Authors: Meghan Etsey, Vashti Price, Dr. Frances McGill – on behalf of AMWA Gender Equity Task Force
“Our Voices, Our Future” is a podcast by the Gender Equity Task Force of the American Medical Women’s Association that explores the challenges, stories, and successes of those working to advance gender equity in medicine. Through candid conversations with changemakers, advocates, and leaders, each episode dives into issues like pay gaps, leadership disparities, and inclusive workplace culture. Tune in to be inspired, informed, and empowered to take action. Full episode listening links are available below the transcription.
Meghan: Welcome to “Our Voices, Our Future,” the podcast where we amplify the voices driving change in equity within medicine and beyond. Brought to you by the Gender Equity Task Force, a committee of the American Medical Women’s Association. We are here to challenge norms, break barriers, and ignite conversations that matter.
Meghan: I’m Megan Etsey, and in each episode, we’ll bring you candid discussions with leaders, change makers, and advocates working to create a more inclusive and just world. No more silence, no more waiting, it’s time to get “Our Voices, Our Future.” Today, we are welcoming Dr. Frances McGill. Dr. McGill began her career as a critical care nurse and was accepted as one of 16 women in the second class at St. George’s University School of Medicine in Grenada, West Indies. Her internship in internal medicine was at the Brigham Waltham Brockton Program in Medicine at Harvard Medical School. She completed her residency in obstetrics and gynecology at the Women and Infants Hospital at Brown University. Most of her career has been in academic medicine in New York and Grenada, with sabbatical leaves in the UK. Combining clinical practice, leadership, teaching, research, and medical education. Her positions include head and director of gynecology and medical student clerkship director at New York Academic Medical Centers. Later, she returned to St. George University as a professor of clinical skills in obstetrics and gynecology. Now, she’s an Emeritus professor and works part-time at a New York City Health Center. Throughout her career, she has participated in medical student and resident selection committees, mentoring medical students, young physicians, physician assistants, and nurse practitioners. She thanks the leaders of the Women in Medicine student organization at St. George University for allowing her to speak on bias in medicine.
Meghan: So first off, Dr. McGill, for those listening and not aware, can you tell us a little bit more about implicit bias and what this means?
Dr. McGill: Yes, Meghan, thank you very much for inviting me to talk to you. Before I talk about implicit and explicit bias, I want to give you a dictionary definition of bias, and bias, by Merriam-Webster Pocket Dictionary, is defined as prejudice. Then I looked up prejudice, which is defined as damage, especially to one’s rights. Particularly with respect to what we’re speaking about today, as an unreasonable attitude for or against something. So, if we think about explicit bias, explicit bias is a bias that we are aware of. As human beings, there are things that we all just don’t like. So, we don’t like certain colors, places, smells, foods, brands, and people. Explicit bias is more of a known bias against a group. Since we’re talking about people, particularly against a group of people, historically, if we look back into the 1950s, there was a lot of bias by white people against black people, so the black people in America, particularly in the South, were segregated. They were not allowed to use the same bathrooms. They could not go into restaurants. They were delegated to the back of public transportation buses and not treated well. Even before that, there was a lot of violence against black people by the slave owners. Similarly, Japanese immigrants in the United States at the time of World War II were taken from their homes and forced to live in camps in the Midwest, and that was another explicit bias that was really against people of a culture or people with skin color.
