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Affirmative Action in Med Ed: Exploring the Consequences of an Adverse Supreme Court Decision

Learning Objectives:
1. Discuss how an adverse SCOTUS decision in the affirmative action cases against Harvard University and the University of North Carolina may negatively impact diversity efforts in medical education
2. Describe the relationship between a diverse health care workforce and health equity
3. Describe the fundamental role of health equity in promoting social justice
1 Credit CME

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The AMA ChangeMedEd initiative works with partners across the medical education continuum to help produce a physician workforce that meets the needs of patients today and in the future. Learn more

Audio Transcript

Joena Chun: Welcome to the American Medical Association Change Med Ed webinar, Affirmative Action in Med Ed, Exploring the Consequences of an Adverse Supreme Court Decision. We would like to introduce your moderator for today's panel, Dr David Henderson. Dr Henderson serves as Vice President, Equity, Diversity, and Belonging in Medical Education for the AMA.

David comes to the AMA from the University of Connecticut School of Medicine, where he served as faculty since 2003. I will now turn it over to Dr Henderson. Dr Henderson?

David Henderson, MD: Thank you, Joanna, and thank you all for joining us for this important discussion. In March 1961, President John F. Kennedy issued Executive Order 10 and 925, which mandated that government contractors take affirmative action to ensure that applicants are employed and that employees are treated during employment without regard to their race, creed, color, or national origin.

Since then, affirmative action has been a central element in efforts to promote diversity in higher education and the workplace. Over the years, the strength of affirmative action policies has waxed and waned as the legal framework of support has changed with numerous challenges. In anticipation of the Supreme Court's decision in the Students for Fair Admissions cases against Harvard University and the University of North Carolina, the American Medical Association has convened a group of thought leaders in medical education and health equity to discuss the potential consequences of an adverse decision and to explore new perspectives that may allow us to continue the journey toward health equity and social justice.

The objectives for this session are as follows. At the end of this webinar, participants will be able to, number one, discuss how an adverse SCOTUS decision in the affirmative action cases against Harvard University and the University of North Carolina may negatively impact diversity efforts in medical education.

Number two, describe the relationship between a diverse health care workforce and health equity. Number three, describe the fundamental role of health equity in promoting social justice. Before I introduce you to today's speakers, I would like to share that the views or opinions expressed during this webinar are those of the individuals expressing them only, not those of the American Medical Association.

The information provided during this webinar does not and is not intended to constitute legal advice. Instead, all information, content, and materials provided during this webinar are for general information purposes only. Now I am pleased to introduce you to our speakers for today's webinar. Dr David Acosta is Chief Diversity and Inclusion Officer for the Association of American Medical Colleges.

Joaquin Baca is Director for Equity, Diversity, and Belonging in Medical Education for the AMA. Dr Mark Henderson is Professor of Medicine and Associate Dean for Admissions and Outreach at UC Davis School of Medicine. Dr Bill McDade is Chief Diversity, Equity, and Inclusion Officer for the Accreditation Council for Graduate Medical Education.

Dr Suzanne Rose is Professor of Medicine and Senior Vice Dean for Medical Education at the Perlman School of Medicine at the University of Pennsylvania. Jada Oweni-Ajay is Region II Chair of the Medical Student Section for the AMA and a rising fourth-year medical student at the University of Missouri-Kansas City School of Medicine.

Thank you all for taking the time to join us today. Now I'll present my first question to my colleague, Joaquin Baca. When contemplating future direction, it's often useful to have some concrete knowledge of where one has been. So Joaquin, how effective have affirmative action policies been in achieving diversity in medical education thus far?

Joaquin Baca, MSPH: Thank you, Dr Henderson. And there's a lot of complexity to that question. And even in framing some of the response, I think it would be good to go through a little bit of the history and timeline of some of the evolution. I've framed it in particular around diversity, equity, and inclusion in medical education, although this is really much more of the legal framework that has been established to get us where we are, specifically around the case that has been presented in the Supreme Court right now.

I think the first thing that happened in affirmative action was around the 14th Amendment, which was ratified in 1868. And the simple fact around that was to rectify the wrongs that had been done through slavery. And if we really are thinking about this from the current context, not really recognizing some of the other factors, such as how the Flexner Report may have shut down several of the Black medical schools across the country, and other factors such as that, and exclusion from, as another example, Black physicians from the American Medical Association and the establishment of the National Medical Association.

Those kinds of things are not included in this. But as this legal timeline is much more broad, we can see that there are certain cases, like the University of California versus Baca and the Fisher vs. University of Texas at Austin, which were highly significant, and the Grutter cases as well, leading up to this particular case, which has a lot to do with, or has everything to do with, how applications are considered in medical schools in particular, or like in higher education more broadly, using the holistic approach to review those applicants, which considers or allows for, under the rulings that I've mentioned, Baca and Fisher and Grutter and Grotz, all around racial consideration in that holistic review.

