Academic rigor has traditionally been recognized as one of the most highly regarded values of medical education. Election to Alpha Omega Alpha Honor Medical Society (AΩA) is arguably the highest honor that can be conferred in medical school. It is purportedly a measure of academic rigor and excellence, but, more important, it is a designation that increases the likelihood of securing interviews at the most competitive residency programs in the country, offering inductees potential access to career opportunities that are highly sought after and disproportionately distributed.
In recent years, wellness1 and, to a lesser extent, equity in educational opportunities2 have also been recognized to be among the highest values of a medical school education. As medical educators we pride ourselves on mitigating unhealthy competition among students. We work diligently to create a level playing field for all students so that all can thrive. We understand the limited value, and harmful effects, of rankings and other external metrics (e.g., Medical College Admission Test [MCAT] and United States Medical Licensing Examination [USMLE] scores) that do not reflect or predict the qualities of what makes a great physician, scientist, or member of society.
While all medical students have earned a great deal of privilege by virtue of their hard work and intellect, we also recognize that race is a profound organizing principle in U.S. society and that the medical profession is historically rooted in racism.3 White students and trainees are the beneficiaries of unearned social privilege. Compared with their peers of color, white students and trainees are more often given the benefit of the doubt in subjective academic performance4 or disciplinary action5; are far more likely to find faculty mentors to whom they can relate on both a professional and personal level6; are more likely to have close friends and family within the medical profession who can offer advice and access; and experience a world that is designed to their advantage.7
The accrual of these unearned social privileges makes white medical students look smarter, more capable, more accomplished, and more likely to be successful as future physicians and scientists, and contributes to an inequitable medical educational experience for students of color. This biased perception is further reinforced by the metrics and honors that are used to measure success in medical school.
There is evidence in the literature and from our own experience at Icahn School of Medicine at Mount Sinai (ISMMS) that students who self-identify as white are disproportionally overrepresented in the national ranks of students chosen for AΩA, the national medical honor society. Boatright et al found that, while there was a strong association between USMLE Step 1 scores and AΩA membership, white students were 6 times more likely than black students and twice as likely as Asian students to be members of AΩA, even when controlling for Step 1 score, number of publications, or other demographic/educational covariates.8
At ISMMS, 18%–20% of every entering class is underrepresented in science and medicine (URiSM), the designation we use to describe students who self-identify as black and/or Latinx. Historically, only 1–2 URiSM students in every ISMMS graduating class have been selected for AΩA: Of the approximately 120 students inducted over the past 5 years, only 5 have been URiSM. Other ISMMS students who are underrepresented in AΩA include students who self-identify as Asian and students who are first-generation college graduates.
Despite the fact that AΩA requirements for eligibility are broadly defined as top quartile measured by academic performance, URiSM students at ISMMS have historically been underrepresented among those selected for AΩA regardless of how our school has defined “academic performance.” Our method of determining the top academic quartile has varied from holistic systems that assigned points for leadership, research, and community service to systems that included Step 1 scores and ones that did not, to systems that were based on class ranking, to systems that were based on clerkship grades alone.
Our acceptance of the persistent underrepresentation of our URiSM students in AΩA as the norm reinforces the racist belief that students who are URiSM are collectively not qualified enough to warrant selection to AΩA, do not embody the highest ideals of medicine, and are somehow academically inferior to their peers. This perspective does not represent our profession’s values or mission.
While criteria for AΩA eligibility are not inherently racially biased, every step leading up to medical school, and medical school itself, is fraught with inequity, conscious and unconscious bias, and institutional/structural racism.
The reasons for these inequities can be divided into 2 categories: those that precede medical school and those that are 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 to death; lack of social, parental, and familial privilege; disparities in the “social determinants of education” (nutrition, safe and clean neighborhoods, mass incarceration); stereotype threat; and internalized racism.9 While all of these variables impact medical education, medical school-specific variables that reinforce inequity 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.10
Our community of medical educators believes that, despite entering medical school with a broad range of MCAT scores, grade point averages, research backgrounds, and community service endeavors, as well as an increasingly broad range of lived experiences, all medical students have the capacity to achieve excellence as physicians, scientists, activists for justice, and servant leaders. Medical students are among the nation’s brightest, most motivated, idealistic, hardworking, and selfless women and men. Yet once they are in medical school, we take the unusual step of trying to distinguish among these very talented students using assessment methods (multiple-choice examinations and subjective clinical evaluations) that have never been shown to predict success or outstanding performance in clinical medicine, science, leadership, or advocacy. These outcome measures are then used to determine who will garner the highest honors, including AΩA, and who will enter the most competitive specialties and the most competitive programs within specialties.
