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An idea whose time has come: the need for increased diversity in medical practice and education.

Introduction

A growing and abundant literature testifies to the fact that race is a central and determining factor for health disparities in the United States (Benz et al, 2011; LaVeist et al, 2008). Moreover, African Americans have long been denied equal access to medical education and careers in high level health industries. In this article, we will examine the relationship between access to medical school for students with diverse life experiences and the availability of medical professionals who can effectively practice in medically underserved communities as primary care physicians. It is possible, that in the near future, it may become even more difficult to admit medical students committed to practicing in medically underserved communities due to legal challenges that could potentially weaken or eliminate the use of holistic review, a multilayered approach utilized by many admissions committees wherein an applicant's unique skills and experiences are taken into consideration (Addams et al, 2010; Steinecke et al, 2007). Medical education programs that incorporate holistic review will be highlighted in the results and discussion sections. Legal challenges have hampered the use of holistic review as it pertains to medical school admissions, specifically within the State of California (Barr, Matsui & Berkeley, 2008). Admissions committees, once thought of as gatekeepers, are beginning to embrace modern methods supported by the Association of American Medical Colleges (AAMC) when reviewing applications (Yzquierdo, 2012). Medical school admissions determine the makeup of the future physician workforce. The cultural competence and makeup of this workforce will either reduce or perpetuate health disparities in the coming years.

Access to Medical Education

The AAMC has published a number of reports on unequal access for minorities to medical school and the medical profession. In Minorities in Medical Education, Castillo-Page (2005) discusses how the AAMC laments that the numbers of minorities in medical schools are alarmingly low. Historically speaking, access to medical education in the United States has been elusive for underrepresented minority students (Reede, 2003). In the past, medical schools relied primarily on an applicant's undergraduate grade point average and MCAT (Medical College Admission Test) scores in order to determine which students to invite for an interview. As a result of the U.S. Supreme Court's decision in 2003 (Grutter v Bollinger), graduate schools may utilize holistic review if a diverse student body contributes to the school's mission and overall educational experience for all students. The decision was not unanimous. Chief Justice William Rehnquist devoted a considerable amount of space in his written dissent to point out that at the time, the percentage of applicants belonging to each racial demographic matched the percentage of those who were accepted to attend law school at the University of Michigan (Grutter v Bollinger, 2003). One of the driving research questions that led to the development of this study was, what if the Rehnquist Admissions Test were to be applied to overall medical school admissions across the United States using both AAMC and AACOM (American Association of Colleges of Osteopathic Medicine) data?

Methods

This quantitative study will analyze both AAMC and AACOM data on medical school acceptance rates using two-tailed chi-square tests with Yates correction to establish significance. The number of African American, Latino, White and Asian American applicants and matriculants will be compared to one another using contingency tables, disaggregated by gender. In the case of AAMC data, overall acceptance rates will be examined using overall numbers and also, with HBCU medical schools removed. The results of a unique and innovative medical program in California, UC PRIME, will also be discussed.

Results

According to the AAMC data (Castillo-Page, 2012a), African American applicants had the lowest acceptance rate of any group in 2011. Figure one shows that African American males had the lowest acceptance rate (42.3) of any group of male applicants and figure two shows that African American females had the lowest acceptance rate (36%) of any group of females applicants.

Separate contingency tables were formed from figures 1 and 2 and analyzed using two-tailed chi-square tests with Yates correction. Comparing African American male applicants and White male applicants, separating the data into columns for number of applicants who were accepted into medical school and number of applicants who were not accepted into medical school produced a p-value of less than .0001, which is highly significant. Similarly, comparing African American female applicants and White female applicants also produced a p-value of less than .0001, showing that the acceptance rates are significantly different. The acceptance rates for African American applicants and Latino applicants also produced significant p-values but surprisingly, while the African American female allopathic medical school acceptance rate was significantly different from the acceptance rate of Asian American females, the comparison of acceptance rates for African American male applicants and Asian American male applicants did not show significance. It is worth noting that when acceptances at HBCU medical schools are removed from the data, the difference then becomes significant with a p-value less than .0001.

