The Corruption of Medicine | City Journal
"The post–George Floyd racial reckoning has hit the field of medicine like an earthquake. Medical education, medical research, and standards of competence have been upended by two related hypotheses: that systemic racism is responsible both for racial disparities in the demographics of the medical profession and for racial disparities in health outcomes. Questioning those hypotheses is professionally suicidal. Vast sums of public and private research funding are being redirected from basic science to political projects aimed at dismantling white supremacy. The result will be declining quality of medical care and a curtailment of scientific progress.
Virtually every major medical organization—from the American Medical Association (AMA) and the American Association of Medical Colleges (AAMC) to the American Association of Pediatrics—has embraced the idea that medicine is an inequity-producing enterprise. The AMA’s 2021 Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity is virtually indistinguishable from a black studies department’s mission statement...
Shaky command of usage and grammar characterizes the entire 86-page tome, making the preamble’s boast that “the field of equity has developed a parlance which conveys both [sic] authenticity, precision, and meaning” particularly ironic...
The reader plunges into a thicket of social-justice maxims: physicians must “confront inequities and dismantle white supremacy, racism, and other forms of exclusion and structured oppression, as well as embed racial justice and advance equity within and across all aspects of health systems.” The country needs to pivot “from euphemisms to explicit conversations about power, racism, gender and class oppression, forms of discrimination and exclusion.” (The reader may puzzle over how much more “explicit” current “conversations” about racism can be.) We need to discard “America’s stronghold of false notions of hierarchy of value based on gender, skin color, religion, ability and country of origin, as well as other forms of privilege.”
A key solution to this alleged oppression is identity-based preferences throughout the medical profession. The AMA strategic plan calls for the “just representation of Black, Indigenous and Latinx people in medical school admissions as well as . . . leadership ranks.” The lack of “just representation,” according to the AMA, is due to deliberate “exclusion,” which will end only when we have “prioritize[d] and integrate[d] the voices and ideas of people and communities experiencing great injustice and historically excluded, exploited, and deprived of needed resources such as people of color, women, people with disabilities, LGBTQ+, and those in rural and urban communities alike.”
According to medical and STEM leaders, to be white is to be per se racist; apologies and reparations for that offending trait are now de rigueur. In June 2020, Nature identified itself as one of the culpably “white institutions that is responsible for bias in research and scholarship.” In January 2021, the editor-in-chief of Health Affairs lamented that “our own staff and leadership are overwhelmingly white.” The AMA’s strategic plan blames “white male lawmakers” for America’s systemic racism.
And so medical schools and medical societies are discarding traditional standards of merit in order to alter the demographic characteristics of their profession. That demolition of standards rests on an a priori truth: that there is no academic skills gap between whites and Asians, on the one hand, and blacks and Hispanics, on the other. No proof is needed for this proposition; it is the starting point for any discussion of racial disparities in medical personnel. Therefore, any test or evaluation on which blacks and Hispanics score worse than whites and Asians is biased and should be eliminated.
The U.S. Medical Licensing Exam is a prime offender...
Black students are not admitted into competitive residencies at the same rate as whites because their average Step One test scores are a standard deviation below those of whites. Step One has already been modified to try to shrink that gap; it now includes nonscience components such as “communication and interpersonal skills.” But the standard deviation in scores has persisted. In the world of antiracism, that persistence means only one thing: the test is to blame. It is Step One that, in the language of antiracism, “disadvantages” underrepresented minorities, not any lesser degree of medical knowledge.
The Step One exam has a further mark against it. The pressure to score well inhibits minority students from what has become a core component of medical education: antiracism advocacy. A fourth-year Yale medical student describes how the specter of Step One affected his priorities. In his first two years of medical school, the student had “immersed” himself, as he describes it, in a student-led committee focused on diversity, inclusion, and social justice. The student ran a podcast about health disparities. All that political work was made possible by Yale’s pass-fail grading system, which meant that he didn’t feel compelled to put studying ahead of diversity concerns. Then, as he tells it, Step One “reared its ugly head.” Getting an actual grade on an exam might prove to “whoever might have thought it before that I didn’t deserve a seat at Yale as a Black medical student,” the student worried.
