The End of Merit in Med Schools Will Be Deadly
Editor’s Note: America is at war. This is not a traditional war, fought on a battlefield against an external enemy. It is a civilizational conflict against an internal enemy: the group quota regime, a revolutionary threat that seeks to reorganize American society around the principle of outcome equality — what the regime’s partisans call “equity.”
This cold civil war may go unnoticed by many day-to-day, but its stakes are often as high as life and death. Here, Roger B. Cohen, a celebrated oncologist and professor in the Perelman School of Medicine at the University of Pennsylvania, explains how the group quota regime has taken hold of the American medical education system and asks urgent questions about the consequences for medicine, for the sick, and for the country.
The United States enjoys a reputation as a bastion of excellence and scientific rigor in medical education. Our country also leads the world in medical progress and innovation. That has not always been the case. It is hard to imagine the backwardness of American medical schools before a man named Abraham Flexner set out to transform them into institutions built on rigorous science.
Flexner was a non-physician commissioned in 1910 by the Council on Medical Education and the Carnegie Foundation for the Advancement of Teaching to analyze and improve a woefully inadequate medical education system. Flexner recommended closure of all but 31 of 155 American medical schools, which included 80% of the white schools (119 out of 148) and 71% of the black schools (5 out of 7).
Recently, Flexner has gone from hero to villain in the wake of the “woke” tsunami that has engulfed American medicine. In 2020, the Association of American Medical Colleges (AAMC) stripped the reformer’s name from its prestigious Abraham Flexner Award for Distinguished Service to Medical Education. David J. Skorton, AAMC’s president and CEO, admitted that “the Flexner report recommended valuable changes in medical education, many of which still have positive impact today.” Yet Skorton demurred:
But that report also contained racist and sexist ideas, and his work contributed to the closure of five out of seven historically Black medical schools. Our action today recognizes the long-standing negative impact of the Flexner report on the training of Black physicians and the health of the Black community in the United States.
A year later, a paper in the American Medical Association’s Journal of Ethics denounced the Flexner report’s “racist legacy,” charging that the reforms it inspired “damaged and marginalized historically Black medical schools.”
The anti-Flexner activists make the truly remarkable claim that Flexner’s recommendations to close shoddy schools gutted the ranks of future black physicians who would have rendered exceptional care to their fellow minority citizens. Of course, that is a pernicious fantasy. Bad medical schools and poorly educated physicians, regardless of race, never benefit patients. Quite the opposite. Better schools produce the best physicians who deliver the high quality medical care that everyone should receive. To claim that Flexner was motivated by a racist desire to deplete the ranks of capable black physicians is both preposterous and slanderous.
Flexner’s idea was to impose a scientific standard of excellence on medical education. His models were the German universities and Johns Hopkins Medical School. In repudiating Flexner, we are turning away from the goal of medical training based on scientifically informed and rigorously grounded standards. Indeed, it is fair to say that we have now entered the post-Flexner era. The watchword today is not science, but anti-racism and identity politics. The New England Journal of Medicine, among others, repeatedly reminds us in its ongoing “Race and Medicine” series that medicine is stubbornly racist by design.
In May 2021, the AMA released its Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity, “dedicated to embedding racial justice” in all medical practice. Among the plans key priorities is one whose implications for medical education and medical school admissions are readily apparent: “Develop structures and processes to consistently center the experiences and ideas of historically marginalized (women, LGBTQ+, people with disabilities, International Medical Graduates) and minoritized (Black, Indigenous, Latinx, Asian and other people of color) physicians.”
The End of Merit-Based Admissions
The medical profession’s leaders, almost without exception or dissent, now vigorously enforce this new orthodoxy of anti-racism. Most notably, they have designed and implemented a new version of medical education explicitly grounded in ideology rather than scientific excellence. In pursuit of this project, the president of the AAMC (which accredits U.S. medical schools) and the chair of the AAMC’s Council of [Medical School] Deans stated publicly in July 2022: “We believe this topic [Diversity, Equity, and Inclusion] deserves just as much attention from learners and educators at every stage of their careers as the latest scientific breakthroughs.”
The AAMC’s DEI Competencies, issued in October 2021, details the new required social justice skills that medical students must acquire. In addition, the AAMC has discouraged the use of the rigorous Medical College Admissions Test (MCAT) as a filter to help select medical students. Dozens of the 158 allopathic (MD granting) U.S. medical schools have made the MCAT optional. Several medical schools, including the prestigious University of Pennsylvania, have programs to admit students from designated “underrepresented” identity groups without requiring the submission of MCAT scores at all. The MCAT itself has been revised to include social justice questions that are easy to ace because the answers are always the same: structural racism is the cause of any group disparities that disfavor underrepresented groups. But even this re-engineered test shows persistent group disparities in test scores, which means that Asian applicants must score almost 4 times higher than black applicants to have an equal chance of admission.
Large discrepancies in qualifications, which endure despite strenuous efforts to dumb down the MCAT, have spawned the euphemistic practice of “holistic review” of medical school applicants, “a process that considers each applicant individually by balancing their academic metrics with experiences and attributes.” The search for a so-called “new excellence” in how medical applicants are chosen places diversity, equity, and inclusion at its core; reduces reliance on demonstrated scientific knowledge and proficiency; and emphasizes applicants’ “attitudes, values, and experiences.” Under holistic review, “it’s the journey, not the destination” that counts.
This reckless demolition of longstanding standards now extends to medical licensing exams. In an effort to reduce purported “racial bias” against self-identified black, Asian, and Hispanic examinees who score lower than self-identified whites, the Step 1 federal licensing exam, taken at the end of the second year of medical school, is now pass/fail and no longer numerically graded. This change works to the disadvantage of graduates of foreign and lower-ranked U.S. medical schools who rely on their performance on that exam to demonstrate excellence and their future potential as physicians.
