Biased questions derail interviews for medical school and residency

“I know many Iranians! They are mostly from Iraq.”

That was how an interview for a medical school spot started for an Iranian-American friend of mine. The interviewer — old, white, and well-meaning — missed the complete irony in his statement that casually blended different countries and cultures like ingredients of a stereotyped recipe. My friend, like many minority applicants, had not prepared for something like this. Should he point out the error? Should he ignore it and move on with the interview, in the hopes that what truly matters — the strengths of his application — is the focus of the conversation?

My friend’s experience isn’t unique. I interviewed for a bioinformatics fellowship during my gap year between college and medical school. I carefully reviewed statistics about US health disparities in advance of my interview — the research topic I had discussed in my application — so I could confidently respond to questions pertinent to my interest in the fellowship. I did not, however, prepare for the question that shaped the entire interview: “What are the major problems in Iran’s health care sector?”

While I had indicated in my application that I was born in Iran, nothing in my resume suggested any affiliation with the country: I did not list Farsi as a language I spoke; I had not been involved in any Iranian student organizations; and I had not taken any coursework related to Iran. Needless to say, I was unable to answer my interviewers’ questions, which repeatedly returned to the subject of Iran despite my attempts to steer the interview back to my interests in US health disparities. I did not get the fellowship.

I kept mum about that awkward experience. But as I began exchanging interview stories with friends a year later when I was applying to medical school, and again four years later as a candidate for residency programs, it became clear to me that the interview process for minority candidates was different than for others.

What I learned from shared stories is that when the interviewees shared similar backgrounds with their often white and male interviewers, the interview focused on their common bond. For interviewees without that shared background, interviewers often relied on assumptions about their gender, race, ethnicity, nationality, or religion.

For example, a white colleague shared this with me about her interviewer: “It turned out our grandparents went to the same high school.” Compare that with a Latina friend interested in basic science research who was asked by an interviewer why she did not want to help out “her” community instead. My friend’s ethnic background and the interviewer’s assumptions about how she should help Latino communities seemed to dictate what “should be” her career trajectory, rather than her demonstrated research experience and interest.

An Asian-American friend of mine, who plays the cello, had an interviewer tell him how “nice” it was to see “an Asian who didn’t play the piano or violin.” An Iraqi friend was asked whether he was Christian or Muslim. A Palestinian friend was asked whether she would get along with Jewish students at the school. A Muslim-American applicant’s interview was dominated by questions about Sharia law. A female applicant, when expressing her interest in pursuing fellowships in either allergy and immunology or gastroenterology was told, “I think allergy would be a better fit for you as a woman.”

While these individuals tried to deal with their interviewers’ questions with poise and composure, the questions weren’t relevant to the interview, detracted from their ability to discuss their actual qualifications, and reflected potential biases that could have influenced the interviewer’s decision. When juxtaposed against the experiences of peers whose interviews were focused on the strengths highlighted in their resumes, and whose personal backgrounds allowed for a close connection with the interviewer, it’s clear that interviewers’ unconscious biases can negatively influence an already stressful interview process.

University of Toronto researchers compiled the results of 2,926 medical school interviews between 2004 and 2009. They found that applicants interviewed on rainy days were rated lower than those interviewed on sunny days. Interviewers probably did not wake up with the conscious thought, “It’s raining today so I’ll give these students lower scores.” More likely, what happened was that the unconscious impact of weather on their moods influenced their perceptions of students. Similarly, unconscious biases related to a person’s gender, race, ethnicity, nationality, and other axes of difference can invisibly influence our thoughts and behaviors about individuals we meet, including those we are interviewing and those we are interviewed by.

Just as it is absurd to think that the decision about whether to admit a student would partly hinge on something as random and out of the student’s control as the weather, it should be equally absurd to have it affected by the student’s background. This is particularly true in a profession that hopes to reflect the diversity of the patients it serves.

What can we do?

Accept the reality of unconscious bias in interviews. In my experience of talking about biases in the medical profession, physicians often have a knee-jerk reaction of denial that they aren’t biased. It is unsettling to our egos and beliefs that we are not always impartial and objective. Yet the reality is that medical professionals aren’t immune to the effects of pervasive racism that permeates American society, including harmful stereotypes of minority populations and patriarchal perceptions of competence and leadership. The first step in attempting to address these biases is acknowledging that they exist in the first place.

This acceptance entails having honest conversations with applicants from racial and ethnic minority backgrounds before and during medical training, and preparing them to effectively handle these unexpected and surprising questions. We are told by those in academic medicine leadership roles that these questions should not arise, but they do. Until we have created institutional cultures that truly embrace inclusion and diversity in word and action, we need to provide adequate preparation for all applicants.

Standardize the interview process. In the business world, unstructured interviews get the highest ratings for perceived effectiveness, but are among the worst predictors of actual on-the-job performance. Managers are often overconfident in their expertise and dislike deferring to more structured approaches. Yet structuring the interview process to minimize variability allows for better comparisons and minimizes subjectivity. A review of 34 studies about the predictive value of residency interviews for positive performance in residency programs had inconclusive results.

The “traditional” approach to interviews is not, in fact, producing the results we want: the most qualified applicants with a broad variety of backgrounds and experiences. New interview formats such as the medical school Multiple Mini-Interview have emerged as part of efforts to reduce this interview bias.

Diversify interviewer pools. In medical school and residency interviews, as in the larger world, interviewers often select candidates that fulfill the 3 Ms: “mini male me’s.” Medical school and residency programs often pay lip service to diversity and inclusion agenda without making the necessary commitments to implementing them. This includes creating gender and racial diversity targets among faculty interviewers, and promoting a culture that encourages raising concerns without fear of consequences or uncertainty about concrete outcomes. Diversity enriches the educational experience and promotes innovation by bringing together people from a variety of beliefs, perspectives, and backgrounds.

Document and respond to negative interview experiences. A hidden curriculum exists in medical school and residency programs that promotes silence and acquiescence. Having a clear and explicit mechanism for interviewees to provide feedback about interviews can help identify patterns, especially if particular interviewers are repeat offenders. Responding to the feedback demonstrates institutions’ commitment to transforming systems beyond a lip service to promoting diversity in medical programs.

Continue the conversation. Achieving diversity in medical schools and the health care work force is not an endpoint but a continuous process that requires us to reflect and reassess strategies, particularly when they involve experiences that happen behind closed doors, like interviews. Establishing ways to reduce bias in the interview process needs to be an iterative process that learns from its successes and failures.

The medical school and residency interview season — marked by hoards of students in crisp black or navy-blue suits and orthodontic smiles — serves as a yearly reminder of how the medical profession can do better to combat bias. Increasing the recruitment of students and practitioners from diverse backgrounds would play an important role to ensure all those interviewed feel welcome to thrive within the profession.

Racial and ethnic minorities currently make up more than a quarter of the total population of the United States, yet less than 10 percent of the physician workforce. In 2014, there were fewer black men in medical school than there were in 1978. Addressing gender and racial disparities in medicine will require a variety of approaches at various levels of training. Eliminating bias in the interview process would be a strong step in the right direction.

Altaf Saadi, MD, is the chief resident in the Partners Neurology residency program at Massachusetts General and Brigham and Women’s hospitals.