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COLUMBIA, Mo. — Diversity is a big problem at medical schools around the country, but perhaps no more so than here.

The University of Missouri School of Medicine is in danger of losing its accreditation next year because it has so few minority students and faculty. There are five black students in the current first-year class, out of 104 students. In 2015, there were two. The year before, there was just one.

This is the third time since 2000 that the school has been called out for its lack of diversity. And this time, the school is moving aggressively to convince students of color to move to the middle of Missouri to fulfill their dreams of becoming a doctor.

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“We have a real issue we need to deal with,” said Dr. Patrick Delafontaine, dean of Missouri’s medical school.

The school is trying everything from individual outreach to minority students to building ties with historically black schools to offering more minority scholarships to expanding programs that prepare students for the rigors of medical school. It has launched a minority lecture series to expose students of color to successful physicians who look like them.

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But in interviews with STAT, more than a half dozen current and former students described a campus that has made it harder for them to succeed. Some said that MU’s lack of diversity means they are more likely to be mistaken for a janitor, to be singled out for ID checks by campus security, or to hear physicians make off-handed remarks about patients of color. They said it was more difficult for them to thrive here than white students. They said they have dealt with subtle and overt displays of racism. And some have questioned whether they made a mistake deciding to attend the school.

This dissatisfaction could have dire consequences: If the school loses its accreditation, a medical degree from here could be rendered essentially worthless.

Several students and alumni said they believe the effort could succeed. But they lamented that there was little they could do about the here-and-now, and the institutional hurdles standing in the way of finishing their medical education.

“There are plenty of things the school hasn’t done a good job of — and there are still stragglers of that old guard that do a disservice to students,” said Samiat Agunbiade, a fourth-year student. “The school is headed in the right direction. But it’s hard to know if it’s going to be enough.”

‘We have a real issue’

As Missouri tries to hang on to its accreditation, it needs to win over prospects like Leslie Fogwe, a 24-year-old native of Cameroon. Fogwe was accepted into two medical schools: Missouri med school and the University of Alabama, Birmingham. Alabama has a better academic ranking and is slightly more diverse. But Missouri has one built-in advantage: Leslie’s brother, Delvise, attends medical school there, and speaks highly of his experience.

“I went to my brother’s white coat ceremony. He filled me in and said they needed diverse students. I’ve tried to go in with a blank page and learn more about the school, the program, and the need for diversity,” said Fogwe, who is about to graduate from Delaware State University.

Leslie’s brother is one of the five black students in the Class of 2020.

Some MU officials acknowledge their failures to move the needle on diversity after their first two citations from the national accreditation organization, the Liaison Committee on Medical Education, in 2001 and 2008. In its 2016 ruling, the LCME said the medical school still faces challenges “that inhibit the enrollment of students and the hiring of faculty in the full range of diversity … to maintain a quality learning environment.” Missouri must now recruit more black, Hispanic and Native American students by 2018.

“It was disappointing but not surprising,” said Delafontaine.

Over the past decade, the LCME has cited nearly half of all US medical schools for lacking diversity. Even prestigious schools like Yale and Stanford have struggled to graduate students of color, according to data from the Association of American Medical Colleges.

Leslie Fogwe
Leslie Fogwe, 24, has been accepted to the University of Missouri School of Medicine. Suchat Pederson for STAT

‘The history isn’t lost’

In the last two years, this college town has seen much racial turmoil, after a large-scale student protest that followed a series of race-related incidents at the university.

Columbia is in the heart of a state that is 83 percent white. The university remained segregated until 1950. Minority students have protested their treatment over the decades.

The aftermath of the student protests, which also followed the 2014 shooting of Michael Brown two hours away in Ferguson, greeted LCME accreditors when they reviewed the medical campus in January 2016, two months after the university system president resigned in response to a boycott by the football team.

“The history isn’t lost,” said Dr. Veronica Catanese, LCME co-secretary. “When the LCME goes out for a review, they’re aware.”

On site, LCME accreditors found the percentage of underrepresented minority faculty was even lower than students, right below 6 percent. According to the report, medical school deans agreed with the accreditors that its diversity was “unsatisfactory.”

Catanese said medical schools generally set their own diversity goals, which the LCME then tracks. Missouri had improved its geographic diversity, growing its number of rural students, but failed to do the same for racial diversity. Rather than set a goal of a number of students, the school proposed changes to recruiting and programming.