Now, implicit bias is a little bit different. Despite wanting to be universal in our thoughts, we all have unconscious biases. Unconscious bias or implicit bias dates back to primitive times when men were certainly not cultured, and early humanity, if we look back, I guess millions of years ago, was tribal, with groups of people living together. The main issues in their lives were foraging for food and protecting themselves from animals and their enemies. In that culture, there was either a fight or a fight mechanism or defining people not in their group as either enemies, foes, or friends. Unfortunately, or fortunately, that has existed in our contemporary brain, but it’s really relegated to being very unconscious. Implicit bias is an unconscious bias against anything. It can be against people’s behavior or people’s groups. It is responded to by a very fast response rather than a very thought-out response. As I was thinking this through more, sometimes we even say something that comes to us, and you look back later and say, How did that come out of my mouth? What did I say? So I think it’s not only behavior, but it’s sometimes how we see things quickly. A lot of research has been done on this by police departments because everyone is aware, particularly over the last few years, of police violence and police shooting people. Then it’s found that the people really did not have an on or it’s police of one color, particularly against people in our black society. What the psychologists have realized is that this is really implicit bias in police officers who feel threatened at a time by someone that they see as a perpetrator. There has been research showing that somebody may have something in their hand that the police officer thinks is a weapon, and really it isn’t. They’re working very hard on that. Similarly, as we move on into our careers, we may have a bias against people of color, people who don’t look like us. We always think that people think and act like us, but we don’t. So what I would like you to do is just take a minute or two. I’m just gonna be quiet for a minute, which is hard for me, and just think about some time in your life, how you’ve quickly responded to a new situation or an unexpected or unplanned event for you. So, your very quick response, and then later on, when you thought about it, would you have thought about it differently? We’ll just stop for exactly one minute.
Dr. McGill: There are many examples of implicit bias. The one that was brought up by the woman who trains physicians and other people in healthcare on bias. Her name is Diana Lautenberger, and she brought up the example of Oprah Winfrey being in Europe, not dressed, not made up, wearing her sunglasses, going into a very expensive bag store, and wishing to buy a bag that was on the top, top shelf, which costs $38,000, more than any people’s salaries. The clerk just started to not reach up for that bag but suggested that she look at other bags because that clerk made the judgment that this woman was not going to afford this ridiculously priced bag and that she would be helpful in terms of not making her feel bad, but in terms of having something reasonable for her. Another classic example I just said to one of the medical students as I was preparing this is how many times the male patient has called you a nurse? So there’s the implicit bias, and it’s there, and nobody means it. We don’t think about it. So that is what we’re going to focus on today, a little bit. It’s really very hard to pinpoint bias, but it’s something that we have to be a little aware of, and we should be seeing the world as they do, not only as us.
Meghan: Thank you, Dr. McGill. That’s a great explanation. I think it sets us up well for this next question. So, can you tell us how implicit bias manifests in medical school admissions and residency matching?
Dr. McGill: Well, I think that there are a lot of issues in terms of the people who interview medical students now and the people who interview residents. They’re often of a different generation, and the newer generation looks different from how we look. They have tattoos that are now visible. When I first taught at St. George’s University in 2008, our chairman was adamant that anyone who had a tattoo going to the hospital had to be covered up. Well, that’s probably no longer possible when I see how popular tattoos are; some are very beautiful. However, I’d be very afraid to have all those needles put in me. Now, we have transgender people who sometimes look very much the part of their designated gender by how they were born. Some people look unisex, and you can’t tell exactly who they are. We have more unisex names, and that is a new phenomenon. People have visible piercings; people have different colored hair. So all of that just may make a little bit of implicit bias just by looking at where they went to school on their application form. If it was a school that you went to or respected, it may bring in some bias. The way they speak. Do they speak well over the internet because everything is done over Zoom? Do they smile over the internet? Do they make good eye contact with you? I think that’s all very difficult compared to a real-life situation where you can go in, greet a person, and smile.