The solution to such academic pressure was obvious: abolish Step One grades. Since January 2022, Step One has been graded on a pass-fail basis. The fourth-year Yale student can now go back to his diversity activism, without worrying about what a graded exam might reveal. Whether his future patients will appreciate his chosen focus is unclear.
Every other measure of academic mastery has a disparate impact on blacks and thus is in the crosshairs.
In the third year of medical school, professors grade students on their clinical knowledge in what is known as a Medical Student Performance Evaluation (MSPE)... The disparity in MSPEs tracked the disparity in Step One scores.
The parallel between MSPE and Step One evaluations might suggest that what is being measured in both cases is real. But the a priori truth holds that no academic skills gap exists. Accordingly, the researchers proposed a national study of medical school grades to identify the actual causes of that racial disparity. The conclusion is foregone: faculty bias. As a Harvard medical student put it in Stat News: “biases are baked into the evaluations of students from marginalized backgrounds.”
A 2022 study of clinical performance scores anticipated that foregone conclusion. Professors from Emory University, Massachusetts General Hospital, and the University of California at San Francisco, among other institutions, analyzed faculty evaluations of internal medicine residents in such areas as medical knowledge and professionalism. On every assessment, black and Hispanic residents were rated lower than white and Asian residents. The researchers hypothesized three possible explanations: bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment. University of Pennsylvania professor of medicine Stanley Goldfarb tweeted out a fourth possibility: “Could it be [that the minority students] were just less good at being residents?”
Goldfarb had violated the a priori truth. Punishment was immediate. Predictable tweets called him, inter alia, possibly “the most garbage human being I’ve seen with my own eyes”...That same day, the executive vice president of the University of Pennsylvania for the Health System and the senior vice dean for medical education at the University of Pennsylvania medical school reassured faculty, staff, and students via e-mail that Goldfarb was no longer an active faculty member but rather emeritus. The EVP and the SVD affirmed Penn’s efforts to “foster an anti-racist curriculum” and to promote “inclusive excellence.”...
Medical schools use wildly different standards for admitting black and white applicants. From 2013 to 2016, only 8 percent of white college seniors with below-average undergraduate GPAs and below-average MCAT scores were offered a seat in medical school; less than 6 percent of Asian college seniors with those qualifications were offered a seat, according to an analysis by economist Mark Perry. Medical schools regarded those below-average scores as all but disqualifying—except when presented by blacks and Hispanics. Over 56 percent of black college seniors with below-average undergraduate GPAs and below-average MCATs and 31 percent of Hispanic students with those scores were admitted, making a black student in that range more than seven times as likely as a similarly situated white college senior to be admitted to medical school and more than nine times as likely to be admitted as a similarly situated Asian senior.
Such disparate rates of admission hold in every combination and range of GPA and MCAT scores. Contrary to the AMA’s Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity, blacks are not being “excluded” from medical training; they are being catapulted ahead of their less valued white and Asian peers.
Though mediocre MCAT scores keep out few black students, some activists seek to eliminate the MCATs entirely. Admitting less-qualified students to Ph.D. programs in the life sciences will lower the caliber of future researchers and slow scientific advances. But the stakes are higher in medical training, where insufficient knowledge can endanger a life in the here and now. Nevertheless, some medical schools offer early admissions to college sophomores and juniors with no MCAT requirement, hoping to enroll students with, as the Icahn School of Medicine at Mount Sinai puts it, a “strong appreciation of human rights and social justice.” The University of Pennsylvania medical school guarantees admission to black undergraduates who score a modest 1300 on the SAT (on a 1600-point scale), maintain a 3.6 GPA in college, and complete two summers of internship at the school. The school waives its MCAT requirement for these black students; UPenn’s non-preferred medical students score in the top one percent of all MCAT takers...
If, despite this gauntlet of review, bias still lurked in the MCATs, the tests would underpredict the medical school performance of minority students. In fact, they overpredict it—black medical students do worse than their MCATs would predict, as measured by Step One scores and graduation rates. (Such overprediction characterizes the SATs, too.) Nevertheless, expect a growing number of medical schools to forgo the MCATs, in the hope of shutting down the test entirely and thus eliminating a lingering source of objective data on the allegedly phantom academic skills gap.