But for students, a lack of diversity can have a profound effect on education. It can mean a lack of camaraderie — critical for success in the school’s team-based curriculum. Minority students told STAT they had trouble fitting in, and it led to isolation, poor grades, and even failed exams.

It can also mean a lack of perspective. Colbey Ricklefs, a white student, said classmates of color bring life experiences to the table that white doctors can learn from. For example, he believes having black students who can talk about historical distrust of the medical profession can give “voice in the classroom about a lived experience.”

“Not having that identity present in the room can mean we miss topics entirely,” Ricklefs said.

Fogwe, who suffered from malaria as a child in a one-doctor town, points to the changing population in the US as another reason why medical schools need to diversify.

“The patient base is changing to become more diverse,” he said. “I think a patient might want to relate with someone who looks more like them.”

At its worst, inadequate diversity can cause students to leave medical school. Josiane Tossa was the only black student to begin at MU in 2014. She left before her first year ended because she felt isolated and lacked support and understanding from her faculty mentor.

“I was made to feel like I wasn’t going to be successful — and that I was at fault,” said Tossa, now studying to be a physician assistant at George Washington University. “It would’ve made a world of difference if I wasn’t the only one in my class.”

‘They don’t like black people’

He may be guilty of wishful thinking, but the most hopeful leader at the University of Missouri is Warren Lockette, the senior associate dean for diversity and inclusion. Last fall, he told Delafontaine that he would build the most diverse medical school in the country in one year.

Earlier this year, Lockette took about 30 medical students to meet Dr. Otis Brawley, the chief medical officer of the American Cancer Society, during a trip to Atlanta. Brawley spoke about his own upbringing, and offered advice on being a minority in medicine.

Lockette hopes outings like this show minority students they have support at Missouri. Another way is by promoting black faculty to visible positions in administration. Dr. Laine Young-Walker, a longtime clinical psychiatry professor, was recently named associate dean of student programs.

Students here said Young-Walker could finally spur changes they hope to see. But improving diversity is daunting: Missouri must fight over a small pool of medical school applicants nationwide — underrepresented minorities make up only 15 percent of applicants.

In recent years, they’ve received more applications from these groups, but most accept offers to other schools. Because many students need financial support, Missouri offers eight scholarships to students “traditionally underrepresented in medicine” and allows others to qualify for in-state tuition after one year.

Missouri launched minority interview days last fall, and dispatched faculty to visit historically black colleges and universities to recruit to minority premed students. By 2018, it will roll out a program to help Missouri’s minority undergraduates get ready for medical school and a postbaccalaureate program to help those with science backgrounds prepare as well.

As part of its efforts, Missouri has invited St. Louis-area high school students to the medical school — and has med students volunteer with younger minorities in Columbia. Lockette wants Missouri to find more ways to expose children to medicine at an earlier age.

“Whatever it is I can do to help,” he said, “I’m willing to provide it.”

That’s a far cry from Young-Walker’s experience here in the early 1990s. “My mom said, ‘Don’t go there, they don’t like black people,’” she said, recalling an incident in which someone put a picture of monkeys on the door of a fellow black student. Still, Young-Walker stayed through her fellowship before becoming faculty.

To her, early diversity initiatives seemed like “lip service” to please accreditors. This time, Young-Walker says it’s different.

“I’ve since seen a true desire and spirit for change,” she said.

Reaching a ‘critical mass’ nationwide

Medical schools nationwide face a diversity crisis. Only 6 percent of US doctors identify as black, Latino, or Native American — even though 32 percent of Americans considers themselves as such. In the 1960s, a decade after Missouri accepted black students, the University of California, San Francisco, integrated. By the 1980s, UCSF had surpassed most medical schools in diversity. That school’s vice dean for education, Dr. Catherine Lucey,‎ said the medical school wanted its students to reflect the nation’s diversity.

“Diversity must be a true manifestation of values,” Lucey said, “not an accreditation decision.”

But without accreditation, medical students can’t apply for residency programs. The LCME rarely revokes accreditation, but did so briefly in the case of San Juan Bautista School of Medicine in 2011. Typically, the LCME acts only if a school fails to correct series of citations — not just one, such as diversity. (Missouri med school was deemed out of compliance in four out of 95 categories that make up LCME’s 12 standards.)