In addition to AAMC data, the American Association of Colleges of Osteopathic Medicine also does a thorough job of reporting data on applicants to osteopathic medical school. Graduates of osteopathic medical schools tend to specialize in primary care at a higher rate than those of allopathic medical schools (Peters et al, 1999). Graduates of both osteopathic (D.O.) and allopathic (M.D.) programs complete four years of medical school followed by a residency program in order to specialize in a specific area of medicine. One key area that differentiates osteopathic physicians from allopathic physicians is the use of osteopathic manipulative treatment (OMT) by osteopathic physicians, which incorporates the musculoskeletal system when possible in treating patients (Johnson & Kurtz, 2002).

Unfortunately, the diversity numbers provided by the AACOM are even more distressing than those of the allopathic schools (AACOMAS, 2012). Figure 3 shows that only 22% of African American male applicants go on to matriculate at an osteopathic medical school, compared to 45% of White male students and Figure 4 similarly shows that only 21% of African American female applicants go on to matriculate, compared to 45% of White female students.

The same methodology was used to examine the AACOM data. Contingency tables were set up then analyzed using two-tailed chi square tests with Yates correction. One difference that stood out between AAMC data and AACOM data is that while allopathic acceptance rates showed high levels of significance mainly between African American applicants and other racial/ethnic groups, osteopathic acceptance rates showed significance with p-values less than .0001 for all groups when compared with White applicants. Due to the smaller sample size, Fisher's exact test was also used to analyze the AACOM data and similarly produced a two-tailed p-value of less than .0001 for all groups compared with White applicants. One slight difference in the data provided by the AAMC and the AACOM is that the AACOM does not provide data on accepted applicants but instead, the number of matriculated students is provided. This may be due to the fact that many students apply to both allopathic schools and osteopathic schools during the same cycle, potentially causing the numbers for accepted applicants and matriculated students to be significantly different, whereas for allopathic schools, these data points do not significantly differ. This issue presents a limitation for this study since it is plausible that a number of underrepresented minority students could have been accepted to osteopathic schools but chose to instead matriculate at an allopathic school.

Discussion

The above figures and other data readily available

on the AAMC and AACOM websites show that still far too many medical schools are reluctant to restructure their mission with the goal of making diversity a top priority. An article published in the Annals of Internal Medicine ranked 141 U.S. medical schools according to social mission (Mullan et al, 2010). The social mission score was defined as the sum of three scaled scores. The first score was the percentage of graduates that pursued primary care. The second scaled score was the percentage of graduates that served in a health professional shortage area (HPSA). The third score measured the percentage of underrepresented minority graduates as compared to the underrepresented minority population of the state in which the school is located. According to the results, historically black colleges and universities ranked at the top of the list.

Medical schools in California as a whole showed mixed results when ranked according to social mission. The University of Southern California, UC San Francisco and Loma Linda University ranked highest in the State on the social mission scale. USC and Loma Linda are private universities and were not affected by Proposition 209, which barred the use of race in public school admissions butUC San Francisco does fall under the scope of the voter-approved proposition. Despite this fact, UCSF has made great strides in maintaining a diverse medical student body. UC Riverside's Thomas Haider program and Charles R. Drew University of

Medicine and Science were not included in the study as stand-alone programs, nor was UC Riverside's recently accredited allopathic medical school, which promises to focus on training primary care physicians who will remain in California's Inland Empire, a region designated as an HPSA by the U.S. Department of Health and Human Services. The UC Office of the President has made it clear on their webpage that non-traditional methods of evaluating applicants is permitted by both SP-1 (which has been rescinded) and Prop 209, specifically listing future service to underserved populations as one of the criteria.

The Greenlining Institute, a public policy institute based in California, pointed to the varying degrees of effective recruitment strategies for the disparity between California's medical schools (Gonzalez-Rivera & Middleton, 2008). The Greenlining study specifically highlighted Charles R. Drew University of Medicine and Science and the Drew/UCLA program as being a top performer with regards to training underrepresented minority physicians. The UC system has also developed PRIME programs at each of its medical schools in order to focus on issues related to medical diversity. The acceptance numbers for the PRIME programs (2011-2012), displayed in Figure 5, were provided by the UC system as part of the PRIME legislative report (UCOP, 2012) and as standalone numbers, closely mirror the racial/ethnic makeup of the State of California.

