Diversity in the Physician Workforce is Essential; What Will Happen If the Supreme Court Overturns Affirmative Action?

In October, the Supreme Court heard Fisher v. University of Texas at Austin. You may have read about the case: the plaintiff, Abigail Fisher, applied for undergraduate admission to the University of Texas at Austin but was turned down. If she had graduated in the top 10% of her high school class, she would automatically have been admitted—but she did not.

When admitting students, the University of Texas first accepts all in-state students who place in the top 10%. This policy is race-neutral and fills about 80% of all spaces. The remaining seats are filled according to an evaluation process which considers six factors. Race is one of them.

Fisher is white and she claims that the explicit use of race as a factor in admission to the university violates the Equal Protection Clause of the 14th Amendment of the Constitution.

Within the next few months, the Supreme Court will announce its decision

            What the Case Means for Medical Schools—and Patients

Last week, the New England Journal of Medicine published an editorial warning that the decision will “chart the future of affirmative action in American higher education . . . including admission of students to our nation’s medical schools.”

The editorial’s authors underline the need for a physician workforce that is ethnically and racially diverse:

“To provide good care, physicians must understand the communities and cultures in which they work. An important way to ensure that physicians understand the lives of their patients and to reduce health disparities is to promote diversity.”

I agree, and would add a second argument: if Fisher wins, the Court’s decision will leave millions of Americans without the medical care they desperately need because they live in a place where few physicians want to practice.

In this two-part post, I will be asking four questions:

1) How do we attract more physicians to underserved communities?  Could we entice them with higher salaries?  (Probably not.  A doctor who doesn’t want to raise his kids in rural Alabama won’t set up shop there even if you double his income.)

2) Should we encourage medical schools to practice class-based rather than race-based affirmative action?  This is, at best, a partial solution. A large percentage of low-income Americans are white. If they were admitted to medical school, those who grew up in rural areas might well decide to practice in similar communities where physicians are needed.. But this would not solve a larger problem—the shortage of  Latino, African-American and Native-American primary care doctors available to work both in inner cities and in the many rural areas where minorities are rapidly becoming the majority.

Multiple studies show that outcomes, communication, and compliance improve when a patient is able to see a physician from his own racial or ethnic group. This is not to say that committed white physicians cannot overcome cultural barriers and build strong patient relationships in these communities. But  many fewer choose to work, and raise their families, in remote rural areas that are primarily Latino, Native American, Mexican-American, or African American.


3) How do we attract more students who will wind up choosing primary care?  (Reducing levels of debt does not seem to be the answer. Surprisingly, students who have no debt are least likely to go into primary care.)

 4) Should medical schools re-think the criteria that they use when admitting students? In what ways? Should they change how and where they train medical students? Should the government revise the way it funds medical schools to reward institutions that produce more primary care doctors?

                                       Underserved Communities

While health care experts debate whether we are facing a serious shortage of cardiologists, orthopedic surgeons and other specialists, one thing is clear: physicians are not well distributed in this country.

This is a long-standing problem. “In 2006, nearly 75 percent of U.S. counties . . .  were designated Health Professional Shortage Areas (HPSAs).   Areas that were not underserved had a surplus of more than 70,000 physicians” explains an article published in Virtual Mentor, the American Medical Association’s Journal of Ethics. 

Building more medical schools, increasing admissions, or creating more slots for residents will only add to these surpluses. Physicians would continue to flock to Manhattan, L.A. and Miami, and their suburbs.

Indeed, in recent years, the number of physicians in the well-served areas has climbed while the number of doctors practicing in underserved areas has fallen.                                

                                A Shortage of Rural Doctors

HPSAs can be urban or rural, but the problem is particularly acute in rural America:

While 21 percent of Americans live in rural areas, fewer than 10 percent of physicians practice in these areas,” reports the AMA’s Virtual Mentor. “As a result, rural residents (and the urban underserved) receive fewer preventive services and suffer from worse health outcomes.” 

