In what some are calling a “persistent failure” of medical schools to improve diversity, a comprehensive new analysis going back 40 years shows the number of students from the most underrepresented groups in medicine — Black males and Native American and Alaskan Native men and women — has declined.
While Black male medical students accounted for 3.1% of the national medical student body in 1978, in 2019 they accounted for just 2.9%. Without the contribution of historically Black medical schools, just 2.4% would be Black men. The number of Native American students also declined, accounting for just a fraction of 1% of the nation’s roughly 22,000 medical students in 2019.
“It is absolutely dismal and appalling and quite frankly unacceptable,” said Demicha Rankin, an anesthesiologist who serves as associate dean of admissions for The Ohio State University Wexler Medical Center, where 25% of students come from underrepresented minority groups. The report was published Wednesday in the New England Journal of Medicine.
While U.S. medical schools have talked for years about their efforts to enroll more students of color, the new data underscore how little progress has been made and should serve as an urgent call to action, said physicians working to increase diversity. “Everytime I see stark numbers like these, I have a moment of depression,” Siobhan Wescott, an Alaskan Native physician who co-directs the Indians into Medicine program at the University of North Dakota, told STAT. “But they remind me how much work there is to do.”
The coronavirus pandemic has highlighted the deeply embedded medical inequities facing the nation — and the need for a more diverse medical workforce. The National Academy of Medicine is among many groups concluding that increasing racial and ethnic diversity among physicians would markedly improve care, access, and life expectancy for minority populations. African American males have the lowest life expectancy of any population in the United States. Studies show access to care and health outcomes improve when physicians more closely represent the patients they care for, partly because of increased trust. One study in Oakland showed Black male patients fared better with Black physicians because they were more likely to undergo preventive care procedures and accept flu shots.
“I’m calling for a new beginning,” said Valerie Montgomery Rice, president and dean of the Morehouse School of Medicine, “because everything we’ve done in the past has not worked.”
In an editorial accompanying the new report, Winfred Williams, a nephrologist at Massachusetts General Hospital and NEJM’s deputy editor, called the statistics “grim” and noted that the racial gap that medicine has been trying to close was actually widening. The study, he wrote, “shows a disturbing lack of progress and no serious, intentional effort on the part of medical school admissions committees to rectify these inequities.” He added, “the medical establishment must be held accountable.”
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STAT contacted a number of medical schools that ranked lowest in diversity in U.S. News and World Report rankings to ask why they had enrolled so few students from underrepresented minority groups and what changes they were instituting to increase diversity. Many said they were taking aggressive steps to improve and agreed their numbers had been poor, often because their admissions committees were not diverse or welcoming, they relied too heavily on MCAT scores to rank candidates, or because students of color they accepted chose to attend other schools.
The number of Black, Hispanic, Native American and Hawaiian or Pacific Islander physicians remains far below their percentages in the general U.S. population. A study released this month shows the percentage of doctors who are Black male physicians has not budged in 80 years. The fact that these groups remain underrepresented in medical school populations as well shows achieving the goal of a physician workforce that represents the nation will take years.
“The data speak for themselves,” said Eli Adashi, the new study’s senior author and the former dean of Brown University’s Warren Alpert Medical School. “It’s a clarion call for action.”
Last August, the Association of American Medical Colleges and National Medical Association, which represents Black physicians, teamed up to take more aggressive action to fight what they said was historically entrenched systemic racism that was excluding people of color from medical school ranks.
“Even the National Academies have called this an American crisis and that’s not an overstatement. This is important for the health of our nation,” said Norma Poll-Hunter, the senior director of equity, diversity, and inclusion for the AAMC. Poll-Hunter, like many working in the field of diversity, said she had mixed feelings about the attention being given only very recently to an issue she has spent 15 years working on. “On one hand, we feel we’ve been saying this for how long and people are finally paying attention,” she said. “At the same time, we now have so many allies and we need to leverage this moment for the long haul.”
For the new study, Adashi and his coauthors analyzed more than 40 years of medical student data, from 1978 to 2019, from some 150 medical schools that had been collected by the AAMC. They included only U.S. citizens, which make up more than 98% of American medical students, because the information for that group included gender, race, and ethnicity and used categories that correspond to U.S Census Bureau conventions: White, Asian, Black, Hispanic, American Indian or Alaskan Native, and Native Hawaiian or other Pacific Islander. (Data collection by the AAMC changed over time to allow students to select more than one race and to designate if they were of Hispanic origin, but Adashi said those changes did not affect the overall results of the study.)
