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Diversifying Medical Education

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To identify the key insights or developments described in this video
0.75 Credit CME

Increasing the number of physicians who are Black, Hispanic/Latinx, and Indigenous benefits everyone in the US, but it cannot be the sole responsibility of historically Black colleges and universities (HBCUs). Valerie Montgomery Rice, MD, president and dean of Morehouse School of Medicine (MSM), and Clyde W. Yancy, MD, of Northwestern Medicine, join JAMA Editor in Chief Howard Bauchner, MD, to discuss options for developing training pipelines of underrepresented minority health science students, and how academic medicine can make racial justice a part of its work and mission. Recorded January 5, 2021.

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Transcript

This transcript is auto generated and unedited.

>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, Editor in Chief of JAMA. This is my first conversations in 2021. And I am joined by two distinguished American physicians. And we're going to be talking about a challenge that's existed in American medicine for many decades, diversity. I'm joined by Valerie Montgomery Rice. Valerie is President and Dean of Morehouse School of Medicine. She's been there since 2011. She's an obstetrician-gynecologist by training. And by Clyde Yancy. Clyde is a cardiologist, Chief of Cardiology at Northwestern, Vice Dean for Diversity and Inclusion and the Magerstadt Professor of Medicine. We're going to start with Valerie's viewpoint, which was published simultaneously with an editorial by Clyde and me. The title of the viewpoint is "Diversity in Medicine, in Medical Schools; A Much-Needed New Beginning." The editorial diversity in medical schools needed for a new bold approach. Valerie, Clyde, thanks for joining me today.

>> Valerie Montgomery Rice: Thank you for having us.

>> Clyde Yancy: Absolutely. Thank you, Howard.

>> Howard Bauchner: So, Valerie, what's the data that underlie the great concern, particularly about black men and women in medical school?

>> Valerie Montgomery Rice: You know, Howard, for me the data became really, really clear when I came to Morehouse School of Medicine about nine years ago. So I came as the Dean and Executive Vice President. And the class size at that time was about 56 students. I assumed that 20 percent of the students would be from the undergraduate schools here in the AU Center. Clark Atlanta University, Spelman and then, of course, Morehouse College. And I was surprised that less than 5 percent of the population that was entering Morehouse School of Medicine at that time was coming from that school, those schools. I then went to the AAMC and said, okay, can I see the data from the HBCU medical schools? Because I knew that HBCU medical schools had been strong contributors of people going to medical school. We looked at a cohort of data and began to see a significant drop-off about 15 years ago that has continued. And so when you look at the data right now, and the data that we talk about in the viewpoint is that black physicians account for 5 percent of all physicians even though African Americans account for 13 percent of the population. And if you look at 2019, of the 21,863 students who entered medical school, only 1,626 of them were black. And of that, the ratio for female to male is about 2.5 to 1. So females are outpacing. So we see a significant drop off in black males going to medical school. And we have not seen any growth in the number of black Americans entering medical school over the last ten years, nothing of significance.

>> Howard Bauchner: I shiver when I hear those numbers, Valerie. You know, the three of us are old enough to know this is not a new issue. I mean, diversity in medical school, obviously, it's been magnified because of the pandemic and the Black Lives Matter Movement. I appreciate it's magnified the issue. But for the three of us, this issue's been around for two or three decades. Clyde, when you hear those numbers, how do you think about them?

>> Clyde Yancy: Well, Howard, first let me thank you for this opportunity to have the conversation. And, Valerie, let me congratulate you for doing the legwork to understand what's the numerical underpinning for these issues that we're addressing? But, Howard, to be directly responsive, let me make this immediately personal. I went to medical school in 1978. The percent of medical students in 1978, like me, black men absolutely unchanged from 1978 through 2016 or 2017 based on a brilliant report by Marc Nivet when he was still part of AAMC. Absolutely zero change in the percentage from when I was a freshman in the late 70s to here I am as a mature contemporary cardiologist. So that puts a bit of a chill on the pause that you've already articulated. And one has to say, regardless of any other circumstances, here is the fundamental question. Is that right? Is that just? And then, when you compartmentalize this in a bucket that contains the price that we've paid disproportionately based on COVID-19. I just authored an obituary yesterday for, black physician who died caring for patients with COVID-19 and suffered disproportionate consequences of the condition. And then you further partner that with the painful awareness of the movement Black Lives Matter. Not for the politics, but for the reality, for the decades of discounting the value of what persons of color can bring into society and into our profession. Then the intersection between those phenomenon, with the quantitative data that Valerie has illuminated, made it very clear that we need to take a bold, unique and different approach to address something that is fundamentally not just. And, again, it was a pleasure to cogitate with you, think with you and then put pen to paper.

