To the Editor:
We appreciate the opportunity to respond to Plaisime and Cerdeña’s letter. Plaisime and Cerdeña note that racism is not just a feature of individuals but of a system. We completely agree with this statement, which is consistent with our article’s recommendations, many of which are mirrored in Plaisime and Cerdeña’s letter, such as structured interview questions on race and medicine, Multiple Mini-Interviews (MMI), and educating admissions committees on structural racism and bias. We are glad they agree with our position that “people’s beliefs can evolve, especially in environments that strive to change curricula, diversify medical schools, and counteract racism in medical culture."1
Our Perspective articulates implementable, evidence-based policies to reform the system and process by which medical students and residents are admitted to our profession. Our proposals are structural proposals. We do not propose that racial attitudes should be absolute criteria for rejection or acceptance. Rather, we elucidate that racial attitudes should be evaluated as part of a holistic admissions review process in order to transform our profession from the inside out and to hold ourselves to some kind of standard when it comes to race and medicine. Future directions for our work include developing racial attitudes assessment instruments—such as surveys, interview or essay questions, and MMI scenarios—and studying their efficacy and impact. Some of these efforts are already underway, with promising results.
Counteracting racism in medicine should include setting standards for individual racial attitudes and behaviors, as well as dismantling systemic racism—a “both/and” rather than an “either/or” approach. In fact, one cannot occur without the other, because individual behavior is the mechanism through which structural oppression is enforced. Attempts to frame our proposals for individual standards as being in opposition to efforts for structural reform are not only erroneous but also harmful. As Professor of African American Studies Imani Perry has cautioned:
“In academia, we often talk about structural or institutional racism versus personal racism … The discourse of structural racism in my mind has lost much of its usefulness. It absolves responsibility and dampens activism."2
Weaponizing the language of structural racism to undermine efforts to set standards for individual behavior also reinforces the harmful paradigm of "racism without racists," as articulated by Bonilla-Silva, wherein anti-racist policies are enacted, but individual racist attitudes and practices are allowed to endure.
Finally, assessing the racial attitudes of medical trainees shows respect and consideration for patients who are Black, Indigenous, and people of color (BIPOC). If a Black patient walked into a clinic tomorrow and could choose between a resident who believes Black people are less sensitive to pain than white people or one who does not believe such a racist falsehood, which do you think they would choose?
Anderson, N., Boatright, D. & Reisman, A. Blackface in White Space: Using Admissions to Address Racism in Medical Education. J Gen Intern Med 35, 3060–3062 (2020).
Perry I. More beautiful and more terrible: the embrace and transcendence of racial inequality in the United States. New York: New York University Press; 2011:42.
Bonilla-Silva E. Racism without racists: color-blind racism and the persistence of racial inequality in America. In. Lanham: Rowman & Littlefield; 2018.
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Anderson, N., Boatright, D. & Reisman, A. Re: Blackface in White Space: Using Admissions to Address Racism in Medical Education. J GEN INTERN MED 36, 1119 (2021). https://doi.org/10.1007/s11606-021-06609-8