Meantime, medical professors need to be reeducated, to ensure that their grading and hiring practices do not provide further evidence of the phantom skills gap. Faculty are routinely subjected to workshops in combating their own racism... her presentation rested heavily on a supposed measure of bias that evidence has discredited: the Implicit Association Test (IAT).The IAT’s own creators have acknowledged that it lacks validity and reliability as a psychometric tool.
Increasing amounts of faculty time are spent on such antiracism activities...
The medical school curriculum itself needs to be changed to lessen the gap between the academic performance of whites and Asians, on the one hand, and blacks and Hispanics, on the other. Doing so entails replacing pure science courses with credit-bearing advocacy training. More than half of the top 50 medical schools recently surveyed by the Legal Insurrection Foundation required courses in systemic racism. That number will increase after the AAMC’s new guidelines for what medical students and faculty should know transform the curriculum further.
According to the AAMC, newly minted doctors must display “knowledge of the intersectionality of a patient’s multiple identities and how each identity may present varied and multiple forms of oppression or privilege related to clinical decisions and practice.” Faculty are responsible for teaching how to engage with “systems of power, privilege, and oppression” in order to “disrupt oppressive practices.” Failure to comply with these requirements could put a medical school’s accreditation status at risk and lead to a school’s closure.
Mandatory instruction in such politicized concepts will help diversify the faculty and administration—for who better to teach about oppression than a person of color? (Part of the appeal of diversity trainings and bureaucracy, whether in academia or the corporate world, lies in the creation of new employment slots dedicated to diversity activities, which can be filled without as great a sacrifice of meritocratic standards.) But being indoctrinated in “intersectionality” does nothing to improve a student’s clinical knowledge. Every moment spent regurgitating social-justice jargon is time not spent learning how to keep someone alive whose body has just been shattered in a car crash. Advocates of antiracism training never explain how fluency in intersectional critique improves the interpretation of an MRI or the proper prescribing of drugs.
The academic skills gap, confirmed in every measure of knowledge before and during medical school, does not close over the course of medical training, despite remedial instruction. Yet the lower representation of blacks throughout the medical profession is solely attributed to racism on the part of the profession’s gatekeepers. Nature accused itself of denying a “space and a platform” to black researchers, without naming any such researchers against whom it had discriminated or any editor who had done the discriminating. In April 2022, the Institute for Scientific Information decried the fact that the proportion of black authors in medical research did not match U.S. census data on the population at large. Black representation had not improved between 2010 and 2020, lamented the institute. If white supremacy lay behind that lack of progress, it was a mystery why the proportion of published Asian researchers over the same decade had outstripped Asian population changes.
Despite the persistent academic skills gap, a minority hiring surge is under way. Many medical schools require that faculty search committees contain a quota of minority members, that they be overseen by a diversity bureaucrat, and that they interview a specified number of minority candidates. One would have to be particularly dense not to grasp the expected result. In recent years, the Memorial Sloan Kettering Cancer Center, the Cleveland Clinic Taussig Cancer Center, the Uniformed Services University of the Health Sciences, the University of Chicago Cancer Center, the University of Pittsburgh Division of Medical Oncology, the Massey Cancer Center at Virginia Commonwealth University, the University of Miami Miller School of Medicine, and the Department of Medicine at UCLA’s medical school have hired black leaders.
These candidates may all have been the most qualified, but the explicit calls for diversity in medical administration inevitably cast a pall on such selections. In at least one case, the runner-up possessed a research and leadership record that far surpassed that of the winning candidate. But he lacked the favored demographic characteristics.
It matters who heads research ventures and medical faculties. Top scientists can identify the most promising directions of study and organize the most productive research teams. But the diversity push is discouraging some scientists from competing at all. When the chairmanship of UCLA’s Department of Medicine opened up, some qualified faculty members did not even put their names forward because they did not think that they would be considered, according to an observer.
College seniors, deciding whether to apply to medical school, can also read the writing on the wall. A physician-scientist reports that his best lab technician in 30 years was a recent Yale graduate with a B.S. in molecular biology and biochemistry. The former student was intellectually involved and an expert in cloning. His college GPA and MCAT scores were high. The physician-scientist recommended the student to the dean of Northwestern’s medical school (where the scientist then worked), but the student did not get so much as an interview. In fact, this “white, clean-cut Catholic,” in the words of his former employer, was admitted to only one medical school.