>> Howard Bauchner: Valerie, you're dean of an important medical school in the United States. Why do you think black students have thrived there?

>> Valerie Montgomery Rice: You know, I asked that same question when I came, because I was educated and trained at majority schools. And my first engagement with the historically black medical schools was when I was recruited to Meharry Medical College to be the chair of OB/GYN. And what enticed me to go, I was Associate Professor at the University of Kansas. I was tenured already. I was, I had a K award [phonetic] I was getting ready to write for my RO1. And I went to the dean and said, you know, I'm thinking about taking this position. She said, oh, no, no, no, wait. You can go and be a chair at a more prestigious school, this is what the person said to me. But I went down to interview because the person was the dean then was one of the few black women who was a reproductive endocrinologist and fertility specialist like I am. I went down there, and they did not have a residency training program in OB/GYN. Yet they had 18 students going into OB/GYN. And I said, what's going on here? Why would these students be interested in going into OB/GYN? They don't even have a residency training program here. The relationship, though, that they had with the faculty and the staff, the confidence in which those students engaged in patient care, I recognized that there was a learning environment that empowered these students to believe that anything was possible. And I was intrigued. And when I finished my tenure there and came here as the Dean and Executive Vice President initially, I saw that same level of empowerment that occurred in the learning environment. Howard, it makes a difference when you go to work every day or go to school every day and race is not the primary issue. That you don't necessarily have the micro-aggressions or the imposter syndrome that follows you around sometimes as an underrepresented minority student when you're at a majority environment. I believe it's the learning environment that we have been able to create and our close connection with the community. Our students are engaged in the community week one of medical school, and that continues throughout the four years. And our conversations are not look to the left, look to the right, one of you are not going to be here. Look to the left, look to the right, you may marry the person to the left or the right. However, what we're saying is that everybody has a responsibility to ensure that everybody walks across that stage.

>> Howard Bauchner: Valerie, do you think we've lost our way with the MCAT scores? You bring it up, this 495 versus 505. I once had a dean at a major medical school, that will be unnamed, said to me, well, could JAMA write about why we could get rid of these U.S. News and world rankings because then I could take students with lower MCAT scores. And I felt, I said to this person, you don't need me to write that. You could make that decision without me saying anything in JAMA. Have we lost our way around the MCAT scores?

>> Valerie Montgomery Rice: So I am a scientists first, and so I started to look at the numbers. So the AAMC, if you ask them for data, they provide you the data.

[ Multiple Speakers ]

>> Howard Bauchner: They do.

>> Valerie Montgomery Rice: Right? Right. And so I asked them for 15 years of data because I wanted to understand what was the factor that was preventing students from HBCU to get into medical school. The MCAT was the gatekeeper. I then looked at the data 15 years from the AAMC and said, what happens to these students who do get in with those MCAT scores that back then would have been, you know, 25, 26 on the old two-digit scoring compared to this 495 and 505? And as we talked about in the paper, they have equal success rates to students who have MCAT scores above 505 to 520. And so we don't see a drop-off in the attrition. And that's why a holistic admissions using the MCAT as one part of an admission strategy such that you can tailor the educational experience for that students, but not allowing it to be the gatekeeper. And you're right, Howard, many schools worry about U.S. News and World Report, which I believe has only used us to create a new revenue stream and have us competing against ourselves. And we fail to see that, and it becomes a problem with allowing us to educate and train the healthcare professionals that the nation needs.

