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Affirmative Action in Medical EducationUnpacking the Supreme Court Decision

Learning Objectives:
1. Explain how the Supreme Court’s decision to reverse affirmative action in cases against Harvard University and the University of North Carolina may negatively impact diversity efforts in medical education
2. Describe the connection between a diverse health care workforce and health equity
3. Recognize the vital role Historically Black Colleges and Universities (HBCUs) play in diversifying the physician workforce
4. Discuss practices for promoting diversity in medical education in the absence of race-conscious admissions policies
1 Credit CME

In response to the SCOTUS decision in Students for Fair Admissions vs. Harvard and UNC, the AMA has convened a group of thought leaders in medical education and health equity to discuss the consequences of the decision, how it may negatively impact diversity efforts in medical education, the relationship between a diverse health care workforce and health equity and the vital role that HBCUs have played in diversifying the physician workforce.

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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

Video Transcript

Joena: [00:00] Welcome to the American Medical Association ChangeMedEd Webinar, "Affirmative Action in Medical Education, Unpacking the 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, 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.

David Henderson, MD: [00:38] Joena, thank you very much. I really appreciate that introduction. And as we begin, we should probably first go through some objectives, just to get that bit of business out of the way. And for this webinar, at the end of this experience, participants will be able to explain how the Supreme Court's decision to reverse affirmative action cases against Harvard University in the University of North Carolina may negatively impact diversity efforts in medical education. Participants will be able to describe the connection between a diverse health care workforce and health equity, recognize the role historically Black colleges and universities play in diversifying the physician workforce, and discuss practices for promoting diversity in medical education in the absence of race conscious admissions policies.

[01:36] And a disclaimer: 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 individual expressing them only, not those of the American Medical Association. 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 informational purposes only.

[02:05] Now I'm pleased to introduce you to today's panel of speakers for this webinar. Dr David Acosta is chief diversity and inclusion officer for the Association of American Medical Colleges. Joaquin Baca is director of equity, diversity and belonging and medical education for the AMA.

[02:26] Dr Diana Huang is the assistant general counsel in the Office of Health Law at the AMA. Dr William McDade is chief diversity, equity and inclusion officer for the Accreditation Council for Graduate Medical Education. Dr Shadi A. Shakeri, professor in the Department of Radiology and chair of the admissions committee at UC Davis School of Medicine. And Jeannette South-Paul. Dr South-Paul is the executive vice president and provost at Meharry Medical College. We will begin this webinar with an introduction and then we'll proceed to engage the panelists.

[03:09] As we're all aware, on June 29, the Supreme Court gutted the use of affirmative action and admissions policies. Affirmative action as a policy was enacted, not so much to address historical effects of racial and gender-based discrimination, but to serve as a counterweight to ongoing discrimination and unequal treatment. In 1961, President John F. Kennedy issued Executive Order 10924 [sic], in which he injected the phrase "affirmative action" into the social lexicon.

[03:37] He was responding to existing employment practices that favored whites and disadvantaged or excluded others. He was making an effort to address contemporary inequitable practices and policies, which of course have deep historic roots. So the argument that affirmative action policies were in place to serve as a remedy to past discrimination is misleading. These policies have been in place to address current structural and systemic discrimination and unequal treatment.

[04:03] The debate over affirmative action shines a light on the truth of the famous quote by William Faulkner from Requiem for a Nun: "The past is never dead. It's not even past." We live in a country with a history of 250 years of slavery, followed by almost 100 years of Jim Crow policies. We now find ourselves 55 years after the end of the Civil Rights Movement. How do we take stock of the historic role of affirmative action?

[04:30] In considering this, it is important to remember that discrimination disadvantages certain populations, and benefits others. If we look back, we find a long and persistent history of policies, laws and practices that that directly and intentionally benefited white communities and purposely excluded others. This began well before the actual founding of our country. As an example, in 1618, we have the Headright System in Virginia, which was part of the great Charter of Privileges. This gave 50 acres of land to any white immigrant set settling in Virginia—50 acres per head.

[05:06] We of course, know what happened one year later in 1619, which marks the arrival of the first African slaves in the slave town colony. So free land just for showing up for some, and enslavement for others. The differential being the color of one's skin.

[05:22] If we move on beyond the founding of our country, to the Naturalization Act of 1790. This Act granted citizenship to any alien, who was a free white person of good moral character, meaning a Christian—preferably a Protestant and not a Catholic. In 1830, President Andrew Jackson... push the passage of the Indian Removal Act that led to the seizure of lands from the Choctaw, Chickasaw, Creek, Seminole, and Cherokee tribes, and ultimately led to the Trail of Tears in winter of 1838.

[05:59] The Mexican-American War in 1846 was an illegal war that seized land from Mexico that became the states of California, Texas, New Mexico, Utah, Arizona, Nevada, and parts of Colorado, and Wyoming. The Dred Scott case in 1857: SCOTUS ruled that the Constitution did not allow a Black person to become a citizen of the United States, and therefore they were not entitled to the privileges of citizenship according to whites.

[06:30] In 1862, Congress passed the Homestead Act which gave 160 acres of land to whites who became owners if they lived on it, and farmed it for five years. A total of 446 million acres—about a 10th of the landmass of the country at the time—were allocated to 1.5 million white families, compared to only 4000 to 5000 Black families. In a study from the year 2000, there were 46 million Americans still alive who could trace their history of land ownership and economic advantage to the Homestead Act.

[07:03] In 1865, General Sherman develop a plan to distribute 400 000 acres of land and 40 acre parcels to freed slaves. President Andrew Johnson rescinded that order later that same year, and the land was returned to its previous slave owners. If we move forward to the 1930s, the benefits of the New Deal created to assist struggling and impoverished citizens were not equally distributed among white and African American populations. This was particularly true in the South due to the pervasive influence in Jim Crow.