That's still what's left. And as you mentioned in the beginning, there were these ebbs and flows of how affirmative action either expanded or opened up more opportunities for greater representation in the field of medicine, but there also were things that were pulled back from legal framework in those other decisions.

Those ramifications are much broader. And so how I can answer the question of whether or not affirmative action has been effective is also based on, from my perspective, how medical schools were basically designed to begin with. And from that perspective, affirmative action was only created to, the way I like to tell it, or I'm trying to design this narrative around this is, you buy a new car and the new car's design is not fundamentally changed by any of the options that you might add to it.

I see that affirmative action basically was an option that was added to the design of medical school admissions where it expanded on who they considered in becoming or applying into medical school. And so I think from that framework, affirmative action was moderately successful, not even highly successful, but did have some success in increasing the numbers for at least a limited amount of time.

The bigger question may be what would have happened if we didn't have affirmative action and how bad would things have been if we didn't have it? That's a harder question to answer. And I think that's one that is highly significant also, though, because as we proceed through this, we don't want to forget that if things were done in particular, as executive order you mentioned by President Kennedy, to try and improve things during a time where things were very bleak and it didn't seem like there was going to be much opportunity or ability to really change anything at that point.

One of the tenants, though, at that point was not only to open up opportunity to students who had been excluded very directly, but also to start to create an environment where there was less of a sense of subordination. And that was one of the immediate things that was removed from affirmative action frameworks early on in some of the decisions that we're looking at.

And that, by taking away slowly things that had the greatest amount of opportunity to correct some of the wrongs, which were initially instilled into things like the 14th Amendment and President Kennedy's original framework, further removed its ability to achieve any kind of real justice in this process.

And by the time we get to the Reagan administration, his presidency, where he kind of slowed down on the use of the Office of Civil Rights to pursue cases of discrimination and really pulled back on the number of people that had been assigned to do the OEO work, Office of Equal Opportunity work, we saw this shifting towards a new framework of what was called diversity, and diversity initiatives.

That part also has had limited success, and I'll let some of the others speak to the numbers or to some of the successes that we might have seen based on some of those efforts. But unfortunately, I've been doing this work for about 20 years, and the numbers haven't changed much, and in particular, especially with African American black men in the United States going into medicine, that number has actually gotten worse in some ways.

So maybe some of these efforts have not been as successful as they could have been, especially if they hadn't been weakened the way that they were through some of these decisions.

D Henderson: Thank you, Joaquin. Thank you very much. I like the analogy of the car and adding options, the basic structure doesn't change.

Thank you. Jada, given your experience as a medical student, how does diversity impact the learning environment?

Jada Ohene-Agyei, BA: Yeah, thank you, Dr Henderson. From my perspective, diversity in medical education amongst the student body can help us in two ways. One of the ways is education itself. I think having that representation in student bodies, we can have the opportunity to learn lessons from each other.

One example is the identity-based national medical associations. Aside from the AMA, I'm also part of SNMA, the Student National Medical Association, which primarily focuses on promoting the excellence and medical success of black African American, the Latin American community, and the Native peoples medical students.

In addition to that, there's LMSA, PAMSA, ANAM. Given all of the complexities in different patient populations, I think these national medical associations that are identity-based have a certain expertise in that a lot of these individuals have had firsthand experience with these disparities. Just being in a class of diverse students in a city like Kansas City where I have medical school, I've been able to learn a lot about different subject matter that I wouldn't have been exposed to previously had I been a part of a more homogenous student population.

The other aspect that I think diversity in medical education can help us is just the workforce itself. There's data to support that most medical students end up practicing medicine or doing residency back where they grew up. And as we all know, we have a physician shortage, particularly in areas that are underserved.

And so I think having that in mind, I think recruiting medical students, qualified medical students, and getting them matriculated and passing and being successful in medical school can only help us in the long run because we're placing more trained physicians that are familiar with the niche patient health disparity issues in different areas where we wouldn't normally have that support.

And so I think this adverse affirmative action decision that may come upon us will really have detrimental effects in the long run in both education and workforce prosperity. Thank you.

D Henderson: Jada, thank you very much. And thank you in particular for sort of placing emphasis on the just the sort of role that the learning environment can play on just from a personal perspective.

Dr Rose, how might an adverse SCOTUS decision in students for fair admissions versus Harvard and UNC negatively impact undergraduate medical education?

Suzanne Rose, MD, MSEd: So good afternoon, everybody. And first of all, my gratitude to the AMA and to Dr David Henderson for including me in this impactful and important webinar.

Wow, what a question. It's such an important question. And I know we've all been thinking about the impact of the SCOTUS decision and will continue to do so, particularly if this results in the elimination of consideration of race in admissions. So in thinking about this, I would like to frame this question by thinking about the entities that would be affected by an adverse decision.

