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Bias in Radiology Resident Selection

Do We Discriminate Against the Obese and Unattractive?

Maxfield, Charles M. MD; Thorpe, Matthew P. MD, PhD; Desser, Terry S. MD; Heitkamp, Darel E. MD; Hull, Nathan C. MD; Johnson, Karen S. MD; Koontz, Nicholas A. MD; Mlady, Gary W. MD; Welch, Timothy J. MD; Grimm, Lars J. MD

doi: 10.1097/ACM.0000000000002813
Research Report: PDF Only

Purpose: To evaluate for appearance-based discrimination in the selection of radiology residents.

Method: A deception study simulating the resident selection process to examine the impact of attractiveness and obesity on resident selection. Seventy-four core faculty from five academic radiology departments reviewed mock residency applications in September and October 2017. Applications included demographic information and photograph, representing a prespecified distribution of facial attractiveness and obesity, combined with randomized academic and supporting variables. Reviewers independently scored applications for interview desirability. Reviewer scores and application variables were compared using linear mixed fixed and random effects models.

Results: Reviewers evaluated 5,447 applications (mean: 74 applications per reviewer). United States Medical Licensing Examination Step 1 scores were the strongest predictor of reviewer rating (B = 0.35 [standard error (SE) = 0.029]). Applicant facial attractiveness strongly predicted rating (attractive versus unattractive, B = 0.30 [SE = 0.056]; neutral versus unattractive, B = 0.13 [SE = 0.028]). Less influential but still significant predictors included race/ethnicity (B = 0.25 [SE = 0.059]), preclinical class rank (B = 0.25 [SE = 0.040]), clinical clerkship grades (B = 0.23 [SE = 0.034]), Alpha Omega Alpha membership (B = 0.21 [SE = 0.032]), and obesity (versus not obese) (B = -0.14 [SE = 0.024]).

Conclusions: Findings provide preliminary evidence of discrimination against facially unattractive and obese applicants in radiology resident selection. Obesity and attractiveness were as influential in applicant selection for interview as traditional medical school performance metrics. Selection committees should invoke strategies to detect and manage appearance-based bias.

C.M. Maxfield is vice chair of education, Department of Radiology, Duke University Medical Center, Durham, North Carolina.

M.P. Thorpe is a radiology resident, Department of Radiology, Duke University Medical Center, Durham, North Carolina.

T.S. Desser is professor, Department of Radiology, Stanford University Medical Center, Stanford, California.

D.E. Heitkamp is a staff radiologist and associate residency program director, Florida Hospital, Orlando, Florida.

N.C. Hull is assistant professor, Department of Radiology, Mayo Clinic, Rochester, Minnesota.

K.S. Johnson is residency program director, Department of Radiology, Duke University Medical Center, Durham, North Carolina.

N.A. Koontz is director of fellowship programs, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana.

G.W. Mlady is chair, Department of Radiology, University of New Mexico, Albuquerque, New Mexico.

T.J. Welch is associate chair of education, Department of Radiology, Mayo Clinic, Rochester, Minnesota.

L.J. Grimm is assistant professor, Department of Radiology, Duke University Medical Center, Durham, North Carolina.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Granted by Indiana University Institutional Review Board (IRB# 1708886894) on September 11, 2017; Mayo Clinic IRB (#17-007970) on October 2, 2017; and Stanford University IRB (Ref #42833) on September 29, 2017. Waived by Duke University (IRB Pro00086317) on August 9, 2017; and University of New Mexico Human Research Review Committee (Submission ID: 17-338) on October 10, 2017.

Correspondence should be addressed to Charles Maxfield, Department of Radiology, 1905 Children’s Health Center, Box 3808, Duke University Medical Center, Durham, NC 27710; telephone: (919) 684-7585; email:

© 2019 by the Association of American Medical Colleges