Are Physicians of Color Being Shut Out of Competitive Specialties?

New research shows bias begins at the earliest stages of a doctor’s career, possibly before they even have a chance to select a specialty.

Photo Illustration by Elizabeth Brockway/The Daily Beast

A recent study has found evidence of racial and ethnic bias in the earliest stages of a physician’s career: medical school. Researchers examined membership in the prestigious medical honor society Alpha Omega Alpha and discovered that acceptances may not be entirely equitable.

Each year, L.D. Britt reviews hundreds of applications for his department’s residency program at Eastern Virginia Medical School.

“The first thing somebody looks at, they look at [test] scores and then they look at AOA, but they usually look at AOA first,” says L.D. Britt, chair of the Department of Surgery.

The honor society, founded in 1902, recognizes achievements in scholarship, leadership, professionalism, and service. The first step to becoming a member requires a medical student to be in the top 25 percent of their class. From those students, a committee at each school then selects no more than one-sixth of the total class size to be admitted into the society. Students who make the cut are widely recognized as being the best of the best and AOA membership is an honor that they’ll carry through their entire careers.

However, a new study published in the medical journal JAMA Internal Medicine highlights a large racial gap in AOA admissions.

Diversity is already an issue in the medical field, said Nicole Nettey, a third-year family medicine resident at Marshall University. And the primarily white honor society can make it feel even more exclusive. “You do see that you’re not as predominant in the medical field,” she said. “And sometimes you do feel like it’s a white boys club and you’re just an outsider.”

The study analyzed incoming applications for medical residency programs at Yale Medical Center, including programs like anesthesia, neurosurgery, and internal medicine. From those applications, the researchers separated out who was a member of AOA and who was not and compared the racial makeup of the two groups. They found that the likelihood of a white student being in AOA was twice as high as an Asian student’s and a whopping six-times greater than a black student’s.

Dowin Boatright, lead author of the study, clinical instructor in the Department of Emergency Medicine at Yale, and a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program, noticed that past studies had pinpointed instances of racial and ethnic bias at later stages of a medical career, “But we really hadn’t seen any literature looking at that for medical students,” he said.

As a black woman, these findings don’t surprise Nettey. “I have a different perspective because I went to a predominantly African-American [medical] school,” she said, “But when I speak to other friends and even at my residency, I see that most of the people that are inducted (into AOA) are usually not of color.”

Multiple studies have shown that physicians of color are much less likely to be promoted to rank of full professorship than their white colleagues, and they’re also less likely to be granted research funding.

Boatright, who is not a member of AOA, thinks that the racial disparities in AOA membership are likely a result of implicit bias. “I believe implicit bias plays a role and I think we could have these findings without explicit racism,” he says.

Boatright points out that in his study, they were able to show a disparity in AOA selection, but because they didn’t know the class rank of each student, it’s unclear where they bias stems from. “It’s unclear if the bias was actually happening at the level of the selection committee or if there’s so much systematic bias in medical school that maybe minorities aren’t even becoming eligible for AOA,” he said.

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In a statement released by AOA in response to the study, the national leadership states, “AOA Councilor and Chapter Best Practices encourage blinded elections, removing student identifiers, and not revealing the names of the candidates until after the process is completed, thereby minimizing any cognitive or implicit bias. AΩA Councilor and Chapter Best Practices also prescribe that Chapters use a rubric of agreed-upon specific categories as the basis of election. AOA will continue to strive to overcome biases of all types and is committed to diversity and inclusion for all members of its society.”

Danny Wongworawat is an Asian physician and head of the Loma Linda University School of Medicine’s AOA chapter. He says to make their AOA new membership selections the committee first looks at who is in the top 25 percent of their class after completing the first two years of medical school and then who is still in the top 25 percent after the third year.

The committee includes Wongworawat and another faculty member, both appointed by the dean, and two students, both of whom are already inducted into AOA and then voted onto the committee.

