Diversity, Equity and Inclusion Bureaucracy Under Attack

Welcome to What Happens Next, my name is Larry Bernstein. What Happens Next is a podcast which covers economics, finance, politics, and the law. Today's topic is diversity, equity, and inclusion bureaucracy under attack. The first speaker will be Jay Green from the Heritage Foundation, who will discuss the Florida Governor DeSantis's challenge to the DEI bureaucracy in Florida's public universities. Jay and I were high school debate partners at Newtrare in Winneck, Illinois, and are still very close friends. Our second speaker will be Dr. Stanley Goldfarb, who runs a not-for-profit called Do-No-Harm. Stanley is the former associate dean at the UPenn Medical School and the author of Take to Aspen and Call Me by My Pronouns. Why Turning Doctors into Social Justice Warriors is destroying American medicine. Stanley will discuss how DEI is harming medical schools' curriculum and medical care. There's much to cover, so buckle up. I make this podcast to learn, and I offer free of charge. If you enjoyed today's podcast, please subscribe for our website for weekly emails so that you can continue to enjoy this content. Let's begin with Jay Green. Thanks for having me on the show again, Larry. Today I want to talk about political courage and how important that is in containing what's called wokeness or political correctness, which we might understand as a set of political beliefs that are not actually widely shared, but are expected of people if they wish to be thought of well. The problem with wokeness or political correctness is not an intellectual problem. It's not proving that these things are bad. People know they're bad. The problem is having the courage to stand up to them. The interesting thing that Governor Ron DeSantis is doing as a political entrepreneur is that he's demonstrating that it's possible to stand up to wokeness or political correctness and not to be punished for it, but instead to be rewarded. And doing so is inspiring similar courage in the leaders of other politicians, as well as in regular people in their various walks of life. So what in particular is Governor DeSantis doing? He is standing up most recently to diversity, equity, and inclusion bureaucracies in higher education or DEI bureaucracies. And it's important to note that DEI bureaucracies are not faculty, they're staff. These are units that are there to articulate and enforce an ideological orthodoxy on campus. The positive way of framing what they do is that they're there to welcome students from diverse backgrounds and to help develop the dispositions that would make those diverse groups feel included on campus. But a different way of framing that is that they're there to impose an approved political orthodoxy on divisive issues. DeSantis is showing that he can reduce them to a great degree. And he's doing that in a number of ways. First, he's ordering the universities to stop any discriminatory practice, which many of these bureaucracies are engaged in. He is also getting legislative action to defund these bureaucracies. That is simply eliminate those positions and those units on campus. And he is also taking away one of their main tools, which are diversity statements that are used in hiring promotion and tenure on campus. And these are essentially statements of religious faith in the wokeness of the DEI bureaucracy. He's taking all of these steps and people are amazed that he's doing that. The only enthusiastic supporters of the DEI bureaucracy on campus are the people in the DEI bureaucracies and a relatively fringe group of students who are mobilized by DEI bureaucracies periodically to menace anyone on campus who deviates from their orthodoxy. But the vast majority of faculty, including left-leaning faculty, don't really like these DEI bureaucracies. First, they don't particularly care for bureaucracy, but second, they don't like being told what they can and can't teach, even if they're highly sympathetic to the goals of DEI bureaucracies. They still don't like the control. Administrators outside of the DEI bureaucracy also don't like it. They endorse it, but they don't like it. The reason why they endorse it is because they think doing so helps them move into a higher position or to a higher status university. But they don't have any deep commitments to these things. We should think of university administrators as comparable to East German bureaucrats. That is, they talk about communist revolution, but they are mostly driven by ambition as opposed to scholarly accomplishment. Students and their families don't care for DEI bureaucracies. None of them like to live in fear that they're going to say the wrong thing or be punished. DeSantis is discovering, to many people's surprise, that not only can you stand up to DEI bureaucracies, but you can find a lot of surprising allies or a lot less resistance than people would have expected. And so he's succeeding in this effort to a remarkable degree, and that is why his courage is being emulated by leaders in other states. Texas is already moving forward with similar measures, with similar rate of rapid success. It's like Reagan standing before the Berlin Wall saying, tear it down at the time it seemed crazy, but in a few years, that wall was gone, and everyone at that time thought, why did someone say this earlier? That's what we're going to say about the political courage that DeSantis is showing here as well. Can you please clarify what it means for a faculty member to make a DEI-required diversity statement? My understanding is that when an individual applies for a faculty position, that he must endorse the DEI mandate. It's a loyalty oath. During the McCarthy era, there were loyalty oaths where you'd have to swear you weren't a communist. This is the reverse of that. You have to swear that you are a devotee of the orthodoxy of the DEI bureaucracy. Give me an example. Sure, it would generally consist of listing past actions that demonstrate your commitment to these values, and pledging your future agenda that would be in service of that orthodoxy. And those include things like how your research affects diverse communities, how in your efforts you have promoted the careers and interests of diverse community members. You have to pledge that you have been committed to the interests of these communities and that your future research, teaching, and service will further advance the interests of those communities. Jay, you