Racial Bias in Grading Medical School Clerkships

I’m glad to be part of an institution is taking this seriously.

For reference, clerkship grades and AOA is determined primarily or largely by instructor recommendations, and NOT primarily by objective indicators of performance.

Deeply concerned by recent national reports demonstrating racial differences in Alpha Omega Alpha nomination and clinical grading, we have begun to look at our own data at Washington University School of Medicine. Our preliminary results demonstrate similar racial differences with white students being more likely to receive honors grades in the clinical clerkships and more likely to be nominated for Alpha Omega Alpha than students of color. At AAMC this week, we heard similar reports from several peer institutions. We have discussed this with the chairs of the departments and the clerkship directors. We will be communicating this to the students today as well. We are working with the department chairs to make presentations on the data to individual departments. There is still more investigation to be done, but as a school, we are deeply committed to understanding why this is, how to address these disparities now, and how to prevent them in the future. To this end, we are planning the following immediate strategies as the first steps in the process:

  1. Convene a series of small group meetings with students to better understand the student experience of racial bias on this campus; Encourage use of the online, anonymous reporting system to gather additional comments that students may feel uncomfortable sharing in person or in groups;

  2. Ensure availability of one on one or other meetings for anyone (students, residents, fellows, faculty and staff) who wishes them with Dean Aagaard, Associate Vice Chancellor and Associate Dean Sherree Wilson, Associate Dean Will Ross, and anyone else you may feel safe talking with;

  3. Develop an immediate process for grade challenges that may be related to racial or gender discrimination, spearheaded by Medical Student Government;

  4. Convene an urgent commission of clerkship directors, students and other key stakeholders to make suggestions for immediate, short and long-term changes to grading and AOA selection, spearheaded by Assistant Dean Steven Lawrence;

  5. Continue a deeper evaluation of the underlying causes that contribute to these disparities through additional analysis of preclinical, NBME, shelf and other data available to us, spearheaded by Associate Dean Eve Colson (Program Evaluation and Continuous Quality Improvement).

We have also reached out to our colleagues who have demonstrated a willingness to work to address this critical issue including UCSF and Mt Sinai, among others. We are committed to ensuring that Washington University is a diverse, equitable and inclusive place for all our students, residents, fellows, staff and faculty. We will not stop until that is the case.

One thing I have very much appreciated at WUSTL is the universal and genuine concern for issues like this. Integration needs be taken seriously, and it is taken seriously here. Rather than looking at how others make mistakes alone, it is most important to fix the problems within our own control.


All Other Things Being Equal: Exploring Racial and Gender Disparities in Medical School Honor Society Induction.


A large body of literature has demonstrated racial and gender disparities in the physician workforce, but limited data are available regarding the potential origins of these disparities. To that end, the authors evaluated the effects of race and gender on Alpha Omega Alpha Honor Medical Society (AOA) and Gold Humanism Honor Society (GHHS) induction.


In this retrospective cohort study, the authors examined data from 11,781 Electronic Residency Application Service applications from 133 U.S. MD-granting medical schools to 12 residency programs in the 2014-2015 application cycle and to all 15 residency programs in the 2015-2016 cycle at Yale-New Haven Hospital. They estimated the odds of induction into AOA and GHHS using logistic regression models, adjusting for Step 1 score, research publications, citizenship status, training interruptions, and year of application. They used gender- and race-matched samples to account for differences in clerkship grades and to test for bias.


Women were more likely than men to be inducted into GHHS (odds ratio 1.84, P < .001) but did not differ in their likelihood of being inducted into AOA. Black medical students were less likely to be inducted into AOA (odds ratio 0.37, P < .05) but not into GHHS.


These findings demonstrate significant differences between groups in AOA and GHHS induction. Given the importance of honor society induction in residency applications and beyond, these differences must be explored further.

The disparity is stunningly high in this study.


This is great! And, if you ask me, long overdue!


Just yesterday there was an editorial relevant to this on American Family Radio Network (which is a very conservative organization with Christian sermon programming and some of the most depressing politics-heavy “Christian talk radio” on its participating stations.) I don’t recall the name of the “reporter” but he described how one university had 82 staff positions somehow related to diversity and bias issues. He deplored the $7 million annual cost, saying “this does nothing to contribute to actual education.” Face-palm.

I guess if discrimination and bias hasn’t affected one’s own life, there is no problem. Right?

(I don’t doubt that some staff positions in some departments in some institutions are highly wasteful and perhaps even “just for show” at times. Very possible. But the “reporter” did nothing to help the radio audience understand the issues involved.)


This is a different issue.

I also question having 82 staff positions for racial diversity. This does not seem to be an effective way of dealing with racial diversity.

In contrast, this email was sent to all faculty, after a primetime conversation with the chairs of all departments, by the dean of the medical school. None of this involved diversity “specialist.” Correctly, this is the the concern of everyone, and everyone is expected to be part of fixing. No one is outsourcing this to diversity specialists so that it is out of view and out of mind.

I am sure that there are valid activities for diversity focused staff, but I doubt there would be nearly as much need for them if the power centers of institutions took this on as a central problem for everyone to deal with.

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I would too—if it was literally true. But you are taking his reporting far too seriously and missing the real problem. Notice I put the word “reporter” in quotation marks. He gave no sources and there was no clear means to investigate what he was saying. From his context, it was clear that the positions [and probably not even the entirety of those positions he counted] were related in one way or the other to racial diversity, discrimination, and bias. An ongoing theme on this radio network is “just get over it” and “All lives matter.” So this wasn’t really a reporter informing us about bloated budgets. It is a network “talking point” that resists delving deep into these problems.

I once heard a speaker on that network claim that African-American Studies departments [“That major isn’t going to get you a job!”] exist simply for addressing “white liberal guilt”—and I wouldn’t be a bit surprised if this “reporter” would count those faculty positions “diversity-related” also. (Of course, depending on how one defines diversity, departments devoted to neglected aspects of history and culture are dealing in diversity.) Moreover, for every on-staff attorney at a university who deals with bias and diversity related litigation, there may be typical support staff like administrative assistants, department librarian, and even a janitor who cleans that building. Staffing can be counted in many ways if one includes all budget implications.

Medical schools are recognizing that dealing with racial bias and discrimination takes a lot of deliberate work. Meanwhile, there are plenty of organizations, including media, who are working hard to say there is no need for any of that focus. (And staff time at a university always involves money in one way or the other, including all support services, facilities, and operating costs.)


One of these days, we should engage with critical theory, and how these departments do scholarship. We won’t do that today. There are actually several complex factors mixing together. It can’t really be handled as a cartoon. Clearly the reporter was drawing a cartoon, but I’m concerned about reprimanding the reporter with another cartoon.

This is the important point. Rather than turning this into a complaint about others (which is often understood through a political lens), we should celebrate this, and make sure we deal with our own issues first.


I work at it; some of my absolute bestest friends are greens!