According to the above figures, the PRIME program should be viewed as a success and model for other medical schools to follow. The percentage of underrepresented minority students in the PRIME program is 57%, which more closely mirrors the California census figures compared to non-PRIME UC medical school statistics. The UC PRIME program shows that holistic review can indeed work effectively, with the overall goal of training culturally competent physicians who reflect the overall population of the State. Each separate PRIME program has the flexibility to focus on the needs of the community wherein the medical school is located, adding a fifth year in order for students to simultaneously earn a Master's Degree. For example, UC Irvine's PRIME-LC program focuses on the Latino community and has as a requirement that applicants to the program are fluent in Spanish. UC San Diego's PRIME program is called PRIME-HEq, focusing on health equity and the reduction of health disparities in medically underserved communities.

Conclusion

The reduction of racial and ethnic health disparities begins with the availability of culturally competent primary care physicians. This process starts well before residency and possibly, even before medical school (Walker, 2010). Undergraduate institutions and medical schools must work closely together to ensure that students of all backgrounds have access to a quality medical education. In addition, nationwide and state specific efforts should be sought in order to increase access to medical schools such as improved financial aid policies for students seeking to complete a post-baccalaureate program. Currently, federal financial aid policy classifies post-baccalaureate studies as undergraduate, barring access to graduate level student loans. The federal government could also follow up on findings that point to a link between federal grant dollars received by an institution and the diversity of the institution's medical school (Carlisle, Gardner & Liu, 1998).

As previously mentioned, the AAMC has published a number of reports on unequal access for minorities to medical school and the medical profession. In Minorities in Medical Education, Castillo-Page (2005) discusses the educational pipeline, which refers to the academic preparation that a student receives prior to medical school. As a new school of medicine (SOM), UC Riverside's SOM is starting with a foot in the right direction by investing programming and resources toward building pipelines to K-20 educational institutions in the surrounding region. Pipeline programs represent an attempt to actively address the need to begin to identify, attract, and prepare young learners for careers as culturally competent care physicians. UCR's SOM has a total of eight Pipeline programs, spanning from K-12 and extending to community college and through undergraduate education. Critical to the mission of such programs is the emphasis on reaching out to and effectively supporting youth from the same backgrounds as the general regional population in need. In a subsequent report, Diversity in the Physician Workforce, CastilloPage (2006) adds that 6.4% of the graduating students at medical schools are minorities. The AAMC argues that minority physicians are crucial for closing the health gap. The 2012 AAMC report, also by Castillo-Page (2012b) includes a section titled, Emerging Topic: The Importance of Creating Diverse and Inclusive Environments. Castillo-Page's reports for the AAMC all agree that minority physicians increase access to health care for minorities, increase patient satisfaction and expand options for patient care.

Without question, progress has been made in the diversification of our colleges and universities (Hill, et al, 2011). There have already been efforts to improve diversity at medical schools, taken up by medical schools themselves, such as UC PRIME and the collaboration between Baylor College of Medicine and the University of Texas-Pan American (Thomson et al, 2010). High quality patient care, specifically at the primary care level, must be patient centered (Waitzkin, 2001). In order to accomplish this, a well-rounded medical staff with diverse medical training and life experience will be vital. Science teaches us through molecular biology and numerous other fields that variance and diversity are strongly favored by nature. Everything from amino acids to DNA to observable phenotypes display nature's preference. We remain hopeful that diversity efforts will continue to improve across the United States and that ultimately these efforts will lead to the reduction of preventable health disparities.

References

Addams A., Bletzinger R.B., SondheimerH.M., White, S.E., Johnson, L.M. (2010). Roadmap to diversity: Integrating holistic review practices into medical school admissions processes. Association of American Medical Colleges.

American Association of Colleges of Osteopathic Medicine Application Service. (2012). AACOMAS applicant pool profile 2012 entering class.

