The world of medicine has been roiled recently by an article published in the Journal of the American Heart Association. The author, Dr. Norman Wang, MD (since fired from his job as an cardiac electrophysiology fellowship program director) argued against affirmative action in medicine, believing that individuals with "weaker" academic credentials shouldn't be accepted into medicine programs. It was subsequently condemned as racist and retracted.
For some time now, several commentators condemned medicine's focus on standardized testing in general- most notably the MCAT and Step 1, believing that a reliance on testing doesn't measure what really makes a good doctor. They tend to favor holistic reviews in their place. Dr. Quinn Capers IV, MD, Vice Dean of Ohio State University College of Medicine, posed this thought experiment:
Though he later clarified that he was not specifically thinking about affirmative action with this question, many others have decried standardized testing as racist and used racial disparities in both medical school admissions and in residency selection as an argument to either abolish standardized testing entirely or significantly reduce it's weighting.
Now, holistically evaluating candidates to a degree is something I agree with in general. You see the consequences of pure emphasis on a test score in China and India, which feature extreme pressure, frequent cheating, and a failure to consider candidates with differing strengths than regurgitating material on a test. And being a doctor is more than just straight memorization of facts- though you do have to know a lot to be a good doctor. Empathy, integrity, communication, leadership, composure in the face of adversity, grit, determination, creativity, curiosity- so many factors that are not captured on a standardized test (except maybe determination) are critical to providing good medical care.
But lets pause and think about what using holistic evaluations as a mechanism to reduce racial disparities means. Since Caucasians and Asians in general score higher than Hispanic, Black, Native American and other under represented minority (URM) students on standardized tests, that means that holistic evaluations will only work to reduce racial disparities if you believe that the personal qualities of URM students systematically outweigh the personal characteristics of Caucasian and Asian students.
This is a very, very dangerous and damaging idea. Especially to Asian students. A dramatic case against Harvard alleging discrimination against Asian applicants noted that Harvard systematically gave Asian applicants lower "personality trait" rankings. In medical school clerkship grading, which are inherently subjective, Asian-American and URM students appear to receive systematically lower scores than Caucasian medical students. This path has been trod before- in the 1920s, Ivy League schools which previously emphasized standardized testing decided that too many Jews were being admitted. So they changed the definition of merit, and began requiring interviews and a "holistic" evaluation, which allowed them to keep the number of Jews allowed on campus at an acceptable minimum.
Holistic evaluations thus should not become a tool to correct racial disparities in medical (or any) acceptance programs. Instead, to correct racial disparities and injustices, I propose that schools transparently use standardized test scores and interpret them in context. I've written about this before, but I truly believe standardized testing can be a valuable and effective tool in diversifying workforces and correcting racial disparities. The key is the principle of interpreting scores in context of socioeconomic status. A 99th percentile MCAT score achieved by the son of a doctor and engineer, who never had to worry about putting food on the table, who could purchase study materials and dedicate a month or more purely to studying is an accomplishment to be considered. But a 75th percentile score by the daughter of a single mom, who studied in between waitressing shifts that she needed to do in order to eat and not go homeless; who would be regularly stopped by police officers for being black and working in a white neighborhood? That's likely just as strong an indication of tenacity and likelihood to succeed.
By formally and openly adjusting for such socioeconomic factors in consideration of standardized test scores, disparities can be clearly adjusted for. And what's more, the real value of such standardized scores- ensuring that every applicant who is accepted has a good likelihood of grasping the curriculum- can be realized. By publicly ensuring that only those candidates who achieve minimum scores which correlate with success in medical careers are accepted, stigma against "affirmative action admits" can be reduced, so long as schools are open and honest about how and why they adjust scores. No one can argue that a student whose parents can afford $5000 for a month-long Kaplan prep course should be compared on the same scale to someone who literally dodged bullets on the way to school every day. My parents could, although I didn't take it. For Step 1 I moved home for a month, my beloved grandmother cooked me a hot breakfast every morning, and I didn't have to worry about anything but studying. If I hadn't scored exceptionally highly with those immense advantages, I shouldn't have gotten into medical school or general surgery.
But if a hand-wavy and opaque "holistic evaluation" is used to cover up a systemic bias against non-URM applicants, especially non-underrepresented minority applicants, I see a real risk of real injustice. We must correct the harms of the past and account for systemic racism, and evaluate performance in light of past opportunity. We must judge future doctors on more factors than just how many questions they can answer right. But it does not follow that we must accept the racist policy that URM applicants have better personal traits than non-URM applicants in order to achieve either of those goals.
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