Dr. Norman C. Wang and Selective Outrage

Back in March 2020, a University of Pittsburgh physician by the name of Norman C. Wang published an article in the Journal of the American Heart Association (JAHA) about the use of race and ethnicity considerations when recruiting for the US cardiology workforce. Wang argued that Diversity, Equity, and Inclusivity offices are ultimately unhelpful in promoting minorities in cardiology practice. He also pointed out that these offices may be unconstitutional and that they often make claims that may be unsupported by the relevant empirical evidence. Towards the end, he advocated race-neutral admissions and hiring practices as an alternative to the current model. The article attracted no controversy upon publication, but that all changed a few months later.

A physician under fire

Over the first weekend of August, a large number of professionals suddenly began condemning Wang online for promoting “historically racist stereotypes” and, as one physician put it, failing to account for the “structural biases” medical students of color face. An interventional cardiologist declared that Wang’s writing aligns with the kind of thinking that “defines systemic racism” and another physician, Dr. Sharonne N. Hayes, tweeted that “The fact that this is published in ‘our’ journal should both enrage & activate all of us”:

After other professionals joined the outcry on social media, the American Heart Association (AHA) announced on its Twitter feed that Wang’s paper did not represent the organization’s values and assured its followers that, “We’ll investigate. We’ll do better. We’re invested in helping to build a diverse healthcare and research community.” A subsequent statement released on August 6th stated that the article would be retracted, and claimed that it “contains many misconceptions and misquotes and that together those inaccuracies, misstatements, and selective misreading of source materials strip the paper of its scientific validity.” Wang did not agree to the retraction and the AHA announced that it would be publishing a rebuttal. The editor-in-chief of JAHA, Dr. Barry London, promised that the peer review process would be reviewed in order “to prevent further missteps of this type,” and on Twitter, Dr. Kathyrn Berlacher revealed that Wang had been removed as Program Director of Electrophysiology. “We stand united,” she added, “for diversity equity and inclusion. And denounce this individual’s racist beliefs and paper.”

The complaints

Numerous articles and statements condemned Wang’s article for its alleged lack of “scientific validity,” but very few offered data-supported arguments refuting the specifics of his points. A former president of the AHA, Dr. Robert Harrington, was quick to describe Wang’s article as “disturbing,” but the only evidence he offered by way of refutation was a study indicating that black patients may prefer a same-race doctor and be more comfortable asking for more preventative services.¹ Had Harrington read Wang’s article more carefully, he would have found that very study cited and discussed by the author on page 12:

…residual confounding in patient-physician racial and ethnic concordance studies is impossible to eliminate as physicians of the same race and ethnicity are not interchangeable. The results have little external validity as the study only involved 14 physicians (8 nonblack and 6 black). Moreover, mortality estimates were extrapolated from single patient-physician encounters using methods so unscientific that the investigators themselves described them as “back-of-the-envelope calculations.”

Wang concedes that some research shows better communication with same-race providers,² but that no strong evidence of improved quality of care or health outcomes beyond speculation could be found. He went on to cite literature where Hispanic men were more dissatisfied with certain aspects of their care with Hispanic providers, indicating the mirroring of demographics does not automatically improve healthcare satisfaction.

In an August 3rd tweetstorm, Dr. Jeff Linder listed eight criticisms of Wang’s article, which were a mixture of polemics and uncharitable mischaracterizations. Linder was upset that the word “racism” did not appear in Wang’s article, even though racism was not the topic under discussion. He also took issue with Wang’s failure to address other barriers that under-represented minorities might face as medical students (he did not elaborate on what those barriers are) and announced that he disliked Wang’s supposedly aggrieved “tone.” Linder also accused Wang of a “profound misreading” of a recent commentary written by the two physicians, Clyde Yancy and Ajay Kirtane:

Reading Wang’s paper alongside Yancy and Kirtane’s, it is not at all clear that he misread their work. He may have simply drawn additional conclusions from their discussion. On page 12 of Wang’s article, he writes:

Recently, Clyde Yancy, MD, and Ajay Kirtane, MD, commented on a study where race and ethnicity was no longer associated with differences in outcomes after accounting for social determinants of health. They concluded, “What was heretofore attributable to inexplicable race/ethnicity-based differences may now be more clearly associated with both biological and social constructs, perhaps independent of race/ ethnicity.”