Barr, D. A., Matsui, J., & University of California, B. (2008). The "turning point" for minority pre-meds: The effect of early undergraduate experience in the sciences on aspirations to enter medical school of minority students at UC Berkeley and Stanford University. Research & Occasional Paper Series: CSHE.20.08. Center For Studies In Higher Education

Benz, J. K., Espinoza, O., Welsh, V., & Fontes, A. (2011). Awareness of racial and ethnic health disparities has improved only modestly after a decade. Health Affairs, 30(10), 1860-1867.

Carlisle, D. M., Gardner, J. E., & Liu, H. (1998). The entry of underrepresented minority students into US medical schools: an evaluation of recent trends. American Journal Of Public Health, 88(9), 1314-1318.

Carlson, J. (2013). Enforcement problem. Modern Healthcare, 43(4), 4.

Castillo-Page, L. (2012a). Diversity in medical education: Facts and figures. Association of American Medical Colleges.

Castillo-Page, L. (2012b). Diversity policy and programs: Who we are, what we do, where we're going. Association of American Medical Colleges.

Castillo-Page, L. (2006). Diversity in the physician workforce. Association of American Medical Colleges.

Castillo-Page, L. (2005). Minorities in medical education. Association of American Medical Colleges.

Gonzalez-Rivera, C., & Middleton, K. (2008). Representing the new majority part Hi: A status report on the diversity of the University of California medical student body. Greenlining Intstitute.

Grutter v Bollinger. 539 U.S. 306; 123 S. Ct. 2325; 156 L. Ed. 2d 304; 2003 U.S. LEXIS 4800; 71 U.S.L.W. 4498; 91 Fair Empl. Prac. Cas. (BNA) 1761; 84 Empl. Prac. Dec. (CCH) P41.415; 2003 Cal. Daily Op. Service 5378; 16 Fla. L. Weekly Fed. S 367. Retrieved from www.lexisnexis.com/hottopics/lnacademic

Hill, P. L., Shaw, R. A., Taylor, J. R., & Hallar, B. L. (2011). Advancing Diversity in STEM. Innovative Higher Education, 36(1), 19-27.

Johnson, S. M., & Kurtz, M. E. (2002). Perceptions of philosophic and practice differences between US osteopathic physicians and their allopathic counterparts. Social Science & Medicine, 55(12), 2141.

LaVeist, T., Thorpe, R., Bowen-Reid, T., Jackson, J., Gary, T., Gaskin, D., & Browne, D. (2008). Exploring Health Disparities in Integrated Communities: Overview of the EHDIC Study. Journal Of Urban Health, 85(1), 11-21.

Mullan, F., Chen, C., Petterson, S., Kolsky, G., & Spagnola, M. (2010). The Social Mission of Medical Education: Ranking the Schools. Annals Of Internal Medicine, 152(12), 804-811.

Peters, A. S., Clark-Chiarelli, N., & Block, S. D. (1999). Comparison of Osteopathic and Allopathic Medical Schools' Support for Primary Care. JGIM: Journal Of General Internal Medicine, 14(12), 730-739

Reede, J. Y. (2003). A Recurring Theme: The Need For Minority Physicians. Health Affairs, 22(4), 91-93.

Steinecke, A., Beaudreau, J., Bletzinger, R., Terrell, C. (2007). Race neutral admission approaches: Challenges and opportunities for medical schools. Academic Medicine, 92(9): 117-126.

Thomson, W. A., Ferry, P., King, J., Wedig, C., & Villarreal, G. B. (2010). A Baccalaureate-MD program for students from medically underserved communities: 15-year outcomes. Academic Medicine, 85(4), 668-674.

University of California Office of the President. (2012). Efforts by UC medical schools to help meet the needs of medically underserved communities (PRIME). UCOP Legislative Report, September, 2012.

Waitzkin, H. (2001). At the front lines of medicine: how the healthcare system alienates doctors and mistreats patients ... and what we can do about it. United States of America: Rowman & Littlefield.

Walker, K., Ryan, G., Ramey, R., Nunez, F. L., Beltran, R., Splawn, R. G., & Brown, A. F. (2010). Recruiting and retaining primary care physicians in urban underserved communities: The importance of having a mission to serve. American Journal Of Public Health, 100(11), 2168-2175.

