In the November 2018 issue of Academic Medicine, Reid Waldman, MD, and his colleagues published "The Ethical and Legal Conundrum Posed by Requesting Residency Applicants to Submit Photographs of Themselves." The authors asserted that the nearly universal practice of encouraging medical students to submit professional headshots along with their residency applications opens them up to discriminatory judgments while providing little substantive positive value. We spoke with Dr Waldman about his investigation into this practice and what recourse is available for students and faculty who have concerns. Medscape: What prompted you to prepare that piece for Academic Medicine? Waldman: We started working on it during last year's admission cycle. We spent a lot of time talking about the admissions process for another paper that we'd done. One of the authors is a lawyer. We started talking about whether it is legal, from a federal stance, to ask someone for a photograph with their application. I think that almost every program encourages it. We found that institutions don't require you to submit a photograph. If they did, that that would probably be in violation of Equal Employment Opportunity Commission (EEOC) regulations. Even though it's not required—as in, you can still submit an application without it—it's required, in the sense that if you don't, that really distinguishes your application, maybe in a negative way, from those around you. It's the very first thing you see. It's big, in the top right corner of the applications. I asked people who are involved in selections what they would think if an applicant didn't submit a photo. They said, "Well, that would seem kind of weird..." So we were curious about how submitting photos affected people and whether that caused discrimination. All we could find was an article about medical schools in Britain. The authors thought that there was discrimination against ethnic minorities, based on identifying information in applications for medical school. They thought that if you eliminated that, discrimination down the line was decreased. I think the photograph in and of itself is a special kind of identifier that is unnecessary. The photograph does not provide useful information that is necessary for selecting qualified candidates. Unless there's a compelling argument for why you need a photograph, which so far no one has brought to me, I think it is unnecessary. Everyone I've shown the article to has agreed with our point of view. I am concerned that this is a possibly illegal practice, that it can cause people to be discriminated against, and that it is unfair. Medscape: Your primary concern is visual identifiers used in a discriminatory way, correct? Waldman: Yes, and I think that there are many types of visual identifiers. Probably the initial things that people think of are race and gender, but there are more than that. This is from hiring literature, recruitment literature. People are discriminated on the basis of weight and on other physical features identifiable through a photograph. I think it goes beyond just the traditional things we think about when we talk about these things. My biggest concern would be that an application never even gets read. If the first thing you're seeing is someone's photograph, you might look at that photograph and immediately have a judgment about the person that clouds your judgment before you even get to the next line. I am worried that it changes the way someone reads an application because it's the very first thing that they see. Medscape: Do you see any value at all to the photographs? Waldman: The argument that is made in favor of the photographs is the idea that you need to identify someone before they come to an interview so that someone doesn't get extended an interview and have someone else come answer questions or vice versa. That's addressed by the EEOC, which says that you can ask for a photograph after someone is selected. But honestly, I don't even think it's about that. I think that we'll see more discussion of how residencies select residents as the residency process becomes more competitive. There are more applicants applying every year. I know that within my own specialty of dermatology, a large portion of highly qualified applicants do not match. This is obviously just one metric that I have offhand, but the National Resident Matching Program (NRMP) releases statistical data about who gets selected into dermatology. I think the highest score cutoff of USMLE Step 1 scores they provided is a 260. I want to say that something like 9% of dermatology applicants who had above a 260 in the most recent year of data didn't match into the specialty. If I remember correctly, that score is above the 95th percentile of test takers, which is very amazing. Obviously, there are lots of other considerations with selecting applicants. It's getting very competitive, and I think that that will cause more people to discuss how we're hiring people. Medscape: What advice would you give to any students who may be nervous about sending in a photo? Waldman: This is tough... As someone who is interested in ethics, my answer is that if you ever feel uncomfortable about something ethically, then you shouldn't do it. If someone told me, "I don't feel comfortable sending a photo to these programs," then I would tell them that they shouldn't do it if they feel uncomfortable. However, individuals who submit a photo are probably at an advantage, as a vast majority of people are doing that. Medscape: What would your advice be for faculty who may have concerns? Waldman: I would say two things. One, if you are in a residency selection meeting or having a discussion with your fellow faculty about resident selection and someone says something discriminatory about an applicant—whether it's because of their photograph or something else—then you need to address that because it's inappropriate. Two, I think that faculties who feel uncomfortable with this practice should discuss with their departments taking action to potentially—at least at a program level—not encourage the photographs with the applications. They don't have to. I don't think it ever hurts to ask, "Hey, is there a reason we're doing this practice?" If no one can give you a reason why a practice is occurring, then I think it's reasonable to challenge its existence. Medscape: What are the next steps across all of residency in terms of this issue? Waldman: The next step is a qualitative study that includes interviews with people who are involved in these processes, [asking them] about their experiences to gain an understanding of the role that something has. I do think people are always scared when discussing topics like discrimination—that whistle-blowing can lead to backlash. I think this is important. The big thing that we're trying to get out there is just an awareness of the practice. Programs at an institutional level can enact change by saying, "Hey, we don't think this is right" and stop doing it. I think it's incumbent upon the programs to enact change because there is a power imbalance between programs and applicants. It is much more difficult for an applicant to exclude a photo than it is for a program to stop asking for photos. Source