With this system, Wongworawat said he doesn’t see how their chapter’s selection could have any inherent bias. But other schools’ process might. “We may be one of the few programs that use students in the top quarter of both sections,” Wongworawat said. “Some people just do top quarter and then weed out by hand,” meaning some chapters may have a more subjective process.

And either process fits with the AOA constitution. The national organization requires committees to have two faculty members, the councilor and the secretary/treasurer, and two students who rotate out each year. To narrow the field of students, the constitution states that the selection committee may use scholastic achievement, as well as “leadership capabilities, ethical standards, fairness in dealing with colleagues, demonstrated professionalism, potential for achievement in medicine, and a record of service to the school and community at large.”

But because the AOA selection committees tend to keep their process private, it’s hard to nail down what the driver really is. “We don’t know what those conversations are behind closed doors,” says Boatright.

And those closed doors are part of the problem. Early in their careers, neither Boatright nor Nettey knew a lot about AOA or its selection process because it just wasn’t talked about. “I knew the society existed, but I knew so little about it,” says Boatright.

Nettey said that her class was told, “that you want to be in AOA because it’s very prestigious and it will be easier for you to get into residency.” But as for the selection process, its criteria, or who did the selecting, Nettey says her class wasn’t given that information.

Nettey notes that the lack of discussion around AOA and its process might be particularly detrimental to people of color. “I didn’t have [a family member] in the medical field and there are a lot of first-time physicians still now in the African-American community,” she said.

The lack of transparency and communication is problematic given the level of influence AOA membership can have on a medical career. Membership has been linked to what academic rank physicians achieve in their career as well as what kind of residency programs medical students are likely to be accepted into (PDF).

In fact, AOA membership may even be keeping certain medical specialities less diverse.

“Some specialties, they don’t even interview you if you’re not AOA,” Britt said who notes that his program is much more interested in a student’s experience rather than their AOA status. “Some of these very select specialties like ophthalmology or sometimes orthopedics.” Other competitive specialties include dermatology and neurological surgery (PDF), which have many more applicants than they have positions available.

This is a fact that many of Adesoji Oderinde’s students worry about. Oderinde is an associate professor of internal medicine at Morehouse School of Medicine and head of the school’s AOA chapter. He says students come to him often, lamenting over AOA acceptance and their residency prospects—but he said that Morehouse residency programs do not exclude candidates solely based on AOA status.

Because some programs won’t even consider non-AOA students, the majority of medical students will never get the opportunity to become a physician in one of the more competitive fields like neurosurgery or orthopedics.

Oderinde, who didn’t have an AOA chapter at the medical school he attended in Nigeria and became a member while he was a resident at the historically black Morehouse School of Medicine, says while he didn’t feel disadvantaged per se, having been a member as a medical student would’ve opened more doors for him.

When Valencia Walker, now a neonatologist at UCLA and the immediate past president of the Association of Black Women Physicians, was a fellow, she remembers a white faculty member quizzing her on various medical facts, asking how much she studied. When she aced the professor’s line of questioning, “What this faculty member said to me was, ‘Oh, I guess you are smart enough to be here,’” Walker said.

“There are many layers to that,” she says, “but I would say had I had on my application that I was AOA, there would’ve been an assumption that I was smart enough to be there. There wouldn’t have been something for me to prove.”

Nettey said she was even asked about AOA during recent job interviews, even though she’s wrapping up a successful residency. “It kind of made me feel uncomfortable,” she says, “Do they think less of me because I wasn’t [AOA]? Are they thinking I’m not a hard worker?”

Boatright thinks paying attention to the diversity of the selection committee itself would be beneficial. “Not much is known about the composition of the selection committee, but perhaps making sure that the selection committee is diverse would help,” he says and points out that most schools have a chief diversity officer that could assist with those goals. But Walker thinks, regardless of who’s on the committee, they should undergo implicit bias training. “Anyone can have bias,” she says.

“We need to make sure things are transparent and if there’s subjectivity, we need to find out why is it subjective and can we make it more objective,” says Britt, paraphrasing Louis Brandeis, “The best disinfectant is sunshine.”