As medical students graduate this spring, American medical schools are celebrating the achievements of the nation’s newest doctors. They are also celebrating something else: an increase in the number of students from underrepresented populations.
From 2017 to 2018, the number of black students enrolled in U.S. medical schools rose by 4.6%, while the number of medical students identifying as American Indian or Alaska Native increased by 6.3%, according to data released by the Association of American Medical Colleges. It’s the latest evidence of a steady increase in the enrollment of nonwhite students over the past several years.
The numbers are encouraging, but only a start, educators say.
“It’s good that the hard numbers are up,” said Dr. Mark Henderson, associate dean of admissions at the University of California, Davis. “But there are real gaps between who our residents are and the communities they serve.”
The increases are also no accident.
In the seven years leading up to 2009, the number of black medical students in the U.S. had been decreasing annually. In 2009, however, the Liaison Committee on Medical Education (LCME) toughened diversity requirements for accreditation. Specifically, the group went beyond its previous suggestion that medical schools “should have policies and practices ensuring the gender, racial, cultural, and economic diversity of its students.”
Citing Supreme Court decisions among its reasons, the LCME now insists that schools “must” have policies and practices in place that achieve what it calls “appropriate diversity among its students….”
It worked, according to a December study in the Journal of the American Medical Association. After 2009, the overall trend of declining enrollment of nonwhite students reversed.
In some cases, schools that have failed to take heed of the new criteria have been forced to pay attention. In 2016, amid complaints of racism and student protests that led to high-level resignations, the LCME deemed the University of Missouri-Columbia medical school “noncompliant” in meeting diversity requirements.
With its accreditation at stake, the school began aggressively recruiting students of color and addressing long-standing problems affecting them. By 2018, the number of black students enrolled there more than doubled, from 12 to 25, while the number of Latino students increased from two to 10, according to AAMC data.
Medical schools have responded to the standards by dedicating space and funding to the task, and appointing individuals to help direct their diversity efforts. Ten years in, they are learning a lot.
From within, and from the top down
Dr. Joan Reede, a pediatrician and Harvard’s dean for diversity and community partnership, emphasized that institutions must go beyond superficial changes, describing a process that is less like plastic surgery and more like gene editing.
“Sure, you can make a pretty picture by adding different-colored faces,” she said. “But the goal of improving representation has to be added to a school’s DNA — has to be embedded in the organizational infrastructure.”
To that end, Reede led a task force that helped develop Harvard’s diversity statement, which it unveiled during a 2017 public forum. AAMC data shows that Harvard’s enrollment of black medical students rose almost 5.3% from 2017 to 2018, while its Latino enrollment has nearly doubled since 2009.
Whether issued as a standalone policy or added to a school’s guiding principles, a written diversity statement, presented publicly, doesn’t just formalize the school’s commitment to diversity and inclusion. It also signals that it’s a priority, explained Dr. Leon McDougle, chief diversity officer at Ohio State University.
“When you say out loud that inclusiveness is a value within the strategic plan of your institution, the faculty will follow, or at least stay out of the way.”
At Ohio State, the number of black medical students rose from 52 in 2009 to 95 in 2018. The number of Latino students rose from 18 to 48.
Dr. Keisha Gibson, who has been promoting diversity and inclusion as both a student and faculty member at the University of North Carolina at Chapel Hill, cautioned that administrators and faculty members tend to respond in three different ways.
“We have people that are activated to help change things because they recognize the issues. Then there are some that recognize the issues but aren’t activated by it. And then there are the ones who just don’t get it,” she said.
“Sure, you can make a pretty picture by adding different-colored faces. But the goal of improving representation has to be added to a school’s DNA — has to be embedded in the organizational infrastructure.”
Dr. Joan Reede, Harvard’s dean for diversity and community partnership
It’s important, she added, for an institution’s leadership to fall firmly into the first category. “When mandates come from the top, that’s when the culture changes,” Gibson said.
