AMA Acknowledges Medical Education Racism of Past, Vows Better Future

Aine Cryts

June 15, 2021

Editor's Note: This story has been updated to reflect further action by the AMA’s House of Delegates to adopt guidelines addressing systemic racism.

A report by the American Medical Association's (AMA) medical education advisory body points to systemic racism or other systems of oppression as causing a lack of representation, exclusion, and marginalization in medical education and medicine.

It is one step of many the organization is taking in an initiative to address and remedy systemic racism in medicine, including in the healthcare workplace.

The medical education report received overwhelming support at the House of Delegates, the AMA's legislative policymaking body, during an online meeting held June 13. Today, delegates adopted a series of guidelines to assist healthcare organizations with anti-discrimination policies.

The Council on Medical Education's report recommends that the AMA acknowledge the harm caused by the Flexner Report, which was issued in 1910 and has since shaped medical education. The Flexner Report caused harm not only to historically Black medical schools, but also to physician workforce diversity and to the clinical outcomes of minority and marginalized patients, according to the medical education advisory body.

The council also recommended conducting a study on medical education with a focus on health equity and racial justice, improving diversity among healthcare workers, and fixing inequitable outcomes from minorities and marginalized patient populations.

The report comes on the heels of the resignation of Journal of the American Medical Association editor-in-chief Howard Bauchner, MD, and another high-ranking editor following a February podcast on systemic racism in medicine. The AMA has since released a strategic plan addressing racism and health inequity that has divided membership.

Flexner Report's Effect on Physician Diversity

The Council on Medical Education's report observed that as a result of the Flexner Report's recommendations, 89 medical schools, including five of the seven existing medical schools training Black physicians, were closed because they didn't meet the report's standards. In addition, the report created a limited role for Black physicians while "hint[ing] that Black physicians possessed less potential and ability than their white counterparts," read the Council's report.

In addition to consigning the role of the Black physician to "educating the [Black] race to know and to practice fundamental hygienic principles," the Flexner Report also observed that "a well-taught negro sanitarian will be immensely useful," per the Council's report.

The impact of the closure of medical schools training Black physicians was dramatic. According to the Council's report, in 1964, 93% of medical students in the United States were men and 97% of those students were non-Hispanic White.

Today, 56% of physicians identify as White, 17% as Asian, 6% as Hispanic, and 5% as Black or African American, per the Association of American Medical Colleges (AAMC); nearly 14% of active physicians didn't report their race in the survey. By means of contrast, the US population in 2019 was 60% White, 19% Latino/Hispanic, 13% Black or African-American, and 6% Asian American, according to the Brookings Institute.

Abraham Flexner, who wrote the Flexner Report, is often referred to as the "father of modern medical education," according to the AAMC. In November, the AAMC observed that the Flexner Report contained racist and sexist ideas and that his work contributed to the closure of historically Black medical schools. Both statements were included in AAMC's announcement about the removal of Flexner's name from its most prestigious award. As of January, the award is now called the AAMC Award for Excellence in Medical Education.

Pathway Programs Can Increase Diversity

Pathway programs, which leverage targeted milestones along the journey to becoming a physician in order to increase diversity, were an area of focus in the Council's report. These programs "can exert a meaningful, positive effect on student outcomes and increase diversity across various levels of educational settings," according to its report.

Centers of Excellence, which provides grants for mentorship and training programs, is one of many pathway programs. During the 2018-2019 academic year, Centers of Excellence supported more than 1,300 trainees — 99% of them were underrepresented minorities and 64% came from financially or educationally disadvantaged backgrounds. In 2006, federal funding was cut to these programs and the number of Centers of Excellence fell.

Still, the report cites the passage of federal funding in 2020 of $50 million for public institutions of higher education that train physicians; educational institutions in states with a projected primary care shortage in 2025 are given priority in the grant-funding process.

AMA Council's Report Garners Support From Delegates

Delegates voiced overwhelming support of the Council's report during the June 13 meeting. Lou Edje, MD, a Perrysburgh, Ohio-based family physician, voiced strong support for the Council's report, in particular its recommendations that recognize the harm caused by the Flexner Report. Edje observed that the Flexner Report, with its elimination of five of seven Black medical schools, "[set] back admissions of Black students into medicine by fifty years."

"Empathy is what we are called to have as physicians. I implore you to simply substitute your ethnicity into these quotes to help understand the historic need for health equity in medicine today. This CME report is part of the antidote to Flexner. We support [it] fully," concluded Edje, who spoke for the Great Lakes States Coalition of the AMA.

Rohan Khazanchi, a medical student at the University of Nebraska Medical Center College of Medicine and a member of the Council, said, "Our broad attempt with this report was twofold: to fill gaps in AMA policy with evidence-based recommendations which could improve diversity in our health workforce and, second, to enhance our organization's vision for truth, reconciliation, and healing to redress the historic marginalization of minoritized physicians in medicine."

According to an AMA spokesperson, the House of Delegates will vote on this and other policies this week, after which the policies are considered final.

Aine Cryts is a veteran health IT and healthcare writer based out of Boston.

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