[07:38] In the 1930s, also, we see the start of real estate practices, which were government-sponsored, that have that we've come to know as "redlining" which thwarted the interest of African Americans in the development of wealth through property ownership, while at the same time financially supporting the same aspirations in white communities. And in 1944, we have the GI Bill, which offered unprecedented opportunities for education and housing to return white GIs, but systematically excluded Black veterans from these benefits.

[08:10] If we imagined a scale, perhaps so much of the one that Lady Liberty holds, and we place a cumulative mass of government sponsored and supported policies and practices that favorite and privileged white communities, which I will refer here to as "historic white affirmative action," we place those on one side. And on the other side of the scale, we can place modern affirmative action policies intended to provide some benefit to communities of color. Although it should be noted that even in this characterization, the major beneficiaries of modern affirmative action policies have been white women. That notwithstanding, the scale would clearly be grossly out of balance.

[08:49] Yet our Supreme Court has essentially accepted the same assertion of privilege posed by Alan Baki in 1978, that admissions policies that provide support for nonwhite applicants are manifestations of reverse discrimination. Our mission, our real reason for existing in medical education is to produce a workforce capable of meeting the health care needs of our increasingly diverse society. Data on health inequity indicates clearly that the workforce as currently and historically constituted, is not meeting that goal. The question before us today is: how do we continue to pursue our mission in the absence of affirmative action policies? So that said, I will turn to Joaquin Baca and, and ask him to provide a perspective on the recent decision in the context of pivotal prior decisions.

Juaquin Baca, MPH: [09:56] Thank you, Dr Henderson. A couple of things that I might start on just to build on the executive order of President Kennedy that Dr Henderson mentioned: That established, in many ways, affirmative action... But its original intent was not just about non-discrimination, it was also about anti-subordination.

[10:23] I think those two factors... What one of the key things that was removed early on in affirmative action were... the anti-subordination clauses of that executive order. There were certain key decisions in the... two Grutter cases there. Also, as as things move towards Fisher, other things were also removed in terms of the strength of the original and framework for affirmative action.

[11:08] I think it moved is shifted from that stance, which I think in terms of the 14th Amendment, which is now being used in a different way than I think originally intended. The equal protection was, I think, originally intended to represent equitable protection, not just equal protection for everyone, but really understanding that certain people had been not regarded in the original writing of the Constitution and this was to make up for it. And that was the case: many people did not experience full citizenship for many years and there had been many barriers that were put in place to keep people from passing through the systems and structures that were created, as Dr Henderson mentioned, forcibly keep certain people out.

[12:04] I think that that's the biggest thing that we could really point out in this is that the non-discrimination framework places the burden of proof on the victims of discrimination, not on the institutions, who may be promulgating the systems and structures that promote discrimination. Generally speaking, institutions only have to do a minimal amount to demonstrate that they are trying to prevent that discrimination, and that their burden of proof is much greater on the person experiencing discrimination. That being said, those decisions moving forward, really set that framework in place in a much stronger way, and thereby removed the strongest aspects of what the original intent of the affirmative action framework was intended to do.

[13:05] I also feel like much of what was described in Dr Henderson's description was was that in medicine, in particular, the Flexner Report, 1910, also had a great deal of influence on who was the archetype or the type of person that we are looking for to become a physician, and who represented medicine in the way that would elevate the field to a place represented respect and trust.

[13:39] And I feel like in that, while it was eliminating a lot of people who were taking advantage of, of the name the term doctor, it also set up a situation where we, again, gave favor towards certain groups of people, and it made sure that others were not represented the closing of most of the Black medical schools, and all of the women medical schools really demonstrated who we felt looked and should represent field of medicine in a particular way. I think that in conjunction with a lot of the other rules and things that had been put in place, created the position where we needed affirmative action to start to erect some of those systems and structures that had been created to be exclusive and try to keep certain people out of the field.

[14:44] I think that's the other part that I think is really important in some of these conversations. I do feel like this decision that currently came out and I'm sure others will be able to comment on this more detail but this current ruling allows for greater opportunities in recruitment, maybe not the same ways that we have been doing things in admissions processes and the holistic review and having racial consideration there, but it does allow for more opportunities in recruitment. And I feel like that's still a strong place to that our organizations institutions can start to build a sense of who we want in the field of medicine and what... a doctor should look like. That doesn't necessarily need to be based on the color of our skin or racial factors, ethnic factors, it can also represent our values and beliefs and... as an example, I think, what sort of leader do we expect a physician to be? And I think one of the questions that is asked, and almost every medical school interview is "Why do you want to be a doctor?" and there are certain responses that we look that are that that the admissions officers look for, in the way that the applicant phrases it. I think that that includes, in one way, as an example, like the type of leader that they see they will be, and that there are different leadership styles and leadership approaches that I think can be really important in gauging who we want to see in those positions.

[16:41] If we are looking for position leader who is very hierarchical and leads in the business fashion, then we're going to get a certain kind of physician out of that. And if we're looking for a servant leader, who will lead based on the needs of the patient and the needs of a population, then you might get a completely different looking physician. So I think those may be directions that we might consider in moving forward, especially given the direction of this decision. And in many ways, affirmative action had already lost most of its power, once we moved away from the anti-subordination efforts. This might give us an opportunity to pivot towards something that might actually achieve something much greater in terms of addressing some of the structural and systemic barriers that have been put in place. Thank you so much.

Henderson: [17:42] Thank you very much. Dr Huang, can you provide a legal perspective for us and help us understand what the likely impact on higher education in the US... most likely to be going forward?