>> Howard Bauchner: Now, Clyde, in our editorial and in Valerie's viewpoint, both emphasize the historic number that four medical schools at historically black colleges, university, one which is quite small, trained 15 or 17 percent of the black students, black medical students in the United States of the four of 155 medical schools. It's a stark ratio. What's the way forward, Clyde? What do your instincts, the data and your experience tell you is the way forward?

>> Clyde Yancy: So several things. One word that we've emphasized and used just in the last 90 seconds several times has been "holistic." We have to understand that as a physiologist I really do commit to importance of competency and the best tool is MCAT. However, that is not sufficient. We understand that there are factors that have to do with drive, with initiative, with grit. And being able to understand these qualitative components, because the real question is not how well the student does on the board exam. The real question is, what happens at the bedside? Is there compassion? Is there stamina? Is there a commitment to care for patients regardless of their circumstances? Those things are not judged well by the MCAT. So that's one big piece, gravitating towards something holistic. The next piece is that, as much as we embrace the magnanimous gifts that have happened so far to make medical schools tuition free, that doesn't educate one single person above the current capacity.

>> Howard Bauchner: Right.

>> Clyde Yancy: It relieves the financial distress, but it doesn't educate one single person above capacity. So the other thing is that I would encourage our peers, I'm in leadership. I'm a vice dean. I would encourage my peers to say, you know what, if all medical schools increased their capacity by one, Howard, by one, we'd have over 100 more physicians trained per year. And if that 100 was just representative of the communities, because not just black, but thinking about Latino, Latinx as well, that would change things. But here is the bold idea. I'm so delighted that Valerie's with us because she's the template. She's in a community that is supported by Emory School of Medicine that serves Grady as a prototypical legacy safety net facility supported by historically black college and university with an amazing legacy. If I go down the list of alumni, this has been the bedrock of black culture, quite frankly. And so this great intersectionality has yielded this beautiful resource that Valerie directs. But that's not the only community in which that can happen. So find other communities that have this [inaudible] of resources and HBCU hospitals that have a mission, a passionate mission and medical centers that are supportive, and we can replicate the Morehouse model. And we can do that for less money than a single new drug discovery would cost in cardiovascular therapeutics.

>> Valerie Montgomery Rice: And, Howard, if I may add to that. So, I mean, you hit the nail on the head. And I agree with you all in your editorial where you talk about opening a new HBCU medical school. Howard, I told you, and I hope that you all saw this last month around the 14th when we announced a partnership.

>> Howard Bauchner: Yeah.

>> Valerie Montgomery Rice: With CommonSpirit Health. And so CommonSpirit Health is the largest not-for-profit health system in the country. The CEO, Lloyd Dean and I have been working on this for the last couple of months. And what we are going to do is take our Morehouse School of Medicine model and partner with them in five of their different regions around the country. They're in 21 states, 142 hospitals. And we will select five of those, and we will do five regional medical campuses with 25 to 30 students at each of those. And then add in to that 10 residency training programs. So we will double our class size in five to seven years.

>> Howard Bauchner: Right, that was going to be my follow up question, Valerie. So will allow you to increase capacity.

>> Valerie Montgomery Rice: Correct.

[ Multiple Speakers ]

>> Howard Bauchner: Because it seems like the success of black students at historically black colleges and universities and associated medical schools demands that we attend to those data. That's where the great gain is, whether it's Morehouse doubling in size or capacity or Drew doubling in capacity or opening up new ones. To me that's what we need to leverage as we look to the next decade so that, if you're both back here in ten years, we're not saying the same thing. That's my great fear, that we look back in ten years and those numbers remain flat.

>> Clyde Yancy: So, Howard.

[ Multiple Speakers ]

>> Valerie Montgomery Rice: Well, Howard, also I have to say this. We cannot absorb the other 151 medical schools of their responsibilities. And I talk about this in the op-ed. And this was astonishing to me when I looked at it, that 14 new medical schools were accredited in the past five years and each of them.

>> Howard Bauchner: Right.

