The Indoctrinologist Is In
Twenty-five years ago, I wrote a book called PC, M.D.: How Political Correctness Is Corrupting Medicine. One chapter described what was then a new form of therapy — "multicultural counseling" — that encouraged white clinicians to ask themselves what responsibility they hold for the "racist oppressive and discriminating manner" by which they "personally and professionally deal with minorities." Another chapter explored flaws in research purporting to show that physicians routinely exhibited racial bias against their patients. In the epilogue, "The Indoctrinologist Isn't In...Yet," I warned readers, "those who care about the culture and practice of medicine must be alert to the encroachment of political agendas."
Today, the indoctrinologist is officially in. Under the approving eyes of major medical entities such as the American Medical Association (AMA), advocates are shifting the primary mission of medicine toward social justice and the identity of the physician toward activist.
Disturbing side effects of this transformational project are myriad. They include the erosion of high academic standards for medical students and trainees, the promotion of equity over optimal clinical care, the establishment of taboos surrounding research topics and interpretations of data, and a focus on social factors that, though they do affect health, physicians have neither the expertise nor a public mandate to address. The threat to the professional development of young doctors and, potentially, to patients' health, is grave.
A TROUBLING TREND
Though hints of the trend surfaced over the preceding two decades, the push for racial justice in medicine exploded in the wake of George Floyd's death in 2020 after a white police officer knelt on his neck. Within a week of the tragedy, the Association of American Medical Colleges (AAMC), a major accrediting body, announced that the nation's medical schools "must employ anti-racist and unconscious bias training and engage in interracial dialogues." A year later, in May 2021, the AMA released its "Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity," while the Journal of the American Medical Association (JAMA) devoted itself to "a heightened and appropriate emphasis on equity and publication of information that addresses structural racism with the goal of overcoming its effects in medicine and health care."
The manifestations of these imperatives are striking. In 2022, for example, incoming medical students at the University of Minnesota stated their commitment to racial justice during their "white coat ceremony" — a rite of passage that marks the beginning of a medical student's training. Newly cloaked in their white coats — uniforms they maligned as symbols of "power, prestige, and dominance" — students pledged to "commit to uprooting the legacy and perpetuation of structural violence deeply embedded within the healthcare system." Before these ceremonies, many students had already been asked in their written applications and later, in face-to-face interviews with members of admissions committees, to describe their experiences promoting diversity, equity, and inclusion, and to explain how they plan to navigate and contribute to diversity in their new medical environment.
Many of my colleagues who teach in medical schools decry this politicization. But with the exception of those with tenure or who have retired, they say little within the institution or outside of it. Many have withdrawn from teaching opportunities, lest they run afoul of strident, hyper-sensitive medical students who seem to be "lying in wait for us to commit a microaggression so they can cause us reputational damage," as one told me. Another remarked how "unrewarding it is to teach...students who just want to focus on social causes of illness."
Perhaps the most dramatic display of this ideological capture took place last summer, when keffiyeh-draped doctors at the University of California Medical Center in San Francisco demanded their institution call for a ceasefire in the war between Israel and Hamas. Their chants of "intifada, intifada, long live intifada!" echoed into patients' rooms.
By oath and inclination, doctors should be focused on treating the patients before them. Today, they are issued a different mandate. According to the AMA's latest strategic plan on racial justice and health equity, doctors ought to "confront inequities and dismantle white supremacy, racism, and other forms of exclusion and structured oppression."
This is an absurd vision. Physicians are wholly ill prepared for such a task: Their primary job is to diagnose and to treat, and to do no harm in the process. They lack expertise in public policy, much less in socioeconomic power dynamics. Even seasoned policy analysts are hard pressed to tease out causal links between health status and sprawling upstream economic and social factors. With so many intervening variables at play, manipulating policy in the service of health may not have its intended effect, while the odds of creating unwanted repercussions elsewhere in the system are significant. The intentions behind the push for social justice in medicine may be laudable, but by urging reform of this kind in the name of health, doctors risk abusing their authority, using the profession as a vehicle for politics, and, ultimately, eroding public trust in the medical field.
The distorting effects of anti-racism and social justice in medicine assert themselves in a number of ways. Our discussion will focus on the pursuit of an agenda called "health equity" and the redefinition of merit in medical training. But first, we must review the kernel of legitimacy in the racial-justice imperative — namely, an enterprise called the "social determinants of health." Against that valid benchmark, radical racial-justice efforts stand out sharply.
