This substack is courtesy of Dr. Ken Lipstock, Richmond, Virginia. This is a copy of his presentation to the Virginia Council on May 22, 2024.
I am Ken Lipstock, an eye surgeon practicing in Richmond for 40 years.
It is both an honor and a profound responsibility to address you today on a subject that stands at the very heart of the medical profession. A new paradigm holds that doctors and doctors-in-training must seek to dismantle supposed systemic biases in healthcare. The principles of Diversity, Equity and Inclusion (DEI) are believed by many powerful organizations to be the panacea for all disparities in healthcare outcomes. Racial health disparities are a persistent and tragic phenomenon. Trying to understand the root causes and potential solutions to these disparities is a noble cause. However, like many members of my profession, I am concerned and skeptical that DEI is the answer. This skepticism was not born out of resistance to change but out of a commitment to the scientific rigor that has always been the cornerstone of medical excellence. The more I engaged with these new policies, the more I felt compelled to question…not just the efficacy but the very implications of these sweeping changes on the core mission of medical training and practice. Our discussion today is not just an academic exercise but a call to reflect deeply on the values we hold dear in the practice of medicine. The ethos of our profession has always been to heal, to reduce suffering, and to advance the well-being of all individuals without prejudice. But now with all the evolving DEI directives, we`re compelled to ask whether they enhance our ability to fulfill these timeless commitments or if they inadvertently lead us astray. I have concluded they most definitely have led us astray. As I was taught early on, “Doctor, First Do No Harm”.
We Need to Take a Critical Look at DEI in Medicine
As I’ve mentioned, the integration of DEI into medical education and practice has been met with a mixture of enthusiasm and skepticism. This skepticism arises not from a denial of the existence of disparities in healthcare but from very serious concerns about the poor quality of research being done to substantiate the DEI healthcare narrative and the misinterpretation and exaggeration of its findings. We must be also be cognizant of the enormous amounting of funding being directed towards these studies which means less funding for research and development for new treatments for many illnesses. Furthermore, we are very concerned about the DEI methods employed to address healthcare disparities and their long-term consequences on medical education and patient care.
Consider this. The Association of American Medical Colleges in its amicus brief for the Harvard affirmative action case stated that if the assignment of high risk black babies was given to black doctors, the survival rate would Double! Justice Ketanji Brown repeated that claim in her arguments. The AAMC referenced a study that literally showed the difference in survival of high-risk newborns was a minuscule 99.6% vs 99.7% or a 0.129% difference. One tenth of 1 percent is a far cry from 200 percent! Furthermore the study did not control for the fact that very, very high risk newborns are referred to white doctors more because there are more white neonatologists than black neonatologists that care for these very high risk infants.
The AAMC and Justice Brown also went astray at those hearings when they claimed that black doctors treat the pain of black patients better than white doctors. The AAMC referred to 4 studies they claimed proved this. However, these studies only documented the fact that pain management was more difficult in black patients. They never even addressed whether the pain was managed better by black than white doctors. It’s unconscionable how such a powerful organization at such high-risk hearings could get the facts so wrong. And the AAMC is the organization that sets the standards for every med school in the U.S.
There Has Been an Alarming Shift in Focus in Medical Education
Traditionally, medical education has been deeply rooted in the sciences such as biology, chemistry and physiology. These disciplines form the bedrock upon which clinical knowledge and patient care practices are built. However, in recent years, there has been a significant shift towards incorporating social sciences and identity politics into the curriculum. This shift was prompted by the growing belief that many health disparities seen across different populations are primarily due to systemic biases within the healthcare system and society at large.
While it is undeniable that social factors play a role in health outcomes, the degree to which these factors should influence medical training and practice remains a contentious issue. The hypothesis that introducing a curriculum heavily focused on DEI will lead to better healthcare outcomes is largely unproven. This approach presupposes that by understanding social issues, future physicians will be better equipped to treat patients from diverse backgrounds. However, it also risks diluting the emphasis on hard sciences which are essential for diagnosing and treating diseases. For example, an entire first year course at the UCLA School of Medicine devoted to “structural racism and health equity” teaches that “weight loss is a hopeless endeavor…. and that fatphobia is medicine’s status quo”. It also calls upon “moving beyond capitalism for our health”. The valuable time spent learning this propaganda is time that should have been spent on the basics of anatomy and physiology.
Let’s Look at Bias and it’s Effect on Healthcare Outcomes
We’re told to believe that the disparities in healthcare are primarily the result of unconscious biases and systemic discrimination. To counteract these biases, medical schools and healthcare institutions have begun to implement training programs aimed at making healthcare professionals more aware of their unconscious biases and encouraging practices that are more inclusive. Exhibit A: SB35: this bill mandated implicit bias training for ongoing re-certifications for Virginia’s MD’s. Thank you, Governor Youngkin, for vetoing this bill!
