REPORT OF THE BOARD OF TRUSTEES DIVERSITY IN MEDICAL EDUCATION (Board of Trustees Report 15 - A-99, Reference Cmte. C)

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The American Medical Association (AMA) Minority Affairs Consortium (MAC) was established in June 1997 to create new pathways for participating in the AMA and to assist the Association in addressing minority health disparities and the professional interests of minority physicians. At the heart of the MAC mission is the need to increase the number of underrepresented minority physicians in the United States. Your Board of Trustees has asked the MAC to provide advice and counsel on ways to increase the pool of minority physicians and the appropriate role of affirmative action in medical education and training. Those views are reflected in this report.

The report discusses the continuing decline in the number of minorities enrolled in medical school and the related negative effect on health care outcomes in minority populations. It identifies the dismantling of affirmative action as an important factor in the recent decrease in minority medical school applicants. Finally, the report suggests ways that the AMA can proactively work to increase diversity and cultural competency in the profession and thereby contribute to improving the status of minority health.

BACKGROUND

The U.S. Census Bureau projected that minority populations in the United States would increase over 15% between 1990 and the year 2000, with Hispanic-Americans representing the fastest growing U.S. population segment. Medical school enrollment is not keeping pace with this increasing diversity in the population. According to the Association of American Medical Colleges (AAMC), underrepresented racial/ethnic groups comprise 21% of the US population but only 8.6% of the US physician population.

The lack of diversity in medicine affects the profession and our patients. Studies show that minority physicians are more likely to provide care to minority populations, practice in underserved areas, and/or serve patients from their own ethnic group. Also, physicians from low socioeconomic backgrounds provide a disproportionate amount of service to patients who are minorities, poor, and Medicaid beneficiaries. The decrease in the number of minority physicians exacerbates health care access and delivery problems in both minority and low socioeconomic patient populations. Improving the health status of all Americans depends in some degree on ensuring access to physicians who reflect the nation's increasingly diverse population.

The profession must be aggressive in confronting and addressing the related and underlying issues that contribute to the existence of minority health disparities. The AMA has adopted a policy of "zero tolerance" toward racially or culturally based disparities in care. This should also include efforts to identify and correct overt or subliminal racial, ethnic and cultural physician bias.

An example of such issues can be found in a recent study published in the February 25 issue of the New England Journal of Medicine, "The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization." In that study, the authors found that "the race and sex of a patient influence the recommendations of physicians [on managing chest pain] independently of other factors." Actors representing each of the possible combinations of race, sex, and age were videotaped portraying patients with similar symptoms, emotions, type of dress, and insurance coverage. Participating physicians were asked to view the videos and assess the patient characteristics believed to be predictive of patient compliance and treatment outcomes. The authors found that:

"the race and sex of the patient affected the physicians' decisions about whether to refer patients with chest pain for cardiac catheterization, even after we adjusted for symptoms, clinical characteristics, and the physicians' estimates of the probability of coronary disease. The findings were most striking for black women."

The authors conclude that the results indicate bias on the part of the physicians. Although they could not assess the form of bias, the authors suggest that "that bias may represent overt prejudice on the part of physicians or, more likely, could be the result of subconscious perceptions."

The negative outcomes from such perceptions can be reduced with a culturally competent physician workforce and a profession that better reflects our diverse population. Medicine must recognize that such bias, regardless of the good intentions of physicians, can negatively impact health care decisions for their patients.

MINORITY ENROLLMENT IN MEDICAL SCHOOLS

The AMA Council on Long Range Planning and Development in Report C-I-90, accurately projected that, although the ratio of all physicians to the general population would narrow by the year 2000, the number of minority physicians would not keep pace with the rate of growth of minority populations.

It is clear that the profession must take additional steps to recruit and train more qualified minority students. A 1998 report issued by the Council on Graduate Medical Education (COGME) on "Minorities in Medicine" identified access problems for underrepresented minorities such as African Americans, Hispanic Americans, and American Indians. It also documented that:

• The racial and ethnic composition of physicians does not reflect the general population.
• Minorities remain "critically underrepresented" in medical schools.
• Efforts to dismantle affirmative action have aggravated the problem.

The AAMC has long tracked the entry numbers of underrepresented populations in medical school. It has classified these underrepresented groups in four racial/ethnic groups: African Americans, Mexican Americans, mainland Puerto Ricans, and American Indians. Enrollment in medical school among these groups increased by 43% after 1986 and peaked in 1994 at 2014. Enrollment did not increase in 1995, corresponding to actions in several key states to dismantle affirmative action admissions policies.

