Diversifying the Medical Classroom: Title and subTitle BreakIs More Evidence Needed?

Despite 30 years of public and private initiatives to increase physician diversity, the proportion of medical school graduates who are from underrepresented minority (URM) groups has stubbornly remained in the 10% to 15% range.¹ This is at a time when the United States has become more racially and ethnically diverse, with current minorities projected to comprise 54% of the population by 2050.² The justification for URM student diversity is often based on the principles of affirmative action and addressing prior injustices. Indeed, the well-documented history of widespread racism within organized medicine³ and the American Medical Association's apology⁴ is a reminder of how pervasive and tolerated such practices were only a few decades ago.

However, there are other compelling reasons for increasing physician diversity. Most notably, thorough and authoritative reviews link physician diversity with better access and quality health care for underserved populations.^{5 - 7} Minority physicians provide disproportionate care to minority populations; racial-ethnic concordance of patient and physician result in improved communication, trust, and patient satisfaction; and patients prefer physicians who share their own cultural, linguistic, and racial backgrounds. Thus, the Institute of Medicine recommends increased physician diversity as a specific and concrete action that should be taken toward eliminating health disparities.⁸ However, in 1978, the Supreme Court ruled that a greater likelihood of serving the underserved is not an acceptable justification for race-based preferences in admissions.⁹

An additional compelling reason for medical school URM student diversity is that such diversity results in an improved educational experience for all students. This educational benefits rationale is the only one that to date has been accepted by the Supreme Court as justification for race conscious admissions policies and only if applied at the individual assessment level.¹⁰ The research base supporting this justification has been increasing, particularly at the undergraduate college level. One study of 25 000 undergraduates at 217 colleges found widespread benefits of diversity on the cognitive and affective development of students of all racial backgrounds.¹¹ A report including a set of 3 longitudinal studies found that the positive effects of diversity on outcomes such as active thinking processes, engagement and motivation, and intellectual and academic skills persisted for several years after leaving college.¹² An in-depth review further concluded that the beneficial effects of undergraduate diversity on measures such as attitudes and feelings toward intergroup relations, institutional satisfaction, cognitive development, and academic growth were most profound for white students.¹³

Nevertheless, there has been a need for additional evidence from more rigorously conducted research, particularly in the medical school setting. Thus, the finding by Saha and colleagues¹⁴ in this issue of JAMA that, after adjusting for various school and student characteristics, increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature. Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity. The study is also one of the first that attempts to examine mechanisms. The educational outcomes achieved through increased diversity have been hypothesized to be mediated by increased interracial interactions (both formal and informal) and by exposure to diverse views. The study by Saha et al examined this hypothesis and found that the increased interactions and sharing of perspectives resulting from URM diversity appeared to mediate the observed findings.

As with all cross-sectional studies, there are important limitations, the most important of which is the inability to address causality. To the extent possible, the study by Saha et al tries to address such limitations through various supporting secondary analyses that explore mechanisms and by not finding similar results for unrelated outcomes such as plans to serve the underserved. One major persistent concern has been that schools whose leadership most value diversity are also those most likely to value and provide a meaningful cultural competency curriculum for all their students. That the findings remained robust after adjusting for school-sponsored diversity-related activities (such as cultural awareness courses) helps address this potential confounder.

Two overarching questions remain. First, is more evidence needed to justify increased medical school diversity? No, but it might help. Second, why have medical schools not been able to tackle this important challenge? There may not be a genuine commitment by academic leaders toward increasing URM diversity, so that it may be more about having the will than finding the way. Despite ongoing evidence of the poor job schools are doing with respect to URM diversity, most medical schools are quite satisfied with their current URM proportions.¹⁵ The emphasis on MCAT (Medical College Admissions Test) scores as an admission metric, especially for minorities, has been repeatedly challenged.^{5 - 6 ,16} Such scores have been shown to be poor predictors of clinical performance, and for minorities also poor predictors of performance in the basic sciences.^{17 - 18} Even with lower grades and MCAT scores, nearly all URM students who enter medical school go on to graduate and become competent clinicians.^{16 ,18} Similar findings have also been noted in law school, where despite having lower LSAT (Law School Admission Test) scores passing rates on the Bar examinations were similar for URM and nonminority students.¹⁹

The existing literature provides numerous well-described and varied approaches successful medical schools have used to increase URM diversity.²⁰ Although most schools may claim that diversity is valued, few embrace such practices or commit the necessary resources. Successful examples include the Albert Einstein College of Medicine, an institution that qualified to become New York State's only federally designated Hispanic Center of Excellence in 2001. It incorporates a curriculum that emphasizes cross-cultural medical education, supports minority faculty development activities and outreach to the local minority communities, and provides targeted resources.^{21 - 22} At Columbia University College of Physicians and Surgeons, input by community groups and subsequent institutional commitment to URM diversity, including commensurate resources, resulted in an increase in URM students from 8% to 23% in 3 years.²³

However, even with an increasing evidence base, many medical schools are unlikely to prioritize increased URM diversity. For such schools, improvements may come only through changes in leadership or external pressure by community and political forces. Recent federal initiatives have been in the opposite direction. In 2005, there were 34 US health professional schools that received Title VII funding to support the Centers of Excellence (COE) program.²⁴ The goal of these COE programs was to increase and maintain high levels of student and faculty URM diversity. Since February 2006, funding for these successful centers has been significantly decreased and the number of federally funded COE programs has decreased to only 4.²⁴

The need for medical schools to reexamine their admission polices is further emphasized by the finding in the study by Saha et al¹⁴ that, while approximately half of all URM graduates plan to care for underserved populations, less than 20% of white and nonwhite/non-URM individuals had such plans. In addition, less than half of all students in these anonymous surveys responded that access to care was a major problem, and only 42% responded that everyone is entitled to adequate health care. These findings alone indicate the need to evaluate the process of admitting and training students in US medical schools.