DEI in surgical subspecialties

[Mr.Smile12]

I am strongly convinced that discrimination is one important cause of the higher attrition rate, even if it is not the only factor. Discrimination does not have to be overt like being harassed with racial insults to result in an unfortunate outcome. It can be subtle and difficult to "prove", and that subtle execution can be just as effective.

URMs (and even non-URMs such as Asians) still experience varying degrees of prejudice and negative effects of implicit bias during medical training which can impact attending ratings of trainee performance. See PUBMED ID: 31032666): ("non-URM minority students were more likely than White students (Adjusted Odds Ratio = 0.53), confidence interval [0.36, 0.76], p = .001, to receive a lower category MSPE summary word in analyses adjusting for student demographics (age, gender, maternal education), year, and United States Medical Licensing Examination Step 1 scores. Similarly, in four of six required clerkships, grading disparities (p < .05) were found to favor White students over either URM or non-URM minority students. In all analyses, after accounting for all available confounding variables, grading disparities favored White students.") So even when adjusting for scores, URMs still receive lower evaluations compared to white students. A similar pattern was recently shown for IM residents in their PGY1 and PGY2 years. It is not a stretch to see how such evaluations can ultimately result in a perception of poorer performance, lower ratings, trainee stress, withdrawals, transfers, and even dismissals.

Conversations with high-performing URM attendings indicate that this implicit bias/discrimination is not uncommon. One of my close colleagues (1st gen black immigrant) who finished top 10 in his/her class at a big state school, AOA, 260s boards, high in-training exam scores, etc and is now an attending in a very competitive surgical subspecialty, experienced several episodes of encountering implicit bias, and in some cases outright racism and xenophobia, with one case requiring the involvement of higher authorities at his/her institution. Consistent with what he/she noticed, the OR techs approached my colleague to say that there were some attendings (usually white) who routinely gave more leeway to white residents (compared to URMs) before taking over a surgical case. It is easy to see how this leads to less independence for a trainee and the negative effect this can have on trainee confidence. My colleague approached this problem by being extra-prepared for every case and taking advantage of the good graces of other surgeons who were more willing to teach and allow him/her operate with a longer leash. Now these are all anecdotes, but almost every URM has encountered at least one sour event of implicit bias/prejuduce clearly influenced by race/ethnicity. This also matches my experience as a URM with very strong performance. If this can happen to high-performing URMs, I would expect a higher frequency for average or marginal URMs. It is not a stretch to see how this can contribute to higher rates of attrition.

Just adding (unless you're citing the same study 🙂 )

‘It was stolen from me’: Black doctors are forced out of training programs at far higher rates than white residents

A STAT investigation found that Black residents leave or are terminated from training programs at far higher rates than white residents.

www.statnews.com

On the medical student side, one can hate the medicine/cure (mandatory training/sessions), but the disease still exists...

Students Who Experience Mistreatment or Discrimination Are More Likely to Leave Medical School

A Yale-led study finds that second-year medical students who experience mistreatment and discrimination have a higher likelihood of leaving school in subsequent

medicine.yale.edu

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[WhereMyLiberalsAt]

However, my white conservative friends specifically complain about their demographic being made scapegoats by leftist teachers

Yeah, I can agree with that. The way I have come to analyze it after trying to tease out the differences in thought processes come down to true core principles. This forum isn't really the appropriate place to discuss it and the amount of writing is something I don't have the time for... But if I had to make a keyword/word cloud it would include contrasting abrahamic religions, original sin, and roles of institutions.

I just find it ironic that they make fun of liberals for forming safe spaces when they're doing the same thing. And that they're so triggered after enduring microaggressions for just 1-4 years, but will still readily dismiss claims of discrimination from minorities and women.

I can't speak to this directly... I don't know specifically how they're constructing these safe spaces (nor does it really matter, I'm taking your word for it and as fact, they have some institutional safe space allowed to them.) But yes the irony is thick and these specific mates of your need to quit being emotionally soft and frail.

There are parts of the curriculum that are going to make people very uncomfortable. That's life, and we have to learn about it. (Not saying you should look forward to it with enthusiasm and joy.) We presume everyone will find ways to discuss their feelings in a safe and mature way like a professional.