Such stories are rife. A UCLA doctor says that the smartest undergraduates in the school’s science labs are saying: “Now that I see what is happening in medicine, I will do something else.”
Funding that once went to scientific research is now being redirected to diversity cultivation. The NIH and the National Science Foundation are diverting billions in taxpayer dollars from trying to cure Alzheimer’s disease and lymphoma to fighting white privilege and cisheteronormativity. Private research support is following the same trajectory. The Howard Hughes Medical Institute is one of the world’s largest philanthropic funders of basic science and arguably the most prestigious. Airline entrepreneur Howard Hughes created the institute in 1953 to probe into the “genesis of life itself.” Now diversity in medical research is at the top of HHMI’s concerns. In May 2022, it announced a $1.5 billion effort to cultivate scientists committed to running a “happy and diverse lab where minoritized scientists will thrive and persist,” in the words of the institute’s vice president. “Experts” in diversity and inclusion will assess early-career academic scientists based on their plans for running “happy and diverse” labs. Those applicants with the most persuasive “happy lab” plans could receive one of the new Freeman Hrabowski scholarships. The scholarships would cover the recipient’s university salary for ten years and would bring the equivalent of two or three NIH grants a year into his academic department. If an applicant’s “happy lab” plan fails to ignite enthusiasm in the diversity reviewers, however, his application will be shelved, no matter how promising his actual scientific research.
The HHMI program and others like it amplify the message that doing basic science, if you are white or Asian, is not particularly valued by the STEM establishment. How many scientific breakthroughs will be forgone by such signals is incalculable...
We encounter a second a priori truth: health disparities are the product of systemic racism; any other explanation is taboo and will be ruthlessly punished.
On February 24, 2021, Ed Livingston, deputy editor for clinical reviews and education at the Journal of the American Medical Association (JAMA), recorded a podcast with Mitch Katz, president of New York City Health and Hospitals, called “Structural Racism for Doctors—What Is It?” Livingston, a UCLA surgeon, asked Katz to define structural racism. Katz gave as examples the routing of diesel trucks through poor neighborhoods and disparities in access to top-level medical care. Livingston responded that Katz had described a “very real” problem: impoverished neighborhoods with poor quality of life and little opportunity, where most residents are black and Hispanic. Livingston agreed with the urgency of making sure that all people “have equal opportunities to become successful.” His only quibble was with the current emphasis on “racism,” which “might be hurting” the cause of racial equality, he said. Livingston had been taught to revile discrimination and yet was being told that he was racist. The focus, as Livingston saw it, should be on socioeconomic disparities, not alleged racial animus.
After the podcast became an instant totem of white supremacy, JAMA disappeared it from the web. Livingston himself was disappeared from JAMA shortly thereafter. (Back at his home base at the UCLA medical school, he faced a show trial from fellow faculty members.) JAMA’s editor-in-chief Howard Bauchner, a professor of pediatrics and public health at Boston University, apparently sensed that he might be next on the chopping block and started issuing serial apologies. The disappeared podcast, Bauchner declared, was “inaccurate, offensive, hurtful, and inconsistent with the standards of JAMA.” JAMA would be “instituting changes that will address and prevent such failures from happening again”—a “failure” being defined as deviation from racial justice orthodoxy. Bauchner genuflected further in an official statement: “I once again apologize for the harms caused by this podcast and the tweet about the podcast.” (JAMA had promoted the podcast with a tweet asking: “No physician is racist, so how can there be structural racism in health care?”) For good measure, Bauchner also released a letter dated March 4, 2021, apologizing for the “harm” caused by the tweet and podcast and expressing his “commitment” to call out “injustice, inequity, and racism in medicine.”
JAMA was once a leading forum for physicians and other scientists to present research to their peers. Now JAMA’s overseers regard a fundamental component of the scientific method—debate—as out of bounds, at least regarding the diversity agenda. Livingston’s disagreement with Katz and the “structural racism” conceit was over language, not substance. Yet because Livingston suggested taking the “racism” out of the “structural racism” phrase and focusing instead on equal opportunity, he had, in Bauchner’s widely shared view, harmed blacks and violated professional standards of journalism. No disagreement is tolerated.