And to be honest with you, such a decision will exert an impact on just about everything. But for a sense of simplicity and for time, let's just think about three areas. One is the impact on admission. Two is the effects on our curricula and a little bit more on our students and learning environment. And three, the influences beyond.

Given the premise that our role as medical schools is to train the next generation of physicians and scientists, not really just merely to train them, but really for a very specific purpose, to care for patients and to care for our communities. So let's start with a very explicit premise that I think we in medical schools agree upon, that diversity in medical education is important.

It's important to our students, to our learning environment, to our patients. And I'm going to try to touch upon that as much as I can with data and observation so that we can support that. But starting with point number one, the impact on admissions. This is the most obvious connection to the SCOTUS decision.

If we're unable to use race in consideration of admissions, then we're going to have to consider other ways to make sure that our goals related to diversity are achieved. And most of us have already thought about this. A lot of us have transitioned to a holistic review of our many, many medical school applicants.

We look at not only the academic factors, but also the experiences that the applicant may have that makes them special, unique, or qualified to be successful in our unique environments. So an example might be, you know, advanced degrees, special talents in art, in music, literature, leadership in sports, or also what we've referred to as miles traveled.

What an applicant might have had to overcome to get to this point, perhaps living homeless in a car for years, caring for younger siblings while parents are in jail, surviving a refugee camp, growing up without a parent who maybe perished in 9-11, and becoming ever more common surviving a school shooting.

So this may widen the definition of diversity, but may not always translate to race. And as we will see in other points, we can't abandon the need for diversity related to race. And I believe that Dr Mark Henderson will be providing more examples of this when he speaks. So let's move on to the other factors in the UME experience.

So how will the SCOTUS decision affect our curricula, our students, our learning environment? We already heard a little bit from Jada about this. So we know that racial diversity in medical education enhances the experience for all students. Students who train in diverse settings are more comfortable treating patients from a wide variety of backgrounds.

Training with diverse peers offers many different advantages to the learning environment. And many of us have transitioned to some type of pedagogy that is team-facilitated instruction. And there's a lot of data showing that diversity improves the performance of teams. So health and healthcare in the United States are not race neutral.

How does that affect our students? So medical students will have to be trained to navigate a profession that is heavily influenced by issues of race. So if practices that promote racial diversity in admission policies are eliminated, medical educators will not only have to consider the admissions processes with our holistic measures, but will need to make sure that our environments continue to provide the best education for our students who are going to care for those diverse communities.

So we've already stated that this is probably best done by starting with a diverse cohort. That said, thinking about the composition of our learning environments, whether with virtual patients or in clinical environments with authentic patients, we will also need to pay attention to this. And so thirdly, the influence of the SCOTUS decision beyond UME.

So diversity across the continuum of medical education is critical as we remember that our students will fill the GME pool, which eventually feeds our academic faculty, our practitioners who are in the community. Diversity in our schools is also a pipeline to the workforce. And we've already heard that having a diverse workforce is critical for our patients.

In fact, patients who belong to a racial or ethnic minority group report having more positive experiences with race concordant physicians and caretakers. So it's really obvious that the SCOTUS decision will affect admissions and beyond, but we don't know how it may affect admissions in colleges, in universities, and further erode our pipeline to medical school.

So to answer the question, how will this negatively impact UME, a SCOTUS decision eliminating the consideration of race affects not just admissions, but our entire educational enterprise, including our curriculum, our learning environment, and of course, our pipeline. So it's incumbent upon us as medical educators to consider these impacts and to prepare with not only recruitment strategies, but creating diverse learning environments and providing the optimal education for all of our students.

D Henderson: Dr Rose, thank you very much. And I think in particular for emphasizing the importance of strategizing to get out ahead of this decision, because we really can't afford to be caught flat-footed because in the states that don't have affirmative action policies, we know the history of what happens immediately after affirmative action has been prohibited.

Dr McDade, what role can and should GME play in promoting health equity and ameliorating health inequities?

William McDade, MD, PhD: Well, Dr Henderson, thank you very much for having me here. I think that graduate medical education plays a particularly important role because every physician who gets a license to practice medicine in the United States has to come through an ACGME accredited program.

So we get a chance to touch all physicians who practice in the country. And graduate medical education is an important facet of developing the individual who's attended medical school to prepare to practice in order to deliver the best possible care. And our goal at the ACGME is to increase the health of both individuals as well as populations through the accreditation process and education.

And one of the things I think that's most important in terms of improving health care is the elimination of health disparities, health inequities. And one of the ways that you can eliminate health inequities is by having a more diverse workforce. And we're at the 20th anniversary of the Unequal Treatment volume that was published by the Institute of Medicine at the time, now the National Academy of Medicine.