I think it is important to distinguish/identify what is producing the uncomfortable emotion. Is it the actual topic being discussed? Or is it the valuable time that is being taken to discuss the topic. The response is the same, discomfort, but the stimuli for the discomfort can be totally different. Also, I completely agree about the italicized part.... However, what should be done and what is done are at odds. Modern higher education is a cesspool of "safe spaces." (safe spaces being a typical modern word, well if you aren't in favor safe spaces, are you pro-unsafe spaces?!?) I believe Greg Lukianoff and Jonathan Haidt write about this quite well in The Coddling of the American Mind.

Get a life.

Bro! what happened to....

Have a good one. Learn to communicate decently, I heard it's free.

You might be right though... I generally only have the smallest amount of time with classmates, and water cooler talk generally consist about bitching about the BS of the week. If I wasn't busy spending time with my children, teaching them how to play sports/instruments, hanging out with my spouse, working out, playing in a band, and that lame ass med school hobby. I could get a life and talk about more productive things with my classmates.

 

[operaman]

I'll stick to the residency portion since that's the main topic of the thread, and the medical school portion deserves more analysis.

So unless I was looking at something different or not I'm not remembering correctly, white attrition rates were around 2%, Asian around 3%, and black around 4%. In a large sample size that's only a couple more black residents compared to whites. I don't have any hard data on the reason(s) behind that, but considering Asians (who have comparable scores to whites) also have slightly higher attrition, I find it more likely it's due to something like discriminatory experiences rather than deficiencies in ability as you're implying.

There are a number of papers out there looking at this. A couple of recent ones I found showed no significant different in attrition between white and Asian residents. Percentages were about the same as what you quote, but the slightly higher Asian number wasn’t high enough to be significant.

I suspect that bias is playing some role in this - it would be impossible not to. It definitely seems that residents who find themselves under the proverbial microscope tend to get dismissed because it’s hard for even good trainees to survive that kind of scrutiny. I suspect there are biases that URM trainees are less qualified and therefore it takes fewer slip ups to get them put under the microscope. Add to this many URMs do in fact have lower academic marks and foundational knowledge than their peers and it only reinforces preexisting stereotypes.

The only solution I’ve seen work for this was pairing troubled URM residents with a good faculty mentor. I remember one person from training who as an intern was struggling mightily, poor knowledge base, barely treading water. They got paired with a URM faculty mentor who put them on an assigned reading program and had regular meetings and worked on clinical skills as well. Now that person is a chief and doing very well.

I don’t think that resident was struggling because of bias, but bias could have definitely prevented them from finishing and in other programs they might have faced dismissal. I think it’s probably there on the margins where discrimination can be a determining factor.

 

[Mr.Smile12]

There are a number of papers out there looking at this. A couple of recent ones I found showed no significant different in attrition between white and Asian residents. Percentages were about the same as what you quote, but the slightly higher Asian number wasn’t high enough to be significant.

I suspect that bias is playing some role in this - it would be impossible not to. It definitely seems that residents who find themselves under the proverbial microscope tend to get dismissed because it’s hard for even good trainees to survive that kind of scrutiny. I suspect there are biases that URM trainees are less qualified and therefore it takes fewer slip ups to get them put under the microscope. Add to this many URMs do in fact have lower academic marks and foundational knowledge than their peers and it only reinforces preexisting stereotypes.

The only solution I’ve seen work for this was pairing troubled URM residents with a good faculty mentor. I remember one person from training who as an intern was struggling mightily, poor knowledge base, barely treading water. They got paired with a URM faculty mentor who put them on an assigned reading program and had regular meetings and worked on clinical skills as well. Now that person is a chief and doing very well.

I don’t think that resident was struggling because of bias, but bias could have definitely prevented them from finishing and in other programs they might have faced dismissal. I think it’s probably there on the margins where discrimination can be a determining factor.

I also can conjecture the obvious... ORM means that there are probably more Asian mentors and providers that are available to support the trainees, so the residents may not feel as isolated compared to URM trainees. Those mentors can also likely provide advice that helps the ORM/Asian trainees persist or can have private conversations with the superiors to get better insight and understanding of those situations. I wish there is more objective evidence that supports what I just typed, but it makes sense on why mentoring, even race/ethnic concordance mentoring and championing, is a tool for inclusion and belonging.

