Societal awareness of racial, gender, and ethnic bias has increased, but other stigmatized groups remain at risk for exclusion. It is important to consider lesser known forms of bias and their potential for influencing behavior.

To this end, in our recent Academic Medicine article, we used the application photograph to study the impact of applicants’ physical appearance on the selection of radiology residents, and found that the applicant’s obesity and facial attractiveness strongly influenced decisions to grant residency interviews. We found this unfortunate pattern of appearance-based discrimination across the spectrum of applicant race, gender, and academic achievement.

Though these findings were disturbing, they were not terribly surprising to us. As readers ponder the implications of our findings for their home institution, we feel it’s important to consider two things: this is not about radiology, and it’s not about the photograph.

We studied selection decisions in our field of radiology, but there is no reason to assume our results would not translate into any field of medicine, and probably throughout higher education. We feel we were studying human nature, not radiology decisions. Shortly after online publication of our paper, a newspaper headline erroneously blurted: “Unattractive people are less likely to get into medical school.” Probably because the general public can better relate to medical school admissions than to residency selection, the story was instantly picked up by newspapers across the country. This “fake news” was both frustrating and funny. But also … probably true. We suspect that had we studied medical school admissions instead of resident selection, the results would probably have been similar. Admissions and selection professionals throughout higher education should make efforts to ensure that this bias does not influence their admissions decisions.

Some have interpreted our findings as suggesting that the Electronic Residency Application Service (ERAS) should eliminate the application photograph. That was not our intention. We are not confident that eliminating the photograph would eliminate appearance-based discrimination. The photograph was ideal to study because it allowed us to isolate the physical features of the applicant, randomize all academic metrics, and eliminate potential confounds. But the application photograph is not the only opportunity to introduce appearance-based discrimination into the resident selection process. The same bias could influence judgements at the interview stage of admissions as well. In fact, the influence of this bias may be stronger during in-person interviews.

We believe the more promising remedy might simply be increased awareness. We suspect the application reviewers in our study were not aware of any potential bias they might hold against the obese or unattractive, and so they were unable to prevent it from affecting their behavior. In contrast, we suspect our reviewers were aware of their potential for holding racial bias and, to whatever extent they did, were able to manage it, and as a group, they strongly favored black and Hispanic applicants over white and Asian applicants in application scoring.

When considering the ramifications of discrimination, racial minorities come to the forefront for historical and social justice reasons, but we should remain mindful that there are other stigmatized groups that are also at risk for exclusion. We hope our article brings awareness to the potential for appearance-based discrimination in admissions decisions throughout higher education.

By: Charles M. Maxfield, MD, and Lars J. Grimm, MD

C.M. Maxfield is vice chair of education, Department of Radiology, Duke University Medical Center, Durham, North Carolina.

L.J. Grimm is assistant professor, Department of Radiology, Duke University Medical Center, Durham, North Carolina.

Editor’s note: This blog post has been updated to reflect that the Electronic Residency Application Service (ERAS) requires a photograph not the National Resident Matching Program (NRMP).

Further Reading

Maxfield CM, Thorpe MP, Desser TS, et al. Bias in radiology resident selection: Do we discriminate against the obese and unattractive? [published online ahead of print May 28, 2019]. Acad Med. doi: 10.1097/ACM.0000000000002813