SOCIAL DETERMINANTS OF HEALTH
Disparities between racial groups are real, with higher rates of conditions such as premature mortality, diabetes, renal disease, hypertension, prostate cancer, and childhood obesity among black Americans compared to whites. According to the Kaiser Family Foundation, such disparities "reflect longstanding structural and systemic inequalities rooted in contemporary and historical racism and discrimination." What should we make of this claim?
Health is indeed influenced by social conditions — sometimes powerfully so. In the 1970s, a cadre of epidemiologists studied the "social determinants of health": the psychological, social, and cultural contexts that contribute to disease and shape people's choices regarding their wellness. Increased awareness of these effects in the 1990s represented a major advance in medical training. Doctors became more attuned to the fact that even their most motivated patients might not be able to afford a medication, take time off work for an appointment, or understand a complex medical regimen. They realized that they could not ignore the effects of poverty and decrepit housing on patient health.
Much of the disadvantage in health status among black Americans is the cumulative product of legal, political, and social institutions that have historically discriminated against them, either explicitly or through passive disregard for policy impact. The Covid-19 pandemic served as an object lesson in differential exposure to adverse health conditions at varying levels. Black Americans and other minority groups — who are more often employed as lower-paid essential workers (e.g., transit workers, building-maintenance staff, grocery-store employees), more reliant on public transportation, and more likely to reside in dense quarters than whites — were indeed at higher risk of contracting and dying from Covid-19.
At the same time, neighborhoods in which blacks are more likely to reside attract lower levels of civic investment. This in turn leads to underfunded hospitals, fewer emergency services, pharmacy deserts, worse air and water quality, and fewer safe options for outdoor exercise. As a result, black Americans have comparatively fewer opportunities for improving their health.
There is indeed a race-related story to tell about why, in the aggregate, black Americans suffer poorer health and receive less care than white Americans. It is a story that delivers real and painful truths. And yet, "systemic racism" is not a useful medical diagnosis. It may have explanatory value, but it doesn't yield targeted, realistic medical prescriptions.
HEALTH DISPARITIES
Within the last two decades, the goal of reducing or eradicating group differences in health care and access to such care (mainly between black and white Americans) has gained enormous momentum. The National Institutes of Health, the nation's largest funder of biomedical research, announced in 2021 that it was dedicating $60 million to the study of health disparities and "the chronic problem of structural racism." Universities have developed doctoral programs, fellowships, and special centers that focus on such disparities. According to Dr. Vinay Prasad, an oncologist at the University of San Francisco's medical school: "Entire careers and labs claim to care about health disparities" among the races. The problem, laments Prasad, is that too often disparities research is "irreproducible, low quality and often unhelpful."
To be sure, researchers are right to identify and explore group-based health gaps. But they should also be humble about their capacity to interpret detail-limited, correlational, retrospective data. They must also be more open to the possibility that patient choice and innate biological factors can be as powerful as social conditions, depending on the particular disparity in question. Properly understood, disparity-identifying studies can be important hypothesis-generating exercises aimed at investigating the factors contributing to poorer health in the disadvantaged groups. Yet nowadays, many academic explorations of disparities are little more than fishing expeditions unguided by a research question or a hypothesis; instead, they appear to be undertaken solely for the sake of finding disparities.
What's more, closing gaps has become a focus all its own. On its face, a narrowed gap seems like progress, but interpreting the results of such efforts is not always straightforward. Changes between groups do not always signify progress — they could be due, for example, to a decline in health of the otherwise advantaged group. If both groups are faring poorly, closing the gap has not really improved patient health. Conversely, even if both groups improve in tandem, the gap will still remain — an enduring discrepancy that researchers might not count as good news. Preoccupation with reducing black-white gap sizes can also distract from the larger problem of health deficiencies in both groups, or perhaps lead analysts to overlook variations in health status between distinct cohorts within each group. Nor is it always clear that disparities indicate inferior care. For example, if well-insured whites are more likely to undergo needless interventions, it would be wrong to subject non-whites to additional interventions in the name of equity.
A focus on reducing health disparities can also lead to questionable remedies. A health-equity program instituted last year at the Mass General Brigham hospital in Boston offers a useful example. Under the program, doctors at the hospital stopped reporting to authorities suspected incidents of abuse or neglect based solely on a fetus's or newborn's exposure to drugs. According to representatives of the hospital's United Against Racism program, "Black pregnant people are more likely to be drug tested and to be reported to child welfare systems than white pregnant people." Sarah Wakeman, Mass General Brigham's senior medical director for substance-use disorder, described the policy as "the latest step in our efforts to address longstanding inequities in substance use disorder care."
