Barriers Thwart Recruitment Of Minorities Into Medicine

Twelve years ago, the Association of American Medical Colleges (AAMC) inaugurated “Project 3000 by 2000,” an effort by the nation’s medical schools to increase the number of minority students entering medical training to 3,000 by the turn of the century.

The project capitalized on an expanding awareness of the long-standing dearth of minorities in medicine. It also addressed the fact that an ethnically diverse physician workforce was not simply politically correct but of practical importance to the future of health care in the United States, where the population is becoming more ethnically diverse.

The project was followed by tangible success—by 1994 more than 2,000 underrepresented minority students entered medical school, up from 1,500 in 1990.

But in medical training as in other areas of American society, affirmative action and race-based decision making have met with resistance. Legal and legislative barriers to affirmative action policies in several states have contributed to a recent decline in the number of minority applicants to medical schools.

The AAMC’s project fell short of its goal of 3,000 minority students by 2000. And in an article in the September/October Health Affairs, AAMC President Jordan Cohen, M.D., and colleagues Barbara A. Gabriel and Charles Terrell renewed the call for long-term educational reforms and short-term affirmative-action policies to increase the ethnic diversity of the country’s physician workforce.

“Knowing that the country is becoming racially and ethnically ever more diverse, we have a moral obligation to select future physicians who are optimally prepared for this challenge,” Cohen told Psychiatric News. “We have this marked skew in the current racial and ethnic makeup of the physician workforce. The long-term solution is something that medicine can’t do anything about—improving educational opportunities from kindergarten through grade 12, which are now disproportionately inferior for students coming from minority backgrounds.

“But in the meantime,” Cohen added, “we know that affirmative action is highly effective for medical school admissions. We can select qualified individuals from the applicant pool to be major contributors to the health care of the country. It’s not a question of experimenting—it’s already been done. But it will be impossible to face the near- and long-term challenges of the profession unless we can continue to use these tools.”

Cultural Competence Critical

The Health Affairs article appears in an issue devoted to physician manpower issues and outlines views that Cohen has put forward in the past—that a racial and ethnically diverse physician workforce is important for “culturally competent” care of a racially diverse patient population; that affirmative action in medical school admissions has proven successful in increasing the number of qualified candidates from minority backgrounds; and that recent legal and legislative actions have set the cause back.

In particular, Cohen cites the 1996 Hopwood v. University of Texas ruling, which prohibited institutions in Texas, Louisiana, and Mississippi from taking race into account in admissions policies, and Proposition 209 in California, which prohibited the same in California public institutions.

Minority Enrollment Declines

The Health Affairs article by Cohen and his colleagues directly attributes a recent falloff in minority applications to those actions, stating that “the annual medical school enrollment of individuals from minority groups underrepresented in medicine. . .has been on a steady decline, dropping from 2,340 for the 1995-96 school year to 1,922 for the 2000-01 school year.”

In an interview with Psychiatric News, he underscored the impact of the Hopwood case and Proposition 209. “It’s hard to identify any other thing that would account [for the falloff], especially given the rapidity with which this has happened,” he said.

Cohen was also explicit about the need for “affirmative, race-conscious” decision making in medical school admissions—a strategy that remains controversial. Opponents have argued that such a strategy is not only contrary to the goals of a “color-blind” society, but that it is liable to diminish the quality of medicine at a time when medical training is becoming increasingly complex.

Cohen calls the latter argument “bogus.” He said, “No one is suggesting that we are going to be admitting anyone who is not qualified to be a doctor. We have a very rich applicant pool that has twice as many applicants as we do positions.”

He added that the rigors of medical school—as well as the rigor and expense of applying to school—tend to attract highly motivated, competent individuals. “There is every reason to believe this is a highly self-selected group,” he said.

‘It’s the Right Message’

Educators who spoke with Psychiatric News agreed with the thrust of Cohen’s arguments.

“It’s the right message,” said Herbert Pardes, M.D., president and chief executive officer of New York Presbyterian Hospital and past dean of Columbia University College of Physicians and Surgeons.

Regarding race-based decision making in medical school admissions, Pardes said it has never been a matter of choosing between candidates who are grossly unequal in qualifications or credentials, but rather of considering race as a factor among candidates whose differences in qualification may be only a matter of degree.

But Pardes, who is a past president of APA, emphasized that the problem of increasing minority representation in medicine has vexed educators for years. “What’s needed is a systematic look at what has and hasn’t worked over the years and the causes of this most recent reduction,” he said.

Not a New Idea

Nyapati Rao, M.D., chair of APA’s Council on Medical Education and Lifelong Learning, said “cultural competence” has been a mainstay of psychiatric training, especially in psychotherapy. “We are not new to this idea of cultural competence,” he said. “Our residency programs require it. This is not just a buzzword. You cannot train psychiatrists to be competent in psychotherapy unless they are culturally competent.”

Rao is director of residency training at the State University of New York Downstate Medical Center in Brooklyn.

Rao noted that another factor in physician manpower is the role of international medical graduates. “That group is slowly becoming extinct due to immigration and exam policies,” he said. “This may have a very large impact on manpower that I don’t believe is being adequately addressed.” ▪