Racism and Educational Barriers Impede Efforts to Diversify the Allergy Workforce

Esther Landhuis

November 09, 2021

UPDATED November 11, 2021 // Editor's note: This article has been updated with additional comments.

In the tenth grade, Kathleen May nearly got suspended from school for fighting. After years in small, innovative classrooms in an affluent suburb of Cleveland, Ohio, May's education took a turn in the 1980s when court-ordered desegregation led to her transfer to an inner-city high school across the freeway. Gangs and drugs were common, and "as a White student, it was impossible to blend in," said May, an allergist-immunologist and associate professor of pediatrics and medicine at the Medical College of Georgia, in Augusta. "I became an immediate target simply because of the color of my skin."

Kathleen May, MD

Those experiences opened her eyes to a painful truth — racism creates educational barriers that keep people in some minority groups poorly represented in medicine and ultimately the allergy workforce.

"White privilege does exist, and opportunities are not equal, and people don't realize it," President-elect May told Medscape Medical News before delivering the Bela Schick Lecture at the American College of Allergy, Asthma, and Immunology (ACAAI) 2021 Annual Meeting, held November 4–8 in New Orleans, Louisiana. "I'm going to make them think about the pipeline in a way they haven't thought about it — from the ground up," May said.

In her talk, "Three Ps: Revisited," May described the downstream effects of population-wide educational obstacles on patients, physicians, and the allergy profession.

Patients "are those who need healthcare" — in other words, "all of us," May said. Poor people and people of color suffer disproportionately from a host of common diseases — among them, atopic dermatitis. The disease is more prevalent in Black patients than in their White counterparts, yet it's often underdiagnosed and undertreated, according to data presented at the ACAAI meeting by Ama Alexis, MD, an allergist and clinical assistant professor of pediatrics at the NYU Grossman School of Medicine, New York City.

And although poor access to care and many other factors contribute to health disparities, "I think that education, or lack thereof, explains a significant amount of the variance that we see," May said.

Supporting this point, she showed a slide that contained a scatterplot from a 2016 study that tracked the outcomes of Georgia high school graduates. It showed that the greater the proportion of those who qualified for free lunch at a given school, the less likely the students at that school were to complete a post–high school degree.

In that study, analysis of the demographics of high school graduates by race or ethnicity showed that decreasing proportions of Black and Hispanic students go on to enroll in post–secondary school programs and to complete degrees. White and Asian students, on the other hand, show proportional increases in both degree enrollment and completion.

Moving down the pipeline, it follows, then, that "reduced diversity among those receiving undergraduate degrees directly impacts the representativeness of our physician population," May said. According to physician demographic trends in 2018 data from the Association of American Medical Colleges, only 5.0% of US physicians are Black, yet Blacks represent 12.4% of the US population. Underrepresentation is worse for other groups: Hispanics make up 18.5% of the population, yet they make up only 5.8% of the physician workforce.

A perspective article published on November 4 in The New England Journal of Medicine offers several reasons why efforts to diversify the physician workforce have hardly moved the needle. "Academic medical institutions have focused disproportionately on the lack of qualified underrepresented minority applicants," the authors write. "Because of this narrow focus, leaders haven't developed a more comprehensive understanding of the structural inequities and system-level biases that prevent recruitment, retention, and advancement of highly talented students, trainees, and faculty from underrepresented groups."

Why is it important to have a physician population that mirrors the US population in terms of ethnicity? A study published in November 2020 in JAMA Network Open found a positive association between patient-experience ratings and racial/ethnic and gender concordance. "In other words, patient satisfaction improves when a physician looks like them," May said.

At the professional level, the American Medical Association adopted a major policy to increase physician workforce diversity. But more importantly, individuals can help promote a physician population that better reflects the country's ethnic and racial diversity. May closed her talk with a few suggestions. "It may start by having an interested undergraduate student shadow you in your office or talking to a bright young student whose career path is uncertain," she said. "Those of us in graduate medical education have the opportunity to be even more intentional — speaking with interested medical students and residents from diverse backgrounds."

Presentations such as May's exemplify how the ACAAI really "captures the zeitgeist," Alexis told Medscape Medical News. With presentations on atopic dermatitis but also on vaccine hesitancy, telemedicine, and health disparities, she said, the conference incorporates "all those things that are relevant right now, which will help us be better doctors."

To encourage more Black physicians to enter the specialty, the ACAAI Task Force on Diversity is partnering with the American Academy of Pediatrics' section on allergy and immunology to bring its Chitra Dinakar Visiting Professor Program to historically Black medical colleges. In addition, they are offering SPARK awards to help pediatric and internal medicine residents learn about the allergy field by pairing them with mentors and covering their expenses for 3 days at the ACAAI annual meeting.

In an interview with Medscape after the Bela Schick Lecture, Cherie Zachary, MD, chair of the task force, said that diversity and equity initiatives often feel overwhelming — like a "big 20-ounce steak. You can't eat it in one bite."

May's personal story was an "elegant way to tackle what would be a complex and difficult topic," Zachary said. By breaking it down "so that it resonates with them on a personal level, it becomes very easy for people to say, how do we approach this?"

In a follow-up comment after her talk, May said that she's hopeful her presentation will start a conversation and help physicians reflect on the opportunities they have been given and what barriers still need to be addressed.

"I benefited greatly from the perspectives of my high school friends of color at the inner-city school I attended, following those initial rough transition days," May added in an email. "I also think that we as people have all had different experiences, and do not think one must experience the ugliness of racial violence to have empathy. Furthermore, we as physicians and allergist-immunologists are healers who strive to make the world a better place, each and every day."

May and Zachary report no relevant financial relationships. Alexis has received consulting fees from Pfizer and Regeneron.

American College of Allergy, Asthma, and Immunology (ACAAI) 2021 Annual Meeting: Presented November 6, 2021.

Esther Landhuis is a freelance science journalist in the San Francisco Bay Area. She can be found on Twitter @elandhuis.

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