In fairness, fetal exposure to drugs presents a thorny problem. Doctors need to help pregnant women and mothers without frightening them away. As a rule, they should involve state-run child-welfare authorities only as a last resort. But grappling with that tension was not the aim of the new policy. If it had been, hospital authorities might have held off on making policy changes without first learning whether black women were being tested in an unfair or clinically contraindicated manner. To answer this question, they would need to know whether doctors were managing black women more restrictively than they were white women who exhibited similar red flags (i.e., missing appointments, appearing intoxicated during visits, having a recent history of drug abuse, etc.). If so, action to correct such discrimination would be warranted.
To my knowledge, this sort of information gathering hasn't taken place. Instead, the policy change was made in the name of health equity in response to presumed racism. Nor was a pilot study conducted to determine how babies and mothers fared under a more relaxed system. Such a study might have shown that the new practice yielded better outcomes for black mothers and babies, but it could just as easily have shown that white women needed to be tested more frequently than they had been. These are important data, crucial not only for informing hospital decision-making, but for caring for the very patients that these sorts of health-equity programs are adopted to protect. Indeed, failures to perform screening in the name of racial justice could end up disproportionately compromising the well-being of black women and their children.
Within medicine, clinical considerations must be driven by the best interests of patients, not by the politics of group identity. This means that medical interventions should not be equally applied across groups, racial or otherwise; their application should be driven instead by the circumstances of each individual patient. In the instance of babies exposed to drugs (assuming health professionals have leeway to detect it), hospital personnel should fast-track the mother to treatment and vital social support. Should a woman refuse help and her unborn or newborn baby's health appear compromised, it may be time to report to protective services. This should be the case regardless of the mother's or the child's race.
Physicians are not charged with closing gaps in the relative health of broad socioeconomic groups; their overarching goal is to promote the health of their patients. That is how they contribute to social justice. The only gap that should concern them, therefore, is the discrepancy between each patient's current and optimal health.
RACIAL CONCORDANCE
Last spring, the Washington Free Beacon drew attention to a popular solution to race-based health disparities when it published comments from the dean of admissions at the University of California, Los Angeles's David Geffen School of Medicine. As Aaron Sibarium reported:
In response to an admissions officer who voiced concern about a candidate for admission to the school...the dean of admissions, Jennifer Lucero, testily asked, "Did you not know African-American women are dying at a higher rate than everybody else?"...The candidate's scores shouldn't matter, she continued, because "we need people like this in the medical school."
The notion that patients fare better when treated by doctors of their own race — a theory known as "racial concordance" — is a major rationale for prioritizing diversity over merit in the medical field. The idea is not completely far-fetched — it's perfectly plausible that individuals with low health literacy or high distrust of the medical system, or immigrants who are not acculturated, respond more favorably to medical personnel who share their background. That said, the evidence invoked to support the benefits of racial concordance (which, upon inspection, ranges from mixed to flawed) does not justify blanket acceptance of the validity of patient-physician race matching to achieve concordance.
In a particularly ambitious, much-cited study, researchers at Harvard's Health Inequality Lab recruited more than 1,300 black men from local barbershops and flea markets in Oakland, California, and randomly assigned them to black or non-black physicians. The physicians were asked to encourage the men to get flu vaccines and be screened for diabetes and high cholesterol. The patients paired with black physicians were more likely to agree to obtain the services, though whether they actually followed through and made necessary lifestyle changes is unknown. Considering the study measured patients' intentions rather than actions, the authors seriously overstated their findings in concluding that matching a doctor and patient by race could lead to a 19% reduction in the black-white male cardiovascular-mortality gap and an 8% decline in the black-white male life-expectancy gap.
In a detailed critique of its methodology, Dr. Stanley Goldfarb and Alexander Raikin of the advocacy group Do No Harm lamented the trust-eroding, racially divisive implications of the Harvard study. "To Black patients," they wrote, "exaggerated claims from a poorly designed and executed study will wrongly tell them that non-Black physicians are less able to treat their illnesses — even when such a physician might be the most qualified or appropriate one for the situation." For black physicians, the study implies that even when they perform better than non-black doctors, "it is not because of the quality of their medical expertise, but rather because their work is — to a significant degree — skin-deep."
