Bright Ideas: The Need for Affirmative Action in Medicine and Beyond

Published: Mar 18, 2023  |  

Neuro-oncologist and health equity scholar

Image created by Nikki Muller with the assistance of DALL·E 2

At the 59th meeting of the Society of Thoracic Surgeons, outgoing president Dr. John Calhoon included “virtuous ideals” in his presidential address. This address, given at a plenary session of a prominent medical society, encompasses the internal debate about inclusion, diversity, equity, anti-racism, and social justice (IDEAS) in medicine. 

Key points—listed verbatim from the slide used during his presentation—were: 

  • Affirmative Action is not equal opportunity 
  • Inclusion not the same as Diversity 
  • Search for the best candidate 
  • Use all hurdles and challenges overcome 
  • Defining people by color, gender, religion only tends to ingrain bias and discrimination 
  • Diversity is occurring rapidly
  • Best metric is simply whether someone does good 

These “virtuous ideals” presented draws upon the false notion of a meritocracy and highlights individual exceptionalism, ignoring inherent privileges and disadvantages that come with the color of our skin, gender, or where we are from. This mindset, which is all too prevalent in medicine, must change to provide equitable care to all. 

The opposition to IDEAS is another example of wanting to keep the status quo. A familiar reaction to any anti-racism, health equity, or social justice training is to condemn affirmative action, which at face value is easily critiqued. By focusing on differences in admission statistics or metrics, while conveniently ignoring the determinants of those differences, it’s easy to make a case for only students and doctors of the highest pedigree. 

Additionally, it would be true that categorizing people on race, gender, and religion only further ingrains biases if we lived in a perfect world. But we don’t. We live in a society that greatly advanced the concepts of divisiveness to create a power dynamic and hierarchy favoring Christian, White men with western European heritage. 

As the importance of social justice and health equity have become mainstream and adopted throughout medical schools, residencies, and professional organizations, there is inevitable backlash. Multiple opinion pieces, including by the Wall Street Journal’s Editorial Board, say medical education has “gone woke.” 

Interestingly, many organizations that criticize learning about social justice and health equity are silent on other inaccurate myths in medical teaching, such as the concept that Black patients experience pain differently than White patients. They also seem to ignore studies showing better patient experiences and outcomes with racial concordance between providers and patients. Other curriculum innovations, including early patient exposure and the movement to incorporate humanistic components to medical training are also met with silence. Only when IDEAS concepts make it into medical education do objections arise. 

Even with affirmative action, Black, Latinx, and Native American physicians only make up 11.1% of the total physician population, while comprising 31.7% of the total U.S. population. These groups are significantly underrepresented, yet face the most significant ire and scrutiny, leading to imposter syndrome and burnout. Students and trainees who are legacy admissions or relatives of prominent faculty and donors, are rarely given the same review. 

As an analogy, imagine a 100-meter dash with two competitors. Competitor A, through advantages of knowing the race coordinator and committee, can start at the 50-meter mark and will win the race almost every single time. Competitor B begins with a disadvantage, a longer distance to run. If Competitor B wins the race by beating the odds, this is an exception. 

Like running a race that begins unfairly, traditional metrics and standards ignore that race-neutral admissions without affirmative action dismiss students who have longer paths to travel. Only a few of these students will make it against the odds. 

Working harder as the solution is a favorite talking point for those who criticize IDEAS. However, cherry-picking examples of exceptional, hard-working individuals supports the myth that everyone can overcome challenges through their work ethic. This myth was often elevated after the election of President Obama, with many declaring that racism was dead. This school of thought minimizes institutional and structural barriers, ultimately contributing to health disparities.  

In the United States, a race-conscious and division-conscious country, race, gender and religion are proxies to capture “isms” (racism, sexism, genderism, and discrimination based on religion). These combined with the social determinants of health, ranging from financial status to physical location, provide insight on likely challenges. A categorization-free world is a nice talking point, but reality is far more difficult unless you are part of a privileged class. Biases, society, and regulations make it so. 

Promoting virtuous ideals and articles that cite the problem of IDEAS in medicine is a familiar tactic in the American playbook. It disregards the importance of diversity, which has shown to improve patient outcomes and combat health disparities and vilifies affirmative action. Defending the notion that someone can pull themselves up by the bootstraps proves why IDEAS is necessary and should be incorporated throughout trainings in medicine and beyond.  

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