops. They can’t afford to be woke: a patient could die on their watch. The dean for DEI of the medical school doesn’t get sued, or even criticized by peers (which is actually much worse.) This really is brain surgery.

    So poor black patients might get their wish: if they get to see a doctor at all, s/he will probably be black (or foreign trained or otherwise desperate.) But it won’t be for the reasons you want to talk too proudly about.
    *Leave aside the possibility that people are never satisfied. The intersectionality of grievance: “OK, so he’s black, but he’s a man. Or he’s cis. Or he’s not queer. Or he’s not indigenous. Like me.” No matter what you do, you’ll have scolding articles like this from the NAS forever.

  15. “The intersectionality of grievance: “OK, so he’s black, but he’s a man. Or he’s cis. Or he’s not queer. Or he’s not indigenous. Like me.” No matter what you do, you’ll have scolding articles like this from the NAS forever.”


    “… to attempt to refute the 1619 Project through genuine and established historical methods is, from the perspective of critical race Theory and its devotees, to reassert the need for the 1619 Project and its approach in the first place.”

  16. One can only hope that the performance differences are erased during medical school and residency. Otherwise, people who gravitate toward doctors who “look like them” may very well obtain care that corresponds in quality to their ethnicity. There are many variables involved when trying to engineer “equity,” and the results may not turn out to be as benign as one might anticipate.

    1. It would be pointless to let a bunch of unqualified people in, only to see them fail and withdraw within a semester or two.
      From my observation, that issue was solved by most universities by offering programs that require almost no academic rigor or even participation, but which result in a “degree”. Those folks gain no useful skills beyond calling things racist and advocating for socialism.
      I think also they use the word “diverse”, but they actually just want more Black people. My eldest’s med school peers are less White than the population in general or most other degree programs. Plenty of kids with Asian and Indian heritage.
      Again, they would not work to admit less qualified folks if they did not intend to see them credentialed. One option to achieve that might be remedial classes. Except the pace of the course of study would not allow that. The well-qualified and studious kids have no time to spare. The same thing goes for higher level engineering programs. My youngest is in one of those, and his whole life is studying and doing assignments.

      I still think the battle to bring “diverse” kids into the tough programs is won or lost in primary school.

  17. If by affirmative action we were only talking about the Harvards and Yales of the world admitting students who would otherwise attend any number of mid- or lower-tier schools, then I would say “let them”. It is about making themselves feel good, not about solving any long-standing problems. Unfortunately, when the top-tier schools scarf up all the minority students who would have attended average schools (and been perfectly capable doctors), then those average schools need to also lower their standards in order to fill their own “feel good” diversity quotas. As Leslie points out above, those less capable doctors will be treating poor people—black, white, brown.

    Once again, we have a case where crusading “progressives” advocate policies the damaging effects of which they rarely have to live with. (Defund the police, anyone? Close the public schools for a year or two? Add your own favorite.) There are valid reasons why “elites” is a pejorative in many poor and working-class communities, not that said elites give a damn.

    1. Exactly the idea Sowell discusses in my above reference^^. Match the school admissions criteria with the student.

      1. See Richard Sander wrt mismatch and law schools.

        Sander, Richard. A Systemic Analysis of Affirmative Action in American Law Schools. Stanford Law Review , Nov., 2004, Vol. 57, No. 2 (Nov., 2004), pp. 367-483.

        …and medical schools.

        Sander, Richard. Affirmative Action in Medical School: A Comparative Exploration. The Journal of Law, Medicine & Ethics 49 (2021): 190-205.

  18. Had another look at this PNAS paper. Agree with Jerry that the arguments about cosmetic diversity are bogus and efforts to achieve it through standards slippage are worrisome. I have heard it alleged that more “holistic” measures “uncontaminated” with things like grades and test scores produce “better” physicians. There is said to be robust evidence for this, not cited in the paper. Probably worth a trackdown sometime to keep an open mind. I think we all agree that doctors should be smart, not slow. People like to grumble about bedside manner but they sue you if you screw up. I personally think that a lot of those other “soft” qualities can be taught and modeled. You would like to screen out psychopathy but how?

    Here I’m more interested in the agenda. First, PNAS is not widely read by practising physicians or those responsible for evaluation of residents. The former read NEJM, JAMA, BMJ and nowadays we subscribe to various digests of literature relevant to our (sub-) specialty. The latter have their own specialized journals and there are numerous conferences about how to keep patients safe from residents while still letting the residents learn. So the forum this paper appears in is not an opinion leader among physicians.

    Second, none of the three authors appears to have any responsibility for training or certification of doctors preparing for independent practice.

    First author Aaron is a practising lawyer with interest in health law who did an MD while also doing his JD. He has not done any post-MD residency training so is not licensed to practice medicine. Except as a closely supervised undergraduate medical student several years ago, he can not ever have looked after a sick patient.

    Second author Bajaj is an undergraduate liberal-arts student at Harvard. He has several publications of an advocacy bent co-authored with his mentor ….

    Senior author Stanford is a fat doctor at Mass General and Harvard. I don’t mean she is fat. I mean her clinical practice is entirely devoted to obesity, a purely outpatient subspecialty in endocrinology. Her bio doesn’t show any responsibility for the longitudinal training and summative evaluation of residents, the “Would you want this doctor looking after your mother?” test, the test you have to pass to get a licence. No stint as clinical teaching unit director, residency program director, service as an examiner or standard-setter on a national specialty board, that sort of thing. Doctors in these entirely outpatient “one-disease” specialties don’t usually take general internal medicine attending call where they have to supervise residents looking after sick hospital patients, or teach them to do procedures requiring critical skills like endoscopy, heart stents, etc. She also has a publication record for advocacy entirely in the realm of anti-black racism (and obesity as a feature of structural racism!)

    Bottom line is that I don’t think any of these authors, including the one practising physician, can speak knowledgeably about the risks and benefits to patients from what they are calling on the Supreme Court to do. When the residency training programs say, “Yes, we are thrilled to be taking these affirmative action graduates. They work out great and the faculty supervisors have every confidence in them!”, then I’ll listen. Meantime, these authors are saying, “We want to see more black faces in medical schools and we want them all to pass. The residencies can pick up the pieces.”

  19. The paper claims that “The current biggest gatekeeper to medical school admission is the Medical College Admission Test…” However, even if the MCAT was eliminated, the demographics of medical school applicants would not reach parity with the population at large, i.e., 12.8% blacks. This is because the “Blacks make up at about 14.5% of US undergraduates, but only 10.5% of college graduates…” (1) The solution is not the elimination of the MCAT. Much earlier interventions are required starting in grade school.

    (1) Sander, Richard. Affirmative Action in Medical School: A Comparative Exploration. The Journal of Law, Medicine & Ethics 49 (2021): 190-205.

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