Diana Huang, PhD: [18:03] Sure, so predictions are always hard but I think we can make two general educated guesses, which i, number one, I think Juaquin alluded to this a little bit, is that universities are going to have to figure out how to legally comply with the majority opinion and students for fair admission, while furthering their own interests and diversity of their student populations. The majority opinions spent most of its time saying how race-conscious programs are discriminatory, and they're now illegal. But at the end of the opinion, there's a paragraph that says, "Well, you can consider how an applicant discusses race, and how it's affected their lives." But the paragraph also says explicitly that you can't do indirectly what we told you, you couldn't do directly. So they're saying you don't use this language as a loophole in your admissions processes.

[18:58] But I think what universities might do is create more opportunities to elicit discussions and considerations of race, so that might mean more essays or more interviews. And it certainly, I think, will turn into more admissions offices expanding—more time, more people, more money, so I think the burden falls on two groups, mainly, which is first and foremost, the student to bring up how race has affected their lives—and that's only if they want to. Then the burden also falls on universities to come up with creative ways to elicit that sort of context.

[19:35] The second thing we can guess about is that there's going to be more litigation on a number of levels. When the court upends the status quo, there's going to be change and with that change comes a lot of litigation. For example, in the past week, we've already seen legal action taken against legacy admissions policies. Lawyers for civil rights filed complaints in the Department of Education against Harvard challenging Harvard's policy of giving preferential treatment to applicants with family ties to donors and alumni. And they say that well, that policy is also discriminatory. So things like that will happen.

[20:12] Then we've also we will also see more efforts to block diversity and inclusion in higher education. For example, out of Wisconsin, the Republican Speaker of the State Assembly recently suggested that he would move to ban scholarships designated for minority undergraduate students, because those grants amounted to discrimination. If that happens, there will certainly be litigation to follow.

[20:35] I talked earlier about potential creative tools for colleges to use to consider race, and depending on what those tools look like, I think those tools will come under litigation fire as well. There might also be litigation in elite high schools that feed into elite colleges. For example, we recently saw the Fourth Circuit, affirm Thomas Jefferson High School's admissions policies in Virginia. Thomas Jefferson is widely touted as one of the best high schools in the nation, it recently changed its policy to give some preferential treatment to economically disadvantaged students, and students still learning English, and that policy was challenged. And the Fourth Circuit said, the policy is race neutral, and it's fine. So, basically, there will be a lot more unrest in this space and that is what usually happens when the Supreme Court upends the status quo. Dr Henderson, back to you.

Henderson: [21:30] Thank you. So if I understand you correctly, it seems that the the major point of contention going forward will be in race conscious policies, and that perhaps other policies that are constructed differently, may pass muster, for lack of a better way to put it.

Huang: [21:53] I think that's right. And I think it again, the onus is going to be on the universities to come up with creative policies in their efforts to further diversity in their populations, and some may pass muster, and some that are maybe not... that don't on their face discuss race, maybe those will pass muster. But I think, again, litigation will follow. And we will see, in time, how that plays out.

Henderson: [22:21] Thank you, it's really very interesting, because I think this puts a lot of pressure on students as well, to share their backgrounds. And I know, by personal experience, being a student from a low-income background, that for many, many, many years, I was very reluctant to be particularly open about my background with people whom I didn't know and trust. And for legitimate reasons, I think, at the time, but I think that may be a fairly sort of high hurdle for many students to negotiate.

[23:10] Absolutely, I think the burden falls first and foremost on the student. And, as you said, not all students—maybe not even many students—want to discuss openly how race is affected their lives. And the majority opinion also said, "Well, the student can't just discuss race, they've got to discuss race, and how it's affected their qualities as a person, how maybe they're better leaders, how maybe they're more courageous. And again, that has a lot to put on a student applicant, who may not has experienced a lot and may not wants to may not want to discuss all of it. And I think that can lead to, of course, race being discussed less and less amongst the applicants because they just don't want to. So it's certainly an issue.

[23:55] Dr Acosta, can you help us understand the impact that the absence of affirmative action policies has had on medical school diversity and states where it's already been prohibited? And what do you think the impact of this decision is likely to be on medical school enrollment overall?

David Acosta, MD: [24:14] First, I want to start by saying thank you, David, for including me in this panel and love to be with all my esteemed colleagues once again, as well. So thank you for allowing me to be here today, as well. ...Just to connect with some of our listeners as well, I also want to say that my pronouns are he and him, and I'm the first generation Latino, and also looked at the impact that... anti-affirmative action law had on me when I applied to medical school as well, which is very, still very real in my heart.

[24:48] So again, to answer the question, David, you know, anti-affirmative action laws have had a significant effect on medical school diversity. But I also need to say that in all of our health professions that it has [impacted]— from public health to pharmacy to nursing. It's not just limited to medicine itself, but especially among our African American Blacks, Hispanic, Latinx, and our American Indian and Alaskan Native students as we have learned from the past. Again, as the adage goes, history has a tendency to repeat itself. And so as a reminder to our listeners, you know, anti-affirmative action laws, and even the SCOTUS decision is not new. It's been around for many, many years. And these have already been active in place in nine states.

[25:31] Remember, did start out in California back in 1996, was one of the first anti-affirmative action laws against the state, followed by Washington and Florida in... several years right after that follow from 2006 on: Michigan, Nebraska, Arizona, Oklahoma, New Hampshire and Idaho also joined forces in being one of those nine states. So the recent SCOTUS division will probably have very limited impact on those public institutions that have already been existing and have already dealt with this and have already developed those strategies.

[26:05] Again, I think it's really important for the sidebars that listeners need to understand: We need to learn from others that have been through this and have had decades of work in really strategizing and moving this forward. And especially with the implication of holistic review as one strategy and moving that forward. So we can't give up the total ghost for that.

[26:23] But private institutions, and these particular states without a doubt will be more heavily impacted, as they may have not been in the past. So as stated in our the AAMC amicus brief, you know, longitudinal studies, we do have those that cite that medical schools that were impacted by affirmative action law experience a significant decrease in their enrollment of URiM students, especially when you compare them to institutions without such bans, and that really vary from school to school, whether public or private, and also from state to state.