were a faculty member until recently at the University of Arkansas. I was actually a department head for 16 years, so I was in administration, as well as a faculty member. Did you have to engage with a DEI bureaucracy at the University of Arkansas? I did, although I have to say that it really did not become an issue until towards the end of my tenure there, because the University of Arkansas was not high status and was a little bit on the periphery of academia, I thought it could escape these fads that were making their way through more elite institutions. But eventually, it makes its way even to highly conservative Arkansas. The very first time I was asked to do such a statement, which was early on in my 16 year time, we simply said that we were committed to diversity of thought, and we got away with it. By the end, it was counting how many of my faculty were in categories that would count. I had a total of six faculty members in my department, one of whom was Hispanic, two of whom were Asian. So I said, I think we're more diverse than the college as a whole, if you're looking at racial and ethnic categories, the DEI took issue with this. Asian did not count, and my Hispanic faculty member did not count because she was from Spain. So she was the wrong kind of Hispanic. It's this very bizarre set of criteria that has no intellectual justification. It's totally contrary to the truth-seeking mission of higher education. My dean was not pushing this because he was a deep believer in advancing the interests of disadvantaged communities. He did not care. He was doing it because he wanted to be provost or dean at a better university. And it's that anti-intellectual, non-truth-seeking DEI orthodoxy that became pretty insufferable towards the end. Arkansas is a deep red state with a Republican governor and a Republican majorities in the state legislature. Super majorities, it's remarkable how large the Republican contingency is in both chambers of the legislature and in the governor's house. So where are the political entrepreneurs in Arkansas? Are they unaware of what is going on in the university? And do you think, wants to become aware of it, that they will follow the DeSantis example? I think that's exactly what's happening. So I think in the past, even in a very red state like Arkansas, policymakers just thought there was nothing you could do about how woke the state university was. They thought that it was like the weather, just something you'd have to put up with. But they also believed wrongly that norms of academic freedom prohibited them from taking steps to alter the wokeness on campus. They were easily confused that DEI bureaucracies were faculty, which would be covered under academic freedom when in fact their actions are not covered under norms of academic freedom. They're a bureaucracy in the same way that the bursher's office or student housing is. No one thinks that the method by which the university assigns students to housing or gets students to pay their bills is protected by academic freedom. Those are simply parts of their bureaucracy that the state can reorganize if it likes. But no one thought they could do it. Fear affects behavior. Attacking the DEI raises the risk of being labeled a racist. I'm really surprised that DeSantis has not been called that because of his challenge to the DEI bureaucracy. Why do you suppose it hasn't been used yet and is it just a matter of time? So he is being called fascist. Racists is used very commonly in political discourse now. It's possible that that's not being used very much right now to describe DeSantis's efforts against the DEI only because they've lost some of their effect. They've been overused in the last several years. So people are looking for new shocking words like fascist or authoritarian. I expect he will also be called racist on this. He just doesn't care. I don't think it has much influence with his base of political support whatsoever, including many people who are black and Hispanic, who find mostly white people hurling around charges of racism to be unpersuasive. Now as to fear, I agree with you that fear is driving the success of DEI on campus. People are afraid, so they submit. It's the political courage of an entrepreneur that is bursting the bubble of that fear. I think there's a super high level of risk aversion among faculty on campuses. Or is it indifference to the typical chemistry or marketing professor, why not just give into this? Most of these guys are narrowly focused on their own intellectual pursuits and can't be bothered to put up a fight. Things are becoming difficult for faculty being indifferent because it's being imposed and infringing more and more on their regular activities. For example, every faculty member at universities now, you have diversity training for hiring on search committees, you have diversity training for avoiding harassment in the workplace, you have diversity training for avoiding microaggressions. These are all separate training modules and everyone is required to do them and document that they have completed those trainings. These take a lot of time and they're incredibly mindnumbingly stupid and repetitive. Faculty don't like that. In addition, every time they want to apply for a grant, submit to a journal, apply to a conference, they're required again to nod towards DEI goals, to demonstrate the fidelity to those goals, to improve your odds of getting your paper accepted at a conference, you're supposed to somehow connect your research to diversity. There's a thing called positionality statements, which is in your research or at your presentations state, where you come from in your identity and how that influences the work you're doing. Academics don't like having to do all this stuff. They know it's stupid and even if they don't think it's stupid and even if they like it, they're familiar enough with Robespierre to know that the mob might someday come after them and their ideological loyalty will be no protection against that mob. As a hypothetical, let's say you're going to a conference to present a paper and you said either you didn't support the DEI goals or that your research had nothing to do with a DEI mandate, what would happen? You could be severely punished if you were an extremely outspoken critic of DEI. We're all familiar with cases of individual faculty members whose life has been made very difficult or got removed from campus for being a very vocal critic of DEI. It's