Meanwhile, Bauchner’s efforts to distance himself from the “offensive” dialogue were not bearing fruit. Ominously, an AMA committee put him on administrative leave, pending an “independent investigation”—as if there were a complex backstory to what were clearly Livingston’s personal opinions. By June 2021, Bauchner, too, was out, even though, as he ruefully observed, he “did not write or even see the tweet, or create the podcast.”
The chance that the AMA would not appoint an intersectional editor-in-chief to replace the hapless Bauchner was zero. But just to be safe, the AMA named a black epidemiologist specializing in racial disparities to lead the search and staffed the search committee with suitably diverse members. The new editor, Kirsten Bibbins-Domingo, is a “health-equity researcher”—also an overdetermined fact, given the career course of many black M.D.s.
Bibbins-Domingo has already announced her determination to bring in “new voices” to ensure that JAMA‘s family of journals regularly “name” structural racism as the cause of health inequities. Will those new voices be conducting the most cutting-edge clinical science? It doesn’t matter: basic science is, at best, irrelevant to structural racism and, at worst, complicit in it.
Livingston’s challenge to the idea that health disparities are caused by racism was sui generis among medical journalists. The hold of that idea within medical publishing is otherwise absolute. The New England Journal of Medicine, another formerly august institution now in thrall to racial politics, presents a nonstop stream of articles on such topics as the “Pathology of Racism,” “Toward Antiracist Allyship in Medicine,” and “How Structural Racism Works—Racist Policies as a Root Cause of U.S. Racial Health Inequities.”
Entire issues of scientific journals have been devoted to racism. Scientific American published a “special collector’s edition” on “The Science of Overcoming Racism” in summer 2021. The edition was dominated by paeans to the IAT, denunciations of the police, and scorn for any suggestion of patient self-efficacy. (Prescribing weight loss to black women, for example, is a “racist” way to fight obesity, wrote a sociology professor and a nutritionist.) A special issue of Science in October 2021 addressed “Criminal Injustice” and “Mass Incarceration.” The issue opened with an editorial by a social work professor claiming that the U.S. crime rate is “comparable to those in many Western industrial nations.” This is a fanciful proposition, in light of the fact that the American firearm homicide rate is 19.5 times higher than the average of other high-income countries, and nearly 43 times higher among 15- to 24-year-olds.
Like the AMA’s Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity, many of these antiracism articles consist of the formulaic rhetoric of academic victim studies, supplemented by the personal narratives that characterized early critical race theory in law schools. Others, though, try to quantify the racism that allegedly produces higher levels of illness and mortality in blacks. Those efforts, done through regression analysis, do not capture the personal behaviors that affect the course of disease, such as compliance with a doctor’s orders, adherence to a medication regime, and showing up for follow-up appointments. In some cases, the regression analysis does not account for the differences in the illnesses suffered by black patients and white patients at the start of the study.
Nevertheless, the second a priori truth—that health disparities are necessarily the product of systemic racism—has devalued basic science and encumbered medical research with red tape. The fight against cancer has been particularly affected. White and Asian oncologists are assumed to be part of the problem of black cancer mortality, not its solution, absent corrective measures. According to the NIH, leadership of cancer labs should match national or local demographics, whichever has a higher percentage of minorities.
Cancer grant applications must now specify who, among a lab’s staff, will enforce diversity mandates and how the lab plans to recruit underrepresented researchers and promote their careers. As with the Howard Hughes Medical Institute’s Freeman Hrabowski scholarships, an insufficiently robust diversity plan means that a proposal will be rejected, regardless of its scientific merit. Discussions about how to beef up the diversity section of a grant have become more important than discussions about tumor biology, reports a physician-scientist. “It is not easy summarizing how your work on cell signaling in nematodes applies to minorities currently living in your lab’s vicinity,” the researcher says. Mental energy spent solving that conundrum is mental energy not spent on science, he laments, since “thinking is always a zero-sum game.”
A lab’s diversity gauntlet has just begun, however. The NIH insists that participants in drug trials must also match national or local demographics. If a cancer center is in an area with few minorities, the lab must nevertheless present a plan for recruiting them into its study, regardless of their local unavailability. Genentech, the creator of lifesaving cancer drugs, held a national conference call with oncologists in April 2022 to discuss products in the research pipeline. Half of the call was spent on the problem of achieving diverse clinical trial enrollments, a participant reported. Genentech admitted to having run out of ideas.