[26:55] More importantly, for some, it really took not just a couple of years, but it took decades to recover from that that loss of enrollment. So just one example in California: the number of African American Black and Hispanic Latinx students enrolled in the University of California undergraduate and medical schools plummeted dramatically in just one year after Proposition 209. For example, the Black and Latino next undergraduate enrollment at UC Berkeley, and UCLA declined by 30 to 40%. So that means that that particular pathway also shrunk pre-health students that were interested in medical students.

[27:32] As a result, we looked at Black students in California medical schools, they hit an all time low right after Prop 209 was passed—that fall being only 5%. Then, after a couple of decades, though, certainly inclined to 11% in 2019, and as Dr Shakeri will probably allude to in her presentation today, is that it's much markedly improved over those years as well. Hispanic Latino students also sank from 15%, immediately after Prop 209 was passed to less than 10%. That again, after a couple of decades, were due to ultimately 17%.

[28:08] There's a recent quote from Katherine Meyer, who's a fellow from the Brown Center on Educational Policy at the Brookings Institute. That said, as a reminder, "The Supreme Court didn't ban affirmative action, they have to ban race based affirmative action and race conscious admissions." And I only say that as introduction to my last point, and that is from an institutional aspect. I'm more concerned about what policies will be impacted and changed abruptly due to the interpretation of the decision.

[28:39] What I mean by this is over restricting their admissions policies due to either misinterpretation or over-interpretation of the decision. For example, just in my own experience in Washington state, Initiative 200 was not really understood by many who are making enrollment decisions. That means including our admissions officers, and deans, and the law is being misinterpreted and over interpreted as well, and extended to other things that the law really didn't address. So the point being here, as I think that's really important, is that it is really critical that our institutions really understand and follow what the SCOTUS decision really states, but even more importantly, what it doesn't state as well, because they have given us some leeway in that sense.

[29:25] From a student aspect, and I'll end with this thought, is that I think we're all concerned what the decision has already symbolized and meant to our students. We're already getting a lot of sentiments to us at the AAMC—in particular from students that are African American Black, Hispanic, Latinx and American Indian—sentiments, such as, do us medical schools actually want them? Another sentiment: does society believe that their presence and then becoming doctors and scientists is important? And lastly, the last sentiment that i remember is that if they happen to get enrolled, will they actually feel that they really belong?

[30:05] So from every crisis, I think does come opportunities, and as we move into strategies in today's webinar, I'd love to share my own personal experiences that I hope can bring some positive impact of when I was at the University of Washington and what we did in order to become innovative, and really creative, and the strategies and all the aspects through the process of not only just selection, but also once the students are there, what did we do and put into place also to help them thrive and not just survive? So with that, David, I'll give it back to you. Thank you.

Henderson: [30:38] Thank you very much. I think your focus on the experience of students is actually really very important. And it's not just a matter of, of getting across the threshold, it's really important to be in an environment where one can succeed, and one doesn't feel that you're just sort of constantly running uphill on a treadmill. And that, I think, is unfortunately often the experience of a lot of underrepresented students in environments that are particularly supportive or inclusive. So thank you.

[31:23] Going from what you have just shared with us, I'd like to ask Dr Shakeri to talk a little bit about what has been achieved at UC Davis—and, David, that may give you an opportunity to chime in about your experience in Washington as well. But, Dr Shakeri, what strategies are potentially available to medical schools, based on your experience at UC Davis, to continue to promote diversity in medical education, despite rulings against affirmative action or race conscious admissions.

Shadi A. Shakeri, MD: [32:01] First of all, thank you so much for the opportunity to be a part of this discussion and share the UC Davis experience in the admissions committee with you. We have had to develop a multi-pronged approach since the ban of affirmative action in our state, some 20-plus years ago and a foundational element, really, of our recruitment strategies has been the development of our admissions mission.

[32:31] We had to ask ourselves, who are we? What are our goals? And what are we trying to do for our patients and our communities? And our admissions mission is really to matriculate a class of students who, as physicians, are going to address the diverse health care workforce needs of our communities, our region, and our state. And that means that in providing a physician workforce, we have had to pay attention to what the health care needs of California are. I think it's well known that there's a great need for primary care physicians across our state. There are data showing that in many regions of California, the recommended supply of subspecialists actually outpaces the recommended supply of primary care physicians, and there's data showing that more primary care doctors in regions can actually improve life expectancy.

[33:29] As you know, California's population is very diverse. The people of California come from varied cultures and backgrounds, speak different languages, and are from across a socioeconomic spectrum. There's also emerging data that the esteemed panelists here are well aware of that when doctors and patients share backgrounds, or have linguistic concordance, or have race concordance, that health care outcomes are improved.

[34:00] And then there's the distribution of California's populations, which also affects the workforce needs. We have great needs in inner cities and we have great vast regions in California that are rural areas. And we know that where you grow up can affect where you end up settling down as a physician and where you end up working. So in aspiring to change the future workforce to meet these workforce needs, one of the critical elements for us has been the development of pathways or tracks within our medical school. And each of these has a specialized curriculum to give students meaningful experiences within the... underserved communities to which they are connected.

[34:51] This really does go back to Dr Acosta's comments about the students and their lives and their investments and our investment in them in terms of how they are able to connect with these communities, and how they would best serve them. So at UC Davis, we have seven separate tracks each focused on workforce needs, and about a third of our class enrolls in one of these tracks and the students that enroll in these programs come from all walks of life. They bring their lived experiences and their varied backgrounds. In addition to that, we have nonprofit and student-run efforts to achieve the scholarly pathway programs, and strong partnerships with GME programs at Kaiser, at community health clinics, at federally qualified health centers, to meet the needs of our underserved patient populations.

