AMA Journal of Ethics^®

Abstract

There are fewer Black men in US medical schools today than in 1970. This and other kinds of ongoing inequity express the systemic racism Black Americans face in health care. Increasing Black physician representation in medicine is key to motivating health equity, so many colleges and universities have developed programs to recruit and retain students with minoritized identities. This article suggests how Black medical school applicants’ lived experiences of racism can contribute prominently to building medicine’s capacity to promote healing and health equity.

Case

One month ago, through a DNA test kit, African ancestry was found to be prominent in AJ’s family past. Currently applying to medical schools with average MCAT scores, some B grades, and an overall “ramp up” in academic performance over the course of college and graduate studies, AJ indicates being African American to the American Medical College Application Service^®. Several schools to which AJ has applied invite AJ for early on-campus interviews. Following an in-person interview at one of these schools, one admissions committee member and interviewer said to the school’s admissions committee chair, “This applicant does not look African American.” The school’s admissions committee chair agrees, but does not say so, and considers how to respond.

Commentary

Having a doctor who looks like you—or having a physician workforce representative of the population—is not enough when discussing what matters in medical school admissions decisions. Although representation is important in admissions reform, an understanding of institutional bias and discrimination is essential, as “the struggle to recognize institutional racism can be understood as part of a wider struggle to recognize that all forms of power, inequality, and domination are systematic rather than individual.”¹ There are policies and practices in place that favor disproportionately admitting White peers over persons of color and dismissing underrepresented students due to academic struggles. To combat these biases and to truly understand the depth, harm, and consequences of systemic racism in institutional life, medical school admission policies and practices must not be informed by assumptions based on racial categorizations. Interviews should directly ask students—or provide them with opportunities—to share their experiences of race in daily life, as well as its influence on their motivations for becoming physicians. This article discusses effects of systemic racism in health care and how Black medical school applicants’ lived experiences of racism can contribute prominently to building medicine’s capacity to promote healing and health equity.

Racism’s Health Effects

Before the Civil War, heinous and harmful medical procedures were inflicted upon Black people by White physicians who believed that Black women were capable of enduring inordinate amounts of pain in contrast to their White counterparts.² For example, J. Marion Sims tortured enslaved Black women by performing gynecological procedures on them without sedation, and, after perfecting his craft, he performed the same procedures on sedated, wealthy White women.³ Yet racism in medicine is not just an issue of the past.

Racism in medicine today directly contributes to the disproportionate number of Black women who die in childbirth.⁴ High-profile examples of wealthy Black women celebrities, such as Serena Williams and Beyoncé Knowles-Carter, demonstrate that bias in medicine is not reducible to class-based bias. The famous tennis star Williams, for example, developed pulmonary embolism postdelivery and needed a computed tomography image and heparin drip; clinicians seemed not to take her concerns seriously and suggested that pain medications might have left her confused.⁵ Knowles-Carter developed preeclampsia, a pregnancy complication that disproportionately affects Black women and is not standardly treated,⁶ and ultimately delivered her twins via emergency cesarean section.⁷ Systemic bias in medicine thus transcends fame, class, and wealth. Incorporating the lived experiences of Black students early in admissions and interview processes would help create a future health care workforce better equipped to address and bring about health equity.

Diverse Representation

According to the US Census Bureau, the Black and Hispanic population in the United States hovers just above 30%.⁸ Yet, according to 2018 Association of American Medical Colleges data, the percentage of Black and Hispanic practicing physicians is less than 11%.⁹ As a result, the lived experiences of marginalized and oppressed groups are less likely to be considered by clinicians providing care. For Black people, the lived experience of racism and discrimination includes redlining, the school-to-prison pipeline, microaggressions, and—most recently—suffering disproportionate morbidity and mortality from COVID-19.¹⁰ Clinicians’ lack of consideration of Black people’s lived experience comes at great cost. For example, the number of Black newborn mortalities in excess of White newborn mortalities per 100 000 births is almost 40% higher when Black newborns are cared for by White doctors than Black doctors.¹¹ Moreover, Black patients are more likely to follow preventative health measures when delivered by Black physicians due to increased patient-clinician comfort levels.¹² Thus, better health outcomes might be achieved when clinicians looks like their patient population and can fully understand, embrace, and consider the daily lives of their minority patients. Black physicians who themselves have experienced disparities in income, education, and housing are necessary to seriously address and rectify health inequity.

Recruitment

Acknowledge racism’s effect on minority applicants. To ensure that marginalized racial communities are adequately represented in the future physician workforce, medical school administrators must take into account racial health disparities when crafting recruitment practices and admission policies. It is imperative that medical schools target underrepresented minorities through the recruitment process—well before the admission interview—based on their lived experiences of medicine and not just of economic and educational disadvantages that impact academic preparedness for medical school. People of color are generally (and rightfully) more distrustful of health care professionals because of historically racist practices (eg, forced sterilization,¹³ medical experimentation on enslaved Black women,³ the intentional withholding of treatment from Black people infected with syphilis,¹⁴ the extraction of a Black woman’s cells for medical use without her knowledge or consent¹⁵), as well as current racist institutional practices more broadly. Potential Black medical student applicants are not immune to skepticism of health care fields, creating a barrier to their accessing medical education. Admission and recruitment practices that recognize and address this distrust and skepticism may have better results in increasing the number of Black matriculants.

