Proxy Problems: Academia and Medicine’s Major Battle

In a dream, I watched a sailor on the deck of a large ship. For hours, he meticulously arranged chairs, polished floors, and tidied every nook and cranny. If a wave jostled the chairs, he’d swiftly readjust them to their meticulously centered arrangement. His attention to detail was extraordinary. The dedication and commitment poured into maintaining this order were palpable. Impressive, to say the least. After achieving this particular perfection, he would turn to a logbook, documenting every move. This log, I sensed, was destined for the ship’s archives, preserved for centuries. I remember watching in awe, and upon waking, found myself ruminating over the sheer display of task management I had just witnessed.

I then headed to work as an assistant professor in academia. There, my actions are observed much like the sailor’s. My professionalism is assessed through my maintenance of a hierarchy with students. The use of formality, an insistence on titles, setting clear hierarchical boundaries; these are the markers that showcase my professionalism. They promote the optics of it. Similarly, in the clinic, my success as a clinician is scrutinized much as I had watched the sailor. What percentage of my patients with high cholesterol, high blood pressure, and diabetes have controlled LDLs, A1Cs, and blood pressures? I accurately maintain records, adjust medication regimens, and strive for patient adherence to treatment plans. All to solidify my standing as a competent practitioner. The students I work with face similar scrutiny. They intensely cram standardized knowledge, drill flashcards with textbook answers, and attend lectures prioritizing supposedly infallible solutions. Then, they have the opportunity to demonstrate their intelligence and potential by achieving high scores on exams. The institution itself is also being watched. To prove its righteous commitment to acceptance and diversity, it admits candidates from various backgrounds. Our new brochure proudly highlights this diversity with statistics and engaging visuals showcasing broad representation.

However, I left out the dream’s most crucial detail: the ship was sinking. Split in two, like a scene from the Titanic. The sailor’s meticulous efforts, the proxy for order and control on the ship, were merely a shadow. Upholding this intangible ideal did little to stop the inevitable sinking. These proxies, I realize, are becoming a delusional fixation in academia and medicine too. When tradition, in the form of arbitrary optics, becomes the metric for professionalism, it displaces the true definition, which lies in meaningful actions and behaviors. When proxies of health become the target for treatment, we miss the root cause. The relentless pursuit of controlling these metrics often translates to absolute risk reductions of less than 1% for many chronic disease medications. The ship still sinks. Framing diversity as another metric to meet fosters a superficial ‘acceptance,’ one that ensures all admitted diversity is neatly assimilated. Diversity is ‘accepted,’ so long as it marches to the institution’s unwavering tune.

Just as individual health deteriorates under the delusion of controlling proxies, the true acceptance of diversity suffers when underrepresented individuals are silenced in favor of tradition. Reflect on the student whose story was shared with me: a young woman from a minority background, with a history of significant trauma, a history the institution knew. When a “required” component of her education threatened to re-traumatize her, she disclosed her vulnerability and requested an alternative. The institution’s response, focused on the unyielding requirement of the curriculum (the proxy for “real life” preparation and professionalism) was insensitive and actively harmful. Her lived experience, which could offer invaluable insight into patient care, was deemed an impediment to the standardized educational process. Her pointed questions, “ How has this university practiced their self-proclaimed passion for including my diversity to improve their existing processes? Was I just a number to add for optics? Why is my mental health less important than a checkbox on a curriculum list?” expose the hollowness at the core of such proxy-driven systems.

And if you dare to point out these incongruities, if you question the system? You are often met with a weary sigh. “That’s naive,” the seasoned faculty will tell you. “Idealistic. You’ll learn how things really work.” What they mean is: you’ll learn to stop questioning. You’ll learn to accept the proxies as reality. You’ll learn to assimilate into the prevailing culture of superficial metrics. This “learning” is not wisdom; it’s the institutional immune system neutralizing a perceived threat to its comfortable, if deeply flawed, equilibrium. To resist this assimilation, to hold onto the ‘naivety’ of questioning, might just be the most profound act of professionalism we have left.