What You Learn Depends on What (and Whom) You Ask

Steve Balch

A study of graduating medical students sponsored by the Association of American Medical Colleges and just published in the Journal of the American Medical Association finds that white students who attended medical schools with greater ethnic diversity rate themselves as more highly prepared to care for minority patients. Score one for diversity’s status as a compelling state interest – or so its authors would have us believe.

Like most surveys, what one learns is heavily conditioned by what one asks, and this survey is no exception. But even taking the survey on its own terms there remains a major lacuna. The authors use two separate measures of an institution’s “compositional diversity,” first, the proportion of “under-represented minority students” and second, the proportion of all non-white students in the student body. Medical schools, of course, are associated with hospitals, and as part of their training, students are brought into regular contact with the hospital’s patients. Since student attitudes about their readiness to treat minority patients would presumably bear at least some relationship to the number of minority patients they clinically encounter, it is not trivial that this variable is absent from the analysis, all the more so since medical schools with larger numbers of minority students might well tend to be located in areas with larger concentrations of minority patients. The claimed association between the confidence of students in their ability to treat minority patients may thus be chiefly explainable not on the basis of student body diversity, but on the basis of simply having already treated them.

That aside, one wonders whether a better measure of compelling state interest might be the overall quality of doctors produced by diversity-driven admission systems than their sense of readiness to deal with one particular task. Moreover, in the age of feel-good education we need to be especially cautious about inferring facts about actual capability from estimations of self-worth, whatever their kind. And if it is capability that is our real concern, wouldn’t it have been of interest to seek the opinions of the recipients of medical care rather than only its providers?

What might the typical patient say about being treated by a doctor of lower aptitude? Or by a physician who had been admitted to training under relaxed standards? How much would it matter to the said patient, if it mattered at all, that the physician at his bedside or operating table was of the same skin color or ancestry, if he or she was also more likely to miss a subtle symptom or botch a critical procedure? In an online response to Inside Higher Education’s coverage of the report, Roger Clegg of the Center for Equal Opportunity aptly reminds us that Patrick Chavis, “the poster student for affirmative action” in the Bakke case, “ended up butchering women … and eventually lost his medical license.”

Another group of potential respondents left silent by this study are those medical students who, admitted ill-prepared, fail to complete their degrees (or subsequently to pass their medical boards). If Richard Sanders’ research on preferential admits to law schools is applicable to the even more rigorous environment of medical education, the number of these must be substantial. How do they feel about their wasted years and expense?

To repeat, in survey research the answers one gets very much depend on what and who is asked. In this case, the researchers have opted to ignore asking about what is essential in medical education – producing doctors at the top of their demanding craft – in favor of inquiring about the tangential. In determining whom to ask, they have chosen those least likely to suffer preferences’ consequences – successful medical school graduates, not patients at risk or wash-outs. Cost-benefit analysis worth its salt must look at the losers as well as the winners, especially when they have the most to lose. Anything less could be considered malpractice.       

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