 

[operaman]

Just adding (unless you're citing the same study 🙂 )

‘It was stolen from me’: Black doctors are forced out of training programs at far higher rates than white residents

A STAT investigation found that Black residents leave or are terminated from training programs at far higher rates than white residents.

www.statnews.com

On the medical student side, one can hate the medicine/cure (mandatory training/sessions), but the disease still exists...

Students Who Experience Mistreatment or Discrimination Are More Likely to Leave Medical School

A Yale-led study finds that second-year medical students who experience mistreatment and discrimination have a higher likelihood of leaving school in subsequent

medicine.yale.edu

I remember that stat news article and the whole UTMB situation awhile back. Knowing a number of people there personally, I knew the complaint was bogus but now that some time has passed we can all see exactly why. Her suit was thrown out with prejudice at the district level and is current before the 5th circuit.

I’ve taken the liberty of downloading a couple documents from the case. One is the district judge’s order granting summary judgement and includes some of the rest of the story that gets conveniently omitted in the stat news piece. The other is UTMB’s appellate brief where they list even more facts in evidence about her poor performance. As always with these stories, it’s amazing how things look when you get both sides of it.

 

[lolthroaway]

There are a number of papers out there looking at this. A couple of recent ones I found showed no significant different in attrition between white and Asian residents. Percentages were about the same as what you quote, but the slightly higher Asian number wasn’t high enough to be significant.

I suspect that bias is playing some role in this - it would be impossible not to. It definitely seems that residents who find themselves under the proverbial microscope tend to get dismissed because it’s hard for even good trainees to survive that kind of scrutiny. I suspect there are biases that URM trainees are less qualified and therefore it takes fewer slip ups to get them put under the microscope. Add to this many URMs do in fact have lower academic marks and foundational knowledge than their peers and it only reinforces preexisting stereotypes.

The only solution I’ve seen work for this was pairing troubled URM residents with a good faculty mentor. I remember one person from training who as an intern was struggling mightily, poor knowledge base, barely treading water. They got paired with a URM faculty mentor who put them on an assigned reading program and had regular meetings and worked on clinical skills as well. Now that person is a chief and doing very well.

I don’t think that resident was struggling because of bias, but bias could have definitely prevented them from finishing and in other programs they might have faced dismissal. I think it’s probably there on the margins where discrimination can be a determining factor.

I'm going to take a couple steps back. The main reason for my comment was that I don't see URM (specifically black) attrition rates as worse enough than whites/ORMs to be noteworthy. And, yeah it's all likely multifactorial, but I feel like you're harping on URMs being less capable. If you can graduate from medical school, you have the academic capability to be a surgeon. It's other factors that become more important for success.

If from the outset you're dealing with bias from attendings, patients calling you slurs or refusing to be treated by you, snide remarks, lack of mentorship, etc. along with the other difficulties of surgery residency, you're more likely to have an attitude of "screw this, I'll do something else." Regardless of how competent you are. But yeah, it's conjecture on my part as well.

 

[operaman]

I'm going to take a couple steps back. The main reason for my comment was that I don't see URM (specifically black) attrition rates as worse enough than whites/ORMs to be noteworthy. And, yeah it's all likely multifactorial, but I feel like you're harping on URMs being less capable. If you can graduate from medical school, you have the academic capability to be a surgeon. It's other factors that become more important for success.

If from the outset you're dealing with bias from attendings, patients calling you slurs or refusing to be treated by you, snide remarks, lack of mentorship, etc. along with the other difficulties of surgery residency, you're more likely to have an attitude of "screw this, I'll do something else." Regardless of how competent you are. But yeah, it's conjecture on my part as well.

Well attrition of black surgical residents is more than double that of others. And of course its multi factorial and bias almost certainly plays a role especially for more borderline trainees.

I do think baseline ability is also a factor and strongly reject the assertion that medical school graduation indicates one has the ability to succeed in a surgical residency.

The biggest issue is that surgical skills aren’t really taught or assessed as part of the MS curriculum, so trainees are coming in with expectations and milestones on which they’ve never really been assessed before. They are excellent test takers and readers, but the actual application of clinical knowledge in direct patient care is sadly too small a part of the medical school experience and basically everyone gets passed along unless there are egregious issues. At some point in any residency you do have to start demonstrating actual competence to practice independently and unfortunately not everyone can do this.

