The Myth and Paradox of Meritocracy In Medicine and Its Effects on Black Students and Doctors
“Meritocrats may be made rather than born, but they are not self-made.” -Daniel Markovits
Although the concept of meritocracy has existed for centuries, the origin of the term can be traced back to a book published in 1958 by Sociologist Michael Dunlop Young. The Rise of Meritocracy is a dystopian political and satirical narrative of the ostensibly merit-based educational system in the United Kingdom. At the time, the term was coined as a pejorative critique of the system’s hypocrisy. However, it has become part of our lexicon and been misinterpreted to suggest that desert is earned through ability and effort. That social and economic rewards come through achievement and not privilege. The myth of meritocracy has been proven to be harmful to disadvantaged kids of color. And since medicine is a microcosm of our greater society, the term has also become incorporated into the lexicon of medical education and clinical practice. However, there is an implicit hypocrisy and in how the term has been deployed that is potentially harmful to Black medical students and doctors. First, it is often used as a smokescreen by non-Black doctors to avoid acknowledging their privilege and its contribution to their accomplishments. Second, it has been weaponized to express resentment around progressive agendas such as diversity, inclusion, and equity in medical schools and clinical practice. And finally, even when Black doctors do play the meritocratic game, and at times better than their counterparts, there is a double-standard and the goalposts of accomplishment are often moved.
Privilege Precedes Accomplishment
“Meritocrats may be made rather than born, but they are not self-made.” Are the people who implore meritocracy in medicine merely camouflaging their privilege? In an article written by Daniel R. Smith, he interviews Toby Young (the son of the author who coined the term) who currently describes meritocracy as exclusionary and an attempt of the elite to legitimize its privilege. It is not uncommon that when people discuss their success, their default is to discuss merit, with failure to acknowledge their inherent advantages. He states in the article, “The well-to-do have seized upon the trappings of meritocracy as a way of legitimizing and perpetuating their privileged status.” And medicine is not exempt. It is not infrequent that the doctors who implore meritocracy have been the beneficiaries of a meritocratic inheritance as described in the book The Meritocracy Trap by Daniel Markovits. The meritocratic inheritance–the excess investments that parents make in their children’s human capital–begins before conception and continues through professional schooling. Meritocrats often come from affluent families, attended elite private schools with legacies, and are now employed at those very same institutions. They ignore “the reality that individual accomplishment almost always lags behind inheritance, accumulated wealth or contacts, and educational credentials.”
For the record, some might consider me to be a member of the meritocratic elite: a Black man, who grew up in the comforts of suburban Kansas City, with two parents who are professionals and bequeathed to me meritocratic inheritance. The only worries in the world I had was what Polo shirt I was going to where to school that day and whether I was going to listen to N.W.A, Public Enemy, or Def Leppard while driving. I prefer to call myself privileged. That being said, the social landscape is changing. It is has never been more important to standup against the inequalities and inequities that we see every day in the world and also in medicine. I recognize my privilege and I hope others can also recognize theirs.
As a community, we should be cognizant of the etymology of this term [meritocracy] and how we use it in medicine–it has been misused, exploited, and deployed to potentially harm and impede the recruitment, retention, and success of Black medical students and doctors.
The Weaponization and Misappropriation of Meritocracy and Excellence
Although it is not commonly characterized this way, America is a caste system. One in which the social construct of race is used as the vehicle to maintain the prevailing hierarchy with Black people in the subordinate caste. In the book Caste: The Origins of Our Discontents by Isabel Wilkerson, she writes, “Caste is the operating system for economic, political, and social interaction in the United States since the time of its gestation.”
Because of this system, there is a dearth of Black doctors in the United States. Only 5% of doctors identify as Black or African-American. When the issue of diversity, inclusion, and equity for Black people is approached in medicine, it is not uncommon for those in the dominant and middle castes to air their grievances and opposition by weaponizing the concept of meritocracy and equating it with excellence. Conversely, they view diversity, inclusion, and equity for Black doctors as antithetical to excellence. In a series of tweets from Dr. Tamorah Lewis, Neonatologist and Associate Professor of Pediatrics at University of Missouri-Kansas City School of Medicine, she indirectly debunks this concept. She advocates for leveling the playing field, not by lowering standards, but reconsidering the elitist, traditional, and implicitly bias methods of evaluation that have historically sidelined Black students and doctors.
