More Diversity in Medicine, More Equity in Health Care Urgently Needed

In 2008, the Board of Trustees of the American Medical Association (AMA) wrote a letter to the National Medical Association (NMA), the organization of Black physicians, apologizing for decades of exclusion and discrimination.¹ In 2021, more than a dozen years later, the medical profession is still struggling to confront its history and chart a better, fairer, and more diverse course.

It’s a long history. The NMA was founded in 1895 at a time when, it states, “Black Americans were subjected to all of the injustices inherent in a dual medical care system.”² For Black doctors, those injustices included repeated rejections of membership in the all-white AMA and, by extension, no opportunities for participation in affiliated state medical associations.

Today, it is fair to say that strides have been made in acknowledging a dual challenge: (1) the underrepresentation of African Americans, people of Hispanic heritage, and Native Americans in the physician workforce; and (2) the institutional racism and sexism that have persisted for decades throughout the medical education system and in the larger world of health care delivery.

Hand-in-hand with those challenges is the reality that glaring disparities in health care persist, disparities that have only become more evident in the throes of the COVID-19 pandemic. Minority groups that have traditionally been underserved by the health care system are disproportionately more likely to get sick and die of COVID-19 and less likely to be vaccinated.

Louis Sullivan, MD, former Secretary of the US Department of Health and Human Services (1989-1993) and the second African American person to serve in that role, said in a recent interview with the Macy Foundation, “Even though I can say I’ve seen tremendous progress [in diversifying the health professions], I can also say that we are doing far worse than anyone had hoped.”³

America’s Medical Colleges Have a Plan

The Association of American Medical Colleges (AAMC), representing 172 medical schools in the United States and Canada and 400 teaching hospitals and health systems, believes it is uniquely positioned to address these challenges and to help the profession heal from within. Its 10-point strategic plan, which was adopted in October 2020, includes:

• Significantly increasing the number of students from racially and ethnically diverse backgrounds who apply to, are accepted by, and enroll in the 172 medical schools in the United States and Canada. Black individuals represent 13% of the US population but only 5% of the physician workforce. Similarly, only 5% of US physicians are Hispanic in a country in which 18% of the population is Hispanic.
• Making medical schools, teaching hospitals, and health systems more inclusive and equitable. Systemic problems within those institutions, the association says, include racism, harassment, disrespect, inadequate mentoring, salary inequities, and isolation.

“We’re now seeing modest increases in medical school enrollment among historically underrepresented groups,” said Geoffrey Young, Senior Director of Student Affairs and Programs at the AAMC. “We need to ensure that the diverse population of our country is reflected in the next generation of physicians.” The AAMC Strategic Plan pointedly mentions the “growing absence of Black men and the invisibility of American Indians and Alaska natives in medical schools and the physician workforce, which are national crises.”⁴

In fact, a recent analysis in The New England Journal of Medicine reports that the percentage of Black men in medical schools was actually less in 2019 (2.9%) than it was 40 years earlier (3.1%) and that American Indian and Alaska Native populations were underrepresented both then and now.⁵ In an article published in the Journal of General Internal Medicine, the author notes that the percentage of Black men and women in the physician workforce has increased by just 4 percentage points in 120 years, and that the percentage of Black men has remained unchanged since 1940.⁶

In an editorial in The New England Journal of Medicine, deputy editor Winfred Williams laments the “disturbing lack of progress and no serious, intentional effort on the part of medical school admissions committees to rectify these inequities.”⁷ Williams, associate chief of nephrology at Massachusetts General Hospital and founding director of its Center for Diversity and Inclusion, observes that physicians of color have shown a deep commitment to serving underserved communities and that health outcomes of minority patients “are measurably enhanced when they receive care from clinicians of their own racial or ethnic background.”

The AAMC’s Young says it’s important to “establish clear pathways for promising young students early in their educational years, pathways that lead confidently to college, medical school and beyond. We need to work with educators at all levels and merge our expertise to move the needle forward for future physicians.” The AAMC Strategic Plan states that inconsistent access to quality education begins as early as prekindergarten.

These issues come alive in the stories of individual physicians. In a recent article on MedicalBag.com, Rebekah Fenton, an adolescent medicine fellow in Chicago, stated, “Many black and minority students aren’t prepared for medical school. I was one of them.” Her story illustrates the point that preparation for medical school needs to begin well before the college years and that students need “early and quality experiences in math and science.”

Fenton also notes that a number of medical schools offer programs for minority high school and college students to encourage careers in medicine, providing an opportunity to “meet a physician who looks like them.” She adds that the lack of racial, ethnic, and socioeconomic diversity in medicine “reflects the unequal opportunities in our society. Calls for increasing diversity in medicine must be matched with advocacy for quality math and science education and supplementary opportunities for the students who need it most.”

Progress and Problems

As recent events demonstrate, there are notable steps forward as well as setbacks on the road to greater diversity and equity in healthcare.