Other studies purporting to find that black patients benefit disproportionately from care delivered by black doctors confuse correlation with causation or fail to account for key variables, and thus their results dissolve on closer inspection. A study published in JAMA Network Open in 2023, to take one example, claimed that counties with higher ratios of black primary-care clinicians were associated with longer life expectancies for black patients. Yet the "community representativeness ratio" the researchers used provided no information about the ratio of black patients actually treated by black clinicians. What's more, it's entirely possible that counties with higher ratios of black representation among physicians are simply places with better social and economic conditions, meaning that patients who live there are more likely to thrive. Dr. Vinay Prasad, the oncologist, asked of the study: "What if white doctors save more lives than Indian doctors? What if Korean Americans save more than Japanese Americans? One can imagine many unpalatable findings from a churning body of low quality observational research with countless analytic plans."
In another high-profile finding that collapsed under scrutiny, CNN announced in 2020, "Black newborns more likely to die when looked after by White doctors." The study appeared in the Proceedings of the National Academy of Sciences, with the finding that black newborns cared for by black doctors are more likely to live than those cared for by white doctors. "These differences," the authors of the study suggested, "may be ameliorated by racial concordance between the physician and newborn patient."
The study received even greater exposure when Justice Ketanji Brown Jackson alluded to it in her dissenting opinion in Students for Fair Admissions v. Harvard. But last September, Harvard economist George Borjas and the Manhattan Institute's Robert VerBruggen published a reanalysis of the data that revealed a major omission in the 2020 study. While researchers accounted for many confounding variables, they did not control for the crucial fact that black newborns are more likely to have lower birth weights (under 1,500 grams) than white newborns. Consequently, the higher-risk babies were more likely cared for in neonatal intensive-care units — and physicians who staff those units are overwhelmingly white (only 3.8% of neonatologists are black).
In short, the race of the doctor was not an important factor in the deaths of the babies; it was the gravity of the infants' illnesses that led to the tragic outcomes. Even if the original study had demonstrated a solid causal connection between infant mortality and the race of the physician, race matching would not have been the optimal response: A better option would have been to carry out additional research to understand why white doctors were less successful in treating black newborns.
Despite its flaws, the media's coverage and the Supreme Court's elevation of the study have given unwarranted credence to the racial-concordance theory. "The finding that white doctors are a lethal danger to black babies was well on its way to becoming a virtuous lie before it was debunked," wrote Occidental College professor Jacob Mackey and technologist Dave Gilbert. "Its normative corollary, the luxury belief that black newborns require racially concordant medical care, still appears to be going strong, if the new programs offering this service are any indication."
MERIT
Last January, when the AAMC reported the impact of the 2023 Supreme Court decision outlawing race-based affirmative action in medical education, the number of black enrollees had fallen by 11.6% between 2023 and 2024, while the number of Hispanic enrollees had decreased 10.8%. The president of the association bemoaned the results as a blow to minority patients' health. Affirming medical schools' continued dedication to diversifying the health-care workforce, he insisted, "evidence shows that a more varied workforce can improve access to health care and the health of our communities."
A diverse workforce is a fine goal, but it should not come at the expense of merit. Unfortunately, the latter seems to be the case at too many of our nation's medical schools.
When deciding whether to admit a prospective student, medical schools take into account the applicant's undergraduate GPA and MCAT scores. The MCAT is especially useful in this regard: A study of almost 8,000 medical students who entered 36 classes of Jefferson Medical College between 1970 and 2005 found that MCAT subtest scores predicted a student's likelihood of attrition, school performance, scores on medical-licensing exams, and ratings of clinical competence in the first year of residency. But before the Supreme Court prohibited affirmative action, medical schools lowered their GPA and MCAT standards for certain applicants in pursuit of a more racially diverse student body.
According to an analysis by economist Mark Perry, between 2013 and 2016, black medical-school applicants with average GPAs (3.40 to 3.59) and average MCAT scores (27 to 29) were nearly four times more likely to be accepted than Asian applicants (81% versus 21%) and almost three times more likely than white applicants (81% versus 29%) in the same applicant pool. Hispanic applicants in that pool were more than twice as likely as whites to be admitted (60% versus 29%), and nearly three times more likely than Asians (60% versus 21%). Overall, black and Hispanic applicants with average GPAs and MCAT scores were accepted to medical schools at rates much higher (81% and 60%, respectively) than the 31% average acceptance rate for all students.
