Patrick Thompson worked his entire life to be a surgeon. He started training his hands to tie surgical knots in middle school, and by high school, the smell and sounds of the operating room already felt familiar. He published research on bone regeneration at age 18. Thompson had a dream, and he had drive. He was determined to do whatever it took to call the hospital his home.

Patrick entered medical school enchanted by the field of orthopedics. But after a few months, he felt his interests pulling him towards gynecologic surgeries. When he brought up his dilemma to a supervising physician, he was quickly shut down. “You really shouldn’t tell people you’re interested in ob-gyn,” the chief resident warned. “They’ll think you’re gay.”

Patrick was shocked. But as he opened his mouth to respond, he remembered earlier that morning another physician had told him to be careful—making one wrong comment to a doctor could guarantee he would be barred from the program come residency application season. He bit his tongue.

Later that same day, Patrick received a text from another attending physician. “Good work in clinic. Grand rounds tomorrow. Lose the earrings.”

Thompson lost sleep. He had chosen to pierce his ears when he came out as a queer man, a promise to himself and the world to live unapologetically. The next morning, he looked at his bare earlobes and felt his spirit fall. “I knew this career would take sacrifice,” he told me. “But I had to ask myself, for how long can you bear to deny yourself a whole existence?” He paused. “For how long can you ‘go back into the closet,’ a place you swore would never again be a prison to you?”

Medical education demands more than a mastery of diagnosis and treatment. Like other medical students with whom I’ve trained, Patrick Thompson learned early about the intense pressures to fit a certain mold. As institutions throw more effort and attention towards improving diversity, parallel efforts towards ensuring inclusion are trailing behind. The gulf between the two creates a work environment that is often unkind, undermining the very diversity of professional staffing that hospitals need and purport to value.

There’s a clear demand for progress in numbers. Just last month, The Boston Globe detailed how Dana-Farber Cancer Institute and Massachusetts General Hospital are expanding efforts to increase their paucity of black and Latino doctors. Currently, only 3 percent of Mass General’s 2,349 physicians are black. Across the nation, medical schools reflect this charge by vaunting offices of diversity and inclusion that recruit a candy-array of applicants from different backgrounds.

Schools record and celebrate the numerical advances as they tick up. Aspiring physicians respond by writing essays on the unique perspectives that qualify them to be members of a diverse, 21st century medical school class. Slowly, the gates of entry into medical school are wedged open to shepherd in varied experiences and identities. Improvement seems like it’s on the horizon.

But I’ve seen how these students, many among my friends, aren’t getting what they bargained for. This admission comes with a cost.

Once they are in school, they are told to leave precisely what they bring to the table at the threshold of the hospital. Women are taught to emulate men (but not too much) and leave gender politics out of the operating room. Some are asked to scrub their tongues clean of accents or Ebonics while queer and transgender students are trained to quiet their identities. Trainees struggling with chronic illnesses or disability learn early on not to associate too closely with their diagnoses, and black and brown students feel pressure to suffer explicit racial insults in silence.

Hospitals and medical schools are training their eyes on the numbers. But these institutions focus so much on the quantitative proof of diversity that they’re missing their failures to safeguard inclusion. The data reflect the problem. Though schools actively seek LGBTQ students, 30 percent of those who matriculate report concealing their identity, a study in Academic Medicine reports. Of those, more than 40 percent do so secondary to fear of discrimination. While the Association of American Medical Colleges (AAMC) reports that 2.7 percent of medical students disclose a disability, researchers corroborate that because trainees fear professional repercussions, the prevalence of disability is likely much higher. All in all, students are often left with a choice: Maintain the authenticity of your diversity and be excluded, or forfeit that sincerity as the price for inclusion. Diversity or inclusion. You can’t have both.

During my orientation to hospital clerkships, a classmate who identifies as trans raised their hand to inquire how they should navigate professional appearance, especially when it was viscerally uncomfortable for them to adhere to what was defined on the lecture slides as “gender-appropriate” dress. Our clerkship director—the woman in charge of medical student learning on the wards—shrugged. “I guess you’ll just have to find your allies,” she offered.

How I wish she would have offered herself as an ally.

