Throughout history, the creation of race, based on distinct and hierarchized categories, has always been preceded by the creation of expanding oppressive systems that require a moral and cognitive justification. In turn, oppression is presumed natural, if some groups are deemed naturally inferior . Further, these systems of subjugation, colonization, and exploitation have often been (and continue to be) fueled by profit motive and the expansion of capitalism.
With this in mind, we consider the “Diversity 3.0” framework presented by the AAMC [26, 27]. While a full analysis is beyond the scope of this commentary, the AAMC offers a view of diversity initiatives and frameworks as subsequent and updating “operating systems,” each new release correcting prior flaws and progressing as a result of lessons learned. Briefly, Diversity 1.0 was concerned with undoing legacies of segregation, upholding Civil Rights legislation, and providing justice to individual applicants previously prohibited from entering medicine. This initiatives’ ultimate failure was attributed to the widespread belief that “diversity (is) at odds with excellence.” Diversity 2.0, therefore, focuses on the benefit of diversity to the larger learning community (read: other white trainees, as opposed to simply achieving justice for trainees of color) and posits that perhaps the educational benefits of diversity will additionally prepare all trainees to better address health inequity (in marginalized patient communities). It is important to note here that diversity is often an imprecise way that leadership refers to the presence or absence of people of color, specifically, rather than as a true depiction of heterogeneity. In Diversity 3.0, diversity itself is re-branded as a valuable “resource” that should be “leveraged” and marketed “to build innovative, high-performing organizations” . According to this definition, neither the professional opportunity of applicants of color (Diversity 1.0) nor the health of marginalized communities (Diversity 2.0) are the primary intended beneficiaries. Instead, we see the medical enterprise, and its advertised “excellence,” as the driving motive. This is referred to as the business argument for diversity. It should be noted that these concepts are widespread and perpetuated even by individuals not directly familiar with the “diversity operating system” framework but who have, rather, tuned in to the discourse du jour. While these approaches are often guided by broader trends, case law, and educational-legal limitations, these broader limitations can also be over-stated by institutional leaders as an alibi for inaction, without grappling with the true meaning of the law, or further, without engaging in physician advocacy when the laws are at odds with racial justice.
In light of the suggestion that Diversity 1.0, 2.0, and 3.0 represent advances in the “operating systems” guiding diversity work, how do we make sense of stagnant or declining levels of marginalized communities represented in medical training? [28,28,30] Further, relative to the concrete and measurable outcomes at the center of Diversity 1.0 and 2.0, outcomes that focus the intended benefit directly to trainees and communities of color, how does one reconcile the need to make medical centers excellent when those medical centers have believed themselves to be “excellent” all along? If a medical center with no faculty of color brings in one, two, three highly accomplished faculty of color, they might then satisfy their arbitrary expectations of diversity and excellence under Diversity 3.0, with no accountability for the experience of those faculty [31, 32]. Those faculty, fulfilling unspoken quotas under this framework, may, instead remain the token few, featured on websites and brochures, who can be pointed to when new concerns for lack of diversity arise .
Consider instead, when Diversity 1.0 was deemed incompatible with the needs of academic medicine because “diversity was at odds with excellence.” Rather than skipping to another framework, we had the opportunity to instead challenge, deconstruct, and redefine what we meant by excellence, understanding that any system which perpetuates structural racism cannot, in fact, be excellent. We had the opportunity to recognize the concept of “diversity being at odds with excellence” as a symptom of racism, a virus affecting the operating system, and we could have refused to proceed to further iterations of the operating system until structural racism; this virus was addressed. Instead of concerning itself with the difficult work of honestly tackling structural racism so as to have an effective system to counter it, the operating system redefined diversity and changed the goal of the system.
In this light, we bring attention to the recent decision to revise USMLE STEP1 to a pass/fail system . While we are encouraged by this transition, our discussion of the Diversity operating system focuses attention on how processes may evolve without resolving root issues. Returning again to the “baseball watchers”—STEP1 could be considered the fence, and group-level disparity in test outcomes the perceived height of watchers. To remove the fence (or to change its height, make it see-through, etc.) does not necessarily change erroneous assumptions of the watchers “being short.” In this sense, the use of STEP1 is testament to implicit institutional values that, without being addressed directly, will invariably present in new forms. For example, because underlying myths have not been corrected, we are not surprised by the already-present objection from groups for whom STEP 1 has provided advantage—for those who believe in the “myth of shortness” (and their own tall stature). Anger is a predictable response when height is made irrelevant.
In sum, Diversity 3.0 attempts to offer a win-win framework and provides even marginalized groups some validation—“yes, you do have something to contribute, you are capable of working in different and creative ways.” Problematically, however, is that contribution is made contingent on the benefit to the medical center and its marketing. Ultimately, if racism was born out of Capitalism , we cannot anticipate the “business argument” to result in racial equity. If oppression thrives in contexts that mask its presence and silence those who suffer, frameworks that do the same cannot generate healing and true transformation.