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Diversity: It's not what medical schools think
"The American obsession with race reflects itself in its medical schools..."

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Diversity:
It's not what medical schools think it is
By Clifford C. Dacso, MD

The American obsession with race reflects itself in medical education. Once the exclusive province of middle and upper class white males, medical schools have pursued the goal of diversity as an article of faith. But as usual, diversity has been defined by race. Maybe it's simply that large organizations have no other way of counting things.

The benefits of a diverse workforce have been demonstrated in a number of settings and ignored in just as many (think US Congress, Presidents of the United States.) In medicine, though, because it is a personal services business, the preferences of the customer should be taken into account. And it has been shown over and over that people like to go to people who look and think like them for their very personal services. And, not surprisingly, the personal service providers like to work with people who look and think like they do.

In the medical work force, it is tempting to advocate doing away with the word “minority.” After all, minority is really just a genteel word for “non-white” and “non-male.” In fact, by 2050, minorities will be the majority in the United States . No, the issue of health care in the diverse populations cuts much deeper than mere language or culture. The real issue is disparity.

Disparity in health care is also a catchword, laden with all sorts of political and social meaning. Disparities take the form of unequal access to unequal quality. Disparity in the current parlance of policy makers and academia has become a shibboleth for “do you believe that there is a shady cabal out there that is actively working to deny select groups the health care that they deserve?” In reality, though, disparity recognizes that there is a measurable difference between the type and quantity of medical care that one person receives as compared to another. And increase in quantity of health care should never be equated with increase in quality.

If, as is generally accepted, it is good to have a doctor who looks and thinks like you, at least in the continuity-of-care fields, then we need to find these people and train them. That means admitting them to medical schools, being sure that they learn the material, and graduating them in fields that provide medical care directly. This is a big job and it is one that the medical schools address relatively grudgingly. The “top” medical schools live and die by the rankings in US News & World Report . It is not worthwhile to cavil about the ranking criteria other than to say they are heavily weighted to peer subjective ratings and numerical measures of achievement. Thus, there are few incentives for a medical school admissions committee to take a flyer on a student with bad—or even middling—numbers.

Efforts have been made to beat the system. Many efforts; and only one has succeeded. The only success: women. In 2003, women assumed the majority among applicants to medical school. This change was even more dramatic among black applicants; women comprised almost 70% of black applicants (data from AAMC). But discussion of race begs the issue. If it is important that physicians relate to the citizenry on a cultural as well as intellectual level, sensitivity and understanding of population issues should be criteria rather than barriers to medical school. But this is tilting at windmills and will never become actual. The medical educator is as much a part of the self-perpetuating oligarchy as is the oil company executive or the US Senator. The solution, I believe, is to work within the system to achieve an end that the system will not.

The MCAT is required for admission to American medical schools. There is a substantial knowledge component to it but everyone realizes that it is, to a large part, a test of English. There may be many explanations for why non-native English speakers do not fare as well on this key barrier to medical school matriculation but the fact is that they perform predictably two standard deviations below native English speakers. So, if America is indeed a melting pot and a nation of immigrants, we effectively discriminate against them by requiring idiomatic English at a native level for entrance into the medical profession.

The University of Houston has a new program called “Experiencing the Future of Health” that will change the dynamic slightly in favor of the applicant to medical school. The university is a microcosm of Houston . It is polyethnic with a large number of students whose first language is not English. And at least in part related to its proximity and affiliation with the massive Texas Medical Center the university has a substantial population of students seeking medical careers. Traditionally, undergraduate pre-medical experiences are limited to observing or “shadowing” a practicing physician or working as a volunteer in a medical setting. In fact, medical schools tend to require such experiences as a proxy for demonstrating understanding of the medical profession. Our program provides a formal experience for undergraduates to work with a physician on the mechanics of the admissions process. This includes anything that the student and physician decide that is useful. It could be rehearsing the interview. Perhaps it is reviewing the application and the essays. Maybe it is the student developing an understanding of what a doctor does during the day. This is very different from other pre-med programs in that it provides for a longitudinal relationship between an undergraduate who may not have the opportunity for day to day contact with medicine to experience it on an as-needed basis. Although the clinical part of this program is at The Methodist Hospital in Houston, the relationships have been with the members of the medical staff who have responded with unprecedented enthusiasm to the opportunity of getting to know their potential new colleagues. And the students have responded in kind comments.htm with enthusiasm and vigor.

The solution to disparities in health care is not simple and indeed it may not even be possible. But changing the face of medicine will require changing the faces of its practitioners.

Clifford C. Dacso, MD, is the John S. Dunn, Sr. Research Chair in General Internal Medicine at The Methodist Hospital and Distinguished Professor of Technology at the University of Houston.