Health Equity

Prioritizing Equity video series: The SCOTUS Affirmative Action ruling

The cost to the physician workforce and historically marginalized communities.


In this Aug. 28, 2023 edition of the Prioritizing Equity series, discussions on how the recent affirmative action ruling undermines policy dedicated to increasing physician diversity, which is vital to the health care ecosystem. We'll also cover the negative implications it will have towards increasing medical career opportunities for marginalized and minoritized people and how it will impact patients and communities.

  • David Henderson, MD—Vice president of equity, diversity, and belonging, American Medical Association
  • Jessica Faiz, MD, MSHPM—Assistant clinical professor of emergency medicine, UCLA; co-investigator with the VA's Center for the Study of Healthcare Innovation, Implementation, and Policy
  • Merlin Chowkwanyun, PhD, MPH—Assistant professor for sociomedical sciences, Columbia University
  • Fernando De Maio— Vice president of health equity research and data use, American Medical Association

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De Maio: Hello, everyone. Welcome to a new episode of the Prioritizing Equity series. I am Fernando De Maio, vice president of health equity research and data use at the American Medical Association, and I have the pleasure of being your moderator for today's conversation. In today's panel, we will look at the Supreme Court's recent affirmative action ruling, given the negative impact that we believe the decision will have on physician diversity and health outcomes in this country.

We will hear from leaders on what is important for us to keep in mind as we think about this issue and, as medical institutions, where we can go from here. In June of this year, the AMA actually formally adopted policy for race-conscious admissions in higher education, urging medical schools and undergraduate admissions committees to proactively implement policies and procedures to support race-conscious admissions practices. And the AMA also joined more than 40 organizations to sign an amicus brief filed for the Association of American Medical Colleges urging the Supreme Court to take no actions that will disrupt the existing medical school admission processes.

The fact is that the end of affirmative action will decrease the diversity of the medical workforce. Already, we have seen that states that have instituted affirmative action bans have experienced decreases in underrepresented students enrolling in college and completing STEM degrees. We know that a physician workforce that is reflective of the diversity of our nation is an integral component of achieving more equitable health outcomes, and that ensuring diversity in the physician workforce itself is a key component of ours coming to terms with the effect of structural racism in health care.

These are obviously the very difficult and weighty topics and very important topics. So I'm honored to now welcome a terrific panel to help us explore and dive deeper into these issues. Please join me in a warm welcome to Jessica Faiz, MD, who serves as an assistant clinical professor of emergency medicine at UCLA and as a co-investigator with the VA's Center for the Study of Healthcare Innovation, Implementation, and Policy. Hello, Jessica.

Let's also welcome Merlin Chowkwanyun, PhD, MPH, who serves as an assistant professor for Sociomedical Sciences at Columbia University. Hello, Merlin. And David Henderson, MD, who serves as vice president of equity, diversity, and belonging at the American Medical Association. Welcome to you all. So first, let's begin. I'd love to know how you are, how you're coming into this conversation today. And in very general ways, to give us a platform for a conversation, what's possibly distinct about the medical school context when we think around affirmative action and the SCOTUS decision? Jessica, I'll turn to you first. How are you and where do you see this issue, broadly speaking?

Dr. Faiz: Yeah. So first of all, thank you, Dr. De Maio, for having me on this panel today. I feel really honored to be part of this discussion with my amazing co-panelists. Obviously, after hearing the Supreme Court decision, despite somewhat preparing for the outcome, I certainly felt disheartened given what it meant for the state of the country and the future of medicine.

But since a bit of time has passed, I think I'm entering the conversation today ready to discuss potential solutions and moving forward, because I know that those who have been fighting thus far for equity are really not about to back down. And in terms of the medical school context, I think the implications for a less racially and ethnically diverse medical student body, which is the real risk here after the ruling, is patients' lives lost. And I think I know that we'll get into that discussion later, but thanks again for having me.

De Maio: Yeah. A pleasure to engage in this conversation with you. Merlin, how are you and how do you see this issue, broadly speaking?

Chowkwanyun: Thank you for having me as well, and thank you for putting this panel on. I know a lot of work goes on behind the scenes for these sorts of events. My reaction is very similar to others. It was alarm, both because I think this is not the only case that has a lot of implications for health equity, Roe v. Wade last year, a somewhat less popular case or known case, West Virginia versus the EPA, which could hamper a lot of environmental justice efforts. So it seems like there's been a lot of very alarming and striking things being passed down by this particular judiciary.