>> Valerie Montgomery Rice: Had diversity and inclusion in their mission. Yet they only, still flat. So only 231 of those students were black out of the 3,000 students that they enrolled. So they were still at about 8 percent. So they did not move the needle. So if we're going to open up new medical schools, particularly those that are talking about they're committed to diversity and inclusion, then their classrooms ought to reflect that. And many of my colleagues who I have a lot of respect for, I think, you know, we said it earlier. One, two more persons of diverse backgrounds in your classroom would get us to 100 to 200 more students being educated and trained. But then, as we open up new medical schools, we ought to hold them accountable to what they said was important to them in their mission ask vision statements.

>> Howard Bauchner: Clyde, how do you think about what Valerie just commented?

>> Clyde Yancy: You know, I think that this really brings an important bit of context into the conversation. How do we get here, Howard? We're talking about novel solutions. The restaurant analogy, putting more butts in seats. Either expanding the current schools or developing really bold, new ways of creating more capacity. But how do we get here? I go back to the Campbell JAMA network open piece that evaluates the consequences of [inaudible] report from over 100 years ago. Just taking five of those medical schools that will close and extrapolating conservatively and liberally, it turns out that that's a miss of over 30,000 physicians that would have been providing care over the last century, predominantly physicians of color. So those people that argue, what is systemic racism? That doesn't exist does it? This is a prototypical example. The decision to close those schools that were black serving and the impact that has had for a century, it shows us what the carryover effect can be for these legacy decisions made under the banner of what was then overtly racist activity. And now we're trying to recalibrate, re-correct. So I think that there are three things on the table. First, all medical schools think about this modest increase that ends up being a major improvement. Second, the schools that are already minority serving finding novel ways like Morehouse system to increase their capacity. And, third, being very bold and creating another model in the Morehouse-Howard prototype and say, let's do one more in the right community and really significantly expand capacity. Because, Howard, right now, Valerie and I are not talking about the short-term fix. We're saying, I'm not focused on 10 years from now. I'm focused on 40 years from now, a generation from now. Because if we don't make a change now, future generations will struggle with the same thing. Ten years is not a long enough window. I'm thinking 20 to 40 years where this will finally be addressed. So I hope, I hope that there's pushback from what you and I wrote and the pushback comes from senior leaders in [inaudible] medicine. Because the response then should be, if you don't want to see number of medical school plus one, then in your own environment increase your capacity.

[ Multiple Speakers ]

That's right.

>> Howard Bauchner: Well, you and I talked about it. You know, we've received probably 10 or 15 viewpoints that said, well, if a medical center can just recruit more physicians of color. But they come from somewhere. So it doesn't help if, you know, one hospital in Boston recruits more black physicians from another hospital in Boston. Or if you want more physicians of color who are orthopedic physicians. Unless the number in the 2,000 increases, they're just going to come from another specialty. That may be helpful in some specialties, but in the long-run the absolute number has to go up. Clyde.

>> Valerie Montgomery Rice: And, Howard, may I just add to that because we go back to one of the things I talked about again. You know, the data where we looked at from the restructured MCAT, and we said that, we looked at those scores been 495 to 505. There were 3,659 black students with MCATs of those score range that didn't get into medical school. That means they graduated from college. They came from some community. They took the MCAT, probably more than once, and yet they did not get in. And we have data to show in several of our papers that shifting the curve, you can shift the curve on those students and have less than a 2 percent attrition rate with students with those MCAT scores. So some of it's low-hanging, meaning that we have a cohort of students that we can recruit from. And with our CommonSpirit initiative one of the things that we're going do, we're going to take all of our 30 years of pipeline experience and go into those communities and begin to grow students from those communities, K through 12, college, and then getting them into medical school. Because we know the highest chance of someone going back and practicing in their Latinx community or their rural community is that they are from that community. And so we're going to do what we know works. And we have multiple models to show that you can be successful.

