An Honor for Whom?: The Meritocratic Myth of AΩA

We have the opportunity to make Perelman a more just, equitable institution by discontinuing the AΩA Honor Society at the medical student level. Let me explain.

On a recent survey from Penn’s Medical Student Government, I was asked to respond to the question, “I believe that AΩA should exist at PSOM at the medical student level.” Let me explain why I marked “Strongly Disagree” and why I’m asking you to do so as well.

In our paths to becoming physicians, the Alpha Omega Alpha Medical Honor Society (AΩA) is the latest in a long series of achievement-based academic hoops—after high school entrance exams, AP tests, SATs/ACTs, Phi Beta Kappa, MCAT, and Steps 1 through 3—that some will be able to jump through while others will not. As Perelman students, we are no stranger to these hoops. Some of us are here because of those hoops, while others of us are here in spite of them. For context, AΩA was founded in 1902 to support and recognize students and physicians who embodied the qualities of an excellent doctor; today, AΩA sponsors a host of programs and awards, including the induction of medical students into its honor society—heretofore the focus of this piece. Induction into AΩA is a selective honor that signals a strong academic performance in medical school. Thus, membership in AΩA grants inductees significant social capital in the residency selection process and beyond¹, and these inductees are increasingly choosing or attaining spots in highly competitive or “lifestyle” specialties². AΩA may seem to reflect the deserved recognition of hard work (i.e. awarding those who can jump the highest) — but, in fact, it exemplifies structural inequities in our educational system³. It is one of many merit-based achievements that serve to reinforce differences in educational success that negatively impact many Black, Latinx, first-gen/low-income, and trans and queer students. In short, some people bring the step stools of wealth, social capital, and societal privileges to the jumping contest. Instead of praising those who have step stools, why don’t we just take the hoops down?

Earlier this year, the national AΩA Board of Directors announced new constitutional changes to the organization’s eligibility and selection process that include an shift towards holistic review⁴.  While we await the results of these changes locally and nationally, we can look elsewhere to anticipate the effects this holistic review process might have on AΩA selection. Studies of the implementation of holistic review in undergraduate^5,6 and graduate medical education admissions⁷, and even AΩA⁸ have found that holistic review processes improve (but often do not eliminate) disparities for URM students. While these increases in the representation of URM students in the medical education pipeline are absolutely important steps towards achieving inclusion and equity, I argue that holistic review does not go far enough for AΩA. “Holistic” review, while an important step in any selection process, presumes that a lifetime (or even just four years) of various obstacles to educational success can be “controlled” for in order to level the playing field. This holistic review process has retroactively given stools to a talented few but fails to address why students need those stools in the first place. The hoops, and the structures that hold up those hoops, still exist.

AΩA claims to honor students based on “competence,” “scholastic achievement,” and “demonstrated professionalism,” all while it “is committed to overcoming the barriers that may impede URM students.” However, these numerous obstacles can never be fully disentangled from metrics of academic performance. Thus, AΩA is founded on a myth of a meritocratic medical school experience.

Take clerkship grades, the foundation of consideration for AΩA, for example. Clerkship grades are based on a composite of one-on-one experiences where a resident or attending evaluates a student. Aggregating evaluations and unconscious bias training help to mitigate—but not eliminate—forms of bias and prejudice that enter into this process. This is a fact supported by numerous scientific studies^9,10,11,12 and recent efforts have sought to explore these evaluations at Penn¹³. Marginalized students, specifically URM students, experience various (at times overlapping) “-isms” (as they’re euphemistically called), phenomena like the “minority tax,”1The “minority tax” is a term that encompasses “the burden of extra responsibilities placed on [URM] faculty in the name of diversity.” This includes but is not limited to: added responsibilities of achieving or advancing diversity and inclusion efforts; added mentorship responsibilities and a lack of mentorship; isolation; discrimination and racism; and un- or underrecognized clinical, community, and educational work; and financial and promotion disparities.¹⁴and the historical underrepresentation of these marginalized groups in the same medical professoriate that evaluates students. These everyday realities make it such that URM and other marginalized students are at a disadvantage, both before and during clerkship, due to the unequal treatment we experience and unequal forms of labor we are expected to perform.  Clerkship grades, while they may consider a student’s ability to be an empathetic and humane healer, are still mostly based on students’ technical knowledge, expertise, and—most importantly—their performance of those skills in alignment with certain, privileged (i.e. white, masculine, gender-confirming) notions of academic performance¹⁵. This means that these forms of bias are insidious and cannot be disentangled or wholly accounted for in something like “holistic” review, as students still have to demonstrate high academic achievement and perform competence to be seriously considered. The equity step stool is given too late in this game.