Medical academia’s efforts to deemphasize testing and reduce the importance of exam-based proficiency comes at a time when other institutions are moving in the opposite direction. Prestigious colleges such as Yale, MIT, Brown, and Dartmouth have recently reinstated the requirement that applicants submit scores on the SATs. Why? Because SAT scores are the best predictor of academic performance and mastery. And in a world of rampant grade inflation and resumé padding, the tests are vital to identifying academically promising candidates who might otherwise be overlooked. The same factors apply to medical school admissions. The MCAT is the most reliable and least manipulable gauge of the types of skills that enable students to do well in medical school and beyond. It is foolish and reckless to abandon the test because all groups do not perform equally.
The Basis of the Group Quota Regime
Why are we conducting this grand experiment in discarding the tried and true methods for choosing future doctors? What problem are we trying to solve? One oft-repeated claim is that we need more black and Hispanic doctors because patients experience better medical outcomes if their doctors “look like them.” This “racial concordance” claim has been extended to “identity concordance” of all kinds, with absurd and alarming implications: must we have gay doctors for gay patients, and white doctors for white patients? And what is the evidence that supports this demand?
A body of highly questionable and downright shoddy research in medical sociology is exemplified by the ‘Oakland study,’ which purports to show that black patients with black doctors have better health outcomes. This study is riddled with basic methodological defects, including the lack of an adequate control group. The study went on to project extravagant lifetime mortality benefits from a single point-in-time observation in a limited sample showing that black patients were more willing to accept recommendations for preventative care from black doctors. There was no evidence presented of any increased use of preventative services or of any actual health benefits.
Another widely cited study of this genre claims that newborn black babies are more likely to survive with black doctors. This deeply flawed study uses an administrative database as a substitute for determining the actual race of the doctors caring for individual babies. These articles and the like are repeatedly and uncritically cited to justify major policy changes. The questionable conclusions of the neonatal study even made it into Justice Ketanji Brown Jackson’s dissenting opinion in the 2023 Harvard affirmative action case. Her opinion cited the claim that “for high-risk Black newborns, having a Black physician is tantamount to a miracle drug; it more than doubles the likelihood that the baby will live.” This highly inflammatory and factually incorrect statement came from an AAMC amicus brief that the brief’s authors quickly corrected 9 days after the Justice’s dissent was published. Perhaps the Justice, who is not a trained statistician, can be forgiven for her dubious citation, but one expects greater rigor from her clerks, who one hopes would be familiar with Stats 101 and the scientific method. What is most remarkable is how two weak studies, and several others in this area, have been rapidly and permanently elevated to hallowed dogma and used to justify sweeping and radical changes in policy without the usual thoughtful academic scrutiny and balanced debate.
The Path Back to Merit
In modern medicine we routinely strive to subject new drugs and treatments to an objective, rigorous, and unbiased analysis of their effectiveness. We want to make sure our interventions really work. Any changes in the way that we evaluate and admit prospective medical students and train young physicians should be subject to a similarly exacting assessment. Not only do we owe this to our patients, but we also have an obligation to our citizens (and the world) to sustain the breathtaking pace of innovation that has been a feature of American medicine over the past 100 years. Maintaining that role requires attracting the very best minds into medical practice and biomedical research. Placing primary emphasis in medical admissions and training on social justice and diversity, equity, and inclusion rather than on candidates’ measured ability and potential scientific acumen grievously undermines that goal.
The recent sea changes in medical school admission and medical education and training are based on a host of assertions and premises that ought to be subject to rigorous testing and scrutiny. We receive assurances from the experts that social justice must now be a top priority because that is what the system wants and needs. And we are told that students admitted under the new dispensation are no less effective and proficient and just as scientifically sophisticated and productive as trainees in the past. Why should we believe these assurances? How do we gauge their validity? What are the metrics, and where is the proof?
Advocates for these changes rarely claim that this radical reform project will promote scientific excellence and sustain the innovation that has long characterized American medicine. Given that changes in who we admit to medical schools and how we train them have been underway for more than a decade, it should be possible to produce some empirical evidence to examine their effects. Here are a few questions that call out for answers: What are the student dropout rates across all groups? What are the pass rates and scores on the three steps of the federal medical licensing exams and the specialty board qualifying exams taken at the end of residency and fellowship? What are graduates admitted on group quotas doing after they finish their training? Are they actively working as physicians seeing patients or are they occupying administrative positions with minimal or no patient care responsibilities? How many are participating in the discovery of new treatments and the creation of new knowledge by engaging in medical research, pursuing academic careers, and publishing their findings? How many are devoting their careers to taking care of people in their communities, which is one of the explicit goals of the racial concordance fad? Or are they setting up shop in more affluent areas that are already well served by medical professionals?
Finally, what is the public’s reaction to the changes that have been made to American medical education? Are current or future patients (all of us) happy with the decision to place social justice competencies, rather than the acquisition of scientific and practical medical knowledge, front and center in medical schools and medical training programs? One must wonder if the “new excellence” will appeal to or help the seriously ill patient treated by a physician with a diverse lived experience who did poorly on a qualifying exam and knows little about his chosen field.
Denying these trade-offs is wishful thinking with no supporting evidence. The time has come to examine without blinking the actual effects of these reforms and the potentially dire unintended consequences. This requires openness to inquiry and transparency of access to the pertinent data, and a rigorous and sustained analysis.
Roger B. Cohen, MD is a Professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania. The views expressed are those of the author.