One thing I have been a little concerned about and a little disheartened about is a very kind of what I would describe as a very reactive approach on the part of a lot of institutions. So we kind of know something might be coming down in the Hill, but we sort of wait until it happens and then there's this kind of despondent period and even shell shock. And sometimes I think we go even further than that and we sort of just accept that it's going to happen, like it's something on a weather forecast and there's not much strategy on what to do beyond just reactivity.

So at a lot of medical institutions, I know that the reaction has been just, "Okay. Here's the Supreme Court decision and let's try to find out how to technically comply with it." But I personally feel we kind of need a bigger-picture framework beyond compliance and also a clearer understanding of whether or not we actually do want to embrace a full-throttled, no-apologies defense of race-conscious admissions. I feel a lot of institutions have been actually very kind of shy and afraid to just say that. And so, it's a little disappointment on my part with some of the larger landscape in terms of how we've reacted to this.

De Maio: Great. Thank you. Yeah. You've raised some really thoughtful points around posture and trajectory and long-term changes and how we react or proactively engage, and I look forward to engaging on these issues in the conversation. And David, how are you and how are you coming to this conversation?

Dr. Henderson: Thank you, and my thanks to Merlin and Jessica for joining this conversation. I have sort of guarded optimism, I think, to paraphrase Zora Neale Hurston. And I think the decision was sort of like a way-off whisper sort of putting on flesh as it slowly approached, and everyone was waiting for it for a long time. And when it was revealed, there weren't terribly many surprises.

I think some of the actual wording in the majority opinion does leave some openings in going forward. But I mean, all in all, I mean, I think this represents an opportunity, an opportunity to see if we can put in place some policies and practices that are more effective than affirmative action had been.

De Maio: Okay. Let's dig into these issues. Thank you all for those opening remarks. Merlin, if I can turn to you, you've recently published an important new book, All Health Politics Is Local, where you examine how health is and always will be political. Can you help us lay a brief foundation for this? How did we get to a place of affirmative action being a component, a necessary action for diversifying our health workforce?

Chowkwanyun: Absolutely. So for the vast majority of the medical profession's existence to the United States, it was a profoundly segregated, exclusionary, and racist profession. And I think if you were to actually rank the professions on kind of a racism index, medicine would maybe be one or two. I mean that in kind of figurative speech. But I think if you actually tried to quantify it with some indicators, I believe that ranking would hold. First, the number of medical schools that would admit African Americans or Jews or other racial minorities was small.

Meharry and Howard really were the only two medical schools that would admit large numbers of African American students. There are a lot of medical schools that were founded basically because of anti-Semitism, like Montefiore here in New York City, one of the few places that would actually take Jewish students throughout most of the 20th century. It wasn't just medical schools either. When it came to membership in county medical societies, the rule was often racial exclusion. And it wasn't just in the Jim Crow South, but other parts of the country as well.

County medical society membership is not as important today as it was in earlier parts of the 20th century, but it was hugely important back then. It affected things like hospital privileges and your ability to get referrals, and African American physicians were basically locked out. This is kind of a whites-only affair in practice in many parts of the country, and same goes for employment at hospitals. If non-white physicians were actually employed in hospitals, it was often in segregated wards, both for patients and for physicians. Again, not just in the Jim Crow South, but especially there.

So all told, medical profession and medical schools were a racially exclusionary affair for most of their histories, and affirmative action is a tool, was one tool to kind of reverse this historical exclusion and some of the aftereffects from it. And I appreciate very much David's point that it is not the only tool that was available. It may not even have been the best tool then or now, but it was, I think, an important tool to actually begin this process of undoing historical exclusion that was very entrenched and, even after the fall of Jim Crow formally in law, I think is still entrenched in many ways. So that's kind of what affirmative action is really was for.

De Maio: Okay. Great. Thank you. You've also reminded me of another great book, The Racial Divide in American Medicine, which very thoughtfully explains, analyzes that local membership and why it was so historically important and how the exclusionary processes worked at the time. David, if I can turn to you, I know you've thought a lot about addressing misinformation around affirmative action, its inception, its primary beneficiaries. Can you walk us through some of that? What are the myths and key facts that we should know about?

Dr. Henderson: Sure, Fernando. Thank you. I'll just begin by just sort of adding one point to what Merlin just said with regard to Black doctors being excluded from professional organizations. And I mean, I think sort of principal among that exclusion was the AMA in not allowing Black physicians to become members. So it's something that the AMA has recently apologized for. But I mean, I think as a national organization, with the AMA taking that stance, it just basically supported the rest of the landscape. And I think that's an important part of that story as well.