And it really spoke to the idea that increasing the diversity in the workforce is an essential piece of this. And as Dr Rose pointed out earlier, in part that's because of racial concordance in the care that's provided by minoritized physicians to minoritized patients. And this established the idea that even in first year medical students, when the AAMC samples in the Mastriculating Student Questionnaire, about 64% of African American students say that they're going to serve an underserved and disadvantaged population.

They come into medical school thinking this is going to be the case. It's about the same number for indigenous physicians and just slightly less for Latinx individuals. And for Asians and white students, it's in the low 20 percentiles. Now if you say we've got four years in the medical school curriculum to persuade those 80% of students who the white and Asian students constitute to take care of underserved and disadvantaged populations, we see in the senior questionnaire that the numbers are practically the same as they were in the matriculating student questionnaire.

We know that minoritized physicians take care of disproportionate numbers of minoritized physicians. So if you're an African American physician, your likelihood of taking care of an African American patient is about 23 times that of a white physician taking care of an African American patient in general.

A work from Peter Bach in 2004 suggested that in fact, if you are a primary care African American physician, that you are about 40 times as likely to care for a black patient than you are if you are a white physician to care for a black patient in primary care. So the idea that diversity is important because of the care that we provide, I think is important.

But it's also important in terms of the work that our faculties do. Diversity on our faculties help to increase the types of research that's done. What we find is that minoritized faculty typically do more research on minoritized communities and diseases that impact those communities in particular.

And we find that they also serve as mentors. They also serve as people can help to enroll individuals in both medical school and in clinical trials in terms of patients. So there's an outsized effect that minoritized faculty have with respect to their ability to impact health equity by being involved in the learning and teaching process and the research process in medical schools.

We see in graduate medical education, though, the idea that when you look at the numbers of African Americans and Latinx residents who've been trained in GME over the last 20 years or so, we haven't really moved the needle very far at all. It was about 4.9% back in 2004, 2005, and it's just barely about 5% right now for African Americans.

For Latinx individuals, it's increased slightly in the last couple of years, but it had been flat for the previous 15 years. And so you say that we have to create a diverse workforce in order to serve the public that we care for, in order to advance the research agenda. And one of the things that we have to do to achieve health equity is recognize that without increasing this diversity, we make it harder on the entire learning environment to understand the types of problems that minoritized populations face.

So I think all together, graduate medical education plays an important role in looking at how one thinks about what can happen when you don't have as much diversity as you need in order to address it, which is the condition that we've been in. You see the health disparities that have loomed large for the last 20 years and continued even before then, and we haven't seen a lot of movement.

And we're hoping that by increasing the diversity in graduate medical education, we can change those outcomes.

D Henderson: Dr McDade, thank you very much, I think in particular for sort of drawing a line from who we educate to the care that's provided and how that care is distributed. Dr Henderson, given your experience in California, and particularly your long experience in admissions, what strategies are potentially available to medical schools to continue to promote diversity in medical education?

Mark C Henderson, MD, MACP: Thanks so much for the opportunity, Dave. And I mean, I would just emphasize a point that Dr McDade made, which is that, you know, not only diversity is not only important to health equity and justice, it's really critical, it's fundamental, we have to have it. So I think when I took over as admissions dean here 17 years ago, that's what my boss told me my job was to do.

And I would say it's taken a lot of years to get to the place we're at. I think what we did here at UC Davis, in a constrained environment that you alluded to, where affirmative action is prohibited is really in five areas. The first was to redefine our admissions mission, and communicate it across our institution, that we were a public school committed to meeting the workforce needs of our state.

That's the first thing. The second thing was we went through a process of rethinking who gets into medical school and who decides. So what that meant was increasing the diversity of our admissions committee, elevating the voice of students, local community members, all who are stakeholders in our community's health.

Third, we changed fundamentally how we looked at applicants, attaching value to non-traditional strengths like going to community college, like growing up in a rural area, like military service. And basically what Dr Rose alluded to earlier is a distance traveled to get here. We instituted implicit bias and a lot of other training for all of our committee members.

And I think one of the most important things we did is we developed a locally derived disadvantage score which explicitly diminishes the importance of traditional metrics that have historically excluded minoritized students. And we've allowed traditional metrics to be interpreted in what I would call the proper context that they should be.

Fourth, we've tried to make the medical school experience more equitable. It's not just admitting a different group of students, but it's making it possible for them to remain connected with their community and their passion and the reason they came to medical school. So we did that by trying to develop pathways focused on community needs, whether it be the rural California, the farmworker community, inner city youth, and of course, primary care, which should be an urgent need for all of us, is an urgent need.

These pathways have additional peer, academic, and financial support. I think we also capitalize on the strength of our students. At UC Davis, we're a majority minority school. Well, I'm going to tell you that changes a lot of conversations, changes a lot about the classroom environment, and it challenges faculty, it challenges preceptors in the best possible way.

