US Medical Schools Losing Ground on Diversity

Marcia Frellick

February 27, 2019

Medical education in the United States is losing ground in racial, ethnic, and socioeconomic diversity and that has implications for access to care and health outcomes, say authors of a perspective published online today in the New England Journal of Medicine.

Efrain Talamantes, MD, with the Center for a Diverse Healthcare Workforce at University of California, Davis, in Sacramento, and colleagues found that between 1997 and 2017, the number of students entering US medical schools who were from racial and ethnic groups underrepresented in medicine grew by 30%. However, with medical school expansions, the overall numbers coming into medical school have grown by 54%, which means a 20% relative drop in underrepresented groups, from an absolute proportion of 15% to 13%.

"There is growing evidence that minority patients report better communication, greater satisfaction, and better adherence to medical treatment when they are cared for by racially and linguistically concordant physicians," the researchers write.

Currently, however, black people make up 14% of the US population but just 4% of physicians; Latinos make up 17% of the population but 4% of physicians; and American Indians and Alaska Natives make up 2% of the population but less than 0.4% of physicians.

Coauthor Mark Henderson, MD, also from the Center for a Diverse Healthcare Workforce, told Medscape Medical News that although schools are expanding and adding more primary care programs, "if we continue to take students in the same way we always have, we are going to not solve the problem we are intending to solve by expanding medical schools."

Ways to Narrow the Gap

One way to narrow the gap, Henderson says, is to seek out students who have grown up in rural and underserved areas rather than those who express on an application the desire to work in such an area.

"Kids will say whatever we want to hear to get into medical school," Henderson said. "We need to focus on who people are and where they come from as a predictor of where they will ultimately practice — rather than their intentions as stated on an application for highly competitive spots."

Another way is to consider community colleges as a pipeline for medical schools, the authors propose. Such colleges generally have much higher diversity than traditional universities, Henderson said. More of their students come from areas that have a high need for healthcare professionals, and those students are more likely to return to practice in those areas after training.

Henderson, who has been in charge of medical school admissions at UC Davis for 15 years, says a community college education is often viewed as academically inferior in medicine admissions offices, even though "that's an assertion that has no evidence behind it."

At UC Davis, the current percentage of medical students from community colleges is 15%, he said, acknowledging that that percentage is on the high side nationally. 

The researchers also point to a class divide.

"Half of the people in medical school today are in the upper quintile of income," Henderson said.

He cited Association of American Medical Colleges (AAMC) data that black and Hispanic medical students are three times as likely as white students to come from families with household incomes of less than $50,000.

"If we're moving toward a system in which only rich kids can go to medical school, that's a big problem in my view," Henderson said.

Several medical schools, including those at the University of Houston and New York University and Kaiser Permanente School of Medicine, have announced in the past year that they are addressing the cost issue by waiving tuition for entire classes.

Community Colleges Have Been Largely Untapped

Norma Poll-Hunter, PhD, the AAMC's senior director for human capital initiatives, told Medscape Medical News that the strategies the authors propose are widely being pursued by member schools.

She said members are looking for ways to reach deeper into communities and engage "atypical" potential medical students, such as those attending community college, though she acknowledged community colleges have been largely untapped for talent in the past.

"I do think that community colleges, especially in states like California, Florida, and Texas, are very strong and strong feeders to the 4-year institutions as well."

Research has demonstrated benefits to diversity that start in the learning environment, Poll-Hunter said.

"When you have more diverse classes, students feel they can work better across different cultures. Diversity among faculty leads to greater dialogue on issues of race and ethnicity and other diversity topics, as well as broader teaching strategies to engage students.

"When you talk about diversity with health professionals — the  underrepresented are more likely to work in underserved areas. So diversity is critical in to advance our mission of providing quality healthcare for all," she said.

Threats to Diversity Raise Debate

In January, UCLA's student newspaper, The Daily Bruin, reported that "[T]he David Geffen School of Medicine is raising its math and science GPA and MCAT cutoff scores to 3.4 and 512, respectively, according to a policy proposal released by school of medicine faculty and students. Many students said they are worried this will negatively affect the school's diversity."

As reported by The Daily Bruin, the proposed change was the subject of a town hall meeting late last year that was attended by more than 300 students, faculty, and alumni. Following that discussion, students put forth a counter policy proposal on ways to increase diversity.

However, exactly what changes are underway at the UCLA medical school are not yet clear. Clarence Braddock, MD, vice dean for education at the medical school, told Medscape Medical News they have not set a minimum admissions cutoff either for GPA or MCAT scores.

"We're in the process of looking at our approach for the coming cycle – people start applying in July," said Braddock, who oversees admissions. "At this moment, as I'm speaking to you, there is no specific level that we're talking about."

He said the school, which gets 14,000 applications per year, is planning in this cycle to double the number they consider.

"As we do that we're looking at a variety of factors. We try to determine what we feel is a wide enough door to have the kind of diversity of applicants, experiences, and backgrounds and such that will align with our values," Braddock said.

Braddock notes that in the latest US News and World Report ranking of medical schools of with the highest percentages of African Americans, UCLA ranks fourth.

"We have a long-standing commitment to excellence and diversity. I say 'and' because we believe they are part and parcel," he said.

The research was supported by the Health Resources and Services Administration (HRSA). Coauthors report grants from HRSA and the American Medical Association outside the submitted work. Braddock and Poll-Hunter have disclosed no relevant financial relationships.

New Eng J Med. Published online February 27, 2019. Full text

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