In 1996, minority enrollment decreased by 5%. The 1997 year marked the first time since 1988 that the number of people applying for medical school openings decreased in virtually all underrepresented racial and ethnic categories. That year both the number of underrepresented minorities applying to and enrolling in medical school dropped. Applications dropped by 11.1% percent and the number of those deciding to enroll declined by 6.8%.

In 1991 the AAMC created "Project 3000 by 2000," with an original goal of increasing the number of underrepresented minority students in US medical schools each year to 3,000 by the year 2000. The AMA participated in the founding of "Project 3000 by 2000" and AMA Policy 350.986 supports the concept of the Project.

Key to the Project initiative is the emphasis on early education/outreach through a network of community partnerships. Medical schools are urged to partner with high schools and colleges with the ultimate goal of strengthening the pool of minority students. In 1996, the Project expanded to include the AAMC Health Professions Partnership Initiative (HPPI), which provides grants to support specific partnerships among health professional schools, pre-professional programs, and minority high schools. Another component AAMC program is the Minority Medical Education Program (MMEP), which offers summer educational experiences to help students from underrepresented minority groups to gain admission to medical school. These and other efforts, such as the AAMC "Health Professionals for Diversity" coalition, are supported by the AMA.

Despite these efforts, the number of minorities entering medical school has actually declined in recent years. Many have attributed this decline to anti-affirmative action initiatives in Texas, Louisiana, and Mississippi. In the 1996 Hopwood decision, the US Court of Appeals for the Fifth Circuit (TX) struck down a minority-weighted admissions policy of the University of Texas law school. The US Supreme Court upheld the lower court finding that eliminated race- and gender-based preferences at public higher educational institutions in Louisiana, Texas, and Mississippi. In California, passage of Proposition 209 banned affirmative action at state universities, having a substantial negative impact on minority enrollment in California medical schools. More recently, the AAMC and a coalition of 51 medical associations, including the AMA, unsuccessfully attempted to defeat the November 1998 ballot initiative in Washington State that sought to ban any form of affirmative action in contracts, jobs, or public higher education.

The AAMC has conducted regional tracking in states affected by anti-affirmative action efforts. The results demonstrate that minorities have been discouraged from applying to medical school. The number of underrepresented minorities applying to medical school in those states declined by 17% in 1997. In comparison, underrepresented minorities applying to medical schools not affected by anti-affirmative action legislation declined by 7 %.

The AMA has opposed efforts to prohibit institutions of higher education from considering factors of race, sex, color, ethnicity, or national origin. The AMA has said that considering such factors is essential in many cases to ensure a diverse student body and to develop a health care workforce that reflects the diversity of society and can more adequately meet the needs of the poor and other minorities.

In addition, many medical schools have actively worked to recruit and retain minority students. The AAMC guide, Minority Student Opportunities in United States Medical Schools, provides a comprehensive listing of medical school practices and programs targeted to underrepresented minority students. A number of these programs are also described in an excellent 1998 report of the AMA Medical Student Section on "Medical School Minority Recruitment and Retention."

AMA POLICY

The AMA has extensive policy supporting the expansion of opportunities for minorities to successfully pursue careers in medicine, and efforts to eliminate minority health disparities. At the Interim 1998 meeting, the AMA adopted the recommendations of Report 3 of the Council on Long Range Planning and Development, "Consolidation of Section 350, Minorities" (see Appendix A). Included in these policies are an AMA endorsement of the AAMC "Project 3000 by 2000," and the recommendations of Board of Trustees Report 50, adopted at the 1995 Interim Meeting, that outlines a series of activities to reduce racial and ethnic disparities in health care. Another significant AMA action was the 1997 establishment of the Minority Affairs Consortium. The AMA currently is engaged in implementing a program to expand cultural competency in the profession.

THE CONCEPT OF AFFIRMATIVE ACTION

The historical purpose of integration was to provide traditionally underrepresented and/or excluded populations with access to opportunities and services that had been previously denied to or not fully enjoyed by them, where "separate but equal" policies had proven inherently "unequal" in practice. While that purpose remains legitimate, integration today is intended primarily as a societal framework for bringing together people of different backgrounds in order to promote common understanding and productiveness. At the same time, effective integration must respect the distinct cultural identities, traditions, and values that exist within minority populations. Society's ultimate goal should be towards a dynamic "pluralism" -- the celebration and nurturing of all aspects of our differences for the betterment of individual citizens, groups and society as a whole.