The last thing I'll say is it's required a lot of investment. It's required scholarships. I think over, I added this up for this talk, it's over $12 million in scholarships, monies that we give to students to try to make education possible for many of them who come from marginalized groups and as Dr.

McDade said, are much more likely to eventually serve and work to improve the health in marginalized communities. We've also done this by really having true community partnerships in our local neighborhood where all of us as academic health centers are located. Whether that's working with a local black church to improve or deliver COVID vaccinations, there's so many ways you can do this, so many needs.

Then finally, I think we've worked with local community colleges, which are a huge source of talent and really reflect the broad diversity of this country. We've given those students access to advising, support, and the other opportunities that are typically only afforded to more privileged students. In a sense, we're making them priority.

Those are some of the ways and I look forward to the conversation. Thanks again for the opportunity.

D Henderson: Thank you very much, Dr Henderson. Can I ask you to comment just briefly on, for those who may not know, on the level of diversity that UC Davis has been able to achieve?

MC Henderson: Yeah, sure. When I took over as admissions dean in 2006, 10% of our students were from underrepresented in medicine groups.

Last year it was 52%. Again, that's been a slow, steady rise. It's not an overnight change. It takes a lot of different interventions on a lot of different levels.

D Henderson: Thank you. That's really remarkable success. Dr Acosta, in the context of their individual missions, what role should national organizations like the AAMC and AMA play in supporting diversity in medical education in pursuit of social justice?

David A. Acosta, MD: Well, my colleagues, David, I want to express my thanks to the AMA and also to you for the invitation and the opportunity to this panel, because as we can already hear, amazing things being said by these amazing colleagues as well. I think to answer the question, what role do our national organizations like us play in supporting diversity in medical education?

I'll start by saying, first, I say, number one, we don't change course. We have to stay the course and we continue to support and navigate the work that many of our institutions have done over the years to ensure that the enrollment into U.S. medical schools remains diverse. We also have to ensure that identity diversity, including race and ethnicity and other socially determined identities are valued and that they're sustained.

As expressed already, we know that multiple perspectives that are generated from people from different backgrounds essentially also really create a better and a stronger learning and workplace environment. But it's also the fact that was also expressed today, just to reemphasize it because it's so important, is that we also know that a diverse healthcare and scientific workforce are really critical components in our nation's responding to addressing health inequities in order to improve the health of every patient in every community across the country as well.

As national organizations, I think we need to do a better job in coming together in solidarity and not working in the silence as we've done in the past. We have a collective power and privilege really to convene national experts across the disciplines, bringing together system-based thinkers that can actually deconstruct the status quo that we are experiencing in finding system-based solutions to affect change.

I'm really reminded of a quote that I recently read by Damien Barr. He said, quote, “We are not all in the same boat. We are in the same storm. Help whoever you can.” And it just reminds me so much again, even though we have this impending storm in front of us that's looming and we're trying to be ahead of it, the reality is that we all do have different mechanisms and state by state, region by region, and even at the local level, we are different and we have to respect that as we look towards the future of this.

And as national organizations, we do need to develop a better mechanism in order to coordinate our efforts as we continue to support our members by understanding their unique needs. I think it's really our job to continue to identify key information, the effective practices, and provide the data that our members really need to create their own narrative, to create their own responses and their action plans when they're challenged.

I also think the national organizations need to share their collective resources, all the tools that have been developed, the data, including talking points, and make them accessible to all of our members because they want to be better educated and be prepared in this space as well. I think, for example, two great resources that are out there that have been published in the recent past, that still there are some people that are unaware of these incredible guideposts.

One is, for example, the playbook, Understanding the Role of Race Neutral Strategies in Advancing Higher Education Diversity Goals. And this is by the College Board and Educational Council's Access and Diversity Collaborative. The AAMC, like the AMA, has also produced guides as well. I think about the Red Book, better known as the Roadmap to Diversity and Educational Excellence, the key legal and educational policy foundations for medical schools.

Both of these and many of them are out there, you know, service guides that can help institutions in identifying those areas in the enrollment process that might need careful examination. These guides can also provide race neutral strategies that institutions may have not considered to take a look at.

You know, the resources and tools that we develop essentially should not also be in competition with each other, but rather they should also be supplemental and complementary to each other as well, and we can do that work. As national organizations, I think we still need to remain steadfast, and we need to weather the storm that may be coming and be prepared.

Our messaging, our process for gathering information, our gathering input from our members and our recommended strategies, we really need to be more visible, clear, and consistent, which is also an important piece of that as well. I also think that national organizations should really, if they haven't been done it yet, develop a contingency plan and convene rapid action teams whose essentially composition would include subject matter experts, both not only just internally within our organizations, but also externally, and how do we draw from our many members who are practicing best practices out there around this, and we need to draw from them and get them, make sure they're included.

