Racial and Ethnic Diversity at Medical Schools — Why Aren’t We There Yet?
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National discourse has galvanized organizations throughout society to identify and address inequities based on race and ethnic group. In medicine, diversity at all levels — from the frontline workforce to executive suites and from classrooms to laboratories — is an essential component of efforts to achieve equity. More than a decade ago, one of us examined data from the Faculty Roster of the Association of American Medical Colleges (AAMC) and found minimal progress in the proportion of medical school faculty belonging to racial and ethnic groups that are underrepresented in medicine (URM).1 Such trends disappear or are reversed when shifting U.S. population dynamics are accounted for. Similar stagnation in the relative diversity of medical school matriculants has been reported.2 Recent AAMC data suggest little improvement in representation among faculty: 5.5% of medical school faculty are Hispanic, Latinx, or of Spanish origin; 3.6% are Black or African American; and 0.2% are Native American or Alaskan Native.3
Why has there been little or no progress in this area? For one thing, it’s challenging to make progress while overlooking a root cause of disparities, and academic medical institutions have focused disproportionately on the lack of qualified URM applicants. 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. Structural inequities and system-level biases privilege White students and those from wealthy backgrounds who have access to high-performing elementary and high schools. High application and entrance-exam fees and high-cost educational resources and test-prep courses advantage students from privileged households. Moreover, many colleges use inequitable criteria to admit students — for instance, prioritizing those who have participated in niche, high-cost extracurricular activities, such as sailing or crew.4 These inequities, coupled with implicit bias among members of admissions committees, contribute to noninclusive environments and result in unequal opportunities for potential URM applicants to enter the medical field.
Medical students also face a dearth of URM faculty role models. To address the lack of diversity among faculty, many medical schools have developed pipeline programs for students and trainees and mentoring and career-development programs for faculty. Such programs are designed to stimulate interest in careers in academic medicine, provide mentorship and funding, and promote research skills. Yet these programs are heterogeneous, and research demonstrating their effectiveness is lacking.1
In addition, medical schools lack appropriate incentives to invest in diversity efforts and are plagued by long-standing faculty bias. The persistence of bias based on race and ethnic group in hiring and promotion is well established. Although the Liaison Committee on Medical Education has required medical schools to implement programs and form partnerships to diversify their student bodies, such efforts have been only marginally successful.2 Recent court rulings that have limited the use of affirmative action in college and medical school admissions may present substantial challenges to race-conscious admissions processes.4
There is no consensus on how to define success or how to measure and track progress toward increased diversity. Evaluations have used various metrics, ranging from the absolute number of URM students and faculty to more sophisticated measures of representation that account for the demographics of an institution’s patient population.3 Defining success and endorsing a clear, unified goal is a critical step toward galvanizing change. In 1991, for example, the AAMC set a goal of enrolling 3000 medical students of color per year by 2000. The campaign came close to succeeding, but it fell short because of political backlash and lawsuits against using race as a criterion in admissions decisions.4
Finally, there has been an overemphasis on recruitment at the expense of retention. Having a welcoming institutional climate and inclusive policies is essential for engaging and retaining URM students, trainees, and faculty and supporting their advancement. There is mounting evidence of differential engagement of the URM workforce, however. For example, one of us found that URM students, trainees, and faculty at health science schools and hospitals affiliated with one university were more likely than their White peers to report a lack of inclusion.5
There are several strategies that medical schools can adopt for addressing these challenges and advancing diversity and inclusion. First, institutions could shift from an applicant-deficit lens to a system-deficit lens, which involves recognizing that failures to adequately diversify are the result of deficiencies in our educational and (supposedly) meritocratic systems — not deficiencies in individual efforts and abilities. This process begins with reevaluating standards for selection and recruitment of medical students, residents, and faculty. Selection methods such as holistic review, which has been championed by the AAMC, aim to place at least as much weight on various experiences that demonstrate an applicant’s skills as on traditional extracurricular activities. Holistic review has been shown to enhance diversity without affecting the average grade-point average or exam scores for the entering class.
Second, pipeline programs could be designed and evaluated in standardized ways. Dedicated resources could be offered to medical schools to invest in and implement programs that successfully support and train students, residents, and faculty of color. One example of such a program is the Harold Amos Medical Faculty Development Program, a 4-year mentored postdoctoral training program established by the Robert Wood Johnson Foundation for physicians, nurses, and dentists from disadvantaged backgrounds.
Third, developing consensus on diversity-related measures and unifying around a set of goals that define success will be critical to identifying and scaling up successful interventions. Although reaching such a consensus will be challenging, we believe it will be important to consider an overarching principle: metrics shouldn’t be based on absolute numbers of matriculants or faculty of a given race or ethnic group, but rather should account for population shifts at the national level and representativeness at the local level. Most states don’t train cohorts of physicians who are demographically representative of their population,2 even though a majority of physicians ultimately practice medicine in the area where they trained. If we believe that increasing diversity is a strategic intervention to ameliorate disparities in care, our workforce should reflect the population we serve.
Fourth, to ensure equitable consideration of all candidates for hiring and promotion, schools could assess whether faculty recruitment and promotion committees are sufficiently diverse and whether members are trained in recognizing their own implicit biases. Similarly, people on admissions and selection committees should be educated about unconscious bias and should understand the ways in which such bias influences perceptions of medical school and residency candidates. Techniques that help screen for or address potential biases should be routinely applied. One established technique is to use a standard set of structured questions during all interviews. A second technique is for interviewers to ask themselves priming questions to identify potential affinity bias. Such questions include “Does this candidate remind you of somebody you know? Is that positive or negative?” and “Are there things about the resume that particularly influence your impression? Are they really relevant to the job?”
Fifth, we can enhance efforts to measure and improve inclusivity in our clinical learning environments. Many URM students, trainees, and faculty report that their institutions have an organizational culture that is not inclusive. The AAMC has supported the use of the Diversity Engagement Survey, which allows academic medical centers to query their members on the factors that drive engagement, with national benchmark data available for comparison. This survey can be augmented with school-specific cultural audits. At our institution, a cultural audit revealed important opportunities for improving inclusivity, such as implicit-bias training for mentors and leaders, structures supporting accountability and bystander advocacy in response to microaggressions and discrimination, and the expansion of collegial networks to support advancement.5 We believe that, taken together, these strategies could substantially move the needle toward diverse representation in medicine.
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