There is no evidence that racist researchers are excluding minorities from drug trials on nonmedical grounds, nor has anyone presented a theory as to why they would. The barriers to such drug trial diversity include a higher incidence among blacks of disqualifying comorbidities, higher levels of personal disorganization, and a suspicion of the medical profession, which suspicion that same profession constantly amplifies with its drumbeat about racism.
In May 2022, a physician-scientist lost her NIH funding for a drug trial because the trial population did not contain enough blacks. The drug under review was for a type of cancer that blacks rarely get. There were almost no black patients with that disease to enroll in the trial, therefore. Better, however, to foreclose development of a therapy that might help predominantly white cancer patients than to conduct a drug trial without black participants.
The requirement of racial proportionality in drug trials is perplexing, since diversity advocates insist that race is a social construct, without biological reality. Suggesting that genetic differences exist between racial groups will brand you a racist. The AMA’s Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity sneers at “discredited and racist ideas about biological differences between racial groups.” If race does not exist, as received wisdom now has it, then the racial makeup of clinical trials should not matter.
The proponents of the systemic racism hypotheses are making a large bet with potentially lethal consequences. In accordance with the idea that racism causes racial health disparities, they are changing the direction of medical research, the composition of medical faculty, the curriculum of medical schools, the criteria for hiring researchers and for publishing research, and the standards for assessing professional excellence. They are substituting training in political advocacy for training in basic science. They are taking doctors out of the classroom, clinic, and lab and parking them in front of antiracism lecturers. Their preferential policies discourage individuals from pariah groups from going into medicine, regardless of their scientific potential. They have shifted billions of dollars from the investigation of pathophysiology to the production of tracts on microaggressions.
The advocates of this change insist that it is essential to improving minority health. But what if they are wrong? If it turns out that individual behavior, pathogens that disproportionately infect certain groups, and other genetic dispositions have a more proximate influence on health than supposed structural racism, then this reorientation of the medical project will have impeded progress that helps all racial groups. Obstetricians working in inner-city hospitals report that black mothers have higher rates of complications during pregnancy and in delivery because of higher rates of morbid obesity, hypertension, and inattention to prenatal care and prenatal-care appointments. Packing those doctors off to diversity reeducation will not improve black childbirth outcomes. It will, though, divert attention from solutions that could improve those outcomes—whether offering help in keeping appointments and complying with a medication regime or encouraging exercise and weight loss. And yet we are told that efforts directed at behavioral change are racist and that convincing patients that they have power over their health is victim-blaming.
Higher rates of Covid fatalities among blacks is the latest favored proof of medical racism, amplified by a 2022 Oprah Winfrey and Smithsonian Channel documentary, The Color of Care. State and federal health authorities gave priority to minorities in vaccination and immunotherapy campaigns, however, and penalized the highest risk group—the elderly—simply because that group is disproportionately white. Those are not the actions of white supremacists. The likelier reasons for disparities in Covid outcomes are vaccine hesitancy and obesity rates. When the constant refrain about medical racism intensifies vaccine resistance among blacks, the widened mortality gaps will be used to confirm the racism hypothesis, in a vicious circle.
Medical science has been one of the greatest engines of human progress, liberating millions from crippling disease and premature mortality. It has also seen its share of dead ends and misconceptions. Science goes astray when politics becomes paramount, as in the denial of plant genetics and natural selection under Stalin. America’s very real history of structural racism, a history that took us too long to remedy, resulted in segregated hospitals and cruel disparities in treatment. That past is belatedly but thankfully behind us.
The scientific method is a natural corrective to such fatal errors. Now, tragically, when it comes to the contention that racism is the defining trait of the medical profession and the source of health disparities, opposing views have been ruled out of bounds and are grounds for being purged. The separation of politics and science is no longer seen as a source of empirical strength; it is instead a racist dodge that risks “reinforcing existing power structures,” according to the editor of Health Affairs.
The guardians of science have turned on science itself."
The genius of this is that minorities will then suffer from worse outcomes (since they'll be more likely to see minority doctors), which will then be taken as proof of racism, the solution to which will be even more social justice - in a vicious circle