Medical students are driven to do the best they can to be the best providers of care, the best innovators in science, and the best agents of change this country has to offer. Their internal drive to excel is constructive and healthy. The external drive to excel on board exams and compete for the best clerkship grades for the sake of honor societies is unhealthy and can be destructive.
Given the importance of social privilege in obtaining high scores and grades, and the inequity in the distribution of that social privilege, the metrics themselves are by definition biased, with students of color having to navigate a much more difficult and tortuous path to success. Propping up systems of assessment that create and perpetuate a widening gap in student performance is unjust and contributes to a culture of unhealthy competition and stress among students. It is no accident that, at the intersection of wellness and inequity, so many students experience impostor syndrome, internalized racism, and chronic self-doubt.
ISMMS chose to suspend student selection to AΩA until we achieve equity in the educational experience for all students regardless of their demographic background, lived experience, and level of academic preparation before medical school. We recognize that, given the complexity and often subjective nature of evaluation in medical education, and the challenge of achieving equity in resources, social capital, and privilege in a society that is inherently racist, it is unlikely that we will ever truly achieve our goal, which by definition means that we have suspended AΩA indefinitely. In this section, we describe the events that led to this decision.
Identifying the problem
Concerns about the near absence of URiSM student inductees in our school’s chapter of AΩA first came to our attention in 2017 after a series of meetings called by our students of color. At these meetings, the students and administrative leadership of the school reviewed the recently published national data on AΩA.8 The students presented our school’s data and made the case that ISMMS’s participation in AΩA was leaving students of color at a distinct professional disadvantage, which would likely last for years despite our efforts to improve our process of evaluating and selecting students to AΩA.
Our initial response was to make a concerted effort to improve our AΩA eligibility and selection criteria and procedures. We recruited a more diverse group of members to the AΩA selection committee and mandated that each member receive training on the role of implicit bias in admission practices. Our institution has a paucity of faculty of color who were themselves selected to AΩA. Thus, we proposed to the AΩA national office that any ISMMS alumni of color who was AΩA and was currently a faculty member, resident, or fellow at any institution should be eligible to be appointed to our selection committee. The national office agreed. We used clerkship grades as the only metric in our top-quartile selection criteria.
Testing a solution
After identifying the proportion of the Class of 2017 students who were eligible for AΩA based on clerkship grades, we blinded selection committee members to the students’ grades, race/ethnicity, URiSM status, and any information related to distance traveled/challenges overcome unless the student chose to self-disclose in the essay responses. Committee members were not blinded to student names. Eligible students were required to complete an application that included a CV; information about service, leadership, and research/scholarly activities; the Medical Student Performance Evaluation meaningful characteristics section; and written reflections (no longer than 500 words each) in response to the following prompts:
- Please share a personal, professionalism, or ethical challenge that you faced during medical school. Please provide an analysis of why it was challenging and how you dealt with it.
- Describe a time during medical school when you led a team. Describe your personal leadership style and the obstacles you faced as the team’s leader. What are your strengths as a leader? What are your areas of development as a leader and how have you committed to working on these areas?
Three members of the selection committee independently reviewed and rated each candidate. Equal weight was given to service, leadership, research/scholarship, and the essay responses. Each candidate received 3 scores for each criterion (1 from each rater), which were averaged to determine a final score. Members of the committee were reminded to be aware of their implicit biases before each committee meeting.
From the final scores, an initial rank-ordered list was generated and shared with the selection committee. Each eligible student was presented to the committee by one member who had scored his or her application. All nominees were reviewed and discussed before voting. Following the review, committee members voted by secret ballot on the nominees using the following scale: 5 = Highly qualified and should be admitted to AΩA; 4 = Clearly acceptable and could be elected to AΩA; 3 = Qualified and would represent AΩA well if admitted; 2 = Less qualified, but would still be a suitable representative of AΩA if admitted; 1 = Should not be accepted into AΩA. Cumulative scores from the voting were calculated, and the order of acceptance was determined by the highest score.
