The Federal Aviation Administration’s “What We Do” webpage describes the FAA’s primary purpose: “We’re responsible for the safety of civil aviation … We issue and enforce regulations and minimum standards … [and] certify airmen.” In addition to those primary goals, the FAA has adopted a secondary objective, which was codified into law by presidential executive order: to increase the racial diversity of its workforce. As early as 2013, FAA officials internally acknowledged “a trade-off between diversity … and predicted job performance/outcomes.” Along with that explicit admission, the FAA asked a provocative question: “How much of a change in job performance is acceptable to achieve what diversity goals?” This question is certainly as applicable to academic medicine as it is to civil aviation.
The institutions of academic medicine ensure the safety of all patients by selecting and training only those who are most likely to provide the best possible medical care. And, like the FAA, this arm of the medical profession has adopted the supplementary mission of increasing racial diversity in the physician workforce. Given these objectives, academic medicine should have a significant interest in answering the same provocative question that the FAA asked itself eleven years ago. Unfortunately, although the diversity-performance trade-off throughout medical education is well understood – and, in fact, perpetuated – its reality is consistently denied or ignored.
A 2017 analysis of medical school admissions statistics showed that white applicants were much less likely to be accepted than black and Hispanic applicants with similar GPAs and MCAT scores. The disparity was strikingly pronounced among applicants with below-average combined GPAs and MCAT scores. These data confirmed that medical schools have consistently ensured that students of races historically underrepresented in medicine (UIM) are accepted at much higher rates than their white counterparts despite comparable surrogates for both mastery of foundational subjects and critical thinking skills under pressure. This practice favoring diversity over performance has predictable and measurable consequences among medical students.
For example, the results of a 2021 study of clerkship outcomes at the University of New Mexico School of Medicine showed that in nearly every clerkship, white students as a group soundly outperformed their peers “of color” in almost every measurable way – from Shelf test scores to clinical evaluation scores to final clerkship grades. Importantly, the study also found “strong correlations [between Shelf test scores] in all clerkships with MCAT scores and Phase I block averages” and “strong correlation [between final clerkship grades and] Phase I block average in all seven clerkships.” Systemic racism in clerkship grading was the identified culprit behind these disparities – but could it be possible that the structural racism committed against these students actually occurred long before their clerkships? The strong correlations between past and future academic performance unequivocally facilitate general predictions about the eventual clinical competence of individual students or student groups. Yet, in full knowledge and possession of this near-prophetic power, decision-makers in academic medicine persist in their current admissions practices that perpetuate the diversity-performance trade-off among aspiring physicians. This begs the question; how can academic medicine maintain and answer for such an imbalance between diversity and performance?
The answer to that question is widely publicized by DEI proponents in academic medicine. For instance, authors from Johns Hopkins University School of Medicine and Howard University College of Medicine recently outlined a “holistic review process” that pathology residency programs could adopt to promote greater representation of UIM groups in that specialty. The authors’ proposed “action items” to accomplish this unquantified goal included “interviewer blinding to USMLE examination scores …lowering or eliminating the minimum USMLE STEP 1 examination score requirement for an interview invitation … placing less emphasis on [Alpha Omega Alpha Honor Medical Society] status and research experiences.” In addition, they posited that admissions committees should expect “potential bias [disfavoring UIM and female applicants] in subjective academic metrics such as [letters of recommendation] and narrative student evaluations.”
Though their acknowledgment of the diversity-performance trade-off was unintentional, it was nonetheless crystal clear: Current efforts to diminish whiteness in the physician workforce cannot realize their full potential, while traditional performance measures remain integral components of the student-to-physician continuum. They also spelled out the fate of time-honored performance assessments in the DEI era – suspicion, diminution, or total elimination of objective indicators of subjective surrogates for real-world achievement and competence.
Ironically, these authors, like almost all DEI proponents, claim that such a “holistic” admissions process, which quite literally turns a blind eye to all measures of excellence, “promotes diversity as a prerequisite for program excellence.” But do DEI practices actually promote excellence among physicians in training, particularly among those for whom the initiatives are intended? One experiment answering this question began in 2022 when the USMLE STEP 1 examination was transitioned to a pass/fail scoring system – a change widely publicized to eradicate its “disproportionate importance” in the traditional residency application process and “encourage a holistic review.” In that very year, international medical academicians noted an alarming “reduction in daily studying time and weeks of advance preparation in 2022 compared to previous years” and a concurrent “notable decline in pass rates among all groups of first-time test takers.” Sadly, students in non-U.S./Canadian schools – the group with the greatest racial and cultural diversity – experienced “the most significant relative drop” in pass rate compared to prior years.
Academic medicine clearly acknowledges the diversity-performance trade-off, perpetuates it through its DEI-driven admissions practices, and has chosen to proverbially divide both sides of the equation by “performance” to attain its diversity objectives. Instead of critically addressing the FAA’s essential question – “How much of a change in job performance is acceptable to achieve what diversity goals?” – academic medicine has opted to avoid the issue entirely through systematic erasure of all measurable indicators of excellence. The consequences of this top-down oxymoronic denial and preservation of the diversity-performance trade-off are felt by many: Aspiring physicians whose likelihood of acceptance into the profession is diminished by their lack of melanin, UIM physicians in training whose clinical acumen continuously reflects their inadequate preparation and especially, patients who deserve the safest medical system and most competent physician workforce.
Landon Kunzelman is a pathology resident.