Social justice practices in medicine are necessary to combat institutional injustices.

Avoid relying solely on racial categories. With the rise in popularity of at-home DNA testing offered by companies such as 23andMe, White people are using “newly discovered” minority DNA to take advantage of programs that target groups underrepresented in medicine (URiM).¹⁶ However, if the percentage of minority heritage is minimal, some students who “appear” White might take advantage of URiM programs and opportunities without having experienced racism.¹⁷ We believe it is abhorrent for anyone to self-identify as a racial or ethnic minority simply to boost their chances of scholarships or admission to medical school. Attempting to pass as a member of a marginalized and oppressed group should be an automatic disqualification.

Admissions Best Practices

While there is no quick fix for reducing racial health disparities, it is medical schools’ duty to address racial disparities in a substantive way. Doing so requires creating “an intellectually engaging space” where doctors and student doctors “can be introduced to the historical, sociological, and anthropological scholarship on race in medicine, its continuities, and discontinuities.”¹⁸ Racism has shaped medical education and the profession overall and remains pervasive. As Welton et al note:

Educational institutions are called such for a reason, because their unspoken norms and social agreements have a long history that has been “instituted” or developed over time, and thus become deeply entrenched into the fabric of how they operate…. This institutionalization process is why embarking on the change needed to achieve racial equity in education—or any change for that matter—is rather difficult, because it forces institutional members to call into question how the norms, practices, and routinization they have long grown comfortable with may in fact be the cause of racial inequities that are injurious to marginalized students, faculty and staff, and even the surrounding community.¹⁹

Accordingly, social justice practices in medicine are necessary to combat institutional injustices. The lived experiences of people of color, especially Black people, are uniquely oppressive. As mentioned, the systems that Black people endure are not equitable to the privileged systems that their wealthy White counterparts experience and enjoy.

To best understand the influence of lived experiences of race and racism on medical student applicants of color, admission interviewers should ask applicants to share such experiences or provide the space and opportunity during the interview for such input. Interviewers should directly ask or provide students the opportunity to share their experiences of race in their daily lives, as well as its influence on their motivation for becoming a physician. For example, during the admissions interview process, the interviewer could ask, “If at all, how has your racial and ethnic identity impacted your life and education?” While interviewers should be mindful not to evoke or trigger racial trauma by such questioning, their assumptions about applicants’ lived experiences of race and racism based on self-identified race during the application process are inadequate to seriously understand the impact of oppressive racial systems on applicants of color. Ohio University Heritage College of Osteopathic Medicine has developed some admissions and interview practices to meet this commitment. On interview day during the group sessions, the Office of Inclusion provides space for interviewees to reflect upon and share their thoughts or feelings about racially traumatizing events occurring in the present, including and especially the death of Black people at the hands of the state and law enforcement.

The virtual admission and interview landscape of the Covid-19 pandemic has allowed interviewees, particularly Black students, to share their experiences and losses during the pandemic. Creating an opening for applicants to discuss the pandemic not only allows admissions interviewers to consider applicants’ lived experiences but also allows student interviewees to gain meaningful insight into their peers as well. The realization of shared experiences among students creates community and a space of shared healing.

Medical school admission committees and practices must embed diversity, equity, inclusion, and antiracism into the fabric of the admissions process to ensure long-term institutional transformation. Admission practices must be thoroughly examined, analyzed, and transformed to consider applicants’ lived experiences if medical schools are to be truly committed to recruiting, retaining, and graduating future Black physicians.

Medical schools must develop recruitment plans that strategically include outreach and pipeline programs targeting underrepresented minorities and must require diversity, equity, and inclusion training for members of medical school admission search committees.²⁰ Such training should acknowledge factors that have historically contributed to medical school admissions decisions and to the disproportionately low representation of people of color in the medical field. Recruitment and admission of diverse people in medical school can be realized by taking the following steps:

• Create and maintain effective early assurance programs that recruit and help prepare students for medical education as early as kindergarten through grade 12.
• Consider partnering with high schools for underrepresented minority students to provide early assurance of medical school admission without Medical Schools Admissions Test^® requirements via BS-MD (joint bachelor of science and doctor of medicine) programs or BS-DO (joint bachelor of science and doctor of osteopathic medicine) programs.
• Offer pipeline programs that adequately prepare students for the rigor of medical education, including one-on-one tutoring in addition to access to learning service specialists.
• Provide free access to test prep (including content exams and board prep) and to study skills and test-taking strategies training during and in advance of the medical school application process.
• Ask probing questions during the interview process about the influence of race and racism on applicants’ lived experiences.
• Provide persons of color upon acceptance with reduced or free tuition and cost-of-living stipends or with scholarships that cover tuition and offset living costs.
• Pair newly accepted students with both underrepresented faculty and underrepresented peer mentors.

There must also be a commitment to retaining and graduating physicians of color. Far too often, pipeline programs and other recruitment strategies achieve their goals in the number of admitted students but not graduates. It is imperative that dollars are committed to providing the support necessary to fill in the gaps of some URiM students’ preparation. Despite the number of persons of color applying to medical school, far too many are accepted and yet fail due to educationally disadvantaged backgrounds and lack of access to resources that are often available to their more affluent  counterparts.²¹ Without a high level of commitment, as outlined in the above recommendations, there will consistently be a decline in the number of students of color who apply to, are accepted and enroll in, and graduate from medical schools.