[35:53] One of our newest tracks, which is near and dear to my heart, is the community college to medical school tract—we call it Avenue M—and this was really born out of the knowledge in our discussions that students who complete residencies in family medicine, which is a critical workforce need, are more likely to have gone to community college, which traditionally, is considered a negative in admissions committees. This is near and dear to my heart, because as a first generation immigrant, I went to community college and growing up in a family with financial hardship, I had to have multiple jobs, my parents had to have multiple jobs. And a track like this at the time I was applying to medical school really might have made a difference in my pathway.

[36:44] So in parts of the different arms of our recruitment strategies, in addition to having a defined mission to serve our communities, the holistic review of the applications has been critical, of course, and that means going beyond the basic metrics of looking at just GPA and MCAT evaluations, we do look at every part of the application, the essays, the questions, everything that the applicant gives us, we are looking for the attributes, and the experiences, which we consider really makes a good doctor, we're looking for people who demonstrate that they've overcome adversity, who have had life experiences, who that has given them grit and resilience.

[37:34] So in addition to that, part of the process of our interviews in the past decade, really, that's been important has been switching from the traditional interview to the multiple mini-interviews where the applicants really interact with a diverse group of interviewers. And we find that this process tends to limit or decrease bias. Other important factors have been the development of inclusive policies and practices, we require implicit bias mitigation training, and a portion of this really is critical to have the support of the entire institution—support from leadership on down. And I can't emphasize how important it is to have the stakeholders participating in the admissions process, have buy in into your whole process from beginning to end, and to really truly be invested in the mission of what we are doing.

[38:48] Lastly, and I think a very important piece, is having built an ecosystem—as our assistant admissions dean calls it—we have an ecosystem of outreach programs so that we can increase the pool of future health care providers that we need. We partner with many different pathways and outreach programs that are supported by undergraduate higher education systems, both the University of California system as well as the California State Universities.

[39:23] And all of that put together—going back to comments that were made earlier—really has taken a great deal of effort. It of course, has not been an overnight process. It has taken years and even over a decade of input from large groups of people who participate in this massive admissions process. And when we look back at our data, as is I think now well known, we have... through this process we have been able in a look back to see that we have been able to increase our matriculants of historically Underrepresented in Medicine, having started at about 10% or so to having a class with over 50% of students who come from disadvantaged or Underrepresented in Medicine backgrounds. Even though this is not what we do in a prospective way, when you look back, everything put together from our admissions process has yielded these types of results.

[40:38] To recap, I would emphasize that the importance of the admissions committee members and volunteers, stakeholders, really has helped us achieve our missions and goals. And this also needs buy in from the communities with significant workforce needs and it has worked to have innovative holistic review processes Incorporated, in addition to understanding the prehealth programs that undergraduate medical education and GME have to work together across the continuum to develop a workforce to meet the needs of our patients and our communities.

Henderson: [41:23] Dr Shakeri, thank you very much. I actually really liked the use of the word ecosystem by your assistant dean, because I think that is a very apt description of the sort of net that you've created, from outreach programs in the community to pathways programs that sort of that merge into tracks within the school, to provide support for students, and the sort of mission-driven foundation that that you seem to operate from. I think those are all sort of excellent examples in and of themselves, but when combined, together, I imagine that there is a good deal of synergy that occurs, and congratulations on your success. It's really remarkable.

Shakeri: [42:26] Thank you. It's been a huge team effort, as you can imagine.

Henderson: [42:31] Thank you. Indeed. Dr McDade, if I may ask you: How might this recent SCOTUS decision impact the diversity of physician workforce and in turn, health equity of the populations we all serve?

William McDade, MD, PhD: [42:52] Well, thank you, Dr Henderson. It's a great pleasure to be with you and the colleagues your views assembled here for this excellent presentation. I think we have to keep in mind the endpoint for what we do in medicine in particular. And one of the elements that the Supreme Court has actually looked to in the past to say what what's in the compelling interest of the country is the avoiding imminent and serious risks to human safety. I think that health disparities—racial and ethnic health disparities in particular—represent an imminent threat to and serious risk to human safety. And to me that is a compelling interest why medicine should be somehow different.

[43:39] The fact is that this applies to undergraduate admissions, it will be naturally moved into medical school admissions and what we're concerned about, as Dr Shakeri just mentioned, the idea that people will change practices at the level of graduate admissions as well. As you know, everyone who trains in the United States has to train in an ACGME accredited program, and ACGME has really made it a point of the last several years now to emphasize the importance of diversity within the training environment. And this improves both the care to patients and the workforce.

[44:17] If we look at the workforce that studies that have been done, if you are an African American physician, the likelihood of you seeing African American patients about 23 to 24 times that of a white physician seeing an African American patient. If you ask a first-year medical student what's the likelihood of serving the underserved, by race it differs such that 62-63% of African American first year students say this is what they want to do when they finish. Contrast that to white and Asian students who are in the 20 percentiles in saying that they want to serve an underserved population.

[44:52] So if you want to maintain the mission of elimination of health disparities, creating a workforce that's more prone to do that is something that I think we still have to value, and ACGME has not moved away from that mission in graduate medical education, to say that it is still important that we maintain diversity within our classes. The question, of course, is how to do it, and I think that the decision the Supreme Court had last week is going to impact the lives of those patients that we ultimately sought to try to improve their health care.

[45:25] And that is because when you had the affirmative action—anti affirmative action work done in the 1990s, Proposition 209, and you looked at the number of in-state minoritized residents or applicants who applied, you saw those numbers dropped, as was discussed before. That plays out such that four years from now, when they apply to medical school, there'll be a diminished class for that, that plays out in graduate medical education such that 4 years from then there'll be a diminished group of residents from whom to choose. So it's almost a double hit to medicine. That is that there'll be fewer people to apply, and their stiffer barriers exist to to have them be accepted.