There are lots of implicit things that could happen in medical school and in residency admissions. Later in the questioning, we’ll discuss how that can be mitigated. What I wanted to do for the audience who may not be totally familiar with medical school admissions was to talk to you a little about that. It is an overwhelming process both for the applicant and the faculty who need to take time out because everything is now pushed on seeing as many patients as you can within a given period. There’s very little academic time for physicians working in hospitals and residency programs, and very little research time. Interviewing candidates is done within the context of a very busy day. Still, for the candidates, the average American graduate from a college or university will apply to 18 medical school programs, and that is done through the AMCAS American Medical College Application Selective System. It is a rigorous application that the candidate has to fill out their demographics, including things about their family and their family finances. One of the biases I read about is that families with better means have a higher acceptance rate to medical schools than those with lower incomes. Although students from lower-income families can apply for financial assistance, each application to each school costs about $150, and the AMCAS application overall is $348. So we’re talking about a lot of money, but if we look at people from less socioeconomic, less positive situations. Applying for loan assistance is also arduous; many students don’t know about it. After the student’s application is screened, they also have to fill in every course that they took, every grade that they received, every school that they attended, and personal statements. I’ll talk to you about a personal statement later on. The Medical College Admission Test (MCAT) is a standard test that students must take. Most medical school applicants are not in a special combined college and medical school program, which is costly. Suppose the applicant is somebody that the school would like. In that case, they often have to fill out a secondary application, which may have a fee again. They may have to answer multiple questions or write another essay. This is not uniform across the board with the American medical schools. So, the process is very arduous. I also talked to you about how arduous it is for the faculty. One of the things that the medical schools look at is the healthcare background. Some students feel compelled to shadow physicians, where they will spend time in a physician’s office or with a physician in the hospital, just following that person around. Some students believe that there’s so much weight put on this from the medical schools that they will spend hundreds, if not thousands, of hours doing it. Some will take a gap year, so a year after college or university, to apply to medical school. Recently, an article talked about how this also adds arduous issues for medical students. That healthcare experience, meaning maybe being a scribe, where the student will join an organization, learn about the electronic medical record, and assist the physician in putting in the patient information so that that student is with the physician observing what the physician does, or perhaps being a medical assistant where they can get some payment, or perhaps being part of a research group doing some of the technical things that are involved in research grants, would be all beneficial. Now, in my day, when I was applying, I worked at a university hospital in an open-heart critical care unit, so I was doing very high-level nursing. Spoke to the dean of that medical school, and he said, “We don’t want any of you people who have any backgrounds; you all have bad habits.” So, I was fortunate enough to be accepted into St. George’s University. I have to tell you, my grades weren’t perfect. I partied, I went to school, and I worked full-time. So, my grades weren’t perfect, but they were acceptable. A lot of the people in my class were from healthcare backgrounds. We had nurses, pharmacists, physical therapists, respiratory therapists, and PhDs because the US system didn’t want them. The US system is now looking at more global candidates and looking for people who have done other things with their lives and other things to demonstrate that they understand the healthcare professions, particularly medicine.
Meghan: Can you tell us if there are particular demographic backgrounds and groups that are disproportionately affected by bias in the medical school admission process?
Dr. McGill: Well, when we look at the data, we look at medical school admissions. Classically, women were not accepted into medical schools. Then, in 1849, Elizabeth. Beth Blackwell, an immigrant from the UK at age 11, wished to attend medical school. She applied to the US. The schools were all male candidates, and she was rejected. Then, she was finally accepted to Geneva Medical School, which was in upstate New York and no longer exists. Her sister had the same issues, but she was finally accepted, and these women started a hospital in New York to take care of women and children. So, they were the people who first opened the doors to medicine. There was a lot of prejudice also against people of color, particularly women of color. In 1864, Rebecca Lee Crumpler, also a nurse, applied to medical school. She was applying because she was so concerned about the prejudice against both women and African American people. She attained admission and started opening the door to women of color. Suppose we look back at the earlier data from the American Medical Colleges, 45 years of data. From 1980 to 1981, when I graduated, the data from 45 years was collated. There were 36,000 applicants for medical school, of which 26,000 were men and 10,000 were women. So, in the 1980-1981 class of this total that was accepted, 49% of the