I'll share three myths with you about affirmative action, and I think the first is that affirmative action policies are in place to remedy past injustice. In 1961, John F. Kennedy issued an executive order in which he called for taking affirmative action to address some of the issues in employment that favored whites and disadvantaged other groups. He was making an effort to address persistent inequitable practices and policies. He wasn't making a specific effort to address anything in the past, but he was looking at things before him in the present.

So the argument that affirmative action policies are in place to remedy past discrimination is misleading. And I think that is one thing that's important, because affirmative action has always been in place to address current structural and systemic discrimination and unequal treatment. The second myth is that affirmative action allows less qualified minority students to take seats away from more qualified or meritorious majority students.

And it's interesting, because in his majority opinion, Chief Justice Roberts sort of parodied a good deal of the argument around this. He said in his opinion that college admissions are zero-sum, and a benefit provided to some applicants but not to others necessarily advantages the former at the expense of the latter. And this zero-sum framing, it's been used historically in the context of race, I think, to prevent poor and middle-class whites from appreciating the fact that they have much more in common with most people of color than their more affluent brethren.

And Heather McGhee actually elaborates the issue of the zero-sum dialogue very well in her book, The Sum of Us. But just a few statistics, and this has to do with the use of the word "merit" and "qualified" as code words for privilege. 70% of medical school matriculants come from the top two quintiles of family income. 24% come from families in the top 5% of income, whereas the poorest medical students, the ones in the lowest quintile, comprise only 5% of matriculants. And the other sort of element of this myth, at least in my mind, has to do with standardized tests, because they've historically played a really big role in medical school admissions.

But the history of standardized testing is grim. And these tests were developed mainly to demonstrate the intellectual superiority of whites, and they've actually done a pretty good job of doing that. They were developed with contributions from eugenicists in the early days and were used in their development to support eugenic theories. So, I mean, I think those issues are important to consider. And the third and maybe most important has to do with who benefited most from affirmative action policies. And this, I think, is a fairly interesting story and part of the story that is little known.

Between 1980 and 2000, the number of women physicians increased by 300%. Most of them were white women. However, between 1978 and 2014, the number of African American male matriculants to medical school actually decreased from 524 to 515. Additionally, the number of students from underrepresented groups matriculating to medical school declined 16% between 1997 and 2017. I mean, so the rarely articulated history of affirmative action policies is that white women have benefited more than other demographic groups. And I think that contribution is certainly important because women were underrepresented in medicine as well, but it's not typically a main feature of the anti-affirmative action narrative.

So in a 1987 article in The New York Times, Derrick Bell, who was the first tenured Black professor at Harvard Law School, proposed some rules for racial relations. And in those rules, his first rule states that racial remedies are the outward manifestations of unspoken and perhaps unconscious conclusions that such remedies, if adopted, will secure, advance, or at least not harm the interests of whites in power. So despite all the self-righteous outrage, this is also true of affirmative action. Affirmative action has not been the boon to underrepresented populations that it is touted to be, nor has it harmed the aspirations of white populations.

De Maio: Thank you, David. This is really vital information that we need to grapple with. And I know, Jessica, there's another key component that I think you can add based on your recent piece that you published, the Supreme Court's affirmative action decision puts lives at risk. Can you tell us a little bit about what you've learned? And in particular, what do people of color gain from having physicians that look like them and reflect their experience?

Dr. Faiz: Yeah. So Dr. Henderson already touched on some of the socioeconomic data for current medical students, with one in four coming from families with incomes in the top 5%. And per the AAMC or the Association of American Medical Colleges in 2022, we still find that the medical student body has percentages very low relative to the population for underrepresented groups, so 9% of Black medical students, 11% Hispanic, and less than 1% of Native American or Native Hawaiian or Pacific Islander students. And this is a little bit higher than the current percentage of physicians, but still underrepresented.

I think it's important to remember that none of this is random and it's a product of structural inequity. So a paper that I published with my colleagues at UCLA recently showed that some of the reasons for these low numbers are related to systemic barriers on the journey to applying to medical school. So we found that Black and Hispanic and Native American students applying to medical school are more likely to have parents without a college degree or attend a low-resourced college, have more difficulty affording medical school admissions tests and prep materials, and have pre-medical debt.

So all of these barriers decreased one's chances of applying to and matriculating at medical school. So the fact that these barriers exist and manifest early is really why we can't be doing enough to recruit underrepresented groups to medicine and why this Supreme Court decision really sets us back while we're already behind.