some of those stories that may justify in academics' minds the fear, but those cases are really quite rare. I think the truth is if you simply didn't do a positionality statement at your presentation or did not bother to mention diversity goals in your proposal for a presentation, you probably would experience relatively little consequence, but again, everyone's very risk averse. So they want to maximize their chance of getting that presentation, maximize their chance of getting the grant. And so they do it in your opening remarks. You refer to DeSantis as a political entrepreneur. What does that term mean? It's been around for several decades. James Q. Wilson wrote about it years ago. A political entrepreneur is someone who advances their own political career by identifying a problem that others have been unable or unwilling to address or were simply unaware of and makes it an issue that they can effectively take on. DeSantis is the Florida governor and he will almost certainly run for president. Why is he choosing to attack the DEI bureaucracy and run a culture war in lieu of focusing on domestic or foreign policy? I actually think the culture war is the big tent in politics right now. It has opposition to wokeness or political correctness cuts across a lot of demographic and traditional political lines. So it's possible for a politician to gain a broad base of support by taking on these positions. It is less popular among elites and since politicians take a lot of their cues from the people immediately around them, they have been reluctant to become unpopular with their immediate social circles. But DeSantis sees the opportunity of winning over a broader base of the electorate, even if he displeases the editorial board at a paper in his state or a fellow parent at his kid's school. He's not as worried about that. He can make a lot of friends with a lot of voters if he takes on these cultural issues. Let's look at other examples of dynamite that DeSantis has thrown into the culture war. The most obvious example was the limitation on the teaching of sex and homosexuality in elementary schools. DeSantis was denigrated by the press and by the Disney Corporation. Was this fight over that issue? And why did he go down that path to attacking the DAI bureaucracy? I think that helped him recognize the opportunity here and it also taught him how easily his opponents would fold. So the issue we're talking about here is incorrectly described as the don't say gay bill. This bill actually, which is now law in Florida, restricts teachers from having lesson plans in kindergarten through third grade that address topics of sexuality, not merely homosexuality, but sexuality in general. It doesn't mean that teachers are unable to answer questions or respond to students who have issues, but it means that they can't develop lessons to teach sexuality or sexual identity to very young children. It's surprising that you would need such a law. You would think this would just be kind of normal practice in school. You're right. He also got into a little bit of trouble with the Disney Corporation. So they had a weak objection to it. And then when it passed, some of the employees at Disney were very upset with the CEO that he had not been more forceful in opposing this legislation. So he responded to this pressure from a relatively small group of his own employees by pledging to be more aggressive, a company took a more aggressive posture after the legislation was passed. DeSantis then recognized that he had leverage over Disney, perhaps more than they had leverage over him. After all, Disney is the beneficiary of various tax breaks, including a special planning district that eliminates their need for zoning approval, for modifications of Walt Disney World. And DeSantis raised the possibilities that he might alter their certain advantages that they have in law, including that tax district. When he did so, Disney folded immediately. Companies care a lot about profit. They make rhetorical gestures to politically correct issues, but if they were really threatened with serious financial loss, they'll fold very quickly. And DeSantis helped demonstrate that with Disney. DeSantis very recently challenged the content on the College Board's AP African American History Exam. This is the same organization that is responsible for the SAT. Given the progressive antipathy for standardized exams, why do the College Board take on the right with progressive content on the AP African American History Test? The fact that College Board drives the bulk of its revenue from the SAT, despite the opposition of some on the left who find it racist or inequitable, that College Board is not an ideologically committed organization. Now, you're asking a different question, which is why would they even have bothered to stray into this fight? They never thought they'd get a fight. They were simply trying to replicate every college course out there. I believe that that AP African American Studies tests probably resembles fairly well what those courses look like in higher education. And they did consult the leading experts. Now, the fact that those leading experts are homogenous in their worldview, that is quite fringe to the rest of America, never crossed their mind. They're just trying to sell tests and they really don't care what way or the other. The theme of this podcast is that diversity, equity inclusion is under attack. DeSantis's actions have attempted to undermine the DEI bureaucracies power. But bureaucracies are strong like bull and they're not gonna get pushed around by a single politician. Good luck to you. For example, if DeSantis mandates no diversity statements, they'll substitute it with something else. They're ideologues and they'll fight the good fight. DeSantis will be governor for a couple more years, but bureaucracies are generally permanent and they hope to infiltrate their ideological positions throughout the university. So they can withstand this temporary onslaught. How will this play out? I think that there are two ways in which DeSantis is making inroads against this calcitrance of bureaucracies that you rightly describe. One is that he is pushing legislation to eliminate these units and to fire these employees. It's very hard for them to fight if they're not employed at the university anymore. Now there is the possibility and DeSantis is aware of this that they'll simply rename these units or rename these positions and rehire