[46:07] And so this ultimately means we're going to reduce that workforce that disproportionately says that it will take care of disadvantaged minoritized groups of people and populations, we'll have fewer researchers who will study problems that primarily impact the diverse communities that they serve, and we will have fewer mentors to help shepherd those individuals through medical school, through college, even to get to the point where they can be selected for graduate medical education.

[46:37] If you think about the dismantling of offices of diversity, equity inclusion that are not related to the Supreme Court decision, but are related to some governmental actions that have taken place, both in the legislature the executive level and at the offices that minoritized individuals who come into an environment that is difficult to manage. And so one of the things I think we have to keep in mind is that when we're changing programs and processes, that we don't do it prematurely, as was said before, that we only do what's necessary. To point out the some of the subtleties in the Supreme Court decision impacting the physician workforce: hiring is a Title VII process within with protections with respect to the Civil Rights Act of 1964.

[47:35] The Supreme Court spoke only to Title VI, which is an admissions process, and I would argue that the hiring process of residents and selection—with the NRMP match and all the rest of that—being a one-to-one admissions process, as in undergraduate medical education and college admissions differs, and the Supreme Court was silent on that particular process. So my hope is that we can continue to produce the physicians from the people who are in training now, that we put lots of emphasis on increasing the pathway as Dr Kerry talked about, and we now have an avenue to involve graduate medical education in that process to through our requirements, and my hope is that we will continue working to try to advance the numbers of people who are available to be selected the residency process that has yet been unchanged. Thanks Dr Henderson.

Henderson: [48:29] Dr McDade, actually, thank you very much for making the distinction that you made. Number 1: the distinction between graduate medical education and undergraduate medical education, and then sort of linking that to employment. Because that, I think, was one of the sort of big concerns that that people voiced before the decision. Namely, what impact it would likely have on unemployment and the overall workforce and diversity efforts within work environments across all sectors.

[49:16] I suspect that that there might be challenges going forward. But again, as you point out, if we can continue to do what we have been doing, then that is likely a reasonable course of action until such time that we do need to pivot and I think the importance of maintaining the stream of students moving through undergraduate institutions, medical school, and the GME so that that flow of individuals doesn't disappear and you don't end up with a large valley, where diversity is significantly diminished, which then reflects itself in in the GME population.

McDade: [50:12] Precisely. I think as long as we stay mission driven in the work that we do to increase our classes, and I'm sure that Dr South-Paul will mention that this is really the approach that the historically Black colleges and universities with medical schools have done. I don't want to steal your thunder, Dr South-Paul.

Henderson: [50:38] Dr McDade, thank you very much. Dr South-Paul, I think Dr McDade sets you up pretty well. Following the Flexner Report, then the number of Black medical schools plummeted, but I HBCUs have survived and have made a considerable contribution to diversifying the health care workforce and I'd just like for you to share some of the lessons that HBCUs have learned over the years that have helped them thrive and become such an important part of the medical education landscape.

Jeanette E. South-Paul, MD: [51:24] So much, Dr Henderson. Thanks, Dr McDade, you did set me up pretty well. I appreciate that. And I appreciate the opportunity to discuss this today. You know, historic medical schools were initially created to address the needs of slaves and freeborn Blacks brought to the US against their will or otherwise in the US, and who had no access to care from white physicians or hospitals.

[51:46] This, I know, is personal to me as someone who was born in a white physician's supportive GP's doctor's office in Hale County, Alabama to immigrant parents, because a Black woman could not be delivered in a hospital south of Birmingham in the late 50s. So this is the whole idea of why we need those who are willing to do this work is so important. The result of an assessment of the nation's medical schools that was released as the Flexner Report has been mentioned before—a report, by the way, that was seriously flawed in methodology and rife with bias—with the closing of 75% of the nation's medical schools and all but two of the 13 historically Black medical colleges in seven states, from Louisiana to Pennsylvania. The only two to survive were Meharry Medical College at Howard University College of Medicine.

[52:36] In the last century, Meharry and Howard have trained most of the nation's Black doctors. For a while, up to 40% of those who had been in practice had been graduates of one of those two institutions. And then Morehouse School of Medicine and Charles Drew University of Medicine and Science were created in the latter half of the 20th century, and has since contributed substantially to the number of minority physicians entering the physician workforce. The four historically Black medical colleges—soon to be joined by a few others that are in the planning—have been faithful throughout their existences to address crises disproportionately affecting medically underserved populations, both Black and other groups, as evidenced by the tremendous work they have spearheaded in their individual communities during the COVID pandemic.

[53:23] It's now well recognized, as has been alluded to before, that there are benefits to having a broad group of clinicians and scientists to solve the most pressing human problems, to enhance critical thinking, to foster innovation, to promote effective communication with all our patients, and to increase access to care for our increasingly diverse population.

[53:41] Now, my friend and colleague, Dr Costa has talked about the amazing work that the Association of American Medical Colleges have done. They've been monitoring physician workforce for decades, and predict a substantial shortage of between 40 000 and 124 000 positions by 2034, which is really not too far away. Yet this projected shortage doesn't account for or predict the appropriate distribution of this increase in physicians who address the needs of our increasingly vulnerable population of patients with their varying needs and accounting for existing health disparities.

[54:16] There's an estimated 35 000 Black medical graduates who might have been available by 2019 to increase this workforce had... many of these historically Black Medical School State State open, work done by my friend and colleague Dr Kendall Campbell and his group. Today, there are fewer Black men entering medical schools than entered in 1978. So this is an issue that is also contributing to a very thin pipeline. And although the Black and Hispanic representation of the US are more than 30% of the total population, their representation of practicing physicians is less than 11%. As Dr Shikari noted, the research is clear that persons value receiving care from racially concordant physicians: they're more likely to feel heard and are better able to participate in decision making—work that Lisa Cooper did at Hopkins more than 20 years ago.