>> Howard Bauchner: Clyde, is there, you know, the cost of new medical schools is debatable. It depends on how you create them. Franciscan Cigarroa, who is on our board who you know, started two new medical schools in Texas, but there's numerous other new medical schools. Can we raise 50? Can 50 or $100 million be raised?

>> Clyde Yancy: Absolutely. When you look at the benevolence that has been so valiantly portrayed in response to COVID-19, it's there. It's just a matter of awareness and being redirected. But there's another point here that I think is really worthwhile making because the pipeline is always the roadblock that is erected when we have these conversations in a broader community. By generating a new resource, like another HBCU tethered medical school, that generates a culture change. That allows secondary school students, high school students, college students to have a new aspiration, something is attainable. It then allows that community to reap the benefits from the presence of that kind of a higher education facility. Here is the other part of this. With the community engagement, it changes the economics. Because there's some shared costs with the HBCU, with the hospital system, with the community, public/private partnerships. We look at the price tag, and it's daunting, 200, 300, $500 million. And we think it needs to come from one unbelievably generous benefactor. But maybe it's an amalgam of community of HBCU, of corporate citizens, of municipalities that are aligned and say, we need to serve our communities better and this is the way that we can do that. So I think, if we are intimidated by the cost, it's because our will is not there. If we're intimidated by the pipeline, it's because our belief in the human spirit is not there. And if we are intimidated by the greater goal, it means we have ignored the burden that we've seen so painfully in these last 12 months.

>> Howard Bauchner: It's been about a half hour, but I mentioned at the beginning I wanted to finish with two more personal questions. Valerie, what's it been like to be a black woman physician in the United States for you?

>> Valerie Montgomery Rice: You know, for me, Howard, I didn't grow up wanting to be a doctor. So I came to this by way of not wanting to be an engineer and having a love for math and science. And I had gotten the job from Proctor and Gamble and decided, you know what, I think I might be too cute to be an engineer. Seriously, it was really that simple. But I loved people, and I looked up encyclopedia, and when you did that word search, medicine comes up. And I decided I wanted to go to medical school. And I came back to Georgia Tech, and I told my professor that, and he thought I was crazy. And I said, you know what, I don't know anything about going to medical school. So I came over to Spelman across the street from me, and I talked to the premed counselor. And at that time Georgia Tech, you all did not offer premed. And she said, you haven't even taken a biology course. And I said, well, I'm going, they're going to let me take both courses at the same time. And she said, well, you have all the other stuff, you sure you want to do this? I said, I don't know, but I wasn't sure I wanted to be an engineer either. And so I went to a Harvard summer program, and I had taken the MCAT and done well and the rest is history; right? I got into Harvard Medical School. And so being a black, female physician has been a sense of empowerment because it is my example of all things are possible if you prepare yourself and believe in yourself. And I've never forgotten those lessons that I've learned about not settling for something because other people had written out a roadmap for me. And so it's been very empowering for me. And I tried to use my voice to influence and empower others such that they can live out their dreams also.

>> Howard Bauchner: Preeti Malani oversees "Piece of My Mind," and we've had five or six pieces written by physicians of color. And they talk about the imposter syndrome, which you mentioned, micro-aggressions. Has that been part of your career, Valerie?

>> Valerie Montgomery Rice: You know, sometimes I think I'm so naive because I think I ignored it. I mean, clearly, you know, I trained, I mean, I went to Georgia Tech. There were not many females in chemical engineering, okay. There were be many black women. There were not many females. So maybe I was just immune to it by the time I got to Harvard Medical School. But I never embraced it. And when I, you know, I thought I was going to be a neurosurgeon, and then I did OB/GYN and figured out that I really wanted to be a reproductive endocrinology and fertility specialist. And my mentor, Dr. Isaac Schiff, white male, was just the kindest person. And that's who I wanted to emulate. And so there may have been micro-aggressions or people putting up barriers, but I did not embrace them and incorporate them. And so I know that this imposter syndrome exists, but I think everybody who goes to Harvard Medical School believes they're an imposter. So I was around a whole bunch of folks who thought we were all imposters. And so I just didn't embrace it. And I just have been, I grew up with enough grit raised by a single parent, mother that I had a lot of examples of how not to let things stop you.