The analysis showed medicine has achieved a measure of gender equity, with women now constituting half of all medical school students compared to less than a quarter in 1978. But gains have not been equal among all women. The number of white women in medical schools increased from 18% to 24% of all students, while the number of Asian women increased from 0.8% to 11.7%. The increase in the number of Black and Hispanic women medical students was more modest. Black women enrollees increased from 2.2% to 4.4%, while Hispanic women enrollees increased from 0.7% to 3.2%.
There was a marked decrease in the number of white men in medical school, from 61.2% to 25.7% and an increase in the number of Asian men from 2.1% to 10.7%. The number of Hispanic male medical students increased from 1.7% in 1978 to 3.4% in 1982 but has remained relatively stable since despite the large growth in the nation’s Latinx population since then.
The new study was the brainchild of a Black and first generation medical student at Brown, Devin Morris, who was born in a small Arkansas town on the Mississippi River and whose unlikely path to medical school was made more difficult by a dearth of Black physician role models and mentors. “Ultimately, if you want to go to medical school, you have to start in high school. That’s something I wish I’d known,” Morris said. “There are so many factors and barriers that relate to this. It starts as a child.”
In his editorial, Williams called for a “serious reexamination” of the medical school admissions process by the National Academy of Medicine or other blue-ribbon panel, and called the matter urgent, saying, “We cannot wait another generation for these changes to occur.” He said the panel could examine which premedical STEM programs have most effectively propelled minority students into medical schools, whether the NIH should tie research funding to the recruitment and retention of minority students and faculty, and whether historically Black medical schools should receive more federal support to train physicians.
Early in the 1900s, historically Black medical schools were more numerous than today. But the Flexner Report of 1910, commissioned to revamp U.S. medical training, led to the closure of five of the country’s seven Black medical colleges. Those closures, along with the barring of Black physicians from U.S. medical schools for the next five decades, left a vacuum “from which medical education has yet to recover,” said Morehouse’s Montgomery Rice.
Hugh E. Mighty, dean of the Howard University College of Medicine, said that while resources to increase class sizes at the nation’s four historically black medical colleges (Howard, Morehouse, Meharry Medical College in Nashville, Tenn., and Charles R. Drew University in Los Angeles) would be welcome, the schools only produce a few hundred physicians a year. “To move the needle nationally, we need to see a similar movement across all medical schools,” he told STAT.
Mighty said asking historically black colleges to remedy the deficit of Black physicians seemed a form of segregation. “If we segregate this, we’re just creating a problem on top of a problem,” he said.
Montgomery Rice agreed it was unfair to place the burden on the nation’s four Black medical colleges. “Stop putting that pressure on us,” she said. “Why do you think out of 158 medical schools we should be the ones to solve this?”
Still, Montgomery Rice said she has been searching for innovative ways to increase the number of Black doctors her institution graduates. The medical school just launched an initiative with the nonprofit health system CommonSpirit Health to train Morehouse students at several of its facilities across the country starting in 2022. The program will increase the Morehouse class size from 105 to 225, she said.
When Scott Strome moved to the University of Tennessee Health Science Center to become executive dean of the college of medicine, there were just 6 Black students in a class of 170. “We vowed to change that,” he told STAT. They’ve worked to cut student debt, drop the requirement that applicants be from Tennessee or neighboring states, and diversified the admissions committee by adding more faculty members of color and local Black physicians in response, he said, to being told by accepted students who declined to come to UT that “not a single person on the admissions committee looks like me.”
There are still fewer than 10 Black students in recent classes, but Strome hopes the changes he’s put in place will soon yield results. “Diversity makes us stronger. It makes us better,” he said. “We’re not accepting a Black student or brown student because we’re doing them a favor. They’re doing us a favor.”
The University of Maryland School of Medicine has dramatically increased the number of students from underrepresented groups it enrolls to about 24% after many years when the enrollment of such students hovered between 11% and 13%, said Sandra Quezada, a gastroenterologist who serves as the school’s associate dean for admission and as assistant dean for faculty diversity and inclusion.
