We are in the throes of interview season. At Yale, my fellow program directors and I have evaluated dozens, maybe hundreds of applications. We have tried to decide which applicants to interview on the basis of objective criteria — board exam scores, grades, deans’ letters. This practice is certainly defensible: how else can we screen the large number of applicants?
But I often wonder. Am I being completely objective? Have I passed over students who might contribute a unique worldview but have not met my tidy cut-offs?
A few months ago, I came across the book Blind Spot – hidden biases of good people. Banaji and Greenwald, two psychologists, have studied the ways our accumulated exposure to culture, social norms, and experience influence our judgments. Even well-intentioned “good people,” who believe they are open-minded and objective, harbor hidden prejudice.
They have developed the Implicit Association Test (IAT) which has been administered to millions of people for more than 20 years and is validated through dozens of studies. The IAT uncovers hidden racial, gender, and age stereotypes — among others — not just by asking us about our attitudes toward certain types of people but by cleverly timing our associations. For example, the IAT explores black/white stereotypes by pairing black- and white-appearing faces with pleasant or unpleasant words in a timed format. You can try it yourself at implicit.harvard.edu. The results are fascinating, provocative … and humbling. Even the most sensitive and self-aware among us have implicit, hidden bias.
Implicit Bias In Deans’ Letters
As medical educators, we may think we are immune to hidden biases, and many of us openly seek to build residency programs that represent the diversity of the patients we care for. But we are not immune — we have a blind spot.
The problem with a blind spot is just that — we do not know what we do not see. David Ross, an associate program director for Yale’s psychiatry residency, evaluated the deans’ letters from 6,000 US medical students applying to 16 residency programs. Using proprietary software, he extracted keyword frequency from four thematic categories — standout traits, ability, grindstone habits, and compassion. He showed significant differences between race and gender. Deans were more likely to describe white applicants as “exceptional,” “best,” and “outstanding,” whereas they were more likely to describe black applicants as “competent.” In describing female applicants, deans frequently used words like “caring,” “compassionate,” and “empathetic.” These differences remained significant after controlling for Step 1 scores.
What are we to make of this? Is it true that women really are more compassionate or empathetic? Are black students only “competent” and not “exceptional?” I doubt it. Is the whole system riddled with bias? Almost certainly.
By the time a student applies to residency, they have made it through college and medical school — and experienced the compound effect of implicit bias through their entire academic career. This phenomenon is deeper than politics and affirmative action and cuts to the core of our educational culture. Is the whole system riddled with bias?
Whom Have I Missed?
Implicit bias is also bidirectional. As I evaluate applicants, what do applicants see when they come to my program? I am a white middle-aged man representing an Ivy League institution. But do applicants know that I am an ordained minister and was one of the first to officiate same-gendered weddings in Connecticut? That I can play the opening riff to “Roundabout” by Yes, that I have a mean backhand on the tennis court?
Does any of that really matter to students seeking a residency program? I hope so. In the same way, I realize that I need to look beyond board scores and evaluations. The solution, in part, may be self-awareness. The only way to “see” a blind spot is to acknowledge one exists. What are my biases? What are yours? Who else should seek to remedy the implicit bias of the health care system but the program directors — the last gatekeepers of the health care profession?
Our residents should reflect the diversity of our patients. I want great students in my residency program, but mostly I want great people. Who will contribute to the culture of the program? Who will bring a joyful presence to morning rounds? Who will spend the extra time with a patient — and enjoy doing so? There are plenty of smart medical students, but who will bring wisdom? These are qualities that are hard to discern in a world where blind spots are so common. We falter because we do not see. Over the years, whom have I missed?
Benjamin R. Doolittle, MD, is an expert in burnout and wellness in residents and physicians. He is an associate professor and program director of internal medicine and pediatrics at the Yale University School of Medicine and the medical director of the Yale Medicine-Pediatrics Practice.
For additional reading on this topic:
The Perils and Rewards of Critical Consciousness Raising in Medical Education
Dealing with Racist Patients
Structural Racism and Supporting Black Lives — The Role of Health Professionals
#BlackLivesMatter — A Challenge to the Medical and Public Health Communities
Graduate Medical Education in the Freddie Gray Era
Bias, Black Lives, and Academic Medicine