Denounce aversive racism in academic medicine

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Structural racism is a form of racism rooted in laws, policies, institutions and practices that offer advantages to certain racial groups while disadvantaging others.1 Although structural racism is well documented as an important factor in Inequalities in health care, its effects on medical students, interns and faculty have received less attention. We believe aversive racism is a critical and overlooked contributor to structural racism in academic medicine.

“We want diversity, but we also want qualified people. “

Aversive racism, an established construct in social psychology, is defined as the manifestation of racist tendencies while denying that one’s thoughts, behaviors or motives are racist.2 According to John Dovidio and Samuel Gaertner, who defined the concept in the 1990s, Aversive racism occurs when people in principle adhere to egalitarian values, but when faced with ambiguous situations or unclear guidelines, they discriminate against people belonging to historically marginalized groups while rationalizing or justifying their actions based on factors other than race.2 Aversive racism is pervasive both in academic medicine and in society at large. In areas ranging from medical school admissions decisions to leadership appointments, aversive racism in academic medicine hinders efforts for diversity, equity and inclusion. Understanding this concept and developing strategies to combat aversive racism will help diversify academic medicine and reduce health disparities.

“If he just kept his head down and stayed under the radar, he would be much more successful.”

Aversive racism undermines the substantial investments in anti-racist initiatives that many institutions have made to combat structural racism. One manifestation of aversive racism in academic medicine is persistent inequalities in the promotion of faculty from historically marginalized groups. Asian and URM professors made up only 18-19% of full professors in perioperative and primary care specialties.3

Another area where aversive racism has substantial effects is the residency application process. Program directors may unwittingly rationalize the selection of a less diverse incoming residency class by lamenting the lack of qualified applicants from diverse backgrounds, rather than acknowledging the barriers that URM applicants face in the selection process. URM students are less likely to receive grades on their clinical placements and receive fewer honor society memberships after graduation than white students. 4 This system hampers the chances of URM students to be matched to competitive residency programs, thus perpetuating disparities in academic medicine.

The same mechanisms are in play when URM candidates for managerial positions are assessed less favorably than their equally qualified white peers. The use of subjective phrases such as “not well suited”, “not what we are looking for” or “I go with my gut on this topic” allows an evaluator’s biases to prevail when guidelines are ambiguous.

“She was a promising candidate, but she just wasn’t the right fit for our department.

In the parlance of social psychology and sociology, aversive racism results from the interplay of normal cognitive processes, including social domination, implicit prejudice, and favoritism within the group.1,2,5 Aversive racism thrives when decisions are left to the judgment of the people. who do not recognize the effects of intergroup dynamics on their thought processes. Social dominance theory explains the mechanisms behind the inevitability of group-based hierarchies. According to this theory, society and social systems have at least two groups – the dominant or superior group, which has the most attributes or resources that society deems valuable (for example, power or money), and the less dominant group (s). 5

In racial matters, the hierarchy is maintained by institutional racism (racial discrimination within the financial, legal and educational systems, among others); interpersonal racism (discrimination, overt or aversive, on the part of members of the dominant group against members of less dominant groups); and internalized racism (conscious or unconscious acceptance of the racial hierarchy by members of less dominant groups) .1 To avoid sanctions or to move up the hierarchy, members of less dominant groups tend to show deference to members. dominant group, a process that reinforces and perpetuates this hierarchy, while those at the top often deny the existence of a group-based hierarchy.5

The hierarchy is maintained in part by societal myths that legitimize iniquity. People at the top of the hierarchy not only have a stronger preference for hierarchical societies than members of less dominant groups, but they are more likely to endorse such legitimizing myths.5 In academic medicine, the myths that legitimize the iniquity include the concept of a meritocracy. – the idea that success rests above all on the capacities of a person, who ignores the effects of structural racism on opportunities. Implicit bias – the unconscious and automatic association of stereotypes or negative attitudes with a particular group – also helps to maintain inequality.2

Implicit bias works in concert with favoritism within the group, which involves preferring members of one’s own group to strangers.2 When faculty members interview candidates for residency, for example, favoritism within the group occurs when an investigator ranks students at a school they personally attended higher than they otherwise would have, putting other applicants at a disadvantage. Aversive racism occurs when people fail to recognize the influence of these forces on their judgments. Social domination, implicit prejudice, and favoritism within the group intersect within academic medicine, resulting in aversive racism that affects the judgments of decision-makers and contributes to structural racism in medicine.

“They’re clearly qualified for the job, but they’re too ‘in your face’; I am afraid that people will not respect their opinions.

Behaviors that reflect aversive racism are detrimental to people belonging to historically marginalized groups, but maintain the positive self-image of those who adopt them.2 For example, Dovidio and his colleagues asked white college students to rate hypothetical university candidates.2 Participants had already completed a questionnaire. , which was used to stratify them into high bias groups and low bias groups (although even high bias students ranked low on measures of bias relative to the general population). Participants then rated the admission records of black and white applicants that were constructed to reflect high, low, or ambiguous academic performance. There was no difference between the most damaging and least damaging participant ratings of top or bottom performers, regardless of the candidate’s race. However, when evaluating candidates with ambiguous results, participants with high prejudices rejected black candidates much more often than they rejected white candidates. Investigators concluded that the ambiguity of the records allowed participants to justify their admission decisions themselves by focusing on the weaknesses of the application.

“But I voted for Obama.”

The Covid-19 pandemic has exposed the structural racism that exists across the United States. Academic medicine is not immune to the scourge of white supremacy and structural racism. No matter how many institutional statements condemning racist acts, we cannot expect to overcome structural racism within academic medicine until we recognize the reality of aversive racism. In addition to examining their role in maintaining a racial hierarchy, members of the academic medical community must do the hard work required to challenge their own conscious and unconscious thoughts and actions that contribute to aversive racism. 2 This work includes unlearning implicit biases, challenging negative stereotypes and legitimizing myths, and eliminating the use of automatic and biased judgments to make decisions, which will require careful and deliberate practice.

Future work will include the development of evidence-based anti-racism programs to break the unspoken racial hierarchy of academic medicine, which contributes to structural racism in health care.1,2,5 Effective programs would help normalize anti-racism attitudes ; provide ongoing and effective anti-racism training to trainees, faculty, managers and staff; and reshaping existing systems that promote “group”. Finally, academic institutions could capitalize on the good intentions and desires of progressive academic leaders to overcome their aversive racist thoughts and actions.2 We hope that academic leaders lead the charge by recognizing the need to openly address aversive racism in the world. part of broader efforts to dismantle structural racism in medicine.

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