This also includes including our communications and our legal teams, and we don't necessarily have a really pull the full potential out of them as in, you know, a communication plan should focus really on the best process to disseminate the information, the data to our constituents, and also the communication teams from national organizations might even consider collaborating and partnering with each other to basically do this work together.

We should also recommend this if our members are same institutions, that is, you know, institutions collaborating within their region as well. So I'll state the obvious, you know, we definitely are in crisis mode, that's why we're here today, and at times, though, this is where we do our best work, and we should leverage that, knowing that crisis could bring on more opportunities looking forward.

So lastly, I'll end with what I've learned, I've been working in the academy in two different states with that affirmative action laws in place, both Washington and California, and that is, one, I think it's really important at this time for us to recognize, to understand and respect how uncertainty impacts and affects us personally, but also how it affects each of our members as well.

Now, our approaches to deal with uncertainty can really vary tremendously, you know, from one person to the next, from one group to the next, from one school, also to from one organization to the next. Number two, yes, it's important to be proactive, but we also must remember not to get too far ahead of the decision that's yet to be made.

Number three, I think also when the decision surfaces, it's going to be really important that we don't misinterpret or over-interpret what that decision is or will say or what the law will say or not say. And this is, I think, where national organizations can really assist our members in understanding what the decision actually means, you know, and more importantly, what it doesn't say and how it might impact institutions in the time frame that's been allotted.

And lastly, I have to also say that we can't forget to really ask, what can we learn from those that have already weathered a similar storm like this? I think about the nine states that have affirmative actions in the United States. So thank you for listening, and I look forward to our Q&A portion of this webinar.

D Henderson: Dr Acosta, thank you very much, I think, particularly for presenting such a sort of solution-based response to that question. And I think that the AAMC, the AMA, and ACGME, I mean, all have sort of substantial pulpits from which to speak back against a lot of the sort of negativity that is likely to come, regardless of how broad the decision is.

And also, I think, to provide support for schools who are sort of at ground level trying to figure out what their vulnerabilities may be based on their policies, because I think fear can be a very strong motivator of behavior. I would like to highlight one question that's coming from the chat, and it actually has to do with something that I think has been alluded to a couple times by you, Dr.

Acosta, in your remarks, and I think by Joaquin at the beginning, and sort of how have medical education institutions and environments sort of reflected the underlying sort of social structure, the underlying inequities in our broader society? And could someone maybe speak to that, and also sort of how we might approach these things differently, how we might reposition ourselves as institutions?

MC Henderson: Well, Dave, I think what you're asking, I mean, I'll just say it. I think Joaquin said this at the beginning. I mean, medicine does not reflect society. I mean, that's fundamentally part of that car, or whatever the metaphor is, the structure that we need to change. I mean, we've talked about race and ethnicity, but we haven't talked about the economics of it.

Again, most medical students are coming from, I'll just say, higher incomes, and that fundamentally, to me, cuts across a lot of these other identities, right? It's so important to think and to speak about, and so we have to have faculty that also reflect the wonderful kind of the spectrum of our society in order to solve some of these problems.

And anyway, I don't know, maybe I got slightly off of your question. I apologize.

D Henderson: I mean, I think what you said was very relevant. I mean, I think we know that over 50% of medical students come from the top two quintiles of family income in this country.

M C Henderson: Top one quintile. Sorry, sorry, Dave. It's worse than that is all I'm saying.

Thank you. That's okay. David knows the data. He should speak to it. Acosta, go ahead.

Acosta: You know, just an answer to you, and that is very true. I think the irony here is, again, we're hoping that most of our medical school graduates are going to basically be serving also in our underserved communities, and regardless of location, as Bill had alluded to, I mean, we have that data that, again, if you look at our graduating seniors as well, it very much tracks that particular data looking at, even though they may have said this at the beginning to get into medical school by the time that they've gone through all these experiences, and regardless if they've already done a lot of coursework in understanding health disparities and how to eliminate them, they work in student free run clinics and spend hours working with population groups that essentially don't have access to any care at all.

You would think that would persuade them, but the reality is that over 47% of them are still undecided if after they graduate, they're going to serve the underserved, number one, and number two, even despite if we don't think about location, again, 54% are saying, I'll take care, I'm not really sure if I'm going to be taking care of underserved populations in that, and that's frightening, because again, but we also shouldn't be really surprised.

Mark was alluding to is, again, when we have students that are coming from the higher income bracket who have never been exposed to this, don't have any lived experiences in it, and don't have to have lived experiences in it, this is the results that we get, the outcomes that we get. I just think, I look at us as medical schools, we're essentially, some people call us the gatekeepers, but I also think that we're the gate openers, because again, it's really on our backs to basically who we are able to bring in and who needs to be in to really create the next physician workforce of the future sort of thing.