Because of such inaction, MU students seem unfazed by the threat of losing accreditation. They feel like deans will do enough to maintain its full standing with the LCME — even if, in their eyes, they’ll be gone before things change.

Change can happen. When UCSF’s Class of 2020 arrived, about a third were underrepresented minorities. Lucey said the schools has rethought its admissions process — less focus on MCAT scores, more focus on life experiences — to reach a “critical mass” of minority students. It’s helped minority students who feared potential cultural isolation consider USCF.

At MU, said Dr. Ontario Lacey, a Missouri med school alum who’s an internist with Naval Medical Center in San Diego, being one of few can lead to misunderstandings.

“We’re told we don’t communicate well, when we may communicate differently,” he said. “It’s hard to prove someone is biased toward you.”

Matthew Bartley was one of a few black students to graduate in 2016. He said he was dinged in a third-year rotation for “unprofessionalism” and “trying to avoid work,” even though, he said, he was showing up early to work and treat patients respectfully.

He was shocked.

“I changed my behavior,” said Bartley, now a surgery resident at the University of Colorado, Denver. “I became a robot who did my work. I felt so nervous something was going to happen again.”

To improve Missouri med school’s diversity, Bartley thinks alumni should play up the positives about the educational experience while remaining frank about the hardships. Deans see their efforts already paying off after getting 60 percent more applications this year from underrepresented minorities.

Still, the question remains: Will minority students accept offers with the LCME report hanging over MU’s head?

Leslie Fogwe
Fogwe’s acceptance letter from the University of Missouri School of Medicine. This image has been altered to protect Fogwe’s privacy. Suchat Pederson for STAT

To some degree, Fogwe has prepared for the lack in diversity, as he specifically applied to medical schools with few minorities to increase his chances of acceptance. He’s one of 22 underrepresented minority students accepted for the next academic year.

Last year, Missouri med school had a lesser percentage of underrepresented minorities enrolled than Alabama.

In the end, Fogwe decided to head to Columbia, where in July he will start the pursuit of his white coat.

Yet the biggest factor may not have been the outreach by the school, but the fact that his brother, Delvise, sold him on Missouri’s strengths. He told his brother of the school’s curriculum, friendly staff — and that the two could get to live together. It only helped that Missouri med school offered Leslie a full ride.

“It’s a better choice for me,” Fogwe said. “I’m assured by the actions. I’d be willing to help in the process in any way.” 

  • Has anyone thought that the lack of diversity is a symptom of greater problem of a lack of qualified candidates. I am not suggesting that minorities are inferior or are not capable of success in medical school. What I am suggesting is that the public education system is failing to produce qualified prospective students. A compromised graduation rate in our minority communities is obviously going to have an effect on the qualified applicant pool. If a student does not graduate high school, how can they continue on to college and graduate school. No Child Left Behind and Common Core, as well a public policy that promotes social promotion, has undermined critical thinking skills and promoted “teaching to the test.” Students graduating from high school are becoming less prepared for the rigors of a college education and much less prepared for the intensity of a rigorous program like medical school. Also, the explosion of DO schools and pharmacy schools has been good in expanding medical education opportunities, but has had the unintended consequence of diluting the qualified applicant pool.