Yancy and Kirtane seem to contend that “race” is a problematic term given “significant within-group heterogeneity.”³ It is unfortunate that Yancy saw fit to retweet the president-elect of the AHA celebrating the retraction of Wang’s article, as both Yancy and Wang express concern regarding the significance of race in decision-making, albeit in quite different ways: Yancy and Kirtane are worried that race is being used to determine health outcomes; Wang worries that those outcomes are being influenced by race-based representation in the cardiovascular workforce. It’s a pity these professionals are unable to have a more nuanced conversation, because polling data indicate that a majority of Americans agree that race should not be a major factor when considering things like admission to higher education.

Wang was also accused of failing to examine the benefits that diversity supposedly brings to decision-making and scientific production (a point made on Twitter by Linder as well as Duke University cardiologist, Dr. Ann M. Navar). This criticism faults Wang not for something he wrote but for something he did not write.

Even if we accept, for the sake of argument, that Wang ought not to have passed over this topic, the idea that better science automatically results from gender and racial diversity has by no means been decisively settled by the relevant literature. This includes research conducted by Dr. Anita Woolley on collective IQ and books by Dr. Scott E. Page, including The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies. Most of the research by Woolley, Page, and other social scientists finds that cognitive diversity (differences in perspective, mental processing, and problem solving)—not ethnic or racial diversity—is the important variable for improving group performance. Woolley’s work does seem to indicate that mixed gender groups do better on assigned tasks than those with only one gender,⁴ but a 2017 study in the Journal of Intelligence found no correlation between gender diversity and collective IQ or group performance,⁵ so this area would benefit from more study. Similarly, it may turn out that racial and ethnic diversity correlate positively with group performance, but this has not been firmly established yet either. Consequently, when a scholar like Page does argue that identity diversity may be beneficial in his book The Diversity Bonus, he also cautions that, “We cannot prove that identity diversity creates beneficial cognitive diversity”⁶ and “The relevance of identity diversity is less obvious on scientific and technical problems.”⁷

There are certainly cases where identity diversity is beneficial for healthcare. Female patients may prefer female providers for obvious reasons and multilingual providers are clearly advantageous to health systems treating foreign patients. But if diversity bureaucracies continue to make empirical claims regarding the decision-making and scientific benefits of racial diversity, it is perfectly reasonable to study this orthodoxy. And if we accepted such claims a priori, it would still be important to assess whether or not diversity bureaucracy is producing the desired workforce demographic changes. This was the impetus for Wang’s piece and he is not alone in this line of inquiry: Even those who strongly advocate increasing workplace diversity have remarked upon the persistent failure of existing programs to produce the desired results.

Finally, Wang’s claim that diversity initiatives disadvantage Asian applicants has been attacked as inaccurate. Even if we exclude wider academic examples such as the Harvard admission rating system and focus instead on medical school admissions, contemporary data continue to show that Asian applicants require higher Medical College Admission Test scores and Grade Point Averages for admission to medical school compared to African American and Latino students. This did not prevent Dr. Navar from tweeting that, “Arguments that efforts to increase diversity hurt Asian Colleagues not backed by much fact.” But Wang had already addressed this objection by citing evidence that Asians undergo “deminoritization” by being counted under the “white” category in the Attributes, Components, Capabilities model⁸ used to assess workforce diversity, and are likely the most negatively affected group by current racial equity practices.^9,10

Diversity bureaucracy and selective outrage

Notwithstanding the above, the AHA continues to defend its statement released on August 5th under the heading: “Wang paper is wrong: Diversity, equity and inclusiveness in medicine and cardiology are important and necessary.” And diversity officers continue to insist that their initiatives lead to better education and problem-solving without entering into a wider discussion about the vital importance of ideological diversity to improve research impact. Some writers have even attempted to discredit the call for ideological diversity as a “trojan horse” for “granting fringe right-wing thought more credence in communities that reject it.” It is not surprising then that Wang has been vilified for a paper that expresses a heterodox view on an important topic.

No comparable outrage was directed at the New England Journal of Medicine when a soon-to-be chief resident of psychiatry ridiculed a suicidal white BLM protestor even as he demanded that fellow practitioners “diagnose racism” in their own practice.¹¹ Nor do organizations retract articles in the Lancet that make unsupported statements such as “white supremacy and the institution of slavery that dates back over 400 years… are maintained by racist policies and practices that construct and reinforce inequitable access to power and resources.”¹² Legal commentator Hans Bader wrote an article about the Wang controversy in which he pointed out that, “Far harsher criticism of affirmative action has been ruled protected speech by the courts” and “Non-lawyers are not expected to know exactly when an affirmative action program is legal versus illegal, and their criticism of an affirmative action program is protected as long as it is reasonable, even if the affirmative action program turns out to be legal.”