We fired a junior resident with an entirely top Ivy League pedigree including MD-PhD and prestigious fellowships. Just couldn’t cut it clinically, and was not a URM either. You can read the court documents I linked above about the black ent resident at UTMB who made some bold claims about racism and discrimination she faced that drove her from residency, but the facts showed she was struggling mightily from the beginning with multiple early evals questioning her ability to complete the program and saying she was the worst resident they had ever encountered despite her being AOA and summa cum laude from med school. Then there was the whole allegedly falsifying medical records and other issues that she failed to mention.

So even graduating top of the class and/or from a top school doesn’t necessarily predict one can become a surgeon. Obviously more borderline students may struggle as well. There’s been great discussion about this among PDs and others in GME because it’s a big issue - losing a resident is a huge loss both to that trainee and to the program. Nobody wants it to happen and everyone is looking for ways to keep it from happening.

 

[lolthroaway]

Well attrition of black surgical residents is more than double that of others. And of course its multi factorial and bias almost certainly plays a role especially for more borderline trainees.

I do think baseline ability is also a factor and strongly reject the assertion that medical school graduation indicates one has the ability to succeed in a surgical residency.

The biggest issue is that surgical skills aren’t really taught or assessed as part of the MS curriculum, so trainees are coming in with expectations and milestones on which they’ve never really been assessed before. They are excellent test takers and readers, but the actual application of clinical knowledge in direct patient care is sadly too small a part of the medical school experience and basically everyone gets passed along unless there are egregious issues. At some point in any residency you do have to start demonstrating actual competence to practice independently and unfortunately not everyone can do this.

We fired a junior resident with an entirely top Ivy League pedigree including MD-PhD and prestigious fellowships. Just couldn’t cut it clinically, and was not a URM either. You can read the court documents I linked above about the black ent resident at UTMB who made some bold claims about racism and discrimination she faced that drove her from residency, but the facts showed she was struggling mightily from the beginning with multiple early evals questioning her ability to complete the program and saying she was the worst resident they had ever encountered despite her being AOA and summa cum laude from med school. Then there was the whole allegedly falsifying medical records and other issues that she failed to mention.

So even graduating top of the class and/or from a top school doesn’t necessarily predict one can become a surgeon. Obviously more borderline students may struggle as well. There’s been great discussion about this among PDs and others in GME because it’s a big issue - losing a resident is a huge loss both to that trainee and to the program. Nobody wants it to happen and everyone is looking for ways to keep it from happening.

And I argue that even though there's a double failure rate, 2% vs 4% isn't particularly noteworthy, and I wouldn't wouldn't be worried that the 4% group was less competent unless I had hard data saying so. You make it sound like there's a significantly higher attrition rate of URMs due to them being less competent.

I said academic capability to be a surgeon. You keep emphasizing lower URM scores in conjunction to attrition rates, and I argue if you can graduate medical school you have the smarts to be a surgeon. That doesn't mean you can get through surgical residency though. I mostly agree with your last three paragraphs, so yeah, I don't know why you mention mention scores in relation to URMs being less prepared for surgical residency or more likey to fail.

 

[Wordead]

And I argue that even though there's a double failure rate, 2% vs 4% isn't particularly noteworthy, and I wouldn't wouldn't be worried that the 4% group was less competent unless I had hard data saying so. You make it sound like there's a significantly higher attrition rate of URMs due to them being less competent.

I said academic capability to be a surgeon. You keep emphasizing lower URM scores in conjunction to attrition rates, and I argue if you can graduate medical school you have the smarts to be a surgeon. That doesn't mean you can get through surgical residency though. I mostly agree with your last three paragraphs, so yeah, I don't know why you mention mention scores in relation to URMs being less prepared for surgical residency or more likey to fail.

It's a lot easier to keep your worldview when you just ignore the statistics you don't like.

How is a 100% difference not noteworthy? Are you serious?

 

[lolthroaway]

It's a lot easier to keep your worldview when you just ignore the statistics you don't like.