  • As a student at Mizzou Med I find this article deeply disapointing. And this begins from the highly inaccurate title. Long before this article was finalized LCME returned to the university in February and found the 4 items mentioned had a sufficient plan to address them and gave Mizzou Med full accreditation. The author of this piece would have had access to this information but did not mention it to add to the (I can only guess) drama of the piece. This is in contrast to SLU Med which was deemed inadequate in at least 20 areas and is the only medical school I know of this year on official probation, we are not one of them as this article tries to suggest. So while I absolutely agree that diversity is an issue we need to work on at our medical school it is not a component that is currently risking our accreditation so please do not continue thinking that fellow readers. I strongly believe that admitting more students of diverse backgrounds into medical school is extremely important. Particularly for a school like Mizzou that learns primarily from a group case-based learning curriculum the things we learn from our peers are important and shape our own experience as a clinician. I was a part of the class mentioned by Josiane Tossa and it is very true she was the only African American admitted that year, I personally know a few others that were accepted by opted to go to other universities, mainly those that were closer to home. Along with feeling isolated as a minority Josie also suffered from intense homesickness having moved from Maryland which as another factor in her decision to leave. There were other minorities represented but admittedly there were more than 10 who could identify as such in a class of 104. I am a white female and I can speak for the fact that our entire class thought this was a problem. A very complex problem alluded to by the statistic mentioned in this article that only 15 % of applicants are minorities. I strongly believe that minority students should be supported by the bottom up with programs that make them empowered to pursue high-achieving fields (this is not just a problem in medicine) so that they can reach the level of being a highly competitive applicant. I disagree with a few commentators who have lamented that supporting diversity at the school will somehow admit students who do not deserve it or do not meet the requirements. This is absolutely false & those who have said this insult every wonderful minority student who is currently attending Mizzou Med. I have worked with many of them and they are highly intelligent, caring individuals who will just a fantastic doctor as I will. The admission process has subjective components (interviewer perception, essays written etc) but the ultimate decision comes down to scoring (out of 25) in which everyone votes & the top and low score are thrown out and the rest averaged together. This numeric score comprised of 5 categories (residency, academics, extracurriculars, research etc) , carried out to 3 decimal places, becomes the number that places an applicant on the virtual “board” and ultimately determines acceptance. This simply does not allow for the preferential acceptance only based on race. The classes that have followed me have done a much better job in recruiting and admitting fantastic minority students who will be kickass clinicians in the future medical workforce. We NEED these doctors, health problems do not discriminate and it is vital that the professionals that take care of our patients represent that patient population. Studies have shown that this can make a difference in patient care outcomes due to cultural awareness, understanding and an improved doctor-patient relationship.
    We do need to improve our diversity at Mizzou but we care deeply about doing so & many efforts have been made. To suggest we are losing our accreditation because of it though is highly false.
    Along with the other impressive accomplishments mentioned by a commentator Mizzou also has impressive numbers for Step 1, our first set of board exams that is the #1 reason residency programs will consider an applicant for a position during application season 4th year. Mizzou has always outperformed the rest of the field with scores consistently >15 points above the national average. This year we blew them out of the water. National average: 228 Mizzou average: 241 (last year’s 239). How bout that for a great med school? #MIZ

  • Yeah, forget about that doctor shortage in the U.S. You know what’s so important? Pumping out different colored doctors! Can’t do that? Psh, guess your med school is losing accreditation! Someone’s grandparent’s gonna have to wait several months to a year longer for care, but hey, the orgasmic ecstasy from more minority doctors is sure gonna make that colon cancer bolt out the door!

    • Please see above comment, we are NOT losing our accreditation.

  • As a foreigner, I find this sickening. What kind of perverse society judges students not on their performance, but based on their race? How do you determine who is “black” enough, anyway, to fulfill the quotas? Is “50% black” enough? 25%…?

    I get racial discrimination when it comes to certain political issues, like immigration. People don’t want to be replaced by immigrants from another continent…
    But we’re talking about health here. How the hell can you in good conscience let a medical student in even though he’s objectively less qualified?
    It would certainly make me think twice before going to a black doctor in America.

    • Your confirmation bias has impaired your reading comprehension. Quotas were not mentioned. I suggest that you read the article before making ill-informed comments.

    • William, what is mentioned is lowering standards to accept more minority students.

      “Lucey said the schools has rethought its admissions process — less focus on MCAT scores, more focus on life experiences — to reach a “critical mass” of minority students.”

    • Well honestly sir I feel is sickening that you believe that supporting black doctors with high school/undergraduate programs and scholarships to assist in their application process and attendance is preference. These students do NOT get a significant advantage in the application process, it’s simply not designed that way. And even if it was medical school is not forgiving of those who can not make the grades. Every student who graduates from a LCME accredited school goes through an extremely rigorous curriculum that does not discrimate what color you are, it only cares that you can make the grade. And if that wasn’t enough we take 2 sets of USMLE board exams while in medical school and 1 after beginning residency that certify we are just as qualified as the next student. You should be ashamed of “thinking twice” to go to a black doctor in America, also stupid, they’re most likely kick-ass.

  • This article is pretty one-sided for a feature story in a major US newspaper. It fails to mention the many great things the Mizzou Medical School has done, not only to improve diversity, but to improve the lives and careers of its graduates.