So in terms of future health outcomes, studies have shown that Black and brown physicians are more likely to spend time listening to minoritized patients and provide guideline-recommended care, and that's led to outcomes like higher medication adherence and preventive care uptake. A recent study showed that for every 10% increase in the number of Black primary care physicians in a county, there was a 30-day higher life expectancy for Black individuals living there.

So we really risk further widening existing health disparities and life expectancy gaps by not doing everything that we can to uphold the diversity of our workforce. And this is not to even mention the benefit that youth and future physicians in Black and brown communities gain from seeing doctors who look like them. So that exposure can really change livelihoods, and I've definitely seen that through my experience teaching and mentoring.

De Maio: Thank you. Merlin, turning back to you, from your perspective as an instructor, as somebody who has been engaged in advocacy in different levels, can you speak a little bit about the policies at organizational levels or state levels relating to increasing diversity in medical education? Do you think that there are policies that can be an effective alternative, perhaps even more effective, to increasing diversity in medical education without affirmative action as we go into this new era?

Chowkwanyun: I'll give sort of a response that's between. It's not so much affirmative action as was practiced before the decision or a world without it. But I actually think, and this kind of echoes something David said earlier about the actual text of the decision, I think organizations can actually explore some of the ambiguity in the decision. There's actually an explicit sentence in the majority opinion that says that this opinion doesn't wholesale ban consideration of race, full stop. It only addresses the particular practices at Harvard and UNC.

And so, the question is how whether or not future courts interpret that decision in this kind of more narrow way or they kind of extrapolate on that to create more kind of wide-scale affirmative action bans. I think a worst-case scenario in that is I think groups, like the one that filed these lawsuits in the first place, will just go after university after university, filing more lawsuits, invoking this case, and that would include medical schools as well, claiming that they are in violation.

But we don't know that's going to happen yet. And so, rather than wait for that to happen, or rather than assume that will happen, I think medical schools should actually think about how they respond to this legally, and they can examine ways that they can actually preserve race-conscious admissions in a way that may not trigger a case for violation. That's a very kind of technical legal exercise, but I think that's what they should do.

And unfortunately, I think a lot of them instead have simply thrown in the towel, which I find tremendously disappointing. A number of universities have already issued statements saying they will stop considering race in admissions rather than exploring some of the ambiguity of the case, at least at this point in time. I think another thing we can do is also reframe the debate in medical schools. So Jessica alluded to this.

Also, I think we can reinterrogate how we allocate these very scarce spots in medical schools. Medical school is probably the most scarce higher ed resource there is in terms of just how many medical schools there are and how many spots there are. And as David pointed out, an overreliance on many dated forms of assessments, standardized tests, board exams that may have questionable connection to the actual quality of a physician that you become later.

The late Fitzhugh Mullan and his Project HOPE organization did a lot of research on this kind of reinterrogating standards and the ways they actually reproduced racial inequality. So I think that kind of conversation should accelerate right now. And as for the state level, so I don't think a promising path is to encourage state governments to fight the federal government or defy the Supreme Court. And the reason I don't think this is, I grew up in Los Angeles, in California. California was sort of the test state for a ban on affirmative action. And we had this ballot Proposition 209 that passed, and that kind of remade the demography of higher education in public California universities. It banned affirmative action.

So if that's a liberal, blue state like California, I think the chances of that kind of state action occurring elsewhere that is a defiance of the Supreme Court probably isn't in the cards. But I think there is some more modest stuff that states can do. States hand out a lot of grants for medical workforce development, including the creation of pipeline programs, especially at the pre-college and pre-medical school level, and that is one way of partially addressing the class division that Jessica and David have both described. So I think states do have some more modest tools that they can use to try to preserve some inkling of diversity in the future.

De Maio: Thank you. Continuing the conversation and thinking along the lines of solutions and possible actions, David, I wanted to come back to you. I know in a recent interview with the AMA, you said something along these lines that pathway programs alone are not sufficient to achieve the level of health care workforce diversity that is necessary to meet our health equity goals. Can you talk a little bit about this, share what other efforts and solutions you see that are being designed and implemented that whole promise? Especially at the AMA, what are we doing to address the impact of this decision?

Dr. Henderson: Yes, Fernando. Thank you again. I mean, I think the evidence that pathways programs in and of themselves aren't sufficient is clear in the fact that, as I stated before, between 1997 and 2017, the number of students from underrepresented groups matriculating to medical school declined by 16%. And so, pathways programs were having a hard time keeping up, and I think in particularly because medical school enrollment has expanded over time.