>> Howard Bauchner: Clyde, what's it been like for you as a black man in American medicine for the last two decades? You've had a remarkably distinguished career. I should mention you're on yet, you're one of the associate editors of JAMA Cardiology. But what's it been like for you?

>> Clyde Yancy: You know, Howard, I am the great-grandchild of descendants of slaves. I'm the grandchild of sharecroppers from the Deep South. I come from a family history that experienced abject poverty and vicious discrimination. I was born in 1958, when Jim Crow was alive and well in the Deep South. Grew up in Baton Rouge, Louisiana. Ostensibly, single-parent family. We had to work so hard for everything. I just heard Valerie's story. And you know what, you had to develop a thick hide. You had to find a way to just ignore what people were saying because you knew you were on a singular mission. And when I juxtapose that with what is rightly identified, as you've just done with a successful career, it's not because I was particularly gifted. It's because I was lucky. The barriers that were erected that put so many other people aside and didn't let them through, somehow or another, serendipity, mentors, grit, I got through those barriers. And so I'm not an N-of-One because I'm so remarkably unique. I'm an N-of-One because I survived a march, a journey, a pathway that was strewn with boulders, with obstructions. The number of times I heard no, unbelievable. And so I think that at this point in time what Valerie and I are discussing and what you've been able to, my gratitude is immense for that, is an opportunity for us to pay it forward. And so we know that for each one of us, from where we've come, there could have been 10 more that could have been with us. And the world in which we're entering, there needs to be that 10 more plus another 10 more. And if these conversations are able to inspire persons to provide resources, encourage leaders to understand what's necessary as the next step in their institutions and, most importantly, encourage some little black boy like I was at the age of 10 that said, I want to be a doctor. Howard, that got so deeply embedded in my DNA, there was nothing that was going to prevent me. I was hell bent. I was going to be a doctor. And once I discovered cardiovascular physiology at the age of 16, said, this is it. Whatever kind of doctor I'm going to be, it's going to be with the heart. I mean, it was purpose almost at a pathological level. Now, it turned out to be not quite so pathologic. But I just had this thing that, I want to be a doctor. Because I saw an N-of-One, the only black physician in my segregated community of over 20,000 people who was forced to do it all. Gallbladders. Vaccinations. Colds and flus. Cancers. Heart disease. And I said, no, he's helping people. I'm going to do that [inaudible]. It's evolved over time. But being able to have this conversation and feel as if I still have something to give and leave these statements as legacy statements that others can read and putt [phonetic] and cogitate and decide, will they embrace them? Will they take the next step? I think that's the right thing. This is a good way to start 2021.

>> Howard Bauchner: Both of you are in important leadership positions. Do you worry about the so-called minority tax, as there's more and more interest in having diverse medical students and residents? You know, I saw, when I recruited an African-American woman into my division at BMC, the dean began to call and ask if she could be on this committee or that committee or this committee. I said, well, I have to ask her if she wants to be on this committee, and she has a research career that she's trying. Do you worry about the minority taxes? Is it real, Valerie, at your institution? How do you guard against it? And the same to you, Clyde.

>> Valerie Montgomery Rice: So it is real even at our institution that's a historically black medical school. And I worry about it for all of my faculty. And what has happened for me is that I remember what my mentor, Dr. Paul Terranova, when I took my first job at the University of Kansas. And myself and another guy were going, coming there, and we were starting a division of reproductive endocrinology and fertility, starting an IVF lab. And I had to take my boards. Oh, and by the way, I came to the job pregnant; right? So it was just the whole gamut. Paul Terranova set me down, and he said, look, you get to be on one committee. He said, now, you want to be a clinician-scientist, and I'm going to put you on my grant to start with. You have to commit to every Friday being in a lab meeting. And for that I will directly supervise your lab technician on Monday and Wednesdays. On Tuesdays and Thursdays, you have to do it. So we had a contract. He forced me to protect myself. And then he protected me from the others who were calling and asking me to be on every committee because I was the only person of color at that time in the entire department of OB/GYN. And so what I say to my colleagues, particularly those in majority institutions who have underrepresented minority junior faculty, mentorship and sponsorship are not the same thing. And you have to protect those faculty members at both levels. And part of your mentorship is protecting them from everybody who wants representation on every committee. Because they do have to publish the papers. They do have to do the research. They do have to have the clinical experience. And so part of our guidance and my guidance that I use with my chairs and my other senior leaders is that we have limits to what we will allow our junior faculty to participate in because we know what the requirements are for promotion and advancement. And I use that, Howard, in this leadership role as a way, the career development as a way that I grade and assess my leaders. That is a part of their performance. And if they fail there, then they're failing a large part of their role.