these same people. But DeSantis is not using just one front of attack. He's also signaling that he is going to appoint trustees to public universities who are similarly focused on eliminating the stranglehold that DEI has on campus. He's only done it so far with one small college called New College, which is a public institution in Florida, but he's done it in a very high profile way. And everyone else got the message. There was a joint statement put out by 28 colleges in Florida where they all pledged that they would immediately review their programs and discontinue any discriminatory practices. DeSantis is attacking this on multiple fronts to help ensure that the bureaucracy empire won't strike back. If DeSantis was ultimately successful in firing all the DEI employees in Florida's public university system, there is still a massive growth market for DEI professionals. There are private universities, corporations, not for profits and board positions. And there's an infinite number of organizations that could have a DEI bureaucracy. You published an article about the DEI bureaucracy at Northwestern University that has more employees than its history department. How should we think about DEI outside of the public university? I think once you break the mindset that this is an unavoidable feature of higher education by removing it from public universities, it will get harder to maintain this at private institutions as well. First, it'll be harder to maintain because students and their families will have choices. If Northwestern doubles down on DEI while the University of Illinois abandons it, they're gonna start losing qualified students to the University of Illinois. That is gonna put some competitive pressure on them to abandon it. In addition, it removes some of the fear that's driving university administration at places like Northwestern and other private institutions. They may be promoting and embracing DEI bureaucracies because they're afraid that they won't be able to get good jobs for themselves moving up the administrator career ladder unless they do so. But if they see that there are other employers out there where they could go, then they don't have to be as afraid. They have alternatives just like students have alternatives. So I think all of this takes the steam out of this. I think it's also worth emphasizing how much of a fad this is. When I arrived at the University of Arkansas in 2005, this was really just not an issue. And it wasn't even an issue at all until a decade after that. We're talking about something that's less than a decade old at most institutions. These things come and go. And so once the steam is taken out of a fad, they begin to collapse quickly. I don't think you should project the current momentum of DEI bureaucracies forever into the future at all institutions. Illinois is a deep blue state. JB Pritzker is a progressive governor who is a Democratic super majorities in both houses of the Illinois state legislature. The trustees of the University of Illinois are directly appointed by the governor. Why would these progressive trustees oppose DEI at the top public university in the state of Illinois? Even very liberal faculty members are not enthusiastic about DEI for the reasons I was saying earlier. They value their autonomy more than they value abstract ideological goals. While they may be sympathetic with DEI goals, they're not willing really to fight for those things. Think of DEI bureaucracies largely as a patronage system. It's a jobs program in a way that is self promoting. It creates more jobs for itself. But I'm not sure that there is a deep reservoir of commitment among most elected Democrats for critical race theory, for example. They tend not to embrace these things, at least not publicly. I suspect it's because they don't see it as good politics and because they don't deeply believe it. Illinois competes with other states. Last time I checked Illinois has been bleeding population while Florida's been growing very rapidly. They might at some point want to reverse that trend. So at some point states that are doing things that are driving people out to other states might need to reverse course. In the 2021 Virginia gubernatorial race, the then governor, McCauffill, said that parents shouldn't be involved in determining the curriculum. It should be left to the experts. And young can, the opponent in the race, ran advertisements showing video clips of a call for articulating that message. Some people believe that those comments cost him the governor's race. And Democrats in the Virginia state legislature took notice of that. Democratic policymakers tend to have an ideological worldview that is more sympathetic to rule by expert. And so their inclinations are more towards those of Governor McCauff and his statement. In addition, their patronage interests are more aligned with protecting and promoting the jobs of the expert class who tend to be their supporters. What young can reveal is that upper middle class suburban moms saw a lot of stuff going on at their schools during the pandemic, particularly having to do with gender ideology and critical race theory that they really didn't like. They tend to be Democrats. These things don't divide neatly. And again, it's a desire for autonomy. That is upper middle class moms want to raise their own kids. And they certainly don't want someone else raising their kids and values that are hostile to those they're trying to teach at home. They detected that happening. That's what mobilized suburban moms for young can after McCauff made that statement. This could be true in a purple state. It doesn't have to be true only in a red state like Florida. Jay, what are you optimistic about as you're away to the DEI and as bureaucracy? I'm very optimistic about the state of political change with respect to DEI in higher education and then eventually more broadly. DEI bureaucracies overreached during the pandemic following George Floyd's murder. They felt emboldened. They acted too aggressively. What we're seeing now is a backlash that is being mobilized by political entrepreneurs. It's succeeding and it's going to spread pretty rapidly and demonstrate success. And as it does, it will accelerate a momentum. Thanks Jay. I'd now like to go to our second speaker, Dr. Stanley Goldfarb, who runs an offer profit called Do No Harm and is the former associate dean at the University of Pennsylvania Medical School. Go ahead, Stan. Well, it's