The erosion of merit-based admissions to medical schools is having an impact on the nation's future physicians. In 2022, researchers analyzed faculty evaluations of 703 internal-medicine residents at six accredited training programs spread throughout the United States. The evaluations covered five areas: medical knowledge, systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism. In all five assessment areas, black and Hispanic residents were rated lower than white and Asian residents.
Notably, these data were from 2016 and 2017 — before medical schools became vocal about their social-justice mission. "Our findings," the authors of the study concluded, "align with studies of assessments [of medical students], which found that race/ethnicity was negatively associated with [underrepresented minorities'] student assessments." The discrepancy, they speculate, could be due to "bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment." While these possibilities are worth exploring, the authors still need to account for the possibility that differences in performance stemmed from weaker preparedness of students admitted under affirmative-action policies.
To compensate for group differences in medical-exam performance, the Federation of State Medical Boards changed its method of scoring the primary assessment tool used in medical training. The United States Medical Licensing Examination (USMLE) is administered by the board in three steps. Step 1, taken after the second year in medical school, tests pre-clinical medical knowledge; Step 2, taken during the final year of medical school, assesses clinical knowledge; and Step 3, taken after the first year of residency, evaluates clinical decision-making. Every student must pass Steps 1 and 2 before they can obtain a state license to practice medicine. Drawing from a large database, the authors of a 2024 study in Academic Medicine (several of whom are on the National Board of Medical Examiners) found that "better provider USMLE performance [as a composite of all three steps] was associated with lower in-hospital mortality."
As of 2022, however, the board altered the reporting of the seven-hour Step 1 exam results from a numeric score to pass-fail. According to the physician-led planning committee that made this change, it not only hoped to reduce the stress of a single high-stakes exam, it also wanted to account for the fact that numeric scoring "negatively impacts diversity based on known group differences in performance."
That victory may turn out to be hollow. The most competitive residency programs in the country have traditionally relied on students' Step 1 scores to select their post-medical-school residents. Without numeric scores to inform their decisions, these programs' admissions committees may resort to relying more heavily on school rankings when accepting applicants, potentially depriving stellar students from lower-ranked schools the opportunity to shine. Step 2, which is still numerically scored, will also likely be weighted more heavily than it has been in the past. What's more, residency admissions committees still have full access to how many times a person has repeated the Step 1 exam.
Medical-school deans have long debated the qualities that make a good doctor. And it is certainly true that test scores don't give a full picture — students' humanitarian proclivities matter, too. But medical school is too far along in the educational pipeline to compromise standards. As my colleague Dr. Thomas Huddle, emeritus professor of medicine at the University of Alabama at Birmingham, put it: "To suppose that we can just train people who have not accomplished much academically and expect them to do well in medicine, seems a huge and implausible leap into the unknown. It's too big a gamble."
THE INDOCTRINOLOGIST WON'T SEE YOU NOW
How far will this experiment in ideological capture go? Already the medical profession is under pressure to become a vehicle for social justice; doctors are encouraged to identify as activists first and healers second. This cultural shift in medicine has been well documented, but it needs to be brought more fully into public awareness.
Fortunately, there are signs of resistance. In the non-profit arena, Do No Harm, an organization founded in 2022 by Dr. Stanley Goldfarb, focuses on "keeping identity politics out of medical education, research, and clinical practice." Do No Harm serves as a support network for demoralized health-care professionals and operates a clearinghouse that documents politicization trends, produces white papers, instigates legal action against health institutions employing discriminatory programs, and exposes the public to "the radical ideology of 'anti-racism' in healthcare." Meanwhile, in Congress, Republican Greg Murphy, a physician representing North Carolina's third congressional district, introduced the Embracing anti-Discrimination, Unbiased Curricula, and Advancing Truth in Education Act of 2024. "I perceive a much more sinister movement undermining the integrity of medicine," he wrote in a Newsweek op-ed. The bill bans DEI mandates at medical schools and denies federal financial assistance to those that have them.
Of course, the rigorous demands of clinical practice, the potential reputational damage to hospitals, and the looming shadow of malpractice litigation may be the best buffers against further ideological encroachment on medicine. In the meantime, doctors must do all they can to treat patients not as members of groups, but as ailing individuals in need of medical assistance.
The American health-care system has many problems, ranging from high costs to limited access to plummeting trust following the Covid-19 pandemic. These burdens fall harder on some groups than others. This poses a serious challenge — one that can only be meaningfully addressed by meeting the needs of patients as individuals and maintaining the highest standards of training and treatment in an environment where the indoctrinologist is no longer in.