    In the past few years, the Mizzou School of Medicine won the nation’s top awards for medical student career advising and educational innovation; the Association of American Medical Colleges’ Award for Exemplary Service on Student Affairs; and developed several innovative programs: the Advice, Support and Medical Career Counseling Program; the Career Advising Tool for Medical Students and ; and MedPrep, one of the nation’s most innovative, diversity-driving programs for new medical students.

    To put the Mizzou Med accreditation issue in better context, it faces fewer LCME “noncompliance action items” than many other US medical schools. St. Louis University is facing almost two dozen of these items. It’s accreditation situation is so bad at SLU, some stories describe it as being on “life support”.

    See
    http://www.unewsonline.com/2017/03/23/slu-medical-school-on-life-support

    http://www.stltoday.com/news/local/education/slu-medical-school-put-on-probation-by-accreditation-agency/article_e61e1775-c17e-560c-9175-ef40bea9768e.html

    Meanwhile, Mizzou’s medical school won the nation’s top honor last year (2016) for medical student career advising: The Association of American Medical Colleges Excellence in Medical Student Career Advising Award.

    See:
    http://www.columbiaheartbeat.com/index.php/news/headlines/1227-041317

    Previous to that award, Mizzou Med won the AAMC Award for Innovation in Education and Research, one of only five recipients nationwide.
    The award recognizes innovative, system-wide processes that improve opportunities for research in quality improvement, HEALTH EQUITY or electronic health records. Other recipients included the University of Chicago, Massachusetts General Hospital, Emory University and Vanderbilt University. Linda Headrick, MD, then senior associate dean for medical education at the MU School of Medicine and Les Hall, MD, then-interim dean of the medical school, led the effort.

    See:
    http://mizzoushoulderdoc.org/news/0215.php

    Rachel Brown, MD, then-associate dean for student programs and professional development at the University of Missouri School of Medicine, received the 2014 Award for Exemplary Service by the Association of American Medical Colleges’ Central Group on Student Affairs.

    See
    https://medicine.missouri.edu/2014/06/award-recognizes-exemplary-service-in-student-affairs

    Finally, in 2013, Mizzou Med started the Med Prep program for “non-traditional” medical students — people from diverse backgrounds who may have been out of college for a while, gaining real-world experience. That first year, more than 40 of these nontraditional applicants enrolled in the MU School of Medicine’s new Mizzou MedPrep program.

    See:
    https://medicine.missouri.edu/2013/04/workshops-to-provide-one-on-one-advising-resources-to-students-from-diverse-backgrounds

  • Dr M is a she. And I don’t understand why your brilliant black doctor friend is considered the expection and not the rule. I graduated from MU in the last 10 years. Why is it assumed that docs who look like me are underqualified but accepted anyway? And your point that students should be accepted on merit only is contradictory to your view on “foreigners”

    • Dr M (female, male, or plant it doesn’t matter to me I apologize for confusing the gender it wasn’t intentional nor assumptive)
      My partner is only exceptional because he is brilliant not because he is black and brilliant. He didn’t get special privilege because he is black and wouldn’t have accepted any short cuts had they been offered
      As you know we are who we are not because of some diversity initiative but because we are by definition the top 1%
      if we force universities to accept from the top 20% simply to get enough minorities then we have dumbed the entire profession and with that sacrificed the health of the nation to boot
      As far as foreigners I think that the comments about having different levels for foreigners is equally wrong IF they are to remain here in the US. If they are simply accepting our education system with the intent to return to their nation then I think we should modify the admission process to whatever level we need to in order to satisfy their quotas but realize that once we lower the standards those grads are no longer eligible for US licensure
      We need to stop trying to fix something that happened over a century ago and realize that there is no possible way to fix things beyond and apology and we need to move on and that includes not making special anything for anyone. Grades and commitment shoud be the standard for everyone if they have grades and extra curriculars and recommendations then all else equal accept them period. Admission committees should be blinded to the process same goes for USMCLE and the like.
      I have trained far more residents and fellows then I have hair left and I see no difference between race religion and or other “defined” issues the only difference is pure passion and knowledge. No matter the skin color sex or the like if they get it they get and do well.
      Sorry for the assumption and apparently the confusion but we need to see this for what it is a failed attempt to adjust what doesn’t need to be fiddled with
      Dr D