very nice to be here with you, Larry. I'm delighted to have the opportunity to talk about my book and the work we're doing at Do No Harm. My book is called Take Two Aspirants and Call Me By My Pronouns. And it derives from an article that I wrote in the Wall Street Journal back in 2019. The reason I wrote that article was because I was finishing my time at the University of Pennsylvania where I had a long academic career and I was associate dean of curriculum. And I had become increasingly frustrated and concerned about the direction of medical education. A new vice dean for medical education, my boss was hired. And after 13 years of, I thought, being pretty successful in that role, having a school that had risen to the number one ranking in American medical schools, she decided that we needed to inject much more of issues related to social factors into medical education, that we needed to turn our students into advocates for various social causes. And it turns out that this was a trend that was occurring throughout medical education in the United States. I became quite concerned about this and eventually expressed my concerns to her. She even told me one day that there was much too much science in the medical school curriculum and that we needed to inject much more about the problems that people in the community were facing, poor housing, gun violence, poor nutrition, and so on. In response to this, it became clear to me that we needed to change things. And another factor that prompted me in that direction was the fact that many other medical schools were taking on these issues. Then I noticed that in the Wall Street Journal, there was an article advocating for medical schools teaching about climate change and that was sort of it. That's what drove me finally to write my article. My article was entitled, Take Two Aspents and Call Me By My Pronouns. And it produced a tremendous backlash in medicine and medical education to the point where two days after they published my op-ed, the Wall Street Journal had an editorial pointing out that I was probably right because the response to my op-ed was so intense that it clearly suggested that I had hit a nerve. So I wrote the book in response to expand on some of these issues. And I really focused on three issues in my book. One is, again, the concerns I had turning the medical school curriculum into one was such a great focus on social factors and social issues. And the reason I was concerned so much about that is it's not that those issues aren't important, but that in fact, I saw that physicians really had no agency in fixing housing or availability of healthy foods or gun violence in the community. There needed to be a strong focus on science and science was exploding in medical care and leading to the opportunity for great improvements in medical care. The second issue that I focused on in the book was the end of meritocracy in medicine and in medical education. The focus on diversity, equity, and inclusion, which has become sort of a catch word for what really is the introduction of critical race theory into medical education and into healthcare as a whole. I thought was just bound to produce a less qualified healthcare workforce and would take focus away from medical education and the acceptance of students from medical school. Intellectual quality and academic achievement had always been the most important factors. And this was becoming downgraded with the goal of creating a much more diverse healthcare workforce. And the point of that was a false premise that we can discuss, which is that there needs to be racial concordance between patients and physicians to have optimum healthcare and that more minority physicians need to be trained in order to achieve that. And the final issue that I confronted in the book is a real decline in the quality of the medical school education as many students were passing through medical school who I felt really weren't qualified to finish medical school and to go on to become practicing physicians. So all of those factors drove me to write the book and to focus on those issues in the book. And after the book was finished, we started an organization called Do No Harm, which is a not-for-profit organization that seeks to expand on these issues and see how we can improve things. And let me just finish up by saying I think there's very good evidence that black patients generally have a great deal of healthcare disparities in terms of outcome compared to white patients. This needs to be improved. And one of my concerns that we'll get to is that the diagnosis of why this is true has been a faulty diagnosis because it's been blamed on bias and prejudice on the part of the healthcare system rather than the real problem, which is proper access to the healthcare system. The problem that will solve the disparities in healthcare is more healthcare for black patients, not a fundamental transformation of current healthcare. Where are we in the teaching of basic science and medical schools and how does focusing class time on social issues undermine medical education? Medical school time is a very valuable thing. And when I was in medical school, which goes back many, many years now, we spent two years in the basic sciences, two years learning normal function of various organs and cellular systems and then a whole year devoted to the diseases associated with those systems. In some schools, this is now down to one year. Now, there's just no way in the face of an ever expanding body of knowledge about medicine that all of the basic science that individuals need to really master to understand clinical science and clinical abnormalities can be accomplished in a single year. And the view has been now that, well, since information is so available online, we don't teach them they can pick up on their own. This turns out to be a terrible error because students need a very strong grounding in the basic sciences and particularly in information sciences, they need to understand how to review the medical literature. And this involves learning a great deal about biostatistics and epidemiology in order to master those issues. And they also need to learn how to take care of very sick patients. And these things are being shortchanged when the focus becomes more and more on social issues and courses on climate change, courses on gun violence on racial issues, which we can get to, which has clearly started to take over the focus of medical