And the trend is accelerating: As of 2007, the American Association of Medical College notes that just 2.9% of medical students planned to practice in a small town or rural area. At the same time, “rural residents often are in greater need than their urban counterparts,” the same report observes. “For instance, rural communities have higher rates of chronic illness and disability and a poorer general health status than urban communities. Rural residents tend to be older and poorer than their urban counterparts.

“Rural residents have more health issues and adverse outcomes, and chronic conditions are more prevalent in rural areas. In addition, according to Healthy People 2010, injury-related deaths are 40% higher in rural communities than in urban communities, while heart disease, cancer and diabetes rates are also higher in rural areas.

These families desperately need primary care physicians: when hospital CEOs in rural areas are asked about physician shortages, doctors who practice family medicine appear at the top of the list.  

                         Why We Need a Work-force that is Racially Diverse

Today, just 6.3% U.S. physicians are African American; 5.5 % are Hispanic. Meanwhile the demographics of this nation are changing. As the NEJM editorial points out: “We need to pick our medical students from a larger pool that does a better job of reflecting the diversity of the patient population.”

The need for Hispanic, African-American, and Native American doctors is growing not just because inner-cities are underserved because the number of low-income minorities living in rural America is climbing.

The population in rural and small town America shot up by roughly 3.5 million between 2000 and 2010, with minorities accounting for fully three-quarters of rural & small town population growth.

Here is an eye-popping number: Today, 25% of rural residents live in counties where the majority of the population belongs to a group that we now label a “minority.”  By the middle of the century, Census Bureau statistics reveal that whites will comprise a majority in less than half of rural counties. 

Multiples studies show that, particularly in the case of primary care and mental health care, outcomes improve “when patients are able to see a practitioner from their own racial or ethnic group. The quality of communication, comfort level, trust, partnership, and decision making in patient-practitioner relationships, all improve–thereby increasing use of appropriate health care and adherence to effective programs.”

Let me be clear: This is not to say that white doctors cannot be extremely effective when working in minority communities. But white med school graduates are less likely to choose to practice in inner cities or poor rural communities that are “majority minority”.

Over time, I suspect this may change. Over the next two or three decades, the U.S. will become more of a true “melting pot”; more Hispanics will speak English; we are likely to see more intermarriage;  and both doctors and patients from different racial and ethnic groups will become far more comfortable with each other. But the patient-doctor relationship is based on trust, and it will take time for that trust to cross the barriers that exist today.

                         Physicians of All Races Tend to Head Home

Most physicians choose to practice in places where they feel comfortable—places that remind them of the communities where they grew up.  The majority of today’s medical students were raised in affluent suburbs or cities. Is should not come as a surprise that  they don’t want to move to inner city Detroit, rural Mississippi or even upstate New York..

As the cost of education rises, the percentage of students from high-income families grows.  In 2000 50.8% came from families living on the top step of a five-step income ladder; by 2005, the share coming from the top quintile had grown to 55.2%. The American Association of Medical Colleges (AAMC) reports that the fraction of students from the lowest quintile remains below 5.5%

Research also shows that students from wealthy families are much less likely to choose primary care. This, too, makes sense. Money is relative, and it shapes expectations.  If a student is coming from a family where his father earns $200,000 a year, the $186,000 median income for a primary care physician might well seem like low pay, not only to the student but to his family. 

Like Wealthier White Students, Minorities and Students from Rural Areas Often Head Home

 “Students coming from rural backgrounds are much more likely to practice in rural settings, and African American students more often choose inner-city practice,” reports the AMA’s Virtual Mentor.  

A recent survey of rural doctors points out that the “majority of physicians in this study mentioned ‘family ties’ as significant in their selection of practice location. While not all future rural health providers will necessarily want to return to their home communities for practice, this is a factor for many.For others, there may be a desire to return to a community similar to their rural home community.