The term affirmative action is used generally to refer to formal admissions or hiring programs that are weighted in some way to affect the diversity of the whole. The term is defined in Webster's dictionary as "an active effort to improve the employment or educational opportunities of members of minority groups and women." The use of the term "race-blind" policies in such programs is usually meant to prescribe that race and ethnicity are not seen as useful factors in that process.

However, the use of race blind policies is, in fact, inherently blind to the ongoing role that race and ethnicity has in economic, social and political life in America. Racial bias is a continuing and resilient barrier for some in American society. While the major strides made during the Civil Rights Movement of the 1950s-1960s removed the most onerous legislative and formal societal barriers to integration, ultimately, we did not solve this issue. As a result, individuals and institutions must employ a full range of knowledge, skills, motivation, and activism to identify and address racial and ethnic disparities and inequities in American society.

THE ROLE OF AFFIRMATIVE ACTION IN U.S. MEDICAL EDUCATION AND TRAINING

Medical Education and Training as a Public Good. The purpose of medical education is to address the societal need for physicians, particularly those who will provide health care to underserved communities. Government involvement and financing in this process reflects the consensus that such training is and should be a "public good" designed to equitably address the health care needs of all its citizens.

Racial/Ethnic Diversity as a Goal in Medical Education and the Profession. The AAMC has stated that it strongly supports the continued use of affirmative action in medical education as a "critical, short-term tool to ensure diversity in the nation's health care workforce [and as something that is] necessary until longer-term solutions to strengthen education for all children are achieved." Most importantly, greater racial/ethnic diversity among physicians benefits underserved minority populations because the minority identity of a physician is often a strong marker for future service to minority populations. Minority physicians may also bring a desired measure of "cultural competence" to their physician/patient relationships. Lastly, minority physicians can serve as powerful role models and mentors within those communities.

Meritocracy and The Use of Test Scores in Medical Schools Admissions. With applications for medical school admission exceeding positions available, well-defined selection criteria must be used to determine who will have access to such training. College grades and standardized test scores can be useful predictors of academic performance, particularly during the pre-clinical years of medical training. However, such grades and scores have not been shown to be directly correlated to other components in the desired physician profile, such as cultural sensitivity, communication skills, compassion, commitment or other aspects of clinical performance. Scores alone are not adequate predictors of who will make the "best" physicians. Candidate selection, conducted exclusively or predominantly, by grades and test scores creates an admissions system with great potential for overlooking individuals who would, in fact, make superior physicians.

THE CONTROVERSY ABOUT AFFIRMATIVE ACTION

Affirmative action ensures that medical school admissions committees can consider race or ethnicity as one of many factors in their decisions. However, the subject of affirmative action tends to produce a spirited discussion on the merits and effectiveness of "preferential" policies in moving us toward a society of truly equal opportunity. Part of that debate concerns the issue of quotas. In medical education, the use of quotas and separate evaluation criteria, as part of an affirmative action program designed to increase the number of minority physicians, tends to invite criticism and legal challenge. The use of multiple admission factors during the application process should preclude the need for using quotas and separate evaluation criteria.

In 1998 a study on the effect of affirmative action policies was published in "The Shape of the River: Long-Term Consequences of Considering Race in College and University Admissions." Authors Derek Bok of Harvard University, a political scientist, and William G. Bowen of Princeton University, an economist, looked at the practice of race-conscious admissions in elite higher education, based on their study of the academic progress, careers, and attitudes of 45,000 students at 28 of the most selective universities over a period of 20 years.

The authors conclude that eliminating affirmative action would have a significant negative impact on minority enrollment in medical and law schools. In addition, they argue that the debate over affirmative action concerns a relatively small number of applicants, and in fact, only affect the probability of acceptance for white applicants by a 2% variance.

CONCLUSIONS AND RECOMMENDATIONS

The purpose of affirmative action is to produce a physician workforce that is reflective of the diversity within our society and to increase the number of underrepresented physicians and other minority health care providers who will serve the needs of minority communities.