education these days. So I think that's the problem. The reason for the social focus is because it creates the possibility of an advocacy core of physicians. And I think the problem with it is detracting from medical education, detracting from the focus on basic sciences. Was medical school education sufficient to help physicians in the COVID epidemic? I think physicians were totally ill equipped either to treat the patients who were ill or to understand the dynamics of the disease, to explain to their patients what the epidemic unfolding would look like, what the basic epidemiologic characteristics of epidemics were. There was an article in the Wall Street Journal at the height of the pandemic about residents at Columbia and Presbyterian Hospital in New York City complaining about how ill equipped they were to deal with the sick patients that they saw in the early days of the pandemic. And they just didn't have any experience in dealing with ill patients or understanding how to run respirators or really any aspects of critical care. To learn that kind of material, you need to spend time. You need to have lots of patient contact. How is medical school teaching split between the basic sciences and clinical trading? And how did it change during COVID? Medical school faculty really come in two flavors. There's the ones that teach the basic science principles and they represent a relatively small component of the medical school. It's basically a graduate school in biological sciences. And then the second part of the faculty that teach clinical disorders and pathophysiology. So medical students are trailing them around as they see patients or maybe spending time with them in their clinics. In COVID, they separated the medical students from the medical school. The medical students all went home and worked mostly through Zoom meetings with their classes. I think there should have been a much more liberal exposure of the medical students to those patients, but they weren't. They were sent home and there was very little interaction with patients during the COVID pandemic. Who should run the curriculum medical school? The students or the faculty? This model of saying, well, you should decide what you really wanna learn and you should figure out how you wanna learn it and we should guide you through that learning as opposed to telling them, look, you have to learn this huge body of information and we'll guide you through it, but you're gonna have to learn this, you can't pick what you wanna learn. We have to tell you what you wanna learn. I'll give you one example, one specific example and I'll come back to something I said before. Students are not that interested in spending a lot of time learning about biostatistics and epidemiology. And yet, if you open up any medical journal these days and see the kinds of studies that are being done, for example, the New England Journal of Medicine, the methods section is usually an incredibly intense section talking about the statistical models that were used in order to interpret the data. If you don't understand something about those statistical models, you cannot understand the validity of the data that's being presented. And unfortunately, medical students and most physicians, myself included, are really totally unable to read the methods section of one of these papers and then go and look at the studies themselves and be critical about what the results actually show. This is what medical students need to learn. They don't wanna learn that. If you tried to teach them that they would reject it, they would be howling at the dean's office that we need to change this faculty that they're teaching us stuff we're not interested in. And we hear about that. We don't wanna learn that basic science stuff. I used to hear that all the time when we met with the students to debrief them about the curriculum. They wanna go and start from day one learning how to be doctors and many schools do that. Many schools put medical students into clinics on day one so they'll understand the relevance of what we're trying to teach them in the classroom. Well, to me, this is absurd. I mean, it really is infantilizing these medical students. And in fact, that's what's really happened to education in the country. We've been fanalized all the students. There's no sense of rigor. There's no sense of demands made on them. And when I say no sense, of course, there's a lot of wonderful students and there's a lot of wonderful education going on. But I think the medical school education has been watered down because of the issue of diversity. And if you have a focus on diversity, you have to compromise how important is problem solving to modern medicine. And medicine, you're in the front line. Patient comes in with a problem. You have to be able to sort through the issues. You have to have a clear idea of what is wrong with that patient at that time. You have to bring lots of information that you have to have right in your head in order to deal properly with that patient and to make a judgment about what that patient needs and how to proceed. And I give the example of the way we test information. We use the multiple choice tests where we give a little story, a stem it's called. And then there are five choices about what's the right answer related to that stem. So the stem might be the story of someone who's short of breath and the five questions might relate to what would be the cause of that shortness of breath. And then the student is supposed to use whatever other information is in the stem to come up with the right answer. I've told the students when you go from the classroom to the clinic, you are going from someone who reads those questions and answers them to someone who writes those questions. When you see a patient, you are gonna be the one who creates the stem, pulls from the patient the right aspects of their clinical history and then creates the four or five possibilities that explain their problem and then you have to pick the right one. So being able to do well on achievement tests, being able to do well on multiple choice tests really does define the way physicians think about things and the way you have to interact with patients. So not to base the capacity of medical students to do this kind of work, not to base it on their academic achievements, on their ability to do well on exams like that is a terrible mistake and that's what's going on. The approach now is supposedly the holistic admissions. Let's get rid of exams, let's get rid of worrying about grades, let's just pick people who really want to be doctors who want to work hard and that's the answer. And that's a terrible mistake because I think ultimately there's gonna be a cadre of students who just aren't very good at being doctors, aren't very good at thinking in this fashion and yet they'll be out there caring for patients. When I was in medical school, the attrition rate in medical school was something on the order of 9%. 