Looking at yearbook pictures of medical students at Eastern Virginia Medical School wearing blackface and dressed like Ku Klux Klansmen and civil war confederates, we felt a complex and familiar mix of emotions: the dull ache of recognition of the hackneyed visual tropes of white supremacy, the sudden self-consciousness (for two of us) about our own brown skin, and a sad weariness that eventually morphed into anger. But none of us felt surprise or shock. The images of white medical students dressed in racist costumes merely affirmed what we already knew—that most medical schools are white spaces where explicit and implicit racism occurs constantly and often goes unmentioned and unpunished.
What makes medicine a white space? As described by sociologist Elijah Anderson, white spaces are characterized by “their overwhelming presence of white people and their absence of black people.1” This is certainly true of medical education, where the number of Black medical students and faculty remains disproportionately low compared with whites.2, 3 A white space, in Anderson’s words, also requires that “prejudiced actors pervade the white space and are singly or collectively able and interested in marginalizing the black person, actively reminding him of his outsider status to put him in his place.1”
Recent research and writing demonstrates that medical schools are replete with such actors.4 Medical schools grant white students membership to honor societies more frequently than Black or Asian students and promote white faculty more readily than Black faculty.5, 6 Medical school faculty often perpetuate false racist beliefs, enforce racial hierarchies in the hospital, and normalize racism by making racist remarks that go unchallenged.7, 8 A 2016 study by Hoffman et al. found that about 50% of white medical students and residents surveyed endorsed at least one false statement about biological race, such as “Black people’s nerve-endings are less sensitive than White people’s nerve-endings” and “Black people’s skin has more collagen (i.e., it’s thicker) than White people’s skin.9” Such evidence of the pervasive racism in medicine has resulted in efforts to dismantle the white space in medical education–committees and deans to increase diversity and inclusion, curricula on health disparities, and education on implicit bias and microaggressions. Many have called for more racial and social-economic equity in medical school admissions.10
We propose a more direct way to address racism in medical training: stop admitting applicants with racist beliefs.
Although an admittedly complex task, there are some approaches worth considering. After all, medical schools and residency programs already evaluate candidates for hard-to-quantify characteristics and attitudes. Admissions officers scrutinize essays and resumes for evidence of commitment, leadership, tenacity, and genuine desire to care for patients. They require letters of recommendation testifying to character and integrity. Some programs use multiple-mini-interviews (MMIs)––where applicants rotate through several rooms responding to different prompts––to assess qualities such as communication, empathy, professionalism, integrity, and ethical reasoning.11 Medical school admissions and residency programs could build on some of these current modes of evaluation to ascertain whether applicants hold racist beliefs or invalid and fixed views on biological differences between races.
For example, a short questionnaire could be used to flag significantly uninformed individuals who may not yet be ready to care for patients or interact with their non-white peers in a respectful manner. Applicants could be given surveys adapted from studies on implicit and explicit bias.9, 12
Application essays are also opportunities to understand an applicant’s views on race in medicine. Many medical schools, including Yale School of Medicine, include secondary essay prompts about applicants’ perspectives on “diversity.” These essays could be enhanced to more clearly elicit applicants’ positions on race: for example, reflecting on their own racial or ethnic identity; or responding to selected passages by prominent scholars on race and medicine, such as Dorothy Roberts or Harriet Washington.
Interview questions evaluating applicants’ views on race could be similar to essay prompts or they could be more direct questions, such as “Do you think Black patients are more likely to be poor historians than white people––and if so, why?12”
MMI scenarios could be based on discriminatory experiences reported by minority faculty, trainees, and students: a peer implying that an underrepresented minority (URM) medical student was admitted only because of “affirmative action”; a professor suggesting that race is biological; or an attending telling a patient not to take a racial slur “so personally.8, 13, 14” Due to the intersectional nature of identity, MMI scenarios could be designed to touch on multiple forms of discrimination simultaneously.4, 15 MMI stations could also ask applicants to respond to a summary of a study on racism in medicine.16,17,18
Student-hosted discussions of race in medicine could involve students and trainees of color engaged in racial justice work or affiliated with groups such as the Student National Medical Association (SNMA) or the Latino Medical Student Association (LMSA). Host students or trainees could then evaluate candidates’ racial attitudes in a more informal setting.
Interviews by minority community members could assess applicants’ attitudes about non-white patients. In White Coat, Clenched Fist, Dr. Fitzhugh Mullan described such a strategy. He recounted how parents from the South Bronx formed Lincoln Hospital’s Pediatric Parents Association (PPA) and participated in interviewing residency applicants in the 1970s. Mullan recalled that “mothers from the PPA spoke up right from the start, often asking tough questions about applicants’ attitudes towards blacks or Puerto Ricans.19” Medical schools and residencies could assemble similar panels of minority community/patient interviewers. This approach would have the added benefit of giving patients a voice in their own healthcare, potentially improving relationships between academic medical centers and their surrounding communities.
Diversifying and educating admissions committees and interviewers is essential, because they will be responsible for locating a given candidate on a continuum of racial attitudes which would then be weighed as part of their overall candidacy. Admissions committees and interviewers should include Chief Diversity Officers, expert consultants on race, and URM faculty and students, and be otherwise diverse in terms of race, ethnicity, and gender.20, 21 Ongoing education and training should help admissions committees and interviewers become aware of their own biases, learn how to counteract them, and stay informed on racism in medicine.21,22,23,24
Holistic review, which was designed to increase diversity among medical trainees, is an example of a successful restructuring of health professional admissions.25 As part of implementing holistic review, several academic medical centers have already taken measures we have proposed in order to assess applicants’ non-academic qualities and attitudes. These measures include adding essays to applications, increasing minority and URM interviewers, diversifying admissions offices, and providing admissions staff with training on race in medicine.20, 26, 27 We argue that assessing candidates’ racial attitudes should be part of these ongoing efforts. Although it will require extra effort to craft these assessments, we believe that it is worth investing time and resources in creating safer environments for all minority patients and trainees at academic health centers.4, 8, 26
Evaluating candidates’ perspectives on race and medicine would do more than simply identify those with racist beliefs. It would also provide URM applicants more opportunities to express their relationship to medicine, demonstrate their understanding of how race operates within medicine, and display their ability to navigate racially complex scenarios in medical practice. Application processes that do not explicitly raise the issue of racism and racial beliefs foreclose the assessment of this important aspect of URM applicants’ potential strengths.
It is important to assess for racist beliefs in future physicians because such beliefs are linked to harm and suffering for patients. While prior health equity research identified differences in treatment, outcomes, and mortality between white and non-white patients, newer research has linked such disparities more directly to racial beliefs among medical providers. For example, Hoffman’s aforementioned study found that white medical students and residents who held a higher proportion of false racist beliefs were also more likely to rate a Black person’s pain as less than a white person’s pain in identical clinical scenarios and were less likely to recommend appropriate treatment to Black patients than to white patients.9
To be sure, people’s beliefs can evolve, especially in environments that strive to change curricula, diversify medical schools, and counteract racism in medical culture. This was the approach taken by the Black Panther Party, which not only rigorously evaluated physicians for their commitment to racial justice before allowing them to practice in their clinics, but then required those physicians to receive a “re-education” on race and anti-colonialism even after they had been accepted as volunteer medical staff.28
Medical school and residency applicants should be held to some kind of standard when it comes to race and racism. And while selecting for students who are committed to racial justice will not fix racism in medicine, it is an important and necessary measure. Medical schools must take active steps to diminish the prevalence of racism in future medical students and doctors. It is a detriment to our profession and to our patients to merely lament the racism we find in our ranks while doing nothing to prevent it in the first place.