[55:11] Such positive doctor-patient encounters result in improved chronic disease management, adherence to recommended care, and ultimately contributes to improve access to care for the most medically underserved. Therefore, continuing to support the education and training of physicians who represent and deliver culturally appropriate care benefits the health of our communities, and therefore, everyone.

[55:35] So how do academic health centers approach this current SCOTUS decision? Well, as has been long mentioned, no one can say with a level of precision regarding what is permissible, and there are going to be subsequent legal actions that are going to test the parameters. So we must consider not being too restrictive, or rather, try to be as inclusive as possible. I would draw attention to the fact that the court's decision also excluded the military academies, in deference to a national security concern: that is the need to build teams that work effectively together and represent the broad representation of citizens who served, raising the issue of compelling national interests.

[56:17] As an Army retiree and someone with that sons who are active duty, this means a lot to me because you recognize that so many of the critical infrastructures and roles in our country are a result of teamwork. And therefore, we as medical schools and academic health centers, play a critical role in developing the teams that are necessary to address the mental and physical well-being of our communities. And these are the same communities where the majority of eligible military recruits emerge. And we already have fewer African American males in the pipeline, fewer Latino males in the pipeline, so reducing the numbers who are healthy enough to be in school for the military academies is an important issue.

[57:03] But not just those academies, but our institutions—our nonmilitary institutions—who are there. We need to keep this healthy pipeline and populate this pipeline for medical careers as a substantial addressing of national security. But also, because this is how we represent the current young people of our nation.

[57:25] What's the best way forward? I think it requires a number of concurrent steps, as have been mentioned. We have to remain focused on our historic mission, and that's what historically Black medical schools do: recognizing that we're serving communities that traditionally got very little attention or no attention at all. And even currently—we're not just talking historically, currently—are often ignored or underserved by virtue of their ability to pay or to pay at the going rate or to have commercial insurance.

[57:58] We need to codify the holistic review that's been referred to as a process that's been embraced by the majority of medical schools, including our historically Black medical schools, so that it's clearly described, and people understand what that means. We recognize that no medical schools admit a student on only one criteria, nobody, but evaluate a broad set of criteria that incorporate academic achievement, leadership experience, personal goals, life experiences, and letters of recommendation.

[58:28] We need to again, as was mentioned before, consider assessing and accounting for overcoming adversity. That is using an adversity tool or a metric—introduced several years ago by institutions already operating in an environment where an affirmative action model was restricted or prohibited, embraced by schools in Texas. I, personally, got an opportunity to learn from that. When UTMB... when Billy Ballard— of Meharry, by the way—was the senior vice chancellor in the late 90s and at schools within the California system, as as previously discussed.

[59:00] Those of us who have been in this environment trying to increase representation and take care of the communities that have been ignored, have looked at this and worked in many areas for years. We need to engage more community members in the admissions process to facilitate medical schools being responsive to changing community needs. Such as recruiting a workforce for workforce to address maternal and child health issues, substance abuse, behavioral and mental illness, and environmental urgencies, all of which disproportionately affect the most vulnerable populations. The populations that HBCU medical schools have served and the populations which all of us around the table today and those of our colleagues want to prioritize.

[59:45] We need to nurture and support the pipeline of candidates applying to medical schools from less traditional environments, and you've heard this. For those of us who grew up in low socioeconomic environments or immigrant communities, for those who started at community colleges as Dr Shakeri mentioned, for those of us who grew up in urban or rural health professional shortage areas, for veterans population that more closely represents the overall US population, and often starts their education process at a slower rate, doing a few sessions, a few courses at a time, while built while working full time. This approach will allow schools of the health sciences to include historically Black and Hispanic serving institutions to continue to recruit those who best meet the health care needs, that have anchored us historically, and which continue to remain urgent concerns.

Henderson: [1:00:41] You can go ahead and continue if you'd like.

South-Paul: [1:00:46] You can see that I have no emotional involvement and engagement of the subject, right? It's just that for those of us who have lived this and have worked in this area for so long, we recognize that if you have not had this exposure, these life experiences, it is not as much as up close and personal. But each of us who have spoken today, have really emphasized our life experiences and how it's shaped our goals as professionals. It's important work.

Henderson: [1:01:15] Thank you. And thank you for sharing the sort of personal insight that you mentioned, the sort of high point of matriculation for Black men in 1978. Because I think the sort of figure in my head is that there were 542 matriculants in 1978 that were Black men, and by 2015, that had fallen to 515. And it's sort of personally significant for me, because I started medical school in 1978 and it's depressing to know that that has occurred during my time in this field and I really appreciate your emphasis on sort of mission-driven approaches, which we have also heard from others. And I think if we all make combatting health inequities, sort of chief among the missions we pursue, that will hopefully give us the room we need to continue to recruit, and matriculate the students that will be necessary to become future physicians to address these issues and move us toward health equity as we move forward. But thank you all very, very much. Does anyone want to have anything they would like to add before we, before we close? Mr Baca, Juaquin, please.

Baca: [1:03:06] Just very quickly, I think one of the things that I would want to emphasize in everything I've heard today is that there is a tendency to treat "different" as "less than," and I think deficit-based models are used are common in a lot of these approaches versus ones that look at asset based approaches and making sure that we appreciate people for who they are and what they bring to the table just like we've been bringing up at the end, especially personal experiences, and the way people... what people bring that maybe... not just added value, but that we are changing the values of what medicine expects, because I think that that's the piece that that is fundamental to this is that we've always accepted the archetype of what Flexner created as the best and we don't recognize that people who have become minoritized in this process are not less-than they are they should be more-than. As an example, adversity scores tend to—in my perspective—just the framing of it, tends to put people in that category of "less than," and because we're counting the things that might people might attribute to their weaknesses... even though we're trying to treat it as an asset in that case, that we still are looking at what most people will consider... just like you were saying, too, you didn't want to bring up your background because there was a fear of how you might be perceived, and I think that fear comes from the larger culture of... what is considered "better than" and I think that's the other part that we have an opportunity to transform.