9% of the students never finished medical school, most of them because of academic difficulties. Nowadays it's less than 3%. So if you take that 6% difference and you say either the students are smarter and more diligent now than they were back then, or the medical school curriculum is now carrying people through who really shouldn't be in medical school, I think the latter is probably the right judgment. And we know another professional schools like nursing, veterinary school, law school, dental school, the attrition rate is much, much higher. Nursing is something like 15%. And so not everybody who starts medical school just because they did reasonably well in college is gonna be a successful medical student and yet we're getting all of these people through. So I think there's a real issue there now. I think that there are plenty of very bright minority students who are doing fine. But on the other hand, if we're going to take minority students in and avoid asking for their academic credentials in a critical fashion, then we're gonna be ending up taking in students that really are less qualified. Very recently many medical schools, Harvard, Yale, Stanford, Penn have decided they're not going to follow the US News and World Report ranking system. They're not gonna submit information that ranking system. And everybody hailed that as a wonderful thing because it would improve medical school classes and relief stress, I don't know what they thought the benefits were, but the real reason for it was because the academic grades and the medical college achievement tests, the so-called SAT for medical school, those scores and those grades counted to a great extent in the ranking system. So you were ranked as much on the quality of your incoming students as anything else based on those achievements. And now without those ranking systems, you can take in whatever students you want and not hurt your academic prestige because there won't be a ranking system. So this is a device for bringing in more less qualified minority applicants and the dean at the University of Pennsylvania School of Medicine said that exactly. That was the exact reason for avoiding the ranking system is that we no longer have to worry about the grades or the standardized test scores of applicants. And I think what this means is we're taking in people that are less qualified and are gonna be less successful as physicians. And we know that how well you do in college and how well you do on the achievement test does predict what kind of medical student performance you'll have and your medical student performance does predict what kind of performance you will have as a resident trainee when you go into a particular specialty. And while we don't have data to show what it means for practicing physicians much harder to get such data, it seems pretty reasonable to suspect that that deficiency will carry through into someone's professional career. Well, it means there'll be more medical mistakes. The federal government did a study many years ago to show that medical errors was a huge problem. 98,000 extra deaths occurred each year because of medical error. The vast majority of those errors were physician errors, picking the wrong medication, picking the wrong diagnosis, not pursuing a diagnosis they should pursue. Now, I think if you have people that are less qualified, they're gonna be more of those errors. Why are there such differences in the quality of healthcare by race? I do not believe that the reason that healthcare disparities exist is because of biased care in the healthcare system. What the literature clearly shows is that there are disparities. The literature has not been able to identify the basis for those disparities. The personal experience of most physicians is that if bias occurs on the part of physicians and all human beings are biased, and I'm sure there are instances where a physician acts in a way towards a minority patient, for example, that might superficially look like they're just being biased, they're just being prejudiced. But in fact, they're tired, they're annoyed, but that doesn't represent a systematic kind of approach that physicians have to African-American patients. Oh, it's been an unfortunate circumstances that individuals have told in anecdotal fashion these kinds of stories and then equated them to, this represents the way black people are treated by physicians. And I just, I don't think there's any evidence for that. And in fact, there are some large studies in the literature looking at racial concordance. There's one very large one. Over several thousand patients tried to see whether black patients using black doctors had better healthcare outcomes, were in better health conditions than black patients who were dealt with by white doctors. There was no evidence whatsoever for that. And the few efforts that both economists and social scientists have tried to use to show that black patients have better outcomes with black physicians are either completely flawed with an absence of an adequate control group, or just of such small size that they're really uninterpreable. If we then say, well, nonetheless, black patients will probably feel more comfortable with black doctors. We're now starting to pursue a course for our society that says that we're gonna racialize our society, that we're gonna turn our society into a society where black patients seek black lawyers, black patients seek black doctors, black patients seek black accountants, white patients seek white doctors, white patients seek white accountants, white patients want white lawyers. Do we really want that to be the way that we've structured our society? And I just think that's the sort of thing that South Africa dealt with. And ultimately, the Supreme Court famously said that segregation is not equal, and that you can't have equal kinds of systems if you segregate racial groups, particularly racial groups that have different economic characteristics. So