Rapid changes to AOA inclusion are inequitable

The social unrest that has erupted in the wake of the George Floyd murder has prompted many U.S. professional organizations, including those dedicated to medical education, to make changes to advance racial and socioeconomic equity. Right now, a fierce debate rages among medical students over how the Alpha Omega Alpha Honor Medical Society (AOA) nominates and inducts fourth-year medical students. An example of this debate is reflected in the new Change.org petition brought by a student group at the Feinberg School of Medicine to abolish the local chapter.

Over the many years of my MD-PhD program, I often questioned the integration of AOA induction into the curriculum. I also favor eventually removing AOA status from the formal residency match process because AOA status no longer reflects its original intention to be a predictor for future contributions to the institution of medicine overall. However, acting rashly to accomplish that constitutes an injustice to any current cohort of third- and fourth-year medical students working under the current system. As with changes to the United States Medical Licensing Exam (USMLE) to pass/fail starting the with the class of 2023, changes to AOA induction should be implemented in a cohort-specific manner a year or two in advance to allow students adequate time to adjust to the new educational paradigm.

AOA originated at the turn of the Twentieth century to counteract the inconsistent and often poor quality of medical education by honoring and promoting promising future physician-leaders in the American health care establishment. Membership further evolved into a presumed marker of academic excellence and professionalism. Subsequently, there is a large representation of AOA members in academic institutions given the presumed goal of AOA members to contribute to the advancement of medicine. Every year 4,000 fourth-year medical students receive nominations and inducted into the organization as a result of a quota-based system wherein medical schools nominate the top quartile of their students for membership by whatever criteria they choose, an irony given its historical origins fighting variability in medical education. With 133 active chapters and a built-in section for AOA membership included as part of the Electronic Residency Application Service (ERAS), selection for AOA membership is an official part of many students’ medical education experience at medical schools in the United States.

All medical students are now subjected to multiple rigorous board examinations, and medical schools undergo lengthy accreditation processes to standardize the training and assessment of medical students, unlike in 1902 when AOA was founded. Competition for admission into many medical specialties has also become more competitive with many more applicants than available for training spots such that that AOA confers significant competitive advantage. However, the use of AOA membership as a social marker to predict future leadership in these fields is less predictive now that more and more medical students engage in extracurricular activities such as research, motivated both by changing curriculum requirements and genuine interest. Additionally, in recent years there is concern that the reliance on USMLE and subjective clerkship grades for selection into AOA disproportionately leads to lower membership by students from racial and social backgrounds historically underrepresented in medicine. Medical schools are confronting these challenges in a variety of approaches, including increased reliance on holistic assessment to determine AOA selection or complete suspension of nominations.

This summer, the change in USMLE Step 1 score reporting from a 3-digit numerical score to a simple pass/fail system was announced to be implemented no earlier than January 2022. This decision was made to allow students time to adjust the planning of their USMLE administration, as well as allow medical schools sufficient time to update medical curricula to reflect the deemphasis on USMLE Step 1 administration for residency applications. It was viewed that a rapid transition in the absence of alternative curriculum elements with which to students can demonstrate their mastery of clinical medicine would force residency program directors to increase their reliance on other subjective factors such as medical school reputation when evaluating prospective residency applicants, which is considered an inequitable outcome.

Changes to selection into AOA should likewise be implemented in a delayed cohort-specific manner regardless of what specific reforms a medical school chooses. Enacting immediate changes in the middle of students’ educational programs is inherently unfair as such action is equivalent to pulling the rug under their feet, just as these students have acclimated to a given educational paradigm. Rash action will also alienate many well-intentioned students only responding to the pressures of the existing educational system and may lead to a backlash in support for long-term efforts to achieve racial and socioeconomic equity in the medical profession, which would be an undesired outcome.

Jose-Marc Techner is a medical student.

Image credit: Shutterstock.com

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