Holistic review processes in medical education have been called a success because they have often increased representation and improved outcomes for URM students. While the representation of URM students have increased after the initiation of such holistic review processes, I ask, which URM students are represented? We, URM students, are not a monolith. As a white Latinx student, I am deeply concerned that only using “URM” as the marker for successful diversity and inclusion has not adequately addressed forms of structural and inter-personal racism, colorism, and anti-Blackness that are enacted in society—including medical school—and continue to exclude Black, Indigenous, and brown Latinx students from these accolades. We, as URM students, are not represented until all of us are represented. This continual disparity in AΩA selection practices, even after the initiation of holistic review, asks us—begs us—to go a step further: end the practice entirely.

As a meritocratic myth, AΩA holds up exemplary students to justify and legitimize an unjust educational system. I do not doubt that my peers who have been inducted into AΩA are brilliant, competent future doctors. I have profound respect for my friends, peers, colleagues, and mentors who have received AΩA—not because they have received AΩA but, by and large, because they are excellent doctors in ways beyond their technical competence. It is truly an honor to learn with and from them every day. However, as a white Latinx, queer, first-generation physician and academic without a family of physicians able to coach my patient presentations or train me in how to behave in the hospital (lessons numerous classmates of mine had before clerkships), I and other students who entered medical school with various societal disadvantages will never, ever have an equal opportunity to be honored by the Perelman School of Medicine through AΩA. Instead, AΩA will reproduce—honor, in fact—the same dynamics of privilege that affect every other facet of the educational experience at Perelman. For whom can AΩA be an honor?  

Importantly, AΩA is not the only way in which students are recognized at PSOM. Here, I am specifically talking about the Gold Humanism Honor Society (GHHS), which has been discussed in this conversation as an analogue to AΩA in the role it might play in bolstering residency applications. [For the sake of transparency, I should state that I have been inducted into GHHS, though this will not prevent me from being critical of it. It—like Perelman—is an organization that I care about and know can continue to do better.2I concede that GHHS, as it is currently structured, does not fairly consider all students for induction because of how peer nominations are selected (not because they are peer nominations). I believe this is a separate problem that needs to be critically evaluated and addressed.] The selection process of GHHS is based on students’ commitment to human qualities of empathy, compassion, care, and concern for patients as demonstrated by how students spend their time before and during their clerkships. Participation in efforts like community clinics, patient voting initiatives, peer mental health support, or diversity and inclusion work do not have the same barriers to entry that traditionally recognized forms of academic achievement have. I believe that the capacity to be a caring, compassionate doctor is not unequally represented among students from privileged backgrounds, but rather reflected across the PSOM student body. While it is true that AΩA and GHHS are two of many possible accolades that grant students an advantage in resident applications, my concern is not that the advantage AΩA or GHHS grant in residency applications is unfair, but that AΩA—unlike GHHS—is an unfair practice because it exemplifies and perpetuates unjust and inequitable educational practices. Furthermore, GHHS recognizes qualities that are not only important for being a good doctor but are, at times, actively discouraged in the “hidden curriculum”3Medicine’s ‘hidden curriculum’ represents the set of social rules, norms, behaviors, and actions that are not formally included in medical school curriculum but, nevertheless, influence the culture of medical schools and hospitals. This hidden curriculum often privileges and reinforces one’s position in a hierarchical professional network over one’s time and commitments to high-quality, humanistic, and equitable patient care. Furthermore, the curriculum can, at times, undermine or even actively go against the explicit codes of ethics, professionalism, and humanism that we are expected to uphold as (future) medical professionals ¹⁶.¹⁶ of American academic medicine.

Here and now, we—as students, faculty, and administrators—have the choice to not reproduce the unequitable dynamics and unjust educational system upheld by practices like AΩA. I am asking that you choose to create a more just, equitable medical school, focused on producing a collective group of technically competent, humane doctors. In the end, that would be the truest honor.

Randy Burson (CDY4 | PSOM & SAS) is a native New Mexican adopted by Philadelphia, and a 4^th year MD-PhD student in the Anthropology department.

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