I think if we try to take black patients and put them in a black healthcare system and white patients in a white healthcare system, we're not gonna get separate, but equal, we're gonna get separate, but terribly unequal. And black communities are often impoverished and often have terrible social problems within the community. And our healthcare system is a very complicated system in this country where hospitals and other medical institutions need to be institutions that generate revenue. If they don't generate revenue, they can't stay open. And it's very hard to generate revenue in neighborhoods that have very high levels of poverty because the insurance systems that support those neighborhoods, the healthcare systems like Medicaid, really are systems that reimburse physicians and hospitals very, very poorly. When you go into poor neighborhoods, you tend to find hospitals often lack the resources that they need to provide the highest level of care. One example of this is in New York City. There's been some very careful studies done of again, going back to the issue of maternal mortality and morbidity of women at the time of delivery. And it turns out if black women go to black hospitals, that is hospitals that mostly care for black patients, they have a much higher morbidity rate, more complications of delivery than white women who go to hospitals that mostly care for white women. However, if black women go to the hospitals that mostly care for white women, their outcomes are the same as the white women. And if white women end up in the hospitals that mostly care for black women, there too, their outcomes are the same as the black women. The issue there is then these hospitals are not specifically prejudiced against black or white women. What they are is lacking in training, lacking in some of the facilities, lacking in staff that are knowledgeable when pregnancies develop severe acute complications. If there is a problem with healthcare in the black community, the problem is mostly access to healthcare and access to really good healthcare. Systems like University of Pennsylvania have built magnificent outpatient facilities in very affluent neighborhoods because they need patients with very good healthcare insurance to supply the institution in order that it can generate enough revenue to maintain its facilities and maintain this as staff and so on. And they don't build those wonderful facilities in black neighborhoods because those neighborhoods really can't sustain the kind of reimbursement that those hospitals need in order to be secure. So this is really an economic problem. How this problem gets solved in this country is something that I'm not really able to answer. But to say that, okay, black patients are having poor outcomes. What we're gonna do is take all our physicians and send them to two weeks of implicit bias training, which is the way some institutions have now said, they're gonna solve the problem is completely ridiculous. That is not gonna solve any problems and spending more and more money on consultants that explain how they're gonna have a more diverse healthcare workforce is not gonna solve the problem of poor outcomes. What's gonna solve the problem of poor outcomes is getting better facilities, getting better health access to the black community. That's what's gonna improve the disparities between outcomes for black patients and white patients. What are you optimistic about? I am optimistic that technology can really help. For example, at Penn, one of the things that was found after the pandemic was that black patients weren't coming back for post-operative appointments after they had some sort of surgical procedure. They were just not showing up. They ended up developing a telehealth medicine approach and improve the patient attendance from about 50% up to almost 90%. Improving access will improve the outcomes tremendously. It's putting the nurses in a van and sending them out to the community with a CT scanner in the van and doing the procedures where the people live and not waiting for them to come into the hospital to get their yearly mammogram, for example. My advocacy is all about just don't blame healthcare disparities on physician prejudice. It's a tremendous waste of time. It undermines the spirit of the healthcare system. It insults the physicians and it makes the patients less trustworthy of their physicians. Improve the access of healthcare to patients and you will improve outcomes. So I think many health systems are starting to understand this even though they still talk a good game about getting rid of their systemic racism, improving access will improve the outcomes for black patients. Thanks to Jay and Stan for joining us today. If you missed last week's show, check it out. The topic was juries, opportunity and peril. Our first guest was Sonali Chakravarti who is professor of political theory at Wesleyan who focuses on the importance of juries to democracy. She is the author of the book Radiquan Franscheismann in the jury room in public life and to now we discussed expanding the use of jury nullification. Our second guest was retired federal district court judge, Gary Finerman who left the bench at the end of 2022 to be a litigation partner at Latham and Watkins. Gary presided over 48 jury trials and he described the seriousness that juries take their job to get to the right answer. Our third guest was David Stellings, a law partner at Leaf Cabrese, Hyman and Bernstein. David is one of the top class action lawyers in the country and represent the class in the famous VW diesel case. David described the challenges working with a jury in complex civil litigation. Our final speaker was the what happens next film critic Darren Schwartz who reviewed the classic film 12 Angry Men and its continuing relevance to understanding the inner workings of jury deliberation. I would now like to make a plug for next week's show on the opioid crisis with Gerald Posner who wrote the book pharma, Greed Lies and the Poisoning of America. Gerald will speak about the conflicts inherent that pharmaceutical firms have with advancing public health and seeking profits. You can find our previous episodes and transcripts on our website, what happens next in six minutes.com. If you enjoyed today's podcast, please subscribe to weekly emails and follow us on our Apple podcast or Spotify. I would like to thank our audience for your continued engagement with these important issues. Goodbye. .