One classmate told me he had to constantly negotiate whether he should bring up that it seemed his team was more willing to let him practice procedures on Hispanic patients. He cared about racial equity—he had said so in his application essay, where he detailed his desire to work in the Free Clinic and combat health disparities—but was worried his supervising colleagues would stigmatize him as a man of color who played the wrong race card. He didn’t want to be labeled as the apprentice who disrupted clinical work to fuss over political correctness. Yet as a medical student, he felt he couldn’t decline the opportunity to learn.

The same week, another colleague spoke about how he had surrendered to silence when an attending physician spoke at length about the unfortunate carelessness of black fathers. My classmate felt weary and horrified that he hadn’t defended men who look like his own dad.

A female resident told me she felt unable to talk about her beautiful new baby girl at work. “I didn’t want to be mommy-tracked,” she explained. Even during pregnancy, she had made efforts to hide her growing belly for as long as possible. Her instincts weren’t wrong. Research from sociologists at Cornell University find a tangible “Motherhood Penalty.” While fathers are often framed as dependable breadwinners and rewarded when they present as parents, women can be perceived as less committed and more irrational just for being visibly pregnant—even before an actual child is born.

Legal scholar and advocate Kenji Yoshino defines “covering” as behaviors that seek to reduce the bite of stigma by reducing the obtrusiveness of a trait or identity. A gay man might not bring his same-sex partner to a work function; an individual struggling with depression might not publicly support others with mental illness; an Asian man might mute his response to a racist joke. In a 2013 report, Yoshino found that a full 61 percent of the 3,129 professionals studied reported covering one or more of their identities, including gender, sexual orientation, citizenship, disability, race, age and more. Of those who reported covering behavior, 73 percent conveyed that doing so was detrimental to their sense of self. When covering demands were made by leaders in the organization, more than half of the workers surveyed disclosed that this expectation limited their perception of available opportunities and affected their commitment to their organization.

Yoshino’s work gracefully captures the issue at hand. Institutional inclusion is promised so long as under-represented identities remain unobtrusive—so long as they do not disturb the system. But professional structures—in the hospital and at large—were never built around women, people of color, workers with disabilities. These systems cannot be diverse and undisrupted. When institutional norms refuse to budge, inclusion becomes a conditional contract—one that hinges on a mandate that students cover their identities, abandon their assets and tie down the very superpowers that would improve the American health care system.

In medical school, it’s not only the enduring hierarchy and constant evaluation that concocts a particularly difficult environment for diversity and inclusion. The argument of “patient preference” is also invoked to rationalize the demand for covering behavior.

On December 10, 1942, Frederick C. Irving, professor of obstetrics and chief of staff of the famous Boston Lying-In Hospital, wrote a scathing letter to Sidney Burwell, acting dean of Harvard Medical School. He detailed his embarrassment and discomfort over the admission of two colored medical students. His primary concern was patient unease, and he unfurled a staunch edict. “Regardless of democratic theories,” he ordered, if “any question is raised by any of the patients, or if any resentment is expressed by any one of them, both students must be immediately withdrawn.” The doctor’s emphatic language is unwavering: He uses the word “any” three times in the span of a sentence. He chooses the word “immediately” to denote the timeline of retribution.

Irving makes it quite clear that “democratic theories” pale in power against the will of the sick. The hospital cannot fixate only on ideals because it must ensure patient comfort. What is also apparent from the letter, however, is that Irving is quite displeased at the prospect of black men in his hospital. But he doesn’t volunteer or identify any racial animus on the part of himself or his institution. Instead, he mobilizes his distaste by placing contempt in the mouths of patients. This scapegoat doesn’t veil the personal and institutional prejudices at play. It merely mirrors them.

As a trans medical student in 2018, Kai Sanchez feels some resonance with the unidentified black students mentioned in Irving’s 1942 letter. During clerkship rotations—even though few patients ever expressed discomfort—doctors, nurses, and other hospital staff constantly counseled Kai to limit their trans visibility. Like Irving, these professionals disguised institutional bias by pointing to the need to ensure patient comfort. “The most common conversations people wanted to have with me—regardless of what rotation I was on,” Kai said, “was to think about how patients would be uncomfortable with me treating them or asking them to use certain pronouns.” Kai paused before continuing. “It was always framed to me that to be a good doctor, I needed to [hide myself].”