And there was a study of GME programs recently that demonstrated that at the current rate of growth, it'll take 50 to 90 years for Black and Latino residents to reach parity with their white counterparts. And so, we need far more than just pathways programs. Things that the AMA is doing specifically in the near term. We have a conference scheduled at the end of September where we're going to bring leaders from medical education from around the country to discuss this issue, and we're making a link between the issues related to admissions and equity in assessment, because those two things are very closely tied together, but often aren't considered together.

We don't want to bring students in to have them have negative experiences. And assessment drives almost everything in medical education. And you could argue that the admissions process is, in itself, a summative assessment that uses other assessments. But assessment is a big part of this picture, and that'll be part of the discussion as well.

We're supporting a research project that will track matriculation of students over the next few years and also collect some data on their experiences. One thing we need to do is do a better job of documenting where students practice. I mean, Jessica commented on some of the positive effects of racial concordance. And I think that's important to do because one of the criticisms of Harvard in the recent Supreme Court case was that it really didn't have any data to support the policies that it was practicing.

And so, I think certainly at the level of medical education, we need to collect that data again to support the policies that we end up putting in place, and as Merlin said, to provide some protection from organizations that seem to be very well-funded that are actively submitting FOIA requests hither, thither, and yon, I think looking for weak spots to exploit.

But I think that there are a number of possibilities for exploring paths forward. Undergraduate institutions provide our applicant pool. I think we need to work really closely with them to help them with their outreach, with enrichment activities so that we can maintain a reasonably diverse applicant pool. Community engagement is really important among medical schools, and we have to work really closely with our local communities.

Education is a social determinant. Children from poor communities sort of lag behind their more affluent peers in readiness for kindergarten. That gap in preparedness is persistent in academic performance throughout K-12 education. And so, poor communities need advocacy. And I think medical schools, academic health centers are in a very good position to provide that advocacy for education, because we need to start further upstream than most pipelines typically do as far as education is concerned.

Community colleges are another potential source of applicants. There are very few applicants to medical school who come from community colleges. UC Davis actually has a program where they are recruiting and mentoring students in community colleges and have created a pathway from community colleges to medical school. And as noted before, only 5% of medical school matriculants come from the lowest quintile in family income. There should be more students there. We just need to find them.

And I can share this personal anecdote. I grew up in a housing project in Chicago on the South Side, and I was fortunate enough to have an opportunity to attend Phillips Exeter Academy. That's where I went to high school. And that, for me, I think made all the difference in my life. But someone had to come find me. I didn't come from the places most of my peers came from. Someone had to come find me. And in the same way, we need to find students. There are many more out there. We just need to find them.

De Maio: And Jessica, turning to you. From your perspective working at an academic institution, what do actions, possible solutions look like?

Dr. Faiz: Yeah. First of all, I can't reemphasize enough how much I agree wholeheartedly with what Dr. Henderson was saying about those upstream interventions that must happen. These interventions right now at academic institutions are so downstream, so I just want to say that I appreciated his sentiments and his suggestions. But improving the diversity of our workforce I think has two really important prongs. So one of which is the recruitment aspect, which really has been the bulk of our discussion today. But next, I do think that retention of underrepresented students, trainees, and faculty in our workforce is crucial as well.

So in terms of recruitment in the face of this ruling, the op-ed that we had published recently highlighted some solutions. So one being something that Merlin also spoke about, strengthening really the use of holistic review in medical school admissions, so employing rubrics that value applicants' diverse experiences and distance traveled to the point that they are today. I think institutions can also consider using input from the communities that they serve in the selection process in trying to diversify their classes.

Next, really eliminating economic barriers for students. So this is removing application fees, continuing virtual interview options to limit expensive travel. And then medical students really need to invest money in scholarship programs and be creative about curricular options for undergraduate students to enter medicine. Dr. Henderson also mentioned UC Davis has adopted this as well. And then finally, from the recruitment standpoint, really educating everyone involved in the medical school application process on anti-racist practices, critical race theory. It's really important to inform admissions decisions.

The study that I mentioned earlier also found that underrepresented students, compared to their white counterparts, are more likely to have pre-health advisors discouraging them from applying in the first place. So this type of education and information is really important. And then as I mentioned, I really want to emphasize that the focus cannot be taken off retention and investing in their underrepresented students already in the medical field. So we can't be welcoming these students to unsafe environments.