How is a 100% difference not noteworthy? Are you serious?

Easy to interpret them in a way to confirm you bias as well.

It's not noteworthy because it's not meaningful.

Incidentally this is why so much junk gets published: it's statistically significant without meaning anything.

Edit for clarity:

Let’s say I’m considering two contraceptive medications. 2/1000 people experience a DVT with medication A and 1/1000 experience a DVT with medication B. Sure, in a relative sense you can say patients are significantly more likely to get a DVT with medication A and beat your chest for its use. However, I don’t find the difference meaningful and will be looking at other factors when deciding which one to prescribe. Not a perfect analogy, but that’s the reasoning I’m applying to these attrition rates.

 

[GadRads]

I rapidly read the opinion and judgement on Daywalker. Her major problem seemed to have been timely completion of notes and a period of erroneous documentation of medical records. As presented, she does not have a strong case, and summary judgement in favor of UTMB seems appropriate. She was not even dismissed. It is entirely possible that she experienced discrimination, but the record does not show this was the main cause of her problems.

I always tell URM trainees that they cannot afford to be marginal, and to grow very thick skin. Even if improper behavior is condoned in one's program, I encourage them to carry out the correct protocol or practice so as not to leave room for professional disrepute. Besides negative preconceived racial biases, it is better to be upstanding ALL the time. This can create a more rigorous experience beyond what is typical, but it does contribute to being a better physician. For example, back in radiology residency, I received a very terrible evaluation in a subspecialty rotation as a PGY2 with comments like "very poor medical knowledge", "resists feedback" (despite not getting any), etc. It was by far my worst evaluation during medical training. The evaluation was very baffling to my PD (given evaluations on my prior 6 rotations) and even to my co-residents who were with me on the rotation. It did not matter that I scored in the 81st percentile on the national subspecialty exam at the end of the rotation. I also strongly felt I had a target on my back everyday on this rotation for no just cause, with subtle and passive-aggressive attacks mainly from a particular attending. For comparison, I did not experience this treatment in any other subspecialty rotation. My approach was to over-prepare and overstudy for case conference in that radiology subspecialty. By the time I was finishing residency, that subspecialty was among my top 2 best strengths.

 

[Wordead]

Easy to interpret them in a way to confirm you bias as well.

It's not noteworthy because it's not meaningful.

Incidentally this is why so much junk gets published: it's statistically significant without meaning anything.

Edit for clarity:

Let’s say I’m considering two contraceptive medications. 2/1000 people experience a DVT with medication A and 1/1000 experience a DVT with medication B. Sure, in a relative sense you can say patients are significantly more likely to get a DVT with medication A and beat your chest for its use. However, I don’t find the difference meaningful and will be looking at other factors when deciding which one to prescribe. Not a perfect analogy, but that’s the reasoning I’m applying to these attrition rates.

Since it seems like you have difficulty with numbers, 1/1000 is 0.1%. Way to move the goalposts to fit your narrative. Your example was 2% vs 4%.

If someone told you one surgeon had 4 people die out of 100, and the other 2, you wouldn't consider that meaningful?

I don't even care about this DEI argument but the logic is just astounding to me.

 

[lolthroaway]

Since it seems like you have difficulty with numbers, 1/1000 is 0.1%. Way to move the goalposts to fit your narrative. Your example was 2% vs 4%.

If someone told you one surgeon had 4 people die out of 100, and the other 2, you wouldn't consider that meaningful?

I don't even care about this DEI argument but the logic is just astounding to me.

So, do you actually think about posts you read or are you just reactionary? I stated it’s not a perfect analogy, but I chose it because it’s simple with hyperbole, and an example of a real-life scenario some time back when people were freaking out about a two- or three-fold increase in DVT of some contraceptive. It made for great headlines, especially for those against the use of contraceptives, but nobody who actually saw the numbers was impressed. There’s a difference between relative numbers and ones with real-life implications.


Your own example has many more confounding variables, but I’ll play along. Based on your 2 vs 4 numbers alone, I can’t really say which surgeon is better or which I’d recommend; there are *so many* things to consider. Just one simple one that immediately comes to mind: is one performing more surgeries on patients with more complications/co-morbidities? There’s a lot going into my analysis; not just four is a bigger number than two.