While today’s communications might not contain the overt discrimination of Irving’s letter, the essence of exclusion remains. Hospitals cite professionalism or pin patients as justification to limit open diversity—advice to “lose the earrings” or erase bits of character do not reflect the hospital’s lack of “democratic theory,” but rather are sincere efforts to ensure consumer satisfaction. Either way, the same message is received: You shouldn’t be here, looking the way you do.

To be sure, patient well-being and security are exceedingly important and absolutely necessary. But it seems only certain patients are having their needs protected. In June of 2013, Jakob Tiarnan Rumble arrived at the Emergency Department experiencing high fever and agonizing pain due to a severe infection. Rumble, who identifies as a transgender man, reports that attending physicians and several nurses were so hostile, aggressive and disrespectful to him that his mother was afraid of leaving him there without supervision According to court documents from Rumble v. Fairview Health Services, in which federal judges delved into civil rights protections under the Affordable Care Act, one doctor “repeatedly jabbed at [Rumble’s] genitals,” and ignored Rumble’s pleas to stop even when he “began to cry from the pain of the exam.” In the aftermath of this ordeal, Rumble “refuses to visit a hospital or doctor’s office alone.”

The health care system certainly needs thoughtful and nuanced ways to negotiate the unequal power dynamics that exist in doctor-patient relationships. Patient comfort is an absolute priority. But when it’s mobilized as a rationale to defy the diversity of medical trainees, imbalances of power become more obvious. How might Frederick C. Irving’s letter have sounded if it were professing the same aggressive concern and fiery advocacy but for a patient like Jakob Rumble? How would Kai’s experience be different if that letter existed?

Kai, in fact, has taken a year of leave from medical school to work specifically on diversity and inclusion efforts. But privately, Kai—like other diversity advocates—wonders if they are doing a disservice to other minorities when they recruit them to work in hospitals that fail to ensure inclusion. I can hear how worn Kai is when they tell me how arduous it was to navigate their medical clerkships with professionals—team members—who felt entitled to constantly comment and counsel on Kai’s body, presentation and professionalism. “It was honestly very exhausting,” Kai admitted. “I met many great people [in medical school], but I also left with a dread that I would find myself as a patient of my colleagues.”

You would think we would have seen more progress.

But in 2014, an AAMC report revealed that the number of black men matriculating into medical school nationwide was less than the number that enrolled in 1978. That was a decade after the assassination of Martin Luther King Jr., the same year affirmative action was first upheld by the Supreme Court, ten years before the ratification of the Civil Rights Restoration Act. In 1978 there were 27 more black men on their way to becoming well-trained black physicians. One for each of the U.S. medical specialties.

In some cases, even quantitative measures of diversity have been painfully slow to change. When I told the statistic about black male doctors to a woman I met at a writing workshop, she was surprised. What a shame, she said. She had two black physicians, and she was delighted with their care. “They sound just like they’re white,” she stated proudly. “If I closed my eyes, I wouldn’t even be able to tell they were black.”

She offered a suggestion. Maybe the recent applicants, you know, sounded too black? I read between the lines. Maybe patients, medical schools, and hospitals would be more welcoming if the new generation of students better fit the mold. Maybe then they would be included.

Every medical student in the United States has written a statement on diversity. Institutions ask applicants to celebrate their distinctions, detail their hardships and find triumph in adversity. But once successful candidates enter the hospital, they are told to surrender their personal effects. Why demand diversity with the intent to dilute it down? What good is diversity when it’s all covered up?

It’s no wonder that medical students report feeling more estranged from themselves as they undergo their professional training. It’s the price of shoehorning a population into one-size-fits-all. But the gnawing sensation of being carved down—sometimes even into something unrecognizable—has much stronger ramifications for some students compared to others. Patrick Thompson worried how long he would have to wait before he could embrace himself in full once again. “The funny thing about earrings,” he whispered, “is that if you take them out and you don’t put them back in, the holes will close.”