The effectiveness of such bias training programs in changing actual healthcare outcomes is still under debate. Studies have shown mixed results, with some indicating minor and short lived improvements in awareness and attitudes, while others see no significant changes in behavior or patient care outcomes. After all, a mainstay of these bias training courses is the Implicit Assessment Test which is supposed to determine if you are unconsciously racist. In 2007 a European psychology study used it to conclude that 68% of whites are racists and ever since then this claim has been amplified by the media and has entered the popular culture. But this popular test has been proven to be completely unreliable. The same person taking the test multiple times will get multiple different answers. And it also fails at predicting who will actually commit racist acts with an astounding 96% false positive rate.
Implicit bias training programs, with their focus on identity and group characteristics, can sometimes lead to a form of stereotyping that can be counterproductive. It can cause divisiveness and mistrust among staff, and contribute to a change where patients are seen more as representatives of groups rather than as individuals with unique health needs.
The emphasis on bias and systemic oppression also leads to a narrative where every health disparity is viewed through the lens of discrimination, potentially overlooking other very important and well documented contributing factors such as genetic predispositions, environmental factors, personal lifestyle choices, lack of preventative healthcare and delays in seeking medical help when significant symptoms do arise. By attributing disparities predominantly to systemic bias, there is a risk of simplifying complex health issues into binary social justice issues, which may not lead to effective or appropriate interventions. Dr. Caplan will discuss this further as illustrated by the issue of the maternal mortality gap between black and white pregnant females. This is an area that has been carefully studied and well documented with a variety of causes, but racist healthcare workers is not one of them.
Clearly social determinants of health are significant and need to be addressed, but I strongly submit that with so much to learn in medical training time is more appropriately spent by MD’s learning anatomy, physiology, pharmacology, diagnosis and the treatment of acute and chronic illness. Let us not forget that there are others available in the healthcare team that may more appropriately address the various social determinants of health such as social workers, nutritionists, public health professionals, and many others.
As we delve deeper into these matters, it is crucial to maintain a balanced view that considers both the potential benefits and the limitations of DEI in medicine. After all, not all issues raised by the narrow view of DEI in healthcare are detrimental. The goal should be to enhance our understanding of how social factors affect health without compromising the scientific rigor and individualized care that are paramount in medical practice.
What Has the Impact of DEI Policies on Medical Practice Been
The implementation of DEI policies in healthcare settings is a multifaceted issue that significantly impacts medical practice. These policies aim to create more inclusive environments and address disparities in healthcare delivery, but they also introduce new challenges and ethical dilemmas. A notable example of DEI influence can be seen in the allocation protocols for COVID-19 treatments and vaccines. During the pandemic, certain states adopted guidelines that prioritized patients based on demographic criteria such as race or ethnicity under the guise of promoting equity. For instance, guidelines in some of these states prioritized racial minorities for COVID-19 treatments and vaccinations, arguing that these groups were disproportionately affected by the virus. A similar scheme of racial preference is now apparent in kidney transplantation, where unnecessary changes to the kidney transplant waitlist are placing black patients with lower need ahead of non-black patients with greater need.
These decisions raise significant ethical questions. The insertion of racial and ethnic considerations into the treatment decisions challenges medicine’s ethical principles particularly the commitment to impartiality in medical care. Whereas medical ethics traditionally embraced the idea that individuals should be treated according to clinical urgency and individual need, the newly fashionable DEI ethical framework posits that treatment should be determined by demographic characteristics.
These policies have brought to the fore concerns about the high potential for reverse discrimination and the erosion of public trust in medical institutions. By appearing to favor certain groups over others in life-saving medical decisions, there is a risk that these policies could undermine the foundational principle of equality in healthcare, where treatment should be based on need not identity. It is essential for the medical community to engage in thoughtful and rigorous debates about the merits and drawbacks of these policies, ensuring that any implementation enhances the delivery of equitable and effective healthcare without compromising ethical standards or the quality of medical care. Unfortunately to date students and medical professionals who question the DEI initiative have been afraid to speak up and discuss these matters due to the real fear of retaliation from those with positions of authority in our medical institutions.
Let’s Look at Specific DEI Initiatives
As we delve into an analysis of specific DEI initiatives implemented within the healthcare system, It is crucial to critically assess their intended goals against the actual outcomes. This evaluation allows us to discern whether or not they mitigate disparities or trigger unintended consequences.