Furthermore, there is also irony in the dominant and middle castes supporting the concept of meritocracy. One could argue those victories are illegitimate because some of the eligible players are sidelined and not in the game. In the book Caste, “A win is not legitimate if whole sections of humanity are not in the game. Those are victories with an asterisk, as if you were to win the gold medal in hockey the year that the Finns and Canadians were not competing. The full embrace of all humanity lifts the standards of any human endeavor.”
Movement of the Goalposts
“…I’d met my share of highly-credentialed, high-IQ morons and had witnessed firsthand the tendency to move the goalposts when it came to promoting women and people of color…”
Every Black person is familiar with the term the “Black Tax.” This axiom is the cost of doing business as a Black person in America. Black people have to work harder than their counterparts to achieve similar outcomes.
But even if Black people play by the rules of the meritocratic game, there is often a double-standard and the goalposts that signify success and accomplishment are often moved. I recall a conversation about the progressive agenda of President Obama with a white conservative friend. One for which my friend did not endorse. But instead of criticizing his policies, he made an ad hominem attack on his credentials. The twice Ivy League-educated, U.S. Senator, best-selling author, and now first Black President of the United States, was dismissed and minimized in my friend’s mind as just a community organizer. The president played by the rules of meritocracy and still it was inadequate.
In his book A Promised Land, President Obama was cognizant of the double standard when he nominated Judge Sonia Sotomayor, then of the U.S. Court of Appeals for the Second Circuit, for the United States Supreme Court. Some questioned her credentials. In response to this concern, our 44th president said, “…I’d met my share of highly-credentialed, high-IQ morons and had witnessed firsthand the tendency to move the goalposts when it came to promoting women and people of color–I was quick to dismiss such concerns.” If President Obama’s and Justice Sotomayor’s accomplishments are insufficient for the dominant caste, what hope is there for the “average” people who are teachers, doctors, lawyers, and engineers? What hope is there for Black doctors in the elitist system that is medicine since it is not impervious to influences from the outside world?
As President Obama wrote in his book, “…not even the highest level of Black achievement and the most accommodating of white settings could escape the cloud of our racial history.”
A well-publicized lawsuit at the Tulane University School of Medicine may provide another real-world example. Dr. Princess Dennar, who would later become the first Black woman to head the Internal Medicine-Pediatrics program, claims that in 2008 she was told by leadership that she could only become co-director because white students wouldn’t rank the program favorably if she was in charge. So, even though this qualified doctor was recruited for this position and played the meritocratic game by the rules set forth by the dominant caste, the goalposts of leadership and success were then moved–only for her to have to navigate through the shark infested waters of discrimination. In addition, it’s alleged that students who had attended historically Black colleges and universities were ranked internally lower than other students–and women or minorities were given less favorable rotations and deprived of earning enough hours in certain types of training to graduate. As President Obama wrote in his book [about the arrest of Professor Henry Louis Gates], “…not even the highest level of Black achievement and the most accommodating of white settings could escape the cloud of our racial history.”
In conclusion, the term meritocracy has been shown to be both a myth and hypocrisy in both medical education and clinical practice. It is often deployed by non-Black doctors as a camouflage to avoid discussing their own inherited privilege and its contribution to their achievement. It has been exploited and used in opposition to the progressive agenda of diversity, inclusion, and equity. Finally, there are real world examples that even when Black people do play the meritocratic game, there are often arbitrary movements of the goalposts of achievement and success. For centuries, the dominant caste has benefited from privilege under the guise of meritocracy and excellence while suggesting the increased presence of Black medical students and doctors is ostensibly antithetical to excellence. As a medical community, we should be cognizant of the etymology of this term and how we use it–it has been misused, exploited, and deployed to potentially harm and impede the recruitment, retention, and success of Black medical students and doctors.