Because diversity remains an important goal for medicine, medical schools should have some discretion on how to achieve it. An ideal affirmative action program uses race and ethnicity as one of multiple factors for selecting individuals from a pool of candidates in order to meet the purpose stated above. Other selection factors that may be useful include academic performance, gender, leadership, character, community service, and other extracurricular performance and/or interests. In addition, medical schools should be encouraged to more heavily weight the likelihood of service to underserved populations as admissions criteria.

Medical schools and other institutions have a responsibility to state publicly their reason for existing, i.e., their mission statement, and their means for accomplishing that mission. For example, a medical school that is established in part to serve rural areas can preferentially admit applicants that are more likely to practice in rural areas. The same process can apply to underrepresented minorities when the academic institution has a stated mission to resolve health issues in those populations.

The goal of affirmative action has not yet been realized in the U.S. medical profession. It is imperative that medicine unite in seeking ways to increase diversity in medical education. Medical school enrollment statistics have shown that the number of minorities in medicine is decreasing, especially in those states where legislation and/or legal decisions have challenged traditional affirmative action admissions policies. In addition to the general "fairness" of balancing the physician workforce to better match the diversity of the US population, the future health of minority communities is at stake. Minority physicians are much more likely to practice in minority neighborhoods. Access to such physicians becomes increasingly important as the US population continues to diversify.

However, such arguments have not stopped "anti-affirmative action" initiatives in California, Washington, and other states perhaps to follow. The AMA must continue to seek ways to support and implement efforts to increase diversity and expand opportunities for underrepresented minorities in medicine. By working in the framework of state medical society/AMA partnerships, the AMA can anticipate and work to prevent the additional erosion of such policies. Such partnerships would provide education on and promote the goals of affirmative action programs aimed at increasing the number of minority medical students. There are a number of AMA units that could appropriately and effectively assist in this effort, including Medical Education, Legislative Activities, Federation Relations, and the AMA Advocacy Resource Center.

Therefore, the Board of Trustees recommends adoption of the following recommendations and for the remainder of the report to be filed.

1. The AMA will request that the AMA Foundation seek ways of supporting innovative programs that strengthen pre-medical and pre-college preparation for minority students;

2. The AMA will support and work in partnership with state and specialty medical societies and other relevant groups to provide education on and promote programs aimed at increasing the number of minority medical school admissions;

3. The AMA will encourage medical schools to consider the likelihood of service to underserved populations as a medical school admissions criterion.

ADOPTED BY THE AMA HOUSE OF DELEGATES, JUNE 1999

APPENDIX A

CONSOLIDATION OF SECTION 350 (Minorities) OF THE AMA POLICY COMPENDIUM (CLRPD) Report 3 - I-98 (Excerpt - Relevant Policies)

H-350.971AMA Initiatives Regarding Minorities: The House of Delegates commends the leaders of our AMA and the National Medical Association for having established a successful, mutually rewarding liaison and urges that this relationship be expanded in all areas of mutual interest and concern. Our AMA will develop publications, assessment tools, and a survey instrument to assist physicians and the federation with minority issues. The AMA will continue to strengthen relationships with minority physician organizations, will communicate its policies on the health care needs of minorities, and will monitor and report on progress being made to address racial and ethnic disparities in care. It is the policy of our AMA to establish a mechanism to facilitate the development and implementation of a comprehensive, long-range, coordinated strategy to address issues and concerns affecting minorities, including minority health, minority medical education, and minority membership in the AMA. Such an effort should include the following components: (a) Development, coordination, and strengthening of AMA resources devoted to minority health issues and recruitment of minorities into medicine; (b) Increased awareness and representation of minority physician perspectives in the Association's policy development, advocacy, and scientific activities; (c) Collection, dissemination, and analysis of data on minority physicians and medical students, including AMA membership status, and on the health status of minorities; (d) Response to inquiries and concerns of minority physicians and medical students; and (e) Outreach to minority physicians and minority medical students on issues involving minority health status, medical education, and participation in organized medicine.