 

[WhereMyLiberalsAt]

How is a 100% difference not noteworthy? Are you serious?

You comment on percent change... Dude comments on percent change...

Way to move the goalposts to fit your narrative. Your example was 2% vs 4%.

What? A percent change is... well a change in percentage BETWEEN those two values...

If someone told you one surgeon had 4 people die out of 100, and the other 2, you wouldn't consider that meaningful?

Your goalpost was percent change. However, the surgeon example should be using percent DIFFERENCE... At least that's what the patient would care about. Which is a different equation.

you wouldn't consider that meaningful?.... the logic is just astounding to me.

The idea that you could just take a percent CHANGE and derive if its meaningful without even considering the power/validity....

 

[Skarl]

Well attrition of black surgical residents is more than double that of others. And of course its multi factorial and bias almost certainly plays a role especially for more borderline trainees.

I do think baseline ability is also a factor and strongly reject the assertion that medical school graduation indicates one has the ability to succeed in a surgical residency.

The biggest issue is that surgical skills aren’t really taught or assessed as part of the MS curriculum, so trainees are coming in with expectations and milestones on which they’ve never really been assessed before. They are excellent test takers and readers, but the actual application of clinical knowledge in direct patient care is sadly too small a part of the medical school experience and basically everyone gets passed along unless there are egregious issues. At some point in any residency you do have to start demonstrating actual competence to practice independently and unfortunately not everyone can do this.

We fired a junior resident with an entirely top Ivy League pedigree including MD-PhD and prestigious fellowships. Just couldn’t cut it clinically, and was not a URM either. You can read the court documents I linked above about the black ent resident at UTMB who made some bold claims about racism and discrimination she faced that drove her from residency, but the facts showed she was struggling mightily from the beginning with multiple early evals questioning her ability to complete the program and saying she was the worst resident they had ever encountered despite her being AOA and summa cum laude from med school. Then there was the whole allegedly falsifying medical records and other issues that she failed to mention.

So even graduating top of the class and/or from a top school doesn’t necessarily predict one can become a surgeon. Obviously more borderline students may struggle as well. There’s been great discussion about this among PDs and others in GME because it’s a big issue - losing a resident is a huge loss both to that trainee and to the program. Nobody wants it to happen and everyone is looking for ways to keep it from happening.

This is interesting to me as it matches some of my experiences as a medical student applying into surgery. There are basically no assessments of technical skills (or formal teaching) and it feel like there's a mismatch between what helps students match into competitive specialties vs. predictors of success. I think a lot of it is because you aren't given many real opportunities to demonstrate these skills/responsibility until you are a resident and by then it is arguably too late.

Are there any traits/qualities you look for in prospective residents which you have found typically help them make the transition when it comes time?

 

[operaman]

This is interesting to me as it matches some of my experiences as a medical student applying into surgery. There are basically no assessments of technical skills (or formal teaching) and it feel like there's a mismatch between what helps students match into competitive specialties vs. predictors of success. I think a lot of it is because you aren't given many real opportunities to demonstrate these skills/responsibility until you are a resident and by then it is arguably too late.

Are there any traits/qualities you look for in prospective residents which you have found typically help them make the transition when it comes time?

You are asking the million dollar question for which we just don't have an answer yet. This gets debated frequently both formally and informally, and the truth is nobody has any way of knowing. You are spot on about the mismatch between how we assess applicants and what matters clinically. Your ability to bang out chart reviews and case reports doesn't really tell us anything about your potential as a surgeon, but it sure is hella important to match. Best things I've found that are plusses are applicants that have done something successfully in their past where they had to take and incorporate feedback and play well with others. Team sports and music/performing arts are big ones and both require you to accept correction and try to improve your performance based on it, so if someone has done either at a high level then that suggests they will do well. Unfortunately lots of great applicants don't have these experiences so they aren't that useful, but when I see them on a CV it's definitely a plus and will definitely get asked about in interviews.

There have been a number of tasks we as a field have thrown at applicants. Some have them draw anatomical structures from memory. One had people carve soap into various items. Another had people do microvascular sewing under the microscope. None have proven to be powerful predictors, though it did seem that it may have helped identify problems at the extremes, ie. someone struggling with micro suturing gets frustrated and angry and cant take corrective feedback well. But in general, everyone was relatively bad at it and everyone eventually learns to do it pretty well.

