Leadership Letters: AOA, Equity, and Wellness

The Icahn School of Medicine at Mount Sinai (ISMMS) holds among its highest values academic rigor, social justice, equity, and collaboration. We pride ourselves on being a school that mitigates unhealthy competition among students. We understand the limited value of rankings and other external metrics (MCAT and NBME scores) that do not accurately reflect or predict the qualities of great physicians, scientists, and citizens. We are also a school that works diligently to create a level playing field for all students. We recognize that many of us are the beneficiaries of unearned privileges throughout our lives, and that these privileges have traditionally been reinforced in the metrics that are used to measure success in medical school.

There is ample evidence in the literature and from our own experience at ISMMS that students who self-identify as white are disproportionally over-represented in the national ranks of students chosen for the Alpha Omega Alpha Honor Medical Society (AOA). For example, approximately 18-20 percent of any given ISMMS class is Underrepresented in Science and Medicine (URiSM), and only one to two students in every graduating class have been selected for AOA: of the approximate 120 students inducted over the past five years, only five have been URiSM. Other students who are underrepresented in AOA include students who self-identify as Asian and students who are first generation college graduates.

These statistics reflect the conscious and unconscious bias that non-white students, in particular students who are URiSM, are collectively not good enough to warrant selection to AOA, do not embody the highest ideals of ISMMS, and are somehow inferior to their peers. We believe that does not represent our profession’s values or mission.

Despite the fact that AOA is flexible in its requirements for AOA eligibility (“top quartile as measured by academic performance”), this underrepresentation has historically been the case regardless of how our school defined “academic performance” for the sake of AOA eligibility. In past years the method to determine the top academic quartile varied from elaborate point systems that holistically included leadership, research, and community service, to years that included Step 1 scores and years that have not; years that have based the top quartile on class ranking and years that have based it on clerkship grades alone. This past year, our AOA selection committee also dramatically changed its selection procedures in an effort to be more holistic, all to no avail: the most recent outcomes for AOA were no different than in past years.

The reasons for this gap in performance can be divided into two main categories:

1. Variables that precede medical school.
2. Variables at play in medical school.

The former includes the poor quality of K-12 education in urban and under-resourced communities; societal and structural racism that is a part of everyday life from birth through college; lack of social, parental, and familial privilege; disparities in the “social determinants of education” (i.e., nutrition, safe and clean neighborhoods, mass incarceration); stereotype threat; and internalized racism. While all of these variables impact medical education, medical school-specific variables include lack of access to adequate academic support; lack of social support; lack of race-concordant teaching, mentorship and advising; unconscious bias in subjective clinical evaluations; and mistreatment based on race/ethnicity.

Intention

Effective spring 2018, we have discontinued our participation in student selections for AOA. We will continue to maintain an active AOA chapter, allowing students to nominate housestaff and faculty to AOA, as well as compete for grants that have historically supported student research and service projects.

We are also committing ourselves to:

1. Establishing true equity in the availability of student resources (including academic support, mentorship and advising from faculty of color).
2. Mitigating bias in evaluations.
3. Eliminating mistreatment based on race/ethnicity.
4. Continuing to nurture a learning environment that values maximizing personal and team achievement over competition.

We plan to closely monitor student outcomes as we implement these interventions.

Rationale

At ISMMS, every medical student should have an equitable educational experience regardless of their demographic background, lived experience, and level of academic preparation prior to medical school. To date, despite the interventions and processes we have implemented, we have not succeeded in achieving this goal. Discontinuing participation in student selections for AOA is an important step towards recognizing that our environment continues to privilege certain students over others. Until we can create a level playing field for all students, we do not want to perpetuate this unfair advantage.

While criteria for AOA eligibility are not inherently racist, every step of the way leading up to medical school—and medical school itself—is fraught with inequity, conscious and unconscious bias, and institutional/structural racism.

Participating in AOA reinforces the bias and racism that we are working so hard to mitigate, and that we hope to eliminate.

Equity in Support, Resources, and Outcomes

We are committed to addressing structural racism in medical education, as well as conscious and unconscious bias in teaching and assessment.

To that end we have been enhancing resources to help students excel academically and are establishing a comprehensive learning and wellness center that will support student success in course, clerkships, and Board exams. We continue to enhance our grading and evaluation policies in an effort to make them more equitable and less reliant on subjective and potentially biased evaluations. We have increased the number and variety of our honors, awards, and graduation distinctions to better recognize the broad range of student activities in which our students excel, and which are closely aligned with our mission. We have increased the number and diversity of our core academic advisors. We intend to track outcomes such as Step 1 and Shelf scores, clinical clerkship evaluations, and clerkship grades so that we can monitor the impact that these interventions are having, and ensure that the impact is sustained.

We believe that this work is our most important priority. We will continue to partner with students, faculty and staff to undo the systems, practices and mindsets that have historically reinforced disparate outcomes for our students.