H-350.978 Minorities in the Health Professions: The policy of our AMA is that (1) Each educational institution should accept responsibility for increasing its enrollment of members of underrepresented groups. (2) Programs of education for health professions should devise means of improving retention rates for students from underrepresented groups. (3) Health profession organizations should support the entry of disabled persons to programs of education for the health professions, and programs of health profession education should have established standards concerning the entry of disabled persons. (4) Financial support and advisory services and other support services should be provided to disabled persons in health profession education programs. Assistance to the disabled during the educational process should be provided through special programs funded from public and private sources. (5) Programs of health profession education should join in outreach programs directed at providing information to prospective students and enriching educational programs in secondary and undergraduate schools. (6) Health profession organizations, especially the organizations of professional schools, should establish regular communication with counselors at both the high school and college level as a means of providing accurate and timely information to students about health profession education. (7) The AMA reaffirms its support of: (a) efforts to increase the number of black Americans and other minority Americans entering and graduating from U.S. medical schools; and (b) increased financial aid from public and private sources for students from low income, minority and socioeconomically disadvantaged backgrounds. (8) The AMA supports counseling and intervention designed to increase enrollment, retention and graduation of minority medical students, and supports legislation for increased funding for the HHS Health Careers Opportunities Program.

H-350.979 Increase the Representation of Minority and Economically Disadvantaged Populations in the Medical Profession: Our AMA supports increasing the representation of minorities in the physician population by: (1) Supporting efforts to increase the applicant pool of qualified minority students by: (a) Encouraging state and local governments to make quality elementary and secondary education opportunities available to all; (b) Urging medical schools to strengthen or initiate programs that offer special premedical and pre-collegiate experiences to underrepresented minority students; (c) urge medical schools and other health training institutions to develop new and innovative measures to recruit underrepresented minority students, and (d) Supporting legislation that provides targeted financial aid to financially disadvantaged students at both the collegiate and medical school levels. (2) Encouraging all medical schools to reaffirm the goal of increasing representation of underrepresented minorities and women in their student bodies and faculties. (3) Urging medical school admission committees to consider minority representation as one factor in reaching their decisions. (4) Increasing the supply of minority health professionals. (5) Continuing its efforts to increase the proportion of minorities and women in medical schools and medical school faculty. (6) Facilitating communication between medical school admission committees and premedical counselors concerning the relative importance of requirements, including grade point average and Medical College Aptitude Test scores. (7) Continuing to urge state legislation that will provide funds for medical education both directly to medical schools and indirectly through financial support to students. (8) Continuing to provide strong support for federal legislation that provides financial assistance for able students whose financial need is such that otherwise they would be unable to attend medical school.

H-350.980 AMA's Role in Preparing Minority and Disadvantaged Youth for Careers in Medicine and the Health Professions: The policy of our AMA is to: (1) Initiate the development of a multi-organizational commission on minority health and education designed to coordinate programs and initiatives to address issues relating to the improvement of minority health and the enrollment and retention of minorities in medical school. (2) Pursue this commission in conjunction with other appropriate national organizations including the National Medical Association. (3) Encourage, sponsor, and promote, as appropriate, the development of innovative elementary, secondary, and undergraduate school programs designed to better prepare minority students and socioeconomically disadvantaged students for careers in medicine and the other health professions. (4) Strongly encourage state, county, medical specialty societies, medical schools, and individual physicians to make an ongoing commitment to participate in these or other programs designed to better prepare minority students for careers in medicine and the other health professions. (5) Encourages individual physicians to make a personal, ongoing commitment to participate in elementary, secondary, and undergraduate school programs designed to better prepare minority students and students from socioeconomically disadvantaged background for careers in medicine and the other health professions.

H-350.981AMA Support of American Indian Health Career Opportunities: AMA policy on American Indian health career opportunities is as follows: (1) Our AMA, and other national, state, specialty and county medical societies recommend special programs for the recruitment and training of American Indians in health careers at all levels and urge that these be expanded. (2) Our AMA support the inclusion of American Indians in established medical training programs in numbers adequate to meet their needs. Such training programs for American Indians should be operated for a sufficient period of time to insure a continuous supply of physicians and other health professionals. (3) Our AMA utilize our resources to create a better awareness among physicians and other health providers of the special problems and needs of American Indians and that particular emphasis be placed on the need for additional health professionals to work among the American Indian population. (4) Our AMA continue to support the concept of American Indian self-determination as imperative to the success of American Indian programs, and recognize that enduring acceptable solutions to American Indian health problems can only result from program and project beneficiaries having initial and continued contributions in planning and program operations.

H-350.982 Project 3000 by 2000-Medical Education for Under-Represented Minority Students: The AMA supports the concept of the Association of American Medical Colleges' project "3000 by 2000," which has as its objective achieving 3000 under-represented minority students entering medical schools annually by the year 2000. (This proposed policy incorporates components of current policy H-350.986)