This the June D&I update, and whoaaaa boy, is there a lot to cover! Traditionally, I like to do a year-in-review with the June email, and I will still do a brief version of that, but we really need to discuss Pride month, Affirmative Action, and the Supreme Court. I apologize if this is longer than you can read in one sitting, but I hope you’ll take the time to mentally engage with these topics. Although it might seem like these are political issues, these decisions have direct impacts on health and health care.
Let’s start with Pride. June is the month where we celebrate the progress made toward LGBTQ equality. June was chosen because it coincided with the famous Stonewall uprising. This is noteworthy because after decades of progress, LGBTQ communities are again under direct attack. As of May, over 540 bills deemed anti-LGBTQ+ by the Human Rights Campaign have been introduced in state legislatures this year alone, which is already new record, and the year wasn’t even half over. Of these, 220 target transgender people. There are 45 new anti-LGBTQ+ laws now on the books. Number one among these is a prohibition on gender affirming care. As health care providers, this is an affront to our mission to provide the best-known medical care to all our patients. The scientific evidence is overwhelmingly in favor of providing gender affirming care, so legislatures are now preventing us from fulfilling our oaths. If legislatures spent a fraction of this much effort in improving access to care and reforming the prior authorization system, think of how much better we and our patients would all be.
Today dropped another bombshell on the already threatened LGBTQ+ community. The Supreme Court just ruled that LGBTQ+ people no longer have the right to avail themselves of services offered to the general public. Imagine what it is like to not know if any business you attempt to patronize will accept your money. This type of stress has medical implications. People who experience more of this type of discrimination, whether it is about sexual orientation, race, gender, or something else, have higher rates of sleep disorders, heart disease, and early death. Discrimination kills people. We’re in health care; we cannot accept the government sabotaging the population’s health by legalizing discrimination. Does anyone really think that the web designer who by law must accept a client is going to suffer ill health as a result? But the couple who is told they can’t get the website because of who they are will. LGBTQ+ people deal with this discrimination regularly, and that takes a major toll on their health, both physically and mentally. That’s how you know which side of this argument is suffering from true discrimination.
And in other Supreme Court news, you’ve all had 24 hours to process yesterday’s race-conscious admissions ruling (often referred to as Affirmative Action). Affirmative Action has long been an unpopular policy. Even liberal states like California banned it by referendum. I’m sure there are a good number of you that are pleased or at least not upset by yesterday’s ruling. I am sensitive to that. I’m going to discuss my thoughts with you, but there are two caveats. First, I’m not a lawyer and this is just a lay interpretation of what I’ve read. Second, I reserve the right to change my opinion as I think and discuss this more, and I see how it plays out in the real world. With that said, here is my initial reaction.
My first objection to the ruling is conceptual. The idea that not permitting the explicit discussion of race will somehow keep race out of the admissions process is naïve to the point of being ludicrous. The Chief Justice said, “Racial classifications are simply too pernicious.” There’s no doubt that racial classifications are pernicious. They were devised centuries ago to justify slavery. Had that not occurred, we’d all be better off, but we can’t change history. “It’s a sordid business, this divvying us up by race,” he said. Again, that’s true! But it’s not in his control to change. The divvying up by race has already occurred. American society has already used quotas, segregation, redlining, poll taxes, terror campaigns, and a whole host of other laws and actions to ensure that Black people could not achieve economic or political equality with White people. These are indisputable historical facts. To now say that none of this SHOULD matter is divorced from the reality that it DOES matter. The Court can’t wish away the past or the present.
My next objection is that Affirmative Action does not discriminate against anybody. That’s a misconception about what it is and what it does. As such, I see no reason the Court should intervene to stop it. I’ve written about this in the past, but I’ll briefly restate. Affirmative action reduces existing discrimination, it doesn’t create it. Being race-conscious in admissions should never mean accepting a person who cannot perform well in school. It’s fundamentally flawed logic to think that a higher test score makes someone more academically qualified than someone else. Does anyone really think that their best quality is their ability to take a multiple-choice test? Has anyone ever asked you as a health care provider what your SAT score was? Nobody cares about grades and test scores in the real world. What they care about is compassion and character. Compassion is built by exposure to diverse populations, including fellow students. Our med school would turn out less competent doctors if we used the plaintiff’s definition of “merit.”
As the pool of qualified applicants always exceeds the number who can be admitted, something other than academic success has to help make admissions decisions. For hundreds of years, that answer was race: the White applicant was chosen. Black applicants weren’t allowed. Now that admissions offices are saying that Black applicants should get just as much opportunity as White applicants (which is the guiding principle of Affirmative Action), suddenly choosing by race isn’t ok anymore? What they’re banning is the mechanism to protect against the type of discrimination that happened for centuries, even though it might not be spun that way on tv.
A quality education requires diversity, whether that’s athletes, musicians, first-generation college students, race, or gender. Why race? Because it colors one’s entire life experience regardless of what racial group you belong to, and regardless of whether or not you recognize how it has influenced your life. Having been “divvyed up by race,” the best thing to do now is to celebrate our differences and come together to learn from each other.
Now that we’ve gotten my objections out of the way, I will admit that I’m not as scared for the future as some of the doomsayers I’ve seen online. Justice Roberts, himself, wrote the blueprint for how we continue to ensure diverse access to education without running afoul of the ruling. It is 100% ok for applicants to write essays about “how race affected his or her life, be it through discrimination, inspiration or otherwise.” This is definitely something we can work with. I hope schools will encourage a reflection on how race has affected their lives by all applicants, not just applicants from ethnic minority groups. Using the essay rather than a checkbox to achieve the same purpose might be more time-consuming, but it doesn’t have to be any less effective.
I also want to touch on Duke Neurology residency recruiting as Dr. Shah and I have been reviewing the ruling to see if we needed to make any changes to our current process. Our conclusion is that we are already doing what the Supreme Court is telling colleges to do. Residency applications are reviewed with the racial designation on the application hidden along with the photo, so we do not know a candidate’s race unless they tell us in the text of their application. We score applications on a variety of dimensions, none of which factor in race, but if an essay speaks of hardships on the basis of race (or any other aspect of their identity or past), we certainly factor that in. We do, eventually, unblind the application to race, but only after they have already been scored and we are preparing for interviews. While I’m not concerned about the legality of our current process, I do worry that if colleges do not take steps to ensure ongoing (and improving) diversity, our pipeline of diverse residency applicants could be reduced in the coming years.
2022-2023 Year in Review: Year of Empowerment
August:
Dr. Len White received the Neurology Department Chair’s Award for Diversity
October:
The revised Faculty Handbook was published online.
November:
Dr. Gabrielle Byrd gave a D&I Grand Rounds lecture on Intergroup Anxiety.
The Alliance to Cure Cavernous Malformation hosted the D&I Committee’s second quarter meeting at the Washington Duke Inn.
January:
The D&I Committee received a donation of $2,500 from The Alliance to Cure Cavernous Malformation to sponsor the upcoming Neurosciences Career Day.
February:
March:
The Neurology residency continues to match a diverse set of residents. Our percentages of women and members of underrepresented racial and ethnic groups far exceeds national averages. We also have MDs, DOs, PhDs, and trainees who completed medical school on 4 different continents.
April:
Dr. Deborah Rose was named our first Chief Resident for Equity, Diversity, and Empowerment and will start this position in July.
Dr. Len White won the Diversity, Equity, and Inclusion Program of the Year Award from Duke Housing and Residential Life
We have a busy year planned for 2023-2024, but I’ll save that for future updates.
--Andrew
Photo of the Supreme Court by Anna Sullivan; used with permission via Unsplash.