A 2009 Graham Center study of “What Influences Student Choices” confirms these findings:  “A rural background increases the odds that a student will choose to practice in a rural area by 2.4 times and nearly doubles the odds  [that he will choose] Family Medicine. It also increases students’ odds of choosing primary care or serving in a community health center by approximately 50% and of serving in a shortage /underserved area by nearly 30%

“It is a potent marker if not a predictor of students who will make these important choices.”

Like students who grew up in rural American, low income minority students also are more likely to choose primary care. Many observers have argued that rising levels of student debt force students to choose the best-paid specialties. But the Graham Report refutes the conventional wisdom:

“The most comprehensive study of this issue concluded that students who choose primary care actually graduate with slightly more debt than their peers. This may be because these students are more likely to be from lower-income families and borrow more for their education than students in higher-income groups.”  By contrast, “those from the highest socioeconomic strata who are most likely to be debt-free are also most likely to be interested in specialty care and in practice sites that afford them a similar lifestyle to that in which they were raised.”

Medical Schools Admit Fewer Students from Rural Areas –and Fewer Minorities

If we want to solve the problem of underserved communities, medical school admissions committees seem to be headed in the wrong direction.

The Graham Center report points to “significant declines in  acceptance of rural-born students to medical schools” noting that this “overlaps so well with the declines in student interest in choosing primary care, rural practice, and care for underserved populations.” 

 “Admission of underrepresented minority students to medical schools” also “has fallen . . .  despite an increasing or stable application rate,” Virtual Mentor observes. (In 2011, Hispanic admissions were up, but in recent years the trend has been anemic, at best.) “In the meantime, students of rural origin and those with an annual family income under $20,000 make up a disproportionately low percentage of medical school enrollment.”  

The AMA’s Journal of Medical Ethics concludes: “Medical schools’ admission criteria seem to be at odds with society’s responsibility to produce physicians who care for the underserved.”

In part 2 of this post I will consider what medical schools might do to produce more students who would choose to practice primary care in underserved areas.


13 thoughts on “Diversity in the Physician Workforce is Essential; What Will Happen If the Supreme Court Overturns Affirmative Action?

  1. I think some of the problem is trying to fit a square peg (the problem) into a round hole solution (traditional physician training and admittance). Maybe more midlevel providers trained specifically from the shortage area may be part of the answer. PAs and Nurse practitioners are already existing nationwide, and in dentistry, the dental therapist model is showing promise among the Alaskan tribes that have traditionally been unable to attract and keep any dentists (the old model)! The dental therapist model is a well-trained dental provider in a narrower and simpler range of dental processes to do a defined set of real and surgical dental procedures under general supervision. It is an essential addition needed in many parts of this country, but organized dentistry has been fighting its expansion for obvious reasons. The Alaskan tribes are outside of the reach of organized dentistry and have been able to go forward with implementation of this model despite initial complains from the dental profession!

  2. NG–

    The Alaska program sounds very good. The basics of denistry– cleaning, and filling teeth — are what most people need, and I can well imagine a midlevel trained to do that very well.
    I also am a big fan of nurse practioners, but the problem is that there is a shortage of nurses in the same places where there is a shortage of physicians. And, it turns out that we have very few minority nurses.
    Only 5.4% are African American and 3.6% are Hispanic.
    The good news is that minority nurses are more likely to pursue advanced degrees in nursing. The bad news is that very few become nursing school teachers, so minority nursing students may have a hard time finding mentors.
    There are some scholarship programs,but clearly this is an area where we need more scholarships and more recruitment. See http://www.aacn.nche.edu/media-relations/diversityFS.pdf
    I’d also be interested in learning more about criteria for being admitted to nursing school.

  3. Maggie:

    Since college comes before medical school, I wonder if there are any good data regarding trends — graduation numbers, science majors — among minority students. I spent 4 years on a medical admissions committee. Those of us on the committee who were very interested in addressing this issue could only work with the applications in the pile in front of us. Are you aware of any programs that take minority students and steer them toward medical school? I know of at least one long-standing program (at Bryn Mawr college) that takes students who graduated from college in some other field and then gives them the pre-medical training they need to apply to medical school. It seems to me that a big chunk of the problem may be at the step before medical school.