“I feel like we’ve been talking about this for years, and there’s a fatalistic mentality because the pool of applicants isn’t diverse,” she said. “It’s obviously a complex problem, with issues of systemic racism disenfranchising Black and Hispanic students before they get to college, but we felt at Maryland there were still things we could do with the pool we have to work with.”
Quezada has added implicit bias training, diversified her admissions committee, and moved to a more holistic review process where people conducting interviews don’t see an applicant’s grades or MCAT scores, metrics that have long been considered gatekeepers and kept out some applicants from minority or poor backgrounds. “People used to say, ‘This was the best interviewee I’ve ever had. This candidate is so inspiring, but their MCAT was borderline, so I’m putting them on hold,’” Quezada said. “We want a broader consideration.”
Quezada said she is also working to make sure students accepted at Maryland feel welcome. “We tell them they will be safe and welcome here. We say that out loud,” she said. Despite being just one of four Hispanic students in her 160-student University of Maryland medical school class of 2006, Quezada said she felt supported and welcomed once she enrolled. “That’s why I feel comfortable and confident recruiting people and telling them this can definitely be a home and a new family,” she said.
Wescott, who co-directs one of the nation’s longest running programs to train Native American physicians at the University of North Dakota, said medical schools need to support underrepresented students and provide the mentoring they may lack, particularly those who do not have any family members in medicine. “There’s so many unwritten rules in medicine. It’s such an intricate system. If you don’t know that insider information, it can be really difficult.” Even small gestures can make a big difference: She recently let a student with a poor internet connection at home use her office to take part in a day-long virtual residency interview.
Oregon Health and Science University officials take issue with the numbers in the U.S. News rankings and say they’ve increased the number of underrepresented minorities in recent years and their current class includes 21% of such students, including eight Native American or Alaskan Native first-year students. That increase is tied directly to a program the school launched in 2018 called Wy’East (the Native name for Mt. Hood), through which up to 10 Native students who were rejected from other medical schools are provisionally accepted into OHSU and spend 10 months in classes, study for the MCAT, and learn self-care skills in preparation for medical school.
“It’s been remarkable,” George Mejicano, OHSU’s senior associate dean for education. “It’s not that they don’t have the chops to be a good doctor, it’s that they started the race 20 meters behind everyone else.”
Meijicano said his school’s focus on diversity also includes efforts to expand the pipeline of high school students and undergraduates interested in medicine, to increase the numbers of doctors in rural areas with physician shortages, and to recruit students from disadvantaged and rural backgrounds — critical because Oregon is a largely rural state.
Medical schools that have worked consistently to diversify their student ranks say it takes resources, time, and effort. When Mark Henderson took over as associate dean for admissions at the medical school at the University of California, Davis, the number of students who were underrepresented minorities was 10%. “I thought that wasn’t right, especially in a state where the majority of residents are Black or brown,” he said. The percentage of these students is now close to 40%. “To get where we’re at is a 10- to 15-year effort,” he said.
This change occurred at a medical school that was the basis for the Bakke case, a 1978 U.S. Supreme Court ruling that banned the use of racial quotas in medical school admissions. Davis is now the top-ranked school for diversity outside of the East Coast and fourth overall in the nation, according to US News.
Henderson and colleague Tonya Fancher have implemented a variety of changes, such as adding a metric to admissions committee rankings that captures applicants’ socioeconomic hardships, developing special clinical training programs, including one that graduates primary care physicians in three years with very little medical debt, and offering specialized coursework and mentoring by minority physicians. “It’s important for students to see faculty that look like them,” said Fancher, an associate dean for workforce innovation at the UC Davis medical school.
Victor Agbafe, a first-year medical student at the University of Michigan Medical School, told STAT he recalled learning when he started in college in 2015 how few Black physicians there were and said he was disappointed little has changed. “With all of the talk, the public focus on these issues, and the evidence that more Black doctors will help improve health outcomes for Black communities, I would have thought there had been some progress by now,” he said.
Agbafe is one of only five Black students in his class of 168, and while he feels supported, he said he notices the lack of Black male mentors. “People like people who are like themselves and because we haven’t had many Black men in academic medicine, it means we have to work harder to find that mentorship and support,” he said.