Structural racism is a form of racism rooted in laws, policies, institutions and practices that offer advantages to some racial groups while disadvantaging others.¹ Although structural racism is well documented as a major contributor to health care inequalities, its effects on medical students, interns, and faculty have received less attention. We believe that 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 exhibiting racist tendencies while denying that one’s thoughts, behaviors or motivations are racist.² According to John Dovidio and Samuel Gaertner, who defined the concept in the 1990s, aversive racism occurs when people in principle approve of egalitarian values, but when faced with ambiguous situations or unclear guidelines, discriminate. people from historically marginalized groups while rationalizing or justifying their actions. based on factors other than race.² Aversive racism is pervasive in academic medicine and in society in general. 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 the persistent inequalities in the promotion of faculty from historically marginalized groups.³ Although Asian students and students from under-represented medical groups (URMs) made up 31% of U.S. medical school graduates in 2018, Asian and URM professors made up only 18-19% of full professors in specialties. perioperative and primary care.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 URM applicants face in the selection process.⁴ URM students are less likely to receive honor grades during their clinical placements and receive fewer honor society memberships after graduation than white students.⁴ The grades awarded in the third and fourth year placements are more subjective and more susceptible to bias than the pass / fail grades commonly used in the preclinical years.⁴ This system hampers the chances of URM students to integrate into 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 subject” 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 language 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 flourishes when decisions are left to the judgment of people who fail to 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 of the dominant group, a process that reinforces and perpetuates that hierarchy, while people at the top often deny it. 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 inequity include the concept of a meritocracy – the idea that success is based primarily on a person’s abilities, which ignores the effects of structural racism on opportunity. Implicit bias – the unconscious and automatic association of stereotypes or negative attitudes with a particular group – also helps to maintain inequality.²

Implicit prejudice works in concert with favoritism within the group, which involves preferring members of one’s own group to strangers.² When faculty members interview residency applicants, for example, favoritism within the group manifests itself when an interviewer ranks students at a school they personally attended higher than they would have expected. otherwise, putting other candidates 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 assess hypothetical college candidates.² Participants had previously completed a questionnaire, which was used to stratify them into high bias and low bias groups (although even high bias students ranked low on measures of bias compared 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, addressing negative stereotypes and legitimizing myths, and eliminating the use of automatic and biased judgments to make decisions, which will require careful and deliberate practice.²

Future work will include the development of evidence-based aversive anti-racism programs to break the unspoken racial hierarchy of academic medicine, which contributes to structural racism in healthcare.^1,2,5 Effective programs would help normalize anti-racist 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 in recognizing the need to openly address aversive racism as part of broader efforts to dismantle structural racism in medicine.