• To help increase the number of Black physicians in the United States, Bloomberg Philanthropies is awarding a total of $100 million over the next 4 years to the nation’s 4 historically Black medical schools: Howard University College of Medicine in Washington, DC; Meharry Medical College in Nashville; Morehouse School of Medicine in Atlanta; and Charles R. Drew University of Medicine and Science in Los Angeles.⁸ The grants will help reduce the debt burden of approximately 800 medical students. 
• The AAMC acknowledges that recent increases in enrollment of minority students have taken place in the relatively “tiny” number of medical schools that have historically served Black and Hispanic students. The trend “shows that other schools must recommit to diversifying their classes to increase those historically underrepresented,” Young says.
• In July of 2020, The Ohio State University College of Medicine and its Wexner Medical Center announced an anti-racism action plan of education and research that describes racism as a social determinant of health and sets a goal of advancing health equity.⁹ A month earlier, approximately 300 medical students, residents, faculty, and staff had joined a demonstration, titled #WhiteCoatsForBlackLives, to bring awareness to racism as a public health crisis.
• In February of 2021, the director of the internal medicine-pediatrics residency program at Tulane University in New Orleans was dismissed from the job while retaining other academic appointments. Princess Dennar was the first and only Black woman to serve as a residency program director at Tulane, a position she had held since December 2009. Dennar believes her dismissal is retaliation for a lawsuit she filed in October 2020 against Tulane alleging a “race- and gender-based hostile environment.” The University says that her dismissal was triggered by a national accreditation review that placed the medicine-pediatrics residency program on “warning status.”’

Clearly there is work to be done. What most can agree on is a need for academic and career pathways. Mary Owen, president of the Association of American Indian Physicians (AAIP), says in a letter to membership that “we must increase the number of Native students on the path to becoming doctors, researchers and medical academics … We have a window of opportunity that we’ve never had because of the social and civic unrest the nation is experiencing following the murder of George Floyd.” The AAIP, celebrating its 50th anniversary this year, wants to work with the AAMC, AMA, and other organizations “to help us develop regional pathways programs to increase the number of Native students excelling in school and considering a health professions career.”

The National Hispanic Health Foundation (NHHF) is working with the Macy Foundation to promote diversity, equity, and a sense of belonging throughout the medical education experience and in the delivery of healthcare.  The NHHF, the philanthropic arm of the National Hispanic Medical Association (NHMA), awards scholarships to students pursuing careers in the health professions, not only to diversify the workforce but also to attract more people from any ethnic background who are interested in serving the Hispanic community.

Elena Rios, president of the NHMA, explained “Why we need more Hispanic doctors” in a commentary published on the Macy Foundation website.¹¹ “Bringing more minority doctors into medical education serves a dual purpose,” she notes, “because they are more inclined to practice in areas with a high proportion of uninsured residents and with a high proportion of underrepresented racial and ethnic groups.” Rios adds that “greater diversity among physicians is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better patient-clinician communication,” as well as more equitable health outcomes.

Charting New Routes to Careers in Medicine

One effort to create clearer and smoother pathways to medical careers for minorities is the Northeast Regional Alliance MedPrep HCOP Academy, a collaborative effort involving Icahn School of Medicine at Mount Sinai, Rutgers New Jersey Medical School, Columbia University Vagelos College of Physicians and Surgeons, and the Manhattan-Staten Island Area Health Education Center. The program provides free preparatory training to residents of New York City and New Jersey from underrepresented and economically disadvantaged groups. College freshmen and sophomores may apply for a program that runs for 3 summers and is designed to develop skills and competencies that will enhance their prospects of admission to medical school. The curriculum includes biological and physical science courses, academic skills development, preparation for the Medical College Admission Test, and help with medical school applications.

The AAMC’s Geoffrey Young says that developing a competitive medical school application typically takes years of preparation. While medical schools have traditionally relied on grade point average, Medical College Admission Test® scores, and other academic metrics, Young suggests that “we also need to look closely at experiences and attributes that a student would potentially bring to the learning environment. And we need to adjust the culture of medicine to reduce the influence of bias and racism within the learning environment.”

References

1. AMA apologizes for past inequality against black doctors. Amednews.com. July 28, 2008. https://amednews.com/article/20080728/profession/307289974/6/

2. History. National Medical Association. https://www.nmanet.org/page/History

3. Humphrey HAJ. A Conversation with Dr. Louis Sullivan on diversity, equity, & inclusion in health care. Josiah Macy Jr. Foundation.  March 31, 2021. https://macyfoundation.org/news-and-commentary/a-conversation-with-dr-louis-sullivan-on-diversity-equity-and-inclusion-in-health-care

4. Association of American Medical Colleges.  https://strategicplan.aamc.org/.

5. Morris DB, Gruppuso PA, McGee HA, Murillo AL, Grover A, Adashi EY.  Diversity of the national medical student body — four decades of inequities. N Engl J Med. 2021;284(17):1661-1668. doi:10.1056/NEJMsr2028487

6. Ly DP. Historical trends in the representativeness and incomes of black physicians, 1900–2018. J Gen Intern Med. Published online April 19, 2021. doi:10.1007/s11606-021-06745-1

7. Williams WW. Medical school admissions — a movable barrier to ending health care disparities?  N Engl J Med. 2021;384:1659-1660.

8. Amid COVID-19 pandemic, Bloomberg Philanthropies commits $100 million to help increase number of lack doctors in U.S. Bloomberg Philanthropies. September 30, 2020. https://www.bloomberg.org/press/bloomberg-philanthropies-commits-100-million-to-help-increase-number-of-black-doctors-in-us/

9. Anti-racism initiatives: improving health equity through anti-racism efforts. The Ohio State University Wexner Medical Center. https://wexnermedical.osu.edu/about-us/anti-racism-initiative

10. Owen MJ. President’s letter. Association of American Indian Physicians. August 27, 2020. https://www.aaip.org/sites/aaip/uploads/documents/Dr_Owen_Letter_8272020.pdf

11. Rios E. Why we need more Hispanic doctors. Josiah Macy Jr. Foundation. November 25, 2019. https://macyfoundation.org/news-and-commentary/why-we-need-more-hispanic-doctors

This article originally appeared on Endocrinology Advisor