I am a scientist, living in a beautiful little town that is home to a fine university with a good medical school and a football program that teeters toward excellence. These two programs have many traits in common and some marked differences. Together, they make a useful paradigm to explore and understand two unfolding events, one of which is tragic and the other almost comical.
The football program seeks and recruits the best players from the best high school programs. Recruits have been assessed for their mental toughness, speed, agility, and pure brute strength. They have been supported by a legion of parents, coaches, and friends. Their ability to stiff-arm a free safety, sack a quarterback, and win the battle of defensive or offensive lines, not to mention throw, kick, or catch a football, confers advantages but acquiring a deep academic understanding of the history of zone blocking advances their playing career not a bit. Recruits who are accepted by our football team will play at least some college games, and a small handful (1.6% nationally) of the best college players will be drafted into the National Football League.
The football program emphasizes brawn over brains. On its face, this brawn is unequally distributed between races: Blacks are overrepresented in the NFL by a factor of five, and Asians underrepresented by a factor of 50.
Medical school recruits get good grades on a myriad of academic exams and programs. They are supported by a bunch of teachers, professors, tutors, and parents. They must be able to survive the horrors of organic chemistry, intermediary metabolism, neuroanatomy, about a thousand drugs, the diagnosis and management of ten thousand diseases, and a thousand-odd lab tests. Most graduates from the medical school will continue their education in a three-year residency, and a substantial number will undergo subspecialty fellowship training. Being liked and respected by their patients confers a clear advantage, but the ability to run over a center linebacker does not.
The medical school emphasizes brains, not brawn. On its face, brains are also unequally distributed between races: Asians are overrepresented in medical schools by a factor of three, and Blacks are underrepresented by the same ratio.
These two programs are classic meritocracies — they consciously and deliberately compete across the world to recruit and retain the elites, trying to be the best football team and the best medical school they can manage. They are consciously and openly striving for excellence, not mediocrity.
So what are the two events that are unfolding? The first involves the National Football League. It has a mammoth liability because repeatedly hitting people’s heads on the football field is bad for their mental health. It causes “chronic traumatic encephalopathy,” a disease with shadowy diagnostic criteria prior to postmortem exam, and has shadowy effects on mental performance. Diagnostic uncertainty is an advantage to lawyers pleading the case of ex–NFL players. These lawyers can claim that any reduction in mental abilities in an ex-player should be compensated. The NFL has agreed to a settlement, including a complex program of testing for neurocognitive impairment, but it requires that mental testing for ex-players be adjusted using “demographically adjusted normative data for Caucasians and African Americans.” According to a legal submission, this means that Black former players are “automatically assumed … to have started with worse cognitive functioning than white former players.” This “race-norming” is claimed to exclude two-thirds of Blacks from receiving benefits for loss of mental ability under the settlement.
Race-norming as such may be hard to defend because Black athletes claiming compensation are a distinct class of affluent college-educated individuals. It might be better to determine whether a claimant’s current test score is below his individually expected score had he not played in the NFL. Each ex-player has an abundance of information from his college days from which to build an expected score. But college athletes have substantially lower academic scores than non-athletes, and Blacks have still lower scores than non-Blacks. Thus, this individual approach would (like race-norming) require a typical Black ex-player to demonstrate a lower test score to receive a compensation package than a typical white ex-player. Either way, this naked assertion of racism led Judge Anita Brody on June 3, 2021, to order a mediation concerning race-norming between the NFL and the ex-players’ legal representatives.
The second organization is the American Medical Association, which has a long and storied history of advancing the quality of medical care and education. It includes about 250,000 doctors and medical students. The average income of full members of the AMA is roughly $250,000, and most are continuously employed for their working lives. The AMA is the richest and brainiest large organization in the world. But, like many brainy organizations before it, the AMA has studiously taken leave of its senses. Its House of Delegates voted in June 2018 to approve a plan for “Continued Progress Toward Health Equity” and hired a chief health equity officer.