applicants, 17,000 people, were accepted into medical school. That was 12,000 men, who comprised 70% of the class and 46% of the applicants, and 5,000 women, 50% of the female applicants but only 30% of the class. Suppose we move forward to contemporary times in the 2004 – 2005 applicant class. There were 52,000 applicants, of which 24,000 were admitted. This is 10,000 men, so 49% of the male applicants, but interestingly, 42% of the class. Now, the women applicants, because the door has been opened by these ladies and those of us who went to medical school in the earlier years. Of the 30,000 female applicants, 14,000, or 47%, were accepted; this was 58% of the class. So, for about the last 20 years, the women’s medical class, the women’s medical students have been 50% or more in the classes. Now, one of the problems as we move forward, looking at this, is that they are now applying to competitive residencies, which are, in general, surgical residencies. When women come out as physicians, and most physicians now are employed, their salaries are about 75% of what their male counterparts are earning. So, that is a big discrepancy, and I’m sure it will be addressed by another forum at AMWA. Classically, because women may be interested in childbearing, and also because their interpersonal skills are so good. That’s been shown in much of the literature. Classically, women have been accepted into residencies that they’re interested in, such as family medicine, internal medicine, and pediatrics. Those specialties, because they’re not procedure-oriented, also have earned less income. Still, they have also been a little more flexible, perhaps in helping women have their childbearing and child-rearing years. If we look at the contemporary statistics, we look at applicants from 2000 to 2002. The data shows that, when looking at American Indians (Native Americans) and Alaskans, about 44% of those people were admitted to medical school. The overall acceptance rate of all cultural groups is about 45%. When we look at Asian Americans, we see an acceptance rate of 49%. If we look at whites, the largest group, their acceptance rate is 43%. Now, Hawaiian and Pacific Islanders have a 38% acceptance rate, and I wonder why that is so low. If we look at Hispanics, their rate is 42%, so a little bit lower. Maybe not statistically significant, but when we looked at black and African Americans. For applicants, there were 4,700, of which 1,600 were accepted, which is a 34% acceptance rate.
When I looked at the data, their MCAT scores and grade point averages were lower. That is an issue that we really need to look at and try to help students of African American background. If we look at international students who are first generation now in America, they comprised 14% of the applicant pool, but their admission rate was 11%. So, this is another group that needs assistance. One of the problems with these two groups is that because they come from less affluent cultures and less affluent societies, they may not have the mentorship, and they may not have the higher-level schools that they’ve gone to. They may not have pre-med committees in every institution. They may not have people in their families who have gone to college or higher education who can assist them. So, these are people that we need to focus on to make our classes more diverse.
Meghan: Can you tell me how holistic review processes have improved diversity in medical school admissions, or do these biases persist?
Dr. McGill: Well, I think all the schools now seek more diversity. Schools that had been primarily white Christian males then accepted women, and now there are more Asian students in the classes. There are more people of color in the classes. There are more people who speak diverse languages in the classes. Unfortunately, under the new leadership in America, we can no longer have DEI noted anywhere. So, the class needs to be diversified in a different way. One of the things that’s important for the candidates, both in medical school and in residency, is that when you’re writing personal statements, do not recapitulate your grades and other things. Do not write, “I wanna be a gynecologist, which I am because I had painful periods when I was young.”. I’ve seen that in people’s personal statements. Talk a little bit about yourself. What I hear resident application candidates saying is. We read on the internet that we shouldn’t write anything in the application itself. Now, the application is at least eight pages long, and as I said, people are very busy. So we’re not going to go through eight pages of looking for what that student did, so we know how to talk to them. So, put something about yourself. I grew up in this, and my motivation was whatever. Maybe your grandmother was sick, which encouraged you as a child. We need one sentence on that, not a whole treatise. Talk about what you did and what your culture was. I came from this kind of background. What struggle did you overcome? What is your motivation to do medicine? What makes you different from another candidate? If you’ve been like an Olympic star or a fighter pilot or something that’s on your application, please put that in your personal statement because that’s what we look at, and that’s what we talk to you about during interviews, and that’s the way you sell yourself. So, I think the schools are still trying to diversify the classes. What we know is that patients want to be taken care of by people who look like them. I guess, in a sense, it’s reverse implicit bias. I was just at a GALA for the clinic where I work in the inner city of New York. There were a number of guests there, and one of the guests was the childhood friend of the man who is a CEO, a Hispanic man who was discouraged by his college professor but then continued on and came back to the clinic that he attended as a child, and now is doing a wonderful job.