You're also spot on that students never really get a chance to learn or demonstrate such skills. Many reasons for this, chief among them the EMR that locks students out of being useful and ever increasing productivity demands and increasing resident classes such that there's little left over for students. Whenever I have students with me, they're often stunned when I take the suction and retractor away and hand them the blade and/or bovie. They're always novices though, and they all struggle because they've never done it before and they're terrified of messing up. I'm not sure I could accurately assess anything other than the extremes of good or bad; 95% of students are smack in the middle of noobville.

 

[Friheten]

The extent to which race should influence our decisions remains an interesting question society continues to grapple with. An interesting comparison can be made to race-based medicine, where the debate centers around whether using race as a category in medical research and healthcare perpetuates bias and harms certain populations. A progressive argument might be that we should instead use measures like ancestry and social determinants of health over an imperfect proxy like race.

Yet the argument takes a different turn when it comes to race-based admissions. In this thread we see proponents of affirmative action suggest that using race as an imperfect proxy, instead of socioeconomic status for example, is justifiable for selecting students and trainees. I would argue that the same criticisms about promoting racial stereotypes and the need for more direct proxies of disadvantage apply in both contexts.

For what it's worth, I personally oppose race-based medicine for the same reason I oppose race-based admissions.

 

[aldol16]

The argument is that socioeconomic factors make admission criteria unfair for low SES individuals, and we're rediscovering lost intellect/talent by not overlooking those who had disadvantages. That's true for some people. However, it's 2023 and intellectual segregation is at an all time high. People gravitate towards and start a family with people of similar intellect and work ethic. Doctors marry similarly intelligent professionals, and then they have kids who are highly qualified to be doctors, and it's not just because they had a stable home and help with schoolwork (though it undeniably contributes). So if the goal is for the physician workforce to represent the US population in SES while fairly identifying talent, it will never happen. A meritocracy naturally and rapidly creates an intellectual and socioeconomic divide, even if it's imperfect.

Schools need to outright say that representation from rural communities and from black/hispanic communities is more important than intellectual prowess for creating an effective physician workforce. That's the reality. On average, the kid from Kentucky is probably not as smart or talented as the kid from NYC with MCAT scores 10 points higher and a better GPA from a more competitive school, and they probably wouldn't be even if they went to private school, but they are a better addition to the physician workforce. Same with a Spanish-speaking hispanic kid or a black kid who can better communicate with and gain the trust of many patients.

The difficulty is in identifying people who would thrive and be suited for medicine despite having lower academic credentials due to their lower SES upbringing. Because you're talking about counterfactuals here. The goal is to find people who would thrive in medical school and as physicians but who are not currently thriving due to the social circumstances facing them. We're not talking about people who are thriving despite their adverse circumstances here - I think we'd all agree that those deserve admission and to become physicians. But finding the ones I'm describing is hard. And it's hard because the consequences of failing to identify these people and making the wrong choice are huge.

This is exacerbated by the fact that to the general public, physician quality isn't something that can readily be used to differentiate physicians. The best measure they have is probably which med school/residency/fellowship their physician trained at but that as we all know is a very imperfect indicator. For all intents and purposes, an MD/DO is an MD/DO in the eyes of the public. So when you make the wrong choice and have somebody who is not intellectually suitable to becoming a physician who then graduates from (or flunks out of) medical school and residency, that becomes a risk for harm.

 

[Kierkegaard's Bud]

The extent to which race should influence our decisions remains an interesting question society continues to grapple with. An interesting comparison can be made to race-based medicine, where the debate centers around whether using race as a category in medical research and healthcare perpetuates bias and harms certain populations. A progressive argument might be that we should instead use measures like ancestry and social determinants of health over an imperfect proxy like race.

Yet the argument takes a different turn when it comes to race-based admissions. In this thread we see proponents of affirmative action suggest that using race as an imperfect proxy, instead of socioeconomic status for example, is justifiable for selecting students and trainees. I would argue that the same criticisms about promoting racial stereotypes and the need for more direct proxies of disadvantage apply in both contexts.