  • So as I understand this the university has to forcefully add non-white students to the roster even if they are lesser in standing then the other acceptances just to be politically correct?
    My partner is black he is brilliant and graduated a year behind me back in the early 80’s. So his position is now going to be somehow reduced because the next generation of black physicians are going to be accepted not based on grades like he was but based on skin color????
    This makes absolutely NO sense. If the blacks how apply are not as qualified they simply don’t get in. If there are not applicants applying to medical students so what! Should we force a diversity just for statistical purposes?
    I graduated in the top 1% of the nation and did so based on academics no skin color or in my case religion. Should I have gotten in because I was Jewish and considered a minority? Man that thought just sickens me. I am who I am because I earned my scalpel not because some politically correct said the my school didn’t meat some point on a bell curve.
    Wake up AMA we want the best and brightest and if that includes ALL blacks or none so be it as long as no one forced the demographics to allow someone not qualified into the system
    Looking at Dr M’s cred I think he would be pretty upset if some foreigner was admitted over him because that year the vogue was suggesting that US medical schools needed to stop locking out foreigners
    The profession is hard enough as it is we don’t need/want unqualified members to leak in because….
    Dr Dave (head and neck surgical oncology)

  • You’re exactly right. I’m trembling with fear and doubt that all my accomplishments through high school, undergrad, med school, residency and fellowship are ALL due to the color of my skin and have nothing to do with hard work, determination, resilience and intelligence. Do you have personal experience with medical school admissions or the racial climate at Mizzou from the perspective of a person of color?

  • Great so more hook ups yet again!!

    Why is this happenening? The only people that have a right to be mad is Indian and Asian they have to score highrer to get in look at the data.

    Just look at the total applicants per year this school shouldnt have more that 8-10 AA students anyway based off of simple math assuming everyone scored the same.

    My best friend in my 20s was black went to Tulane guy is awesome (Internal Med), but quotas?

    No, quota unless you score the mean gpa and mcat imo. If not well give it to the asians and indians. Its not about color its about who is the best.

    If you are a UR and score top 10% and dont get in then you have a case, but as a dad who sent kids to college that wont be happening. You will get in!!

  • Can there be an asterix on the licenses for those who were admitted not for their skill, but for their “diversity”?

    • Did you also question the credentials those who were admitted due to their privilege as a non-minority? As an African-American alumni physician who graduated from a top 10 university, served on the admissions committee at MU, and practices at a top-3 hospital, it frustrates me to hear assumptions that students of color who are admitted are underqualified. That is far from the case. Students of color not only have worked hard academically but also overcome racial, social and economic struggles to achieve.

    • Then Dr. M, you should stop championing policies that make those assumptions rational.

      Sounds like you want to fix a societal problem at the end not treat the cause. If a student is objectively unqualified they do not deserve a place in any school.

      The problems seems to be that there are fewer qualified African American students which is not going to be solved by strong arming Mizzou admissions committees.

      But this is not the place for rational discussion, because “activism”.

    • That’s exactly my point. MU gets applicants of color who are qualified to attend medical school with MCAT scores, GPA, and community service that make them competitive and qualified. The article points out that one of the biggest problems is the racial climate of MU and Columbia makes students of color second guess attending. It no one wants to address that. People are always quick to assume that any time a person of color is selected, it’s only based on color and not on merit. You are quick to cite affirmative action when you don’t get selected instead of considering that person of color’s qualifications were as good or better than yours. Also, affirmative action benefits white women significantly but people don’t understand that. Prime example: Abigail Fisher.

    • Dr. M your premise is false from beginning. There is a lowered bar, and it seems odd that that is in dispute. Students that do not meet mcat and Gpa requirements are routinely admitted for diversity. Abigail fisher didn’t meet the minimum qualifations for either group so it is a bit of a red herring my friend.

      Nothing in this piece suggests that the climate at Mizou is unique and that disparities exist across all schools.

      You haven’t responded to the central point, because it is indefensible, especially for someone who would have been accepted without special treatment, and is now saddled with the burden of doubt.

    • Only if there is an asterix for those who were admitted for their white privilege, naturally. Of course, that’s where the absurdity of your question is revealed. You are assuming that efforts to enhance diversity are a zero sum game. Although the amount of impotent outrage that you suffer more than makes up for the positive consequences of outreach to minorities, I won’t let the exception prove the rule.

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