One of the guests said, “I had some spicy food, and I went to my private physician who is in New York City in one of the upscale neighborhoods. I told him I just had indigestion, but it’s been going on for a long time. So he gave me some antacids and sent me home. Then I started feeling a little bit worse. So I called my friend, the man who’s the clinic’s CEO, and I asked him, Do you have a black cardiologist for me? ” He said, “We just hired one”. He went to the black cardiologist, he was listened to, and he went from that office to the hospital where he had four stents placed in his heart.” So, it just shows that there still is implicit bias in terms of culture and how people talk to each other. We don’t know what exactly this patient really said to the doctor. We don’t really know exactly what the doctor said to the patient. Still, there is a big need for diversity in medical school classes. We know that if they cater to people in their own culture, those people are very appreciative.
Meghan: How would you say that interviewers ‘ unconscious preferences affect the way that applicants are evaluated?
Dr. McGill: Well, we try very hard on admissions committees. I’ve been on admissions committees at two major institutions, a US institution and an international institution, and sat on residency selection committees probably since we were residents. So, I have served on multiple committees. What all of those committees have is they have standards for the interviewers. Generally, the interviewer will grade the candidate objectively on a standardized form that all of us share, which is a numerical grade. It’s like a Likert scale or some verbal standardized responses to the candidate to evaluate everything in the candidate or evaluate just the interview, depending on where you are and how your committee is formed. Having standardization among the evaluators should overcome some of the implicit bias. If we know, for example, that Megan says, “Oh. I like her because she went to the same school as me, and I know that those students are good because I’m very good.” We will say the director of the admissions committee should take Megan aside and say, “We have to be objective, not go on happenstance.” Those things happened in the past. I think they’re happening less now. If a student appears to be problematic in the interview. Then, maybe they can be offered a different interviewer, or in one of the committees that I work with, the students are interviewed by eight different people in one afternoon, which is quite arduous for the students. When you think there are 8 evaluators, if one evaluation is off-kilter, it may be the interviewer. If six or seven of those evaluations are off-kilter, then maybe it really is the student who would not be a fit for our school. So, I think people are trying very hard to have the format and evaluation be objective. It should be a conversation. We want the students or the resident applicants to be talking to us, not just going through thinking, “Okay, I have to say this now. So I’m saying this, and this is what I have memorized.” We want to understand you as a person, see if you fit, and evaluate your communication skills. We’ve already seen your academic skills. Otherwise, you wouldn’t be getting the interview.
Meghan: Why would you say it’s crucial to address these implicit biases?
Dr. McGill: Well, I think it’s crucial to address it so that we can have an objective evaluation of students and so that we can hopefully accept students and physicians into our medical school and into our residency who will fit in our programs, who will excel in our programs, and who will be very good academically and interpersonally with the patients that they take care of and be a credit to our institution when they finish.
Meghan: How can admissions and residency committees hold themselves accountable for having these fair selection processes?
Dr. McGill: Well, I think we just discussed this because we all have been trained in implicit bias. All of the committees will have meetings before the interview sessions or periodically go over the standards that are expected. I think everyone is constantly updated on those standards. The other thing that I think goes across the board is if the interviewer personally knows the student, he or she must refrain from interviewing that student or making a judgment on that student, because you’d probably be prejudiced either for or against him.
Meghan: Dr. McGill, can you tell us just lastly, what advice you have for applicants from underrepresented backgrounds navigating through these challenges?