After baldly declaring that meritocracy is “a myth,” the resulting “AMA Equity Strategic Plan,” published May 2021, addressed medical education:
Medical education has largely been based on such flawed meritocratic ideals, and it will take intentional focus and effort to recognize, review and revise this deeply flawed interpretation, which ignores, or purposively obscures, the underlying root causes of causes (of health and of other metrics of success) that are socio-structural in nature and, often, rely on discredited and racist ideas about biological differences between racial groups.
The AMA waded farther into this swamp. It published a podcast for its Journal of the American Medical Association by Dr. Ed Livingston, a senior JAMA editor, and Dr. Mitch Katz discussing structural racism (caused, apparently, by the inequitable distribution of diesel smoke). The podcast stated that “given that racism is illegal, how can it be so embedded in society that it’s considered structural?” It was accompanied by a tweet that stated that “No physician is racist, so how can there be structural racism in health care?” This provoked the editor-in-chief of JAMA, Dr. Howard Bauchner, to announce that the podcast and accompanying tweet were “inaccurate, offensive, hurtful, and inconsistent with the standards of JAMA.”
Despite deleting the podcast and tweet, Dr. Bauchner was also assigned to the scrap heap on June 1, 2021. He is likely confused, thinking he has done all the right things. But his confusion is caused by none other than himself in failing to establish and hold fast to the “standards of the JAMA.” Every scientist knows that we cannot communicate effectively unless we agree on what words mean. It is the duty of every journal editor (and a standard of JAMA) to ensure that this is the case. Thus, before discussing whether a physician is racist or not, Bauchner could have defined what the term racist means. His failure to do so caused his confusion and led to his downfall.
The task of defining racist is (as it happens) not easy. Take for example two questions.
Has the physician in question ever considered that sickle cell anemia is more common in Blacks than whites?
Has the physician in question ever declined to see a patient because of the race of the patient’s spouse?
The answer to the first question is about 99% yes, and to the second question about 100% no. The truth is that every good physician takes racial characteristics into account when considering diagnoses and planning the care of a patient, but no physician tries to restrict or degrade the lives of individuals based on their race. If racist is defined only in terms of malignancy, the statement that “No physician is racist” is correct. If racist is defined in terms that include routinely using race to arrive at the best management of patients, then essentially every physician is racist.
We might also ask what the AMA means by equity, a vacuous term that is most distinguished by not being equality. It has no meaning outside a grievance alleged by one group of individuals against another. To illustrate this, consider trying to establish equity between the students on our football team and students in our medical school. It is unlikely that a student in the medical school would be a starter on the football team, and unlikely that a player on the football team could pass medical boards. If the medical school happened to play the football team, the principles of equity would require us to spot the medical school about 100 points. And we would need to spot the football players about 100 points each to achieve equity if they attempted to pass the MCAT exam. Equity and excellence just can’t co-exist.
The AMA quite needlessly roused a rabble with its equity initiative. The resulting Plan was fulsomely endorsed by the AMA’s president-elect, Dr. Gerald Harmon. Neither he nor the AMA will find themselves able to control it.
Instead of huffing and puffing about equity and whether physicians are racist or not, maybe the AMA could do something useful. It could use its enormous resources to enter the NFL controversy and the whole question of race. It can start by explaining how “racist ideas about biological differences between racial groups” have been “discredited”. More important, it can conduct a factual and dispassionate analysis as to the extent to which the occurrence within an individual of elite brains or elite brawn is determined by that individual’s ancestry and national origin.
The stakes for both organizations are high. If the AMA is right in its current stance on equity, the NFL will have to compensate every Black player whose intelligence falls below that of the average college-educated male. In the face of the enormous present cost and future liability involved, the NFL will cease to exist as we know it.
And if the AMA has got it all wrong about equity, it will have so much egg on its face that it might as well not bother to exist.