Cultural change is what will help schools retain students from underrepresented backgrounds, said McDougle. “You can recruit all you want,” he said. “But if they don’t feel welcome, they won’t stay.”
It’s not just about the students
Medical schools have historically failed to diversify their faculty. With this in mind, the LCME has called for schools to diversify staffing as well.
“In the U.S., racial numbers among medical faculty are even worse than [for] the students,”said Henderson, the associate dean at UC Davis, which launched its Center for a Diverse Healthcare Workforce in 2016. “It’s mostly white men, so you don’t have mentors to support students who might feel like impostors just being here.”
Henderson recommends putting department heads in charge of faculty recruitment efforts.
“Incentivize deans to value faculty diversity,” he said. “Designate resources, offer funding, dedicate recruitment packages.
“Physicians are intensely competitive,” he added. “And if they know we’re measuring the percentage of the underrepresented, and their department is showing low numbers, they’re motivated.”
But when it comes to recruiting and supporting students of color, a diverse faculty must provide more than visible role models, said Reede, who founded a minority faculty development program for Harvard in 1990.
“I’m not just interested in who gets a seat at the table, but whose voice is heard once they’re sitting there, and how much their voices influence policy,” Reede said.
Making diversity part of accreditation criteria has effectively changed the definition of what makes an institution viable. Similarly, school leaders are rethinking what makes a medical student successful.
Some schools are reevaluating their entry and matriculation requirements, including test scores. They are also taking into account non-academic factors such as socioeconomic status.
Henderson said this is where he often finds the most resistance to diversity initiatives.
“The pushback comes when our average [test score] is lower,” he explained. “Someone in leadership came to me and said, ‘We’re bringing the wrong people into this medical school.’ There’s a lot of entrenched bias, and it can get very antagonistic. But a score on a test does not make a physician,” he added.
McDougle agreed. “They’ll start talking about scores, which have nothing to do with clinical care,” he said. “A high MCAT score does not correlate with high performance in medical school.”
He recalled helping a faculty member understand why it’s important to get away from narrow, often race-based notions about prospects for success.
“This one physician decided to require that residents in his subspecialty program had to come from a top pre-med and have at least five publications,” he said. “I asked him if he had done all that way back when. Then I got, ‘Well, I was from a small town, and my family wasn’t well off,’ and all that. I said, ‘But you got into your specialty, didn’t you?’”
All medical students, but especially those from underrepresented communities, can now expect more help. Today, schools may assign them coaches to help with writing essays and developing portfolios; training in test taking, time management, and other academic survival skills; counseling to help detect and manage learning disabilities and cope with social isolation and academic pressure.
“Of course we’re looking at our pipeline to make sure we get people who can handle the rigors of medical school,” added Gibson. “But we also have to make sure we are setting them up for success.”
Play the long game
Not all news is encouraging when it comes to diversity.
In February, the New England Journal of Medicine examined medical school enrollment data over a 20-year period, 1997 through 2017. While the authors noted a 30% increase in residents from “racial and ethnic groups underrepresented in medicine,” they also found that the proportion of such students had dropped from 15% to 13%.
The authors pointed particularly to the “growing gap between the racial, ethnic, and socioeconomic makeup of medical school classes and that of the general population.”
Nationally, Latinos make up 17% of the U.S. population but only 4% of physicians. There’s a similar disparity for African Americans, who also make up 4% of the nation’s doctors but 14% of the population.
“Ultimately, that’s the problem we’re trying to solve,” added Henderson, a co-author of the NEJM perspective. “But this is the long game.”
Some schools saw steady increases over the past several years, according to the data from the AAMC. In others, numbers often stagnated or even dropped in the intervening years between 2009 and 2018. This happened with black students at Harvard and UC Davis.
“That’s how health interventions work,” McDougle said. “You don’t tell a patient to lose weight, or to stop smoking and they become healthy right away,” he said. “There’s some up and down.
“A public health campaign to reduce obesity or eliminate a contagious disease takes time to show improvement,” he added. “You have to stick to it to see long-term results.”