>> Howard Bauchner: Clyde, you're at a majority institution. And there's a lot of committees at Northwestern, and they want diverse makeups of those committees. I don't know the number of black and brown physicians you have. How do you think about it at Northwestern, particularly in both your role as a division chief of cardiology and head of diversity and equity?

>> Clyde Yancy: Give you two perspectives. The first one, again, is personal. I wouldn't be here if it wasn't for the will of a strong black woman, my mother. And she reminded me repeatedly to who much is given, much is expected. And mentors early in my career pulled me aside and said, you have something to offer medicine, and we want to help you do that. So when I hear the minority tax, and I've heard it in multiple iterations, it makes me pause and think about that. Because for certain committee assignments, and it does take judgment. If not me, then who would execute that function and do it as it needs to be executed? Anyone who thinks that life is fair has missed the boat a long time ago. And this disproportionate responsibility is a fact of life. But if you turn that disproportionate responsibility into an enormous opportunity, then it's different. Now, let me transfer my thoughts over to Northwestern. I'm sensitive to the attrition when we bring young physicians into our community. And I want to be personally responsible that their ascension, whether it's clinical or academic, is unimpeded. Since I've been Vice Dean of Diversity and Inclusion, we've dropped our turnover rate for physicians of color from 50 percent per annum to about 8 percent per annum. But it's not just been because we've managed their time, it's because we've changed the culture in which they work. And we've endorsed their work. We've celebrated their work. We've given them a community that says, we support who you are and what you're doing. And there's a greater goal. There's a greater purpose. And I think redefining the task so the task is not the work in front of you right now, but the initial impact of that work changes it. So as Valerie highlights, these are very important conversations that need to happen at a professional level, but one on one. What is the trajectory for that person? What are the gifts that person brings to the table? There may be people who need to do three or four different things. There may be people who are skilled at multitasking. But there may be those who need to do one thing. So I thinks it's the skill of leadership, particularly senior leadership to be sensitive and understand how to position themselves. But I go back to what my mother always told me, to who much is given, much is required. And I think that's what I continue to execute.

>> Howard Bauchner: This is Howard Bauchner, Editor in Chief of JAMA. And Valerie Montgomery Rice the President and Dean of Morehouse School of Medicine. And Clyde Yancy, Vice Dean for Diversity and Inclusion, Chief of cardiology at Northwestern. And I've been talking about one of the great challenges in American medicine, diversity. And how to ensure that in 10 years we don't have to have the same discussion yet again. Valerie and Clyde, I can't, thank you both for the viewpoint. And, Clyde, for the editorial. And I've said this before, the great privilege at JAMA is to work with just remarkable individuals on a daily basis. People should read everything that Clyde Yancy writes. He has a way with the English language that some, Clyde, I've asked you, where did you learn? But you and Don Berwick and David Naylor and Mary McDermott, you have a gift of words, which I'm so jealous of. It is magnificent. Valerie and Clyde, thank you so much for joining me.

>> Clyde Yancy: Thank you, Howard.

>> Howard Bauchner: And I'll stay in touch. This is an issue that will stay in JAMA for many years to come. Talk care and happy new year.

[ Multiple Speakers ]

>> Valerie Montgomery Rice: Happy new year. Bye-bye.

>> Clyde Yancy: Happy new year.

>> Howard Bauchner: Bye-bye.

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