One DEI Initiative is Patient-Physician Racial Concordance
Patient-physician racial concordance is grounded in the belief that matching patients with doctors of the same race or ethnicity enhances communication, trust and ultimately health outcomes. While some studies report improved patient satisfaction under such arrangements, the evidence indicates that concordance is not a solution for improving health outcomes. A recent comprehensive review of the literature has carefully documented that the literature overwhelmingly indicates that concordance is not associated with better care or better outcomes. Moreover, the few studies that assert otherwise are fraught with immense methodological issues that cast doubt on their conclusions. Do we really want to encourage the resegregation of healthcare without a proven benefit to health outcomes?
What About Recruitment and training Strategies?
In response to DEI objectives, many medical schools and healthcare organizations have revised their recruitment and training strategies to emphasize demographic diversity. While a diverse medical community is beneficial for numerous reasons, including promoting a broad range of perspectives and experiences, history demonstrates that a focus on demographics comes at the expense of focus on merit-based criteria. This approach not only challenges the principle of meritocracy but also risks compromising the quality of medical education and healthcare delivery by prioritizing identity over competence. For example, strict testing standards have been dropped on the grounds that testing is racist. With the goal of increasing admissions to med school for those minorities previously underrepresented, 40 institutions have dropped the MCAT requirement. But studies show that low MCAT scores predict low performance in med school and a lesser likelihood of comprehending the courses that matter most to patient care. Furthermore, in order to allow more minority students to qualify for competitive residency programs, the Medical Licensing Exam’s First Section, which has typically been relied upon by residency programs to select candidates, has been changed to a Pass Fail system. What are the consequences of all this? Notably, a recent study observed that patients assigned to internists who scored highest on their American Board of Internal Medicine certification exams were less likely to die and less likely to be readmitted than patients assigned to doctors who scored lowest. Competency and excellence truly do matter.
What are the Broader Social Considerations of DEI in Healthcare?
The focus on identity and group characteristics within healthcare settings can have the unintended consequences of reinforcing divisions rather than bridging them. Policies that shift societal values in healthcare from a focus on individual merit and clinical excellence to group identity could lead to a perception that healthcare quality is secondary to social objectives and potentially erode trust in the healthcare system itself. Trust is foundational in healthcare; patients need to believe that decisions about their health are being made based on medical necessity and best practices and not sociopolitical considerations. As a result we are already heading to a situation where, for example, black patients will fear white doctors and visa versa.
DEI also Presents Complex Ethical Challenges in Healthcare
One of the central tenets of medical ethics is the principle of treating individuals with impartiality and according to their specific health needs. DEI initiatives that introduce considerations of race, gender or other identity factors into treatment decisions can complicate this ethical mandate. For example, if DEI policies lead to prioritizing certain groups for treatment based on historical injustices, healthcare providers might find themselves navigating a moral quandary. We have previously mentioned two such examples: COVID 19 treatments and renal transplant priorities. This tension can lead to moral distress among healthcare professionals who may feel that they cannot always act in the best interests of their patients due to policy constraints.
Then there are the Legal Challenges
The implementation of DEI initiatives in healthcare also introduces a range of legal challenges. DEI initiatives often face legal scrutiny, particularly when they involve changes to hiring practices, admissions policies or patient care protocols that are perceived to prioritize identity over merit or medical need. The legal battles frequently hinge on the interpretation of civil rights laws and the Constitution. Legal challenges might argue DEI initiatives lead to reverse discrimination creating a contentious environment that requires careful legal navigation.
What About Academic Freedom and Permissible Discourse?
The introduction of DEI principles into medical schools and healthcare institutions often comes with guidelines on permissible discourse. This raises questions about academic freedom and the extent to which institutions can or should regulate the speech of students, faculty and staff to promote a respectful and inclusive environment. While the intention behind such regulations is to prevent harassment and discrimination, it is often perceived as stifling open debate and the free exchange of ideas, which are crucial for academic and scientific progress. In some cases, discussions about DEI initiatives can become highly polarized. Such polarization can hinder constructive dialogue and lead to social tensions within educational and healthcare institutions. Managing these dynamics effectively requires a balance between fostering an inclusive environment and upholding the principles of free expression and academic inquiry. It means committed leadership from the top. Unfortunately all too often these days, the top is part of the problem.
As I conclude our examination of DEI initiatives in healthcare, it is clear that, on balance, these initiatives are doing more harm than good. Returning to a proper course requires the medical profession to first and foremost reaffirm our commitment to the core principles of medicine…scientific integrity and the prioritization of individual patient care above all. Healthcare must remain a field driven by empirical evidence and a dedication to patient outcomes, not swayed unduly by shifting social or political currents.
Looking forward, let us return to a system centered around excellence. A system where diversity is celebrated not only in demographics but also in thought and approach.
References available upon request
Thank you to Dr. Lipstock for sharing this critical assessment of the field of medicine.
Sheila M. Furey, MD