Despite a more diverse selection committee (7/15 members were faculty members, residents, or fellows of color) and a more holistic selection process than in previous years, the outcome was no different: only one student of color was selected to AΩA. It was evident that, as we anticipated, the rate-limiting step was our eligibility criteria: using traditional and biased academic metrics (clerkship grades), very few students who are URiSM met the threshold for top 25% of the class.
Making the decision
Following this experience, our medical education leadership team had a series of discussions during which we weighed the risks and benefits of suspending student selection to AΩA. The benefits included creating a more equitable learning environment for all students, removing the stress of competing for AΩA, and making an important statement about academic culture and expectations that was consistent with our values and mission. The risks included giving disproportionate weight to Step 1 scores, as residency directors would have less access to “objective” criteria like AΩA status when reviewing ISMMS students’ applications; disappointing current students, some of whom may have hoped they would be elected to AΩA; deterring candidates for whom AΩA was important from applying to our medical school; and creating an impression among candidates for MD and MD/PhD programs that our school was less rigorous than other schools.
We came to the conclusion that equity and wellness in medical education are more important than achievement and competition and that the benefits of withdrawing from AΩA outweighed the risks. We presented our case to our dean, who wholeheartedly supported our proposal. We then presented this proposal to Student Council, whose members also agreed that, despite being controversial, withdrawal from AΩA was the right thing to do. Across all stakeholder groups, there was general consensus that, given the high stakes and complexity of this proposal, and given the fact that the students who have historically been most impacted were in the minority, the proposal would not be put to a student body vote or rely on student consensus but would be presented as a decision made by school and student leadership.
An announcement was sent to all students and meetings were scheduled with each class separately to explain the decision and its rationale and to hear student feedback. Very few students attended the class meetings, and those who did represented the full spectrum of opinions: vehemently for, vehemently against, and somewhere in between. We received emails and phone calls from a number of disgruntled students, parents, and alumni as soon as word got out. Why were we doing this at all? Did we appreciate the extent of the negative impact it would have on the school’s reputation and on our students’ ability to secure the most competitive residency spots? Could we not make this policy change for the incoming classes and allow current students to remain eligible for AΩA? We also received emails and phone calls from students and alumni praising our decision and expressing pride in knowing that they were associated with a school that stood by its values.
Our intention was to contact the national AΩA office as soon as the decision was shared with all of our students. Instead, the national AΩA office reached out to us after they heard of the decision from unhappy parents who also happened to be alumni. The national office was disappointed and concerned, but quickly came to appreciate that we shared the same interests, even though we were taking different positions. We were focused not on flaws with AΩA but on flaws in the structure of medical education; our systems of evaluation, assessment, and grading; and the inequity in available mentorship for students who are URiSM. In fact, we valued our close relationship with AΩA and the many awards and grants our students, residents, and faculty had received over the years. We intended to maintain our chapter and continue selecting residents, fellows, and faculty. To their credit, AΩA leadership visited us for a day of discussions with our dean, our medical education leadership team, our AΩA councilor, and students of color. No one’s mind was changed by the end of that day, but we all had a newfound respect for the challenges of achieving what, for the most part, were our shared goals.
Since its inception, AΩA has had as its motto “Be Worthy to Serve the Suffering.” We must ask ourselves, what makes one most worthy of serving the suffering and who decides what it means to be worthy? Is it academic excellence? A demonstrated commitment to underserved communities? Does it require firsthand knowledge of what it means to suffer, to be underserved, disadvantaged, discriminated against? Is it conceivable that the founders of AΩA intended for this process to be driven predominantly, or even in part, by examination scores and subjective clinical evaluations that are, by their very nature, biased?
We are committed to addressing structural racism in medical education, as well as conscious and unconscious bias in teaching and assessment. We are committed to empowering students who are URiSM by giving them a platform to provide timely critical feedback, and forming an alliance with them to properly implement that feedback. We are committed to actively redistributing power, social privilege, and resources in an effort to create a medical education experience that is equitable and just. Our goals include (1) establishing true equity in the availability of student resources, (2) mitigating bias in clinical evaluations as well as conscious and unconscious bias in teaching and assessment, (3) eliminating mistreatment based on race/ethnicity, and (4) continuing to nurture a learning environment that values maximizing personal and team achievement over competition (Table 1). We believe that this work is the medical education community’s 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 students of color.
Suspending participation in student selection for AΩA is an important step toward recognizing that medical school learning environments continue to privilege certain students over others. Participating in student selection for AΩA reinforces the bias and racism that we are working so hard to mitigate and ultimately hope to eliminate.
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