Yzquierdo, E. (2012). Who are the gatekeepers? A descriptive study of university of California medical school admissions committee members. Dissertation Abstracts International Section A, 73.

JOHN ISAAC--CLAREMONT GRADUATE UNIVERSITY

KENDRICK DAVIS--UNIVERSITY OF CALIFORNIA RIVERSIDE SCHOOL OF MEDICINE

RUTHITA FIKE--CLAREMONT GRADUATE UNIVERSITY

PAUL ISAAC--CHARLES R. DREW UNIVERSITY OF MEDICINE AND SCIENCE

ASIA ARCHER--CHARLES R. DREW UNIVERSITY OF MEDICINE AND SCIENCE

CLEMENT AROH--CHARLES R. DREW UNIVERSITY OF MEDICINE AND SCIENCE

ADAKU UME--CHARLES R. DREW UNIVERSITY OF MEDICINE AND SCIENCE

John Isaac is a Retention Coordinator at Charles R. Drew University of Medicine and Science and a doctoral candidate at Claremont Graduate University.

Kendrick Davis is the Director of Medical Education and Assistant Clinical Professor at the University of California Riverside School of Medicine. He earned his PhD in Educational Psychology from the University of Oklahoma

Ruthita Fike is the Chief Executive Officer of Loma Linda University Medical Center and Executive Vice President for Hospital Affairs, Loma Linda University Adventist Health Sciences Center.
Figure 1--AAMC Data (2012) on Male Applicants to Allopathic Medical
Schools

Race/Ethnicity      Applicants    Accepted    Percentage

African American    1107          468         42.3
Latino              1655          824         49.8
Asian               4645          2048        44.1
White               13506         6527        48.3

(source: AAMC)

Figure 2--AAMC Data (2012) on Female Applicants to Allopathic Medical
Schools

Race/Ethnicity      Applicants    Accepted    Percentage

African American    2108          763         36.4
Latino              1804          877         48.6
Asian               4296          1981        46.1
White               10451         5050        48.3

(source: AAMC)

Figure 3--AACOM Data (2012) on Male Applicants to Osteopathic Medical
Schools

Race/Ethnicity       Applicants    Matriculated    Percentage

African American     285           64              22
Latino               459           118             26
Asian                1587          574             36
White                4933          2240            45

(source: AACOMAS)

Figure 4--AACOM Data (2012) on Female Applicants to Osteopathic
Medical Schools

Race/Ethnicity      Applicants    Matriculated    Percentage

African American    442           94              21
Latino              445           95              21
Asian               1542          516             33
White               3807          1711            45

(source: AACOMAS)

Figure 5--Prime Participants 2011-2012 *

Fall 2011                            UCD         UCI         UCLA
Race/Ethnicity:

Native American/Alaskan Native       1           0           0
Black/African American               0           2           8
Mexican American/Chicano/Other       12          39          28
  Hispanic/Latino
Pacific Islander                     2           0           2
Multiple race/ethnicity (URM)        3           2           9
Total URMs                           18 (32%)    43 (80%)    47 (66%)
Asian American                       6           1           12
White/Caucasian                      33          10          12
Other/N on-Reporting                 0           0           0
Total Participants                   57          54          71

Fall 2011                            UCSD        UCSF        Total
Race/Ethnicity:

Native American/Alaskan Native       0           0           1
Black/African American               5           17          32
Mexican American/Chicano/Other       14          20          113
  Hispanic/Latino
Pacific Islander                     0           8           12
Multiple race/ethnicity (URM)        0           0           14
Total URMs                           19 (39%)    45 (63%)    172 (57%)
Asian American                       14          11          44
White/Caucasian                      16          16          87
Other/N on-Reporting                 0           0           0
Total Participants                   49          72          303

* Participants include all PRIME students enrolled both at UC and
other institutions.

(source: UC PRIME 2012 legislative report)
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Author:Isaac, John; Davis, Kendrick; Fike, Ruthita; Isaac, Paul; Archer, Asia; Aroh, Clement; Ume, Adaku
Publication:The Western Journal of Black Studies
Geographic Code:1U9CA
Date:Mar 22, 2014
Words:3497
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