Dr. McGill: Well, actually, I think my advice is for everyone, and that is to believe in yourself. That you can do, finding a mentor who believes in you. All of us have been told, “No, we couldn’t do it, or we shouldn’t do it.” Find somebody who believes in you. If you are in a school where there’s a pre-med program and they have an advisor, once you finish, sometimes it’s hard to keep that relationship up, but you can certainly explore that. If you are not successful the first time, then try again.
Study very hard in your undergraduate or medical school studies. Pay attention to the books or articles, or whatever kind of handouts are given by the instructors. Do not rely on the senior students who say, Oh, you don’t have to read that because it’s too much work. Just do the question book, or just do the little mini book. Doing practice questions is very good. You need to do it after you’ve learned the material, not use the practice questions and the answers in the book as a way of learning the material. That is not a way to learn to be a pre-med student. You need to get the process of how to think through things before you take your MCAT. It certainly is not a way to learn medicine. For undergraduate students who may be financially disadvantaged, there are Pell Grants, or at least there are. I think we don’t know what is going to happen with the American administration as it is now. Pell Grants are federal grants for undergraduate education. They usually do not have to be paid back, but it’s dependent on family income. So, there is a complicated application procedure. Federal grants are usually available at least for secondary and tertiary education for medical schools. Again, it depends on the applicant’s financial status and the family.
There are some other ways that you can skirt around the cost of medical school. Some schools are now becoming three-year programs, so you have very little summer vacation, but you finish after three years instead of paying four-year tuition. That’s where we are now because in the fourth year of medical school, classically, that has been a year of what we call electives. So, the student has finished their core rotations. They’ll do things that they may or may not have learned, or they’ll do rotations in specialties that they would like to apply to, so that the people at those institutions have seen them. We have to see how going to a three-year school plays out. I’ve had some experience with it, and for the candidates who know exactly what goal they have, it has worked out pretty well.
In New York City, at the New York University School of Medicine in Manhattan and the Albert Einstein College of Medicine in the Bronx. Those schools are tuition-free. They have been very graciously funded by benefactors. There is also a Uniformed Force of a School of Medicine based in Bethesda, Maryland, where you can apply like other applicants. Certainly, a little advantage if you’ve been in ROTC or you’ve been in one of the paramilitary careers, but you can apply, and there is no tuition for that. You actually get paid a small stipend, but when you come out of that school, you must serve in the military forces. That is not your choice, nor is where you’re deployed to a hundred percent your choice. So there are ways to do those things. What I would say is study, study, study. Take time for yourself, a little time off on Saturday or Sunday, and do your best in your courses and your best on your examinations. I wanna thank you very much, Meghan, for inviting me. It’s been very lovely and very nice to speak to all of you who listened, and I hope I didn’t talk too much.
Meghan: Thank you so much, Dr. McGill. This has been a great discussion full of valuable information. That’s a wrap on this episode of “Our Voices, Our Future”. We hope today’s conversation inspired you, challenged you, and reminded you of the power of raising your voice. The fight for equity doesn’t stop here. Join us in the movement. Subscribe wherever you get your podcast, and if you love this episode, share it with someone who needs to hear it. Until next time, stay bold, stay vocal, and keep the conversation going. This is “Our Voices, Our Future”
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About the Authors
Meghan Etsey, MS4
Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world.
Vashti Price is a third-year medical student at St. George’s University. She holds a Bachelor of Science in Biology from the University of Louisiana at Lafayette, a Master’s in Biological Sciences from Alcorn State University, and a Master’s in Health Sciences from Meharry Medical College. With a strong passion for public health and health equity, Vashti has dedicated much of her time over the years to volunteering with underserved populations, including individuals experiencing homelessness and children in need. Her commitment to service continues through her involvement with the American Medical Women’s Association, where she serves on the Gender Equity Task Force and the Sex & Gender Health Collaborative Committees. Vashti is particularly interested in the intersection of medicine, public health, and community outreach. Outside of her academic and clinical pursuits, she enjoys spending time with friends and family, attending festivals, exploring new cities, and winding down with a good Netflix series.