Building a Diverse Physician Workforce

The article by Grumbach and Chen in this issue of JAMA¹ confirms that postbaccalaureate programs are an effective means for increasing minority and disadvantaged students' acceptance to medical schools. These findings are timely, because the medical profession in the United States is in great need of documented ways to achieve substantially more racial and ethnic diversity. Absent sufficient diversity, medicine simply cannot fulfill its obligation to provide optimum health care services to everyone.² In 2005, only 1043 US medical school graduates were black, only 936 were Hispanic/Latino, and only 96 were Native American. In aggregate, these graduates comprised fewer than 13% of all graduating MDs that year.³ That value is about half of the representation of these minority groups in the US population—a population that is increasingly diverse.

Grumbach and Chen's findings are especially noteworthy because the University of California, the setting for their research, has been denied the use of affirmative action programs in medical school admissions since the 1996 passage of Proposition 209. This was a ballot initiative amending the state's constitution to prohibit preferences based on race and sex in public contracting, employment, and education.⁴ One result is that the percentage of underrepresented minorities matriculating to California medical schools dropped from a high of 21.99% in 1992 to 15.6% in 2000.⁵ Consequently, this study offers an important approach to satisfying the 2003 Supreme Court ruling in Grutter v Bollinger et al,⁶ which called for institutions intent on using race-conscious admission policies to make a “serious, good faith consideration of workable race-neutral alternatives that will achieve the diversity the university seeks.” Justice O’Connor's majority opinion in this case expressed the expectation that “25 years from now, the use of racial preferences will no longer be necessary.” To meet that deadline, much more research on the effectiveness of race-neutral alternatives to affirmative action is needed.

Using California as their “laboratory,” Grumbach and Chen also offer a preview of the nation's not-too-distant future. In this state, where “minority” populations are now in the majority, only 139—or just under 14%—of all California medical school graduates in 2005 were black, Native American, or Hispanic/Latino.³ This must be considered in the context of the California Wellness Foundation's prediction that the state will experience “a shortfall of approximately 17,000 doctors by 2015.”⁷

Earlier this year, the Association of American Medical Colleges (AAMC) called for a 30% increase in enrollment at Liaison Committee on Medical Education–accredited medical schools by the year 2015 to offset the impending shortage of physicians nationwide.⁸ Implementing this increase will be a monumental undertaking. Doing so while remaining committed to increasing the racial and ethnic diversity of the entering medical school classes will be doubly difficult. But increasing physician supply and increasing diversity are both critically important and inseparable goals. Health care disparities, inadequate access to care, and gaps in the quality of care will only worsen if a larger physician workforce in the future is no more diverse than it is today.⁹ Preparing tomorrow's physicians means substantially increasing the efforts to locate, encourage, and support talented and capable young people from diverse backgrounds and cultures who are willing and prepared to pursue careers in medicine.

Postbaccalaureate programs are designed to prepare college graduates to succeed in applying to medical school, but they differ widely in size, format, curricula, and mission. Many are committed to increasing minority and disadvantaged students' representation in medical school.^{10 - 11} Wayne State University School of Medicine established the nation's first such program 37 years ago, enrolling black students who had initially been rejected by the school. After 1978, the program opened enrollment to all racial and ethnic groups. By 1997, 160 (83%) black students and 51 (94%) of other races/ethnicities who graduated from the program between 1969 and 1992 had completed medical school.¹²

Strengthening programs that reach minority students earlier in their education is also crucial; indeed, it is an essential strategy for closing medicine's diversity gap permanently. So-called “pipeline” programs refer to elementary school and high school (ie, K-12) and undergraduate efforts designed to support and sustain students' interest in medicine throughout their early education. This term reflects the reality that the US educational system is like a leaky pipe, failing to retain and adequately prepare many students, especially minority students, for postgraduate study of any kind.

Pipeline programs face daunting obstacles, such as building partnerships between medical schools, undergraduate institutions, and public school systems despite many organizational and operational differences.¹³ However, there are bright spots, particularly among programs targeted at college undergraduates. One example has been the Minority Medical Education Program, a free 6-week summer program for college undergraduates funded by the Robert Wood Johnson Foundation from 1989-2002. A 1998 study reported a mean medical school acceptance rate of 63% for the 3155 students completing a Minority Medical Education Program and applying to medical school over a preceding 9-year span.¹⁴ The AAMC and the American Dental Education Association initiated the Summer Medical and Dental Education Program in 2005 at 12 sites across the United States. The format of this program has been refined to target freshmen and sophomore undergraduates, and it offers students the unique option of exploring either medicine or dentistry. Funding for this major pipeline initiative has also come from the Robert Wood Johnson Foundation.

Bolstering medical schools' relationships with the K-12 segment of the pipeline is another promising approach. The AAMC has had 10 years of experience with the Health Professions Partnership Initiative, a nationwide effort to strengthen the pipeline by involving medical schools and teaching hospitals directly in assisting the efforts of undergraduate institutions, K-12 schools, and their surrounding communities (with funding from the Robert Wood Johnson Foundation and the W. K. Kellogg Foundation). Case studies of participating academic medical centers indicate that many have chosen to continue their partnership programs despite the discontinuation of foundation support and despite sharp declines in federal funding (eg, Title VII).¹⁵

Despite the early loss of so many promising students from the educational pipeline,¹⁶ some improvement in college graduation rates among several minority groups has occurred in recent years.^{17 - 18} However, this has not been accompanied by an increase in applications to medical schools by these graduates, even among minorities earning BA degrees in biology (Gwen Garrison, PhD, Director of Student and Applicant Studies, AAMC; oral communication, July 2006). The result is a growing gap between a larger number of apparently well-prepared college graduates and a continued paucity of minority applicants to medical school. Possible reasons for this include students' concerns about the cost of attending medical school, the time it takes to become a physician, and the demands of the life of a physician, among other issues.¹⁹ Addressing their concerns with information and support offers a new target of opportunity for efforts to increase the racial and ethnic diversity among medical students.

To address this problem, the AAMC has developed a campaign called AspiringDocs.org. The goals for this program will be to provide information and interactive support to minority students, using a dynamic and multidimensional Web site intended to give comprehensive answers to questions about careers in medicine. This fall, 4 undergraduate institutions (California State University, Fresno; Rutgers University; University of Arizona; and University of Pittsburgh) will serve as institutional partners to test the AspiringDocs.org Web site and a series of print advertisements supporting the campaign.

Grumbach and Chen's finding that the University of California's postbaccalaureate premedical programs increased minority and disadvantaged matriculants to medical school adds empirical support for the long-held belief that a sturdy scaffold of academic preparation and mentoring can offset at least some of the accumulated disadvantages experienced by many minority students interested in a career in medicine. Their findings should encourage other schools to establish postbaccalaureate programs that have special appeal to minority students.

Given the magnitude and complexity of the obstacles to closing medicine's diversity gap, multiple strategies must be aimed at all levels of the educational pipeline. While pursuing efforts at the early K-12 stage, students who have managed to survive the vicissitudes of their early education and who have made it through college must not be neglected. Many college graduates will require a well-designed postbaccalaureate program to be successful medical school applicants; many others might also succeed if only they were well informed about the application process and inspired to join the ranks of aspiring physicians.