I think it's just wonderful, it's wonderful to be on this panel with Mark Henderson and his team and what they've been able to show, despite what's in the system. We can change it, but again, I think the most important thing that they've demonstrated is that you got to be deliberate, you have to have intent, you got to be patient, but also you got to put the work in.

The majority of people, again, and this is not just about numbers, but it's also about bringing in the right people who have these lived experiences, because man, that just enriches not only the classroom, but also enriches what happens at the bedside as well. Also, I think our patients also become, feel that they also are part of that process.

I think we're able to teach those types of students that are willing to also listen to them, humility as well to really understand the patient's experience. Then together, that turns out to be just the best learning environment. I think if anything, David, to answer your question, the reality is I think we're finally starting to have some of these conversations, as Mark alluded to, to talk about how do we unpack the structural racism?

What does it really mean? Because people, they don't know what that means. I think we have to provide examples, we have to point this out. We have to make visible what's been invisible to people as well, because it's been there all along for those of us who've done the work.

D Henderson: Thank you both very much. That question actually sort of dovetails to another question from the chat, and I'll just read that here.

It says, am I understanding the position of the panel to be that the ethnicity of the patient should dictate the ethnicity of the physicians treating them?

Baca: I wonder if I could build off of what was said in the previous answer as well. I'm sorry, Dr McDade, I'm trying to do this quickly, but I think some of this might be about reframing approaches, not necessarily about necessarily reflecting one group and how you draw around that.

But I think as an example, patient-centered medical care re-centers the experience of the patient first and then builds the care around that. Similar, I think CBME centers education around the student versus around the didactic experience of the teacher delivering something to a teacher along with other things.

It's not time-limited and other factors, but I think that re-centering is the more critical aspect of how we should be thinking about addressing, making sure that the workforce aligns to the needs of the patients. And it should be systemic, just like Dr Henderson and Dr Acosta were mentioning. And I think Dr.

McDade has brought that up in different contexts as well.

McDade: So racial concordance isn't forcing people to go to physicians of their own race or ethnicity. It's not disallowing physicians or patients to see who they'd like. It's not forcing people to work in certain environments, although you have to think of the historical aspects of this.

When the Flexner Report was published in 1910, Abraham Flexner wrote in Chapter 14 of that book on the medical education of the Negro that it was essential to have Negro physicians trained in medical schools that catered to them, in part because you wanted to ensure that the 10 million, at that time, African-Americans who existed in the United States after freedom from emancipation from slavery would not infect the 60 million whites who were in the community.

And that, in fact, you couldn't depend on white physicians to care for those African-American patients. And so you had to keep at least two medical schools of the seven that were open at the time available to teach. That's the same report that really, upon which the medical education structure has been structured for the last 100 years.

And so it sets up a dynamic of training physicians to care for certain communities as a function of race or ethnicity. I'm not even saying that that's important. What I'm saying is that the actuality of it is that minoritized physicians tend to practice in minoritized communities and tend to care for minoritized patients disproportionately.

The group from Harvard actually published a paper in Academic Medicine several years ago suggesting that there's a race-conscious professionalism that's involved in the part of minoritized physicians who do this. That is, they see that they navigate a certain pathway between professional behavior and for the care of the patients and populations that they hold as most dear.

And the idea that we're forcing people to take care of patients because of their race or ethnicity is just a false sort of structure. That is that people choose to do it because they're more comfortable in those environments, they adhere to medical advice more avidly, they feel that there's a similar or perceived shared worldview when their physicians are the same race or ethnicity as they are, there's better communication, there's better language concordance.

And really, there's the idea that there's psychological safety involved in concordant relationships, which is why people choose it. Trust is really the big issue that has impacted how we care for patients in the United States these days. And people live in marginalized or isolated communities by and large that are defined by race and ethnicity, and they tend to seek medical care in those very same communities.

And so that's why it's essential to have a workforce that actually reflects the population. But it's also essential that all physicians learn how to take care of every patient. And that's why the concept that Melanie Turbline and Jan-Marie Garcia developed in 1990s on cultural humility is so important to be taught in medical school.

It's really, it subjugates the dominant cultural perspective with respect to listening to what your patients are going through, their issues that they bring to the patient-physician relationship, and really learning in the continuous process. And it's different than cultural competency, which implies that there's some end point or some mastery of material.

And really says that let's put down our own cultural norms and practices in favor of listening to our patients to better care for them.

Rose: I would like to just add, I'm glad you brought up cultural humility, not just the diversity in our communities, but also in our own medical schools. So we've done, many of us have done a decent job in diversifying our medical student body.

Maybe we're doing okay in GME. We're still, many of us are still suffering with our faculty. So you don't necessarily have to have somebody who's race concordant to be your mentor, but having a pipeline across the continuum in medical education is so important. And including that cultural humility in the curriculum of a medical school really requires a diverse faculty as well as a diverse student body.