  4. Hi Chris-

    There are mentoring programs that steer minorities kids toward med school Before they enter college (I know of one in Harlem.)

    And there are programs that let students take the pre-med courses that they didn’t take in college so that they can apply to medical school. (I) actually though about doing this.)
    The problem is that the minority students we’re looking for (the ones who come from low-income rural or inner city families) can’t afford them unless they offer full scholarships. .
    I looked into the “feeder schools” that send minority applicants to med school and found Howard University at the top of the list (producing more minority applicants than any other school), followed .by two other historically black universities. The other top feeder schools were almost all state universities. Ivy league schools and other expensive private universities produced almost no minority applicants.
    Of course the Ivy’s don’t take (or recruit) many low-income minority students in the first place, and insofar as they do take some, they probably don’t have mentoring programs designed to help them in the science courses they need, and to steer them toward med school.
    Howard University, by contrast, probably has an excellent mentoring program for pre-meds.

    Finally was interesting to me that most of the minority applicants came from public universities that attract many more low-income and middle-income students. Those who oppose affirmative action often suggest that middle-class white students are being denied admission while minorities coming from wealthy families are admitted. In the case of med school, that doesn’t seem to be the case.

  5. Thanks for all the info, Maggie. I just was curious if part of the problem was lack of qualified applicants. From your comment that doesn’t seem to be the case.

  6. Chris-
    On average, minority applicants who are accepted do have slightly lower MCAT scores and GPAs.
    They don’t go to the competitive prep schools and colleges where students really hone their test-taking skills. And most minority applicants cannot afford the very expensive courses that prepare you to take the MCAT.
    But their scores and GPAs are still very good (we’re not talking about admitting “B” students) and research shows that when in medical school, while they still don’t do as well on tests, they do at least as well when graded for clinical practice. (I’ll be writing about this in part 2 of the post.)(
    This is why some physicians involved in med school admissions argue for lowering the bar on MCATS and GPAs — just a bit. This would also
    let med schools admit a broader pool of students who are not as “grades-driven” and who actually take humanities courses while in college–even though they know they won’t necessarily be able to “ace” them by memorizing everything that will be on the test. They’ll have to think critically, and learn to write. (When I taught at Yale, I always had a few excellent, very bright pre-meds who learned a lot reading George Eliot, though they didn’t always get A’s.

  7. I taught medical students for 20 years and it never seemed to me that MCAT and GPA meant much after a basic minimum of competency. I was a humanities major myself (double major, actually, in history and religion) and took just enough science courses to qualify for medical school. That pathway didn’t hurt my med school performance any, and I think in fact it made me a better physician.

  8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743759/

    I wonder if Maggie is aware of several studies showing that graduates of historically black medical schools have higher rates of medical malpractice, higher rates of disciplinary action by the state medical boards, etc

    The way you fix this occurs in ELEMENTARY school, not medical school. By the time medical school application occurs, its too late.

    • Jason–

      Thinking about it, it strikes me that this is a very serious charge–made without any evidence.
      I don’t want to let comments on HealthBeat spread misinformation.
      If you don’t provide evidence to back up your claim, I will feel I have to delete your comment. (I will wait a few days for your reply)

  9. Jason:

    The link in your comment is interesting, but it doesn’t specify any particular schools (or kinds of medical schools). Did these authors publish the specifics elsewhere?

    And why would you say this: “The way you fix this occurs in ELEMENTARY school, not medical school. By the time medical school application occurs, its too late.” What does elementary (or secondary or college) education have to do with this issue? What is too late?

  10. Jason–

    I got the link to work, and read through the entire PDF–I didn’t find any reference to “historically black universities”

    Perhaps I missed it? Please send an excerpt from the article discussing black universities and malpractice.