Meanwhile, the multi-billion dollar diversity industry in the US continues to thrive as corporations scramble to signal their commitment to diversity in our wake of recent social unrest. Perhaps this is what compelled physicians to attack Wang as a racist—the need to display their own purity lest they fall victim to any new policies enforced by incoming diversity officers. It could also be that Wang’s paper threatened the validity of those closely tied to diversity offices. The aforementioned Dr. Sharonne Hayes is the chief diversity and inclusion officer of Mayo Clinic in Rochester, MN, and a review of the individuals who celebrated the article’s retraction on Twitter shows a similar trend.

Conclusions

This selective outrage and harassment will not surprise those familiar with the general milieu, but publicly disowning anyone who critically examines medical dogmas has an insidious knock-on effect: It undermines trust in medical journalism and has a chilling effect on future inquiry. Such an effect has already been documented in the US university system, and it poses a particular threat to the study of medicine. Our profession functions well because constructive criticism, the need for empirical data, and a willingness to change have hitherto been so deeply entrenched. This tends to be especially true in cardiology—medications called “beta blockers” that were controversial years ago for certain heart ailments are now among those most widely prescribed for patients with these same diseases. New research on old diabetic medications is also improving the way we treat pathologies of the heart. Medicine thrives when challenging orthodoxy and expanding its vision. Even if Wang’s prescription of race-neutral admissions proves to be undesirable, we can only benefit from discontinuing practices that do not produce the intended results.

I rely on and enjoy reading medical journals to guide clinical practice, and I’m dismayed by the refusal of the JAHA to stand by one of its contributors and defend the expression of a heterodox view. It is equally unsettling that many of the criticisms of Wang seem to rely on the medical public’s ignorance of his article or misrepresentations of its arguments. Wang, as I understand him, simply wants a system that treats health practitioners as individuals—a recommendation he spells out clearly in his conclusions. Unfortunately, his article was published at a time when we are regressing to group essentialism.

References:

¹ Marcella, A.; Garrick, O.; Graziani., G. “Does Diversity Matter for Health? Experimental Evidence from Oakland.” American Economic Review. 109,12 (2019): 4071-4111.
² Cooper-Patrick L, Gallo JJ, Gonzalez JJ, Vu HT, Powe NR, Nelson C, Ford DE. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583–589
³ Yancy CW, Kirtane AJ. Race/Ethnicity-Based Outcomes in Cardiovascular Medicine. JAMA Cardiol. 2017;2(12):1313-1314. doi:10.1001/jamacardio.2017.3826
⁴ Woolley, A.W.; Chabris, C.F.; et al. Evidence for a Collective Intelligence Factor in the Performance of Human Groups. Science. October 29th, 2010: 330 (6004); 686-688; DOI: 10.1126/science.1193147
⁵ Bates, T.C.; Gupta, S. Smart groups of smart people: Evidence for IQ as the origin of collective intelligence in the performance of human groups. Intelligence. 2017. 60, p46–56, ISSN 0160-2896,
⁶ Page, S.E. The Diversity Bonus: How Great Teams Pay Off in the Knowledge Economy Princeton University Press. Princeton, New Jersey. 2017: p136
⁷ Ibid, p153
⁸ Douglas, P.S.; Williams, K.A; Walsh, M.N. Diversity Matters. J Am Coll Cardiol. 2017; 70:1525-1529
⁹ Wang, N.C. How do Asians fit into the American College of Cardiology’s Diveristy and Inclusion Initiative? J Am Coll Cardiol. 2019: 74:257-260
¹⁰ Lee, S.S. The de-minoritization of Asian Americans: a historical examination of the representation of Asian Americans in Affirmative Action admissions policies at the University of California. Asian Am L J. 2008; 15:129-152
¹¹ Mensah, M. O. Majority Taxes-Toward Antiracist Allyship in Medicine. N Engl J Med. 383, 23 (2020). DOI: 10.1056/NEJMpv2022964
¹² Barber, S. Death by Racism. The Lancet. 20,8 (2020). https://doi.org/10.1016/S1473-3099(20)30567-3