Henderson: [1:05:01] Thank you very much for that. Thank you. Dr Acosta, David, please.

Acosta: [1:05:06] Here's one thing that we haven't talked about, David, that we need to pay attention to: I think Chief Justice Roberts gave us a little bit of a nugget that we may have to concentrate on, and that is metrics. Metrics are very important, because in his opinion, he had stated pretty strongly that he felt that the Harvard and UNC cases did not present very clear goals of why they want due deference to race-conscious admissions, but also they didn't have any metrics that they were convinced that they could actually use to measure what those goals were about.

[1:05:40] I think—more than anything else, I think—what are some of the things that we can do, despite all the stuff that we have mentioned today, which are good example, and Dr Shakeri had talked about it as well, is that we really got to think about: How can we—how can an AMA, how can ACGME, how can AAMC and other organizations—how can we help our members?

[1:06:03] In the sense of developing solid, evidence-based outcomes that validate the processes, the policies, all the activities that we have in place to support our URAMs, as well, that are pretty crystal clear, that show that benefit. For an example: where do our people go? Where do they practice? What type of leaders do they end up becoming. We don't have a solid repository that we can actually hit on, go to, and say, "Because of our admissions, because of our mission, and because of what we've done in admissions policies, this is where our graduates go. These are the communities that we take care of." Proving the fact that that's why this is so important. This is the work that they got involved with: resolving, and eliminating health care disparities, regardless of what profession they're in.

[1:06:49] But I think those are the evidence based outcomes that we need to begin to show and be very clear about, very, very transparent. It's not the only solution, but it's something that tends to be missing. It's not just about the demographics and the numbers that we produce. It's really about the outcomes, about where do they go, because that's the intent: Our hope is they are going to go back to the communities that need them the most, and the ones that we've taken care of closely, how many end up staying around the communities and taking care of the communities that they trained upon and stay in that area. So many of them become faculty that demonstrate this work can do research in health inequities and that sort of piece, because I think once we begin showing that, it'll be a little bit helpful in our favor.

Henderson: [1:07:33] Thanks to David, thank you very much. And, interestingly, that aligns very well with some conversations that Joaquin and I've been having within the AMA about developing data for diversity science to support the importance and the impact that diversity in medical education has. So thank you. Bill, Dr McDade.

McDade: [1:08:01] Thanks, Dr Henderson. I wanted to comment a little bit in the same vein as David, in that the metrics that were talked about in the Supreme Court decision, I think are quite important. There was a, almost a fixation on the length of time that you would need to have diversity as a goal. As if you could say, "We're not going to need affirmative action in 25 years," or as UNC put forward, "We're not going to need it after five years."

[1:08:33] I think the best metric is to measure health care outcomes, and the impact that minoritized physicians have on health care outcomes. And as long as we have health disparities that are more positively affected by a diverse workforce than a monolithic, nonminoritized workforce, we have a metric that we can use to say we have to keep up the production of minoritized physicians in this country. And to me, when we fix that problem, I'll walk away. You know, we're done as far as I'm concerned. But I don't think that's going to be achievable in the in the short term at all and I think that trying to put a time stamp on it is a fool's error.

Henderson: [1:09:16] Thank you. I couldn't agree with you more. Couldn't agree with you more. Does anyone else have anything that they would like to add before we close? Thank you all very much. This has been invigorating, truly.

[1:09:35] So in closing, I'll sort of use a quote by Judge Ketanji Brown Jackson, who wrote in her dissenting opinion: "With let them eat cake obliviousness, today, the majority pulls the ripcord and announces colorblindness for all by legal fiat. But deeming race irrelevant in law does not make it so in life."

[1:09:57] Colorblindness on its face is an attractive concept. In our nation, with its foundational history of racism, which is not only a social construct, but is codified in law and public policy, colorblindness is functionally racism blindness. When we say we don't see color, what we're really saying is that we don't see racism. People of color have no choice but to be race conscious because ours is a racist society. Racism is the mortar that holds together the bricks of white supremacy.

[1:10:32] However, the question may remain whether the Constitution as a document should be colorblind. In the 1967 decision of the Fifth Circuit Court of Appeals in US vs Jefferson County Board of Education, the aptly named Judge John Wisdom wrote: "The constitution is colorblind in the sense that a classification that denies a benefit causes, a harm, or imposes a burden must not be based upon race. But the Constitution is color conscious, to prevent discrimination being perpetuated and to undo the effects of past discrimination." The majority on our current Supreme Court seems to disagree with this perspective.

[1:11:21] I'll close with a quote from Heather McGee, in The Sum of Us. She writes: "We need leaders who see color, who recognize the profound impact that social hierarchies have, and continue to have, on our national well-being, and who create new visions of how we can recognize our American diversity as the asset that it is."

[1:11:49] At this pivotal time in medical education, we were called upon to be such leaders, and if anyone has asked the question: "Who beat us and when but now?"

[1:12:00] Dr King famously said: "The arc of history bends toward justice." It bends better with shoulders behind it. My thanks to you all for lending your voices and your expertise to this very important discussion. I believe we need to look at the laws of affirmative action as an opportunity to work collaboratively, to develop data-driven approaches, to continue our march towards health equity. I am eagerly looking forward to working with you all to accomplish that goal. So thank you all very, very much. This has been a very insightful conversation and a very necessary conversation. So thank you for your contribution to it.

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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.

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