Diversifying the Medical Pathway in a Post–Affirmative Action World | Equity, Diversity, and Inclusion | JAMA

As 3 Black men at different stages of our medical careers, we symbolically and numerically represent the 3% of enrolled medical students and practicing physicians in the US who identify as Black men, unchanged from 1920. Given our experiences as often one of the few present within our health care environments, we are well attuned to the deficit of underrepresented individuals in medicine, defined by the Association of American Medical Colleges as those who identify as American Indian or Alaska Native, Black or African American, Hispanic or Latino, or Native Hawaiian and Other Pacific Islander.¹ Research demonstrates that a racially diverse medical workforce results in improved self-reported patient experiences, reception to medical recommendations, and reduced health care spending.^2–4 These findings are particularly true for Black individuals, who are affected by some of the poorest health outcomes in the US.⁵ Unfortunately, efforts to increase the numbers of underrepresented individuals in medicine have fallen behind strides made by nonunderrepresented groups.

Despite this, in June 2023, the Supreme Court ruled to eliminate the ability to use race as a factor in admissions for institutions of higher education. This new ruling threatens a tool that, like many others, has been imperfect in its application but has helped to modestly improve the number of American Indian, Black, and Hispanic individuals in higher education,1 including medical schools, at a time in which burgeoning data show that health inequities are widening.⁵ Herein, we present a pathway to help organize and promote individual, institutional, professional, and societal actions to increase the number of underrepresented individuals in medicine within the medical workforce in a “post–affirmative action” landscape.

The foundational steps to a medical career often start in grade school. Thus, we first propose the earnest effort to achieve equity in funding for public K-12 schools. School district expenditures on education have a significant impact on student education outcomes. Controlling for family income, when there is an increase of Black-White segregation between school districts, funding shifts in a manner that disfavors Black students.6 Furthermore, it is estimated that White school districts receive $23 billion per year more than non-White school districts despite similar numbers of students.⁷ Not unexpectedly, even talented students from lower caste education systems have less access to advanced placement courses, often resulting in lower grade point averages and poorer performance on standardized tests. Given this inequity, there must be continued emphasis on restructuring the allocation of school funding, particularly from local property taxes, to invest equally in each K-12 student, if we are to be consistent with a doctrine of education meritocracy.

Second, we propose the formalization of partnerships between medical institutions and K-12 schools in underserved zip codes to provide early exposure for students to various medical careers and access to early scientific research opportunities. Many such programs exist on an ad hoc basis but greater institutional support for such programming and targeting of underrepresented students can help increase awareness of the necessary scientific and research foundation needed to succeed in college and, subsequently, medical school. Furthermore, we can look to successful programs, such as the Stanford Medical Youth Science Program, for guidance on how to effectively and longitudinally lead these partnerships, including in states like California that have long since banned affirmative action.8

Third, at the undergraduate level, the Medical College Admissions Test (MCAT) and the expenses associated with preparing for and taking the examination often serve as a barrier to many underrepresented individuals in medicine seeking to attend medical school, often at the expense of better-resourced students.9 To address this issue, we propose free MCAT preparatory services for college students through partnerships between undergraduate institutions’ offices of career services and test preparatory companies to provide the resources to qualifying students. These services would be funded from general university operating funds that are raised through a mixture of tuition, the federal Pell program, and other grant funding, as well as philanthropy. The criteria for qualification for such a service could be based on financial aid status, quality of K-12 schools attended, and institution-specific determinations of academic eligibility, with the goal of helping to increase the diversity of students who have the necessary information and resources needed to obtain medical school admission.

Fourth, we recommend the following sets of action on the part of medical schools to help increase the pool of underrepresented medical school matriculants. Given that standardized testing skills are one form of competence that play an outsized role in medical school admissions, and one wrought with racial and ethnic inequities,9 we propose the expansion of early medical commitment programs. These programs, such as the Program in Liberal Medical Education offered at Brown and Northwestern Universities or the FlexMed program at the Icahn School of Medicine at Mount Sinai,¹⁰ guarantee talented students at the end of high school or in the second year of undergraduate studies with admission to medical school (without an MCAT requirement) on the basis of their coursework, extracurriculars, and continued success. In addition, medical school admission offices should embark on intentional recruiting trips to Historically Black Colleges and Universities, Hispanic-Serving Institutions, Tribal Colleges and Universities, and schools that rank the highest on metrics of socioeconomic and racial diversity. As medical schools consider other creative approaches to diversify the student body, including the use of student zip code alongside other traditional evaluation metrics in the admissions process, caution with such strategies must be taken given the uncertainty around the implications of the current legal landscape.

Our final recommendation draws on the majority opinion written by Supreme Court Chief Justice John Roberts, who noted that universities can—and we suggest should—consider “an applicant’s discussion of how race affected his or her life, be it through discrimination, inspiration, or otherwise,” using holistic review. In other words, race cannot be used as a criterion for admission alone, yet an applicant can discuss how they may have been impacted by race (or racism). This allows for a race-conscious approach that is specific to an individual’s circumstances, experiences with their identity, and their path traveled. This approach is distinct from a group race-based approach and will necessitate that admissions committees perform a broader assessment of an applicant, considering myriad factors, including why race might matter for an individual. We affirm that holistic review can be a tool to advance workforce diversity while remaining consistent with Justice Roberts’ opinion that “what cannot be done directly cannot be done indirectly.”

With the Supreme Court decision, the era of affirmative action has come to an end. But why did we have it in the first place? It was implemented to affirmatively remedy results of prior and ongoing racial discrimination. Yet it is noteworthy that for nearly 50 years, the prevailing justification for affirmative action has been that diversity is a compelling state interest, whether or not the lack of diversity was the result of racial discrimination. Nevertheless, as long as such discrimination, and the associated lack of distributive justice, continues to result in unequal representation, there must be some form of redress. There will be practical challenges, economic costs, and potential unintended consequences to implementation of this proposed pathway, perhaps even for those who might benefit the most. However, this is the time to engage actively, boldly, and creatively to solve the pressing need to diversify the medical workforce. The health of our nation depends on it.

Corresponding Author: Utibe R. Essien, MD, MPH, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon Ave, Ste 850, Los Angeles, CA 90024 (uessien@mednet.ucla.edu).

Published Online: September 18, 2023. doi:10.1001/jama.2023.17089

Conflict of Interest Disclosures: Dr Essien reported receiving research funding from the Department of Veterans Affairs and the American Heart Association (Amos Medical Faculty Development Program). Mr Agbafe reported receiving consulting fees from Third Culture Capital. Dr Norris reported being supported by National Institutes of Health grants P50MD017366, P30AG021684, and UL1TR000124 and the American Heart Association and receiving consulting fees from Atlantis Dialysis Inc.