D Henderson: Thank you all very much. I mean, I think we have touched on some really very important issues. There is one other question from the attendees, which we don't have time to answer in fullness now, but it may align with some of the statements that Dr Acosta in particular made, but also I think Dr McDade with regard to sort of how we move forward.

And the question is, can someone from the panel provide an action plan of what schools should be doing right now to better prepare for the SCOTUS decisions? And I don't necessarily know that we have time to create a laundry list in this particular moment, but I do think that there should be an opportunity after this webinar is completed for leaders from at a minimum the three national organizations, the AAMC, ACGME, and AMA to sit down to come up with a set of suggestions, recommendations for schools.

And if we can get that accomplished prior to the decision, we can try to get it out then. If not, then hopefully shortly thereafter. But I think that's a really important question, and I think it should sort of prompt us to action. We're nearing, I'm sorry, Jada, go ahead, please. Yeah, I'm sorry.

Ohene-Agyei: I just wanted to throw in one really quick thing because I think that question is so important, especially as it regards to the current discourse around affirmative action.

One of the things I love about this panel is that we've heard like so many amazing perspectives about what affirmative action really is and particularly about what it isn't. I think just from my experience, a lot of the discourse around what affirmative action is, is pretty damaging and inaccurate. I think a lot of medical students that look like me or look like any member of our panel can relate to the statement that I suffer from a certain degree of imposter syndrome because I've been told that the only reason I got to where I am is because I'm Black or because I'm a minority.

And that kind of invalidates or negates any kind of work that you put into getting where you are today. And so I just love that this panel was about appreciating the diversity and cultures and the different narratives that we bring to medical education because it'll benefit patients in the long run.

Actually, I'm sure a lot of us saw, or if you didn't, I can tell really quick a few weeks ago when the match decisions were posted and the schools were celebrating on social media, Twitter in particular, Stanford surgery programs or catechal programs for general surgery, plastic surgery and vascular surgery.

Of the 13 resident cohort, only one was male. Then the overall core cohort, it was pretty racially diverse. And an overwhelming a number of those comments in Stanford's comment section were pretty disparaging and pretty horrible towards these residents, basically saying that they are the beneficiaries of satisfying a quota, that they didn't deserve to be there, that patients were going to die on the operating table because they weren't qualified to be the surgeons for the program that they were accepted to.

And that really struck a chord with me personally, because I've heard those comments said to my face before. And I just love that this panel took the opportunity to talk about from admissions perspectives how that isn't true. That's not the goal of affirmative action. This is to benefit medical education and patient outcomes in the long run.

And so I just wanted to put that out there to really what medical schools can do in anticipation of the SCOTUS decision is to kind of rectify the discourse, maybe have a panel of this on their own and just talk about it openly and just be very transparent about their admissions objectives and their directives to ensure that diversity is instilled and maintained in medical student bodies going forward.

So that's what I want to say. Thank you.

MC Henderson: Well, I'd add, Jada, that's a beautiful, thank you. And Dave, when you convene this group of leaders, I think we can hold the leaders of such institutions accountable. That is for elevating, empowering their students. And as Jada said, it's about the patients. Everything we're doing, it has to be about the patients.

And of course, that's what this is for. But our students like her are the way for us to improve that care. Anyway, thanks for saying that, Jada.

D Henderson: Jada, thank you very much. And Dr Anderson, thank you very much as well. So as we are about to run out of time, we should bring this to a close. And I want to thank the panel for their time, their expertise and for engaging such a open, honest and vigorous discussion.

I think the central question here is how does medical education continue to strive toward meeting its primary mission, which is to produce a workforce that meets the needs of our nation, potentially in the absence of affirmative action policies? We know that the current workforce is not well suited to accomplish that mission, as Jada just pointed out.

We learned at the start of this discussion that affirmative action has not been as influential as some of its major opponents seem to state. I think that as we contemplate a future either without affirmative action or one with severely restricted policies, we need to figure out how medical education can reposition itself.

It can be argued that, and I think someone actually alluded to this earlier, change always provides opportunities. So how can the loss of affirmative action policies help us move forward toward transforming medical education? One change may be to fully focus on our mission. I will argue that, and I think it's been well argued here, that diversity was never the mission.

Health equity is our mission. Diversity then becomes a necessary outcome along the path toward achieving that mission. And there are many other structural and institutional changes that are also necessary outcomes. At the end of the day, we need to decide whether we want to try to be worthy of our mission or simply perpetuate the structural inequities that inform our broader society.

The anticipated SCOTUS decision should provide the opportunity to engage such a debate. I believe I speak for the panelists here when I say I look forward to this debate, and I hope those in attendance do as well. Therefore, we're committed to continue this dialogue. Thank you again to all the panelists.

Thank you to all our attendees for joining us today. And we look forward to seeing you at our next webinar as part of our Change Med Ed webinar series. Thank you all very, very much.

Audio Information

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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