For what it's worth, I personally oppose race-based medicine for the same reason I oppose race-based admissions.

The lack of good foundation in public health is showing. In prominent studies of maternal mortality, controlling for SDoH didn’t fully resolve disparities in fact in some studies the gap is as big as 2x. Race whether you like it or not provides a framework for fully understanding such medically relevant situations. It should never be the only one, in fact, IMO shouldn’t be in top 3 but fully discounting it is foolish.

 

[Friheten]

The lack of good foundation in public health is showing. In prominent studies of maternal mortality, controlling for SDoH didn’t fully resolve disparities in fact in some studies the gap is as big as 2x. Race whether you like it or not provides a framework for fully understanding such medically relevant situations. It should never be the only one, in fact, IMO shouldn’t be in top 3 but fully discounting it is foolish.

That’s not the point I’m making. I think it’s inconsistent to argue for race as an important factor in one context but not in another. Both affirmative action and anti-race based medicine are championed at progressive medical institutions, which feels contradictory.

 

[Kierkegaard's Bud]

That’s not the point I’m making. I think it’s inconsistent to argue for race as an important factor in one context but not in another. Both affirmative action and anti-race based medicine are championed at progressive medical institutions, which feels contradictory.

I go to a “progressive medical institution”, never heard of anti-race medicine. Those institutions aren’t anti-race, like I have said, they want to consider more powerful variables that can better explain reality.

 

[Friheten]

I go to a “progressive medical institution”, never heard of anti-race medicine. Those institutions aren’t anti-race, like I have said, they want to consider more powerful variables that can better explain reality.

Race-based medicine is wrong. How should physicians oppose it?

Race is a social construct, not a biological or genetic category. Learn how to help dismantle practices based on the false idea of racial essentialism.

www.ama-assn.org

Yes, I also think we should consider more powerful variables that can better explain reality, in medicine and admissions.

 

[EngineerPreMD]

The difficulty is in identifying people who would thrive and be suited for medicine despite having lower academic credentials due to their lower SES upbringing. Because you're talking about counterfactuals here. The goal is to find people who would thrive in medical school and as physicians but who are not currently thriving due to the social circumstances facing them. We're not talking about people who are thriving despite their adverse circumstances here - I think we'd all agree that those deserve admission and to become physicians. But finding the ones I'm describing is hard. And it's hard because the consequences of failing to identify these people and making the wrong choice are huge.

This is exacerbated by the fact that to the general public, physician quality isn't something that can readily be used to differentiate physicians. The best measure they have is probably which med school/residency/fellowship their physician trained at but that as we all know is a very imperfect indicator. For all intents and purposes, an MD/DO is an MD/DO in the eyes of the public. So when you make the wrong choice and have somebody who is not intellectually suitable to becoming a physician who then graduates from (or flunks out of) medical school and residency, that becomes a risk for harm.

I think we agree, but I don't think there's a huge risk of admitting someone who is not intellectually suitable. It's more that you're going to wind up missing out on some intellectual ability if your goal is equal representation, which it clearly is just judging by the language we use in DEI (i.e., ORM, URM). Personally, I think that's okay. I don't think we need our community doctors to be Cornell grads with 95th percentile MCATs and multiple publications. We should just say that out loud though instead of pretending that low SES people with lower stats are just as smart as the Ivy League grads but for some social circumstances. We should admit some people to be field-changing physician-scientists and others to be amazing community clinicians.

The main point I was trying to make is that we're rapidly segregating society by intellect, mental health, discipline, and other factors related to success. Doctors, lawyers, engineers, and other successful professionals are all meeting in social circles that are basically built and reinforced by higher education, and they're getting married and having kids with those same traits. Small town cashiers are doing the same. These aren't small trends. These are overwhelming realities, and increased education requirements are only reinforcing this further. There are definitely people out there who would thrive if only their social circumstances changed. However, you can't scrounge up enough of these people to make doctors look like the US socioeconomically without turning down people who are better suited for the role based on intellect, discipline, mental health, etc... and that's only going to continue to compound in coming generations. So just stop trying to pretend that it's all in the name of finding the smartest most talented people. Just say you're finding the best people for the job, and those are people who can relate better to poorer patients. It's more direct and more likely to succeed.