So academic institutions really have a responsibility at every stage, medical students, trainees, and faculty members, to have concrete goals to retain these physicians. So I think some actions can include investing in funding and resources in those who are doing equity work to eliminate the minority tax, and then changing the infrastructure and culture of the institutions to allow these trainees to thrive. So David mentioned briefly too, but making sure that evaluations are equitable and remediation processes aren't steeped in bias. All of these concrete steps are important to make sure that we are welcoming medical students into an inclusive environment and supporting them all the way through.

De Maio: Thank you. And I keep coming back to something. Jessica, you mentioned earlier in the conversation that none of this is random, and we know the deep-rooted nature of the problem. We're clear on the statistics. We're clear on the issues at hand. So I think in coming to a close, I want to ask you a question. All are kind of looking forward.

Where do we find hope? How do we sustain energy and drive and commitment for this, recognizing the long historical trajectory of how the problem has come to be the way that it is, the political barriers, the structural violence that currently operates in our world? I don't know. Looking forward, what do you see coming down in terms of medical education, ensuring physician workforce diversity? What does these next phase of this work look like? David, if I could start with you.

Dr. Henderson: Yes. I've been around for a little while. And I started medical school in 1978, so I was part of that cohort in '78 that just sort of dwindled in ensuing years. But change seems to sort of ebb and flow. I mean, and I think the typical metaphor is it sort of moves in pendulum motion. And we've somehow accepted that so that there's progress, and then things slide back again, and then there's more progress and then things slide back again.

And I don't know why we accept that. It does not have to be that way, because that movement just basically guarantees a perpetuation of the status quo, and the status quo is static. And so, I think that we need to sort of break the mindset that we have had because we don't actually have to accept that phenomenon. And I think there are paths forward. I think those paths will most likely and most productively be found and traveled by many of us working together.

One of the things that this country has been very adept at historically, socially is dividing groups. And there are many more groups of people who have much in common who don't really appreciate that. And so, I think finding ways to articulate and take advantage of commonality of experience when there may not be any commonality of identity are going to be important, and creating some well-articulated, unified voice that can speak for the many of us who will, in a generation, be the majority in this country.

De Maio: Thank you. Jessica, any closing words?

Dr. Faiz: I'm not sure if this is as optimistic as your question asked for, but I just think that in order to move forward, I think it's really important that everyone understands that this ruling really sets a dangerous precedent that really threatens future policies to promote equity. So in terms of medical education, I think even prior to this ruling, we had a long way to go in terms of changing the face of medical education, eliminating racist teachings, supporting those who have been marginalized.

So I really think that it's important to light a fire and emphasize that we need to consider some of the actions I mentioned before and then really investing money in communities upstream of medical education to make sure that we are ensuring a diverse workforce and ultimately saving lives.

De Maio: Right. Right. And Merlin, the last word goes to you.

Chowkwanyun: I agree with Jessica that we should not blind ourselves or talk ourselves into kind of romanticism. It's a bad decision, and it's a decision that may be bad beyond the decision itself if it's used to buttress similar kinds of decisions in the future. So I do think it's important to be sober about the near-term prospects and dangers. But I also always tell my students that if you leave a class of mine and the only thing you can say is that the world is terrible, then I've failed at my job. So I appreciate the spirit of the question. And in that spirit, I would say there's actually a lot of foment.

I think a lot of it is generationally inflected, but not entirely, foment for progress in medical schools and medical institutions, and I'll just highlight three of them. One is just the huge amount of interest among some medical students in the movement for Black lives and police brutality and protesting anti-immigrant policy in the past few years. There have been a lot of white coat die-ins across the country in the past five years around these sorts of issues.

The second is that there's a really reinvigorated labor movement in medical schools. A number of residents have organized and won union recognition. This is something that I think is unheard of at some of these institutions, or you would not have bet on it five years ago. And a third thing is I think many medical schools, I think because of pressure, again, some of it generational, have actually started to take the community relations portion of their work seriously, including very parochial institutions that have historically terrible relations with the communities around them.

So these are three shards that I think can be built on. And I think it's worth highlighting them because, oftentimes, if you grow progress in one domain and another domain and another domain, it has a cascading effect that could spill over to the particular diversification effort even if we don't know exactly how it might. So there's a lot of energy out there.

And then the last thing I would say is, I think this is a good time to also interrogate scarcity, the scarcity assumption in medicine. There are not many medical schools. And then within medical schools, there are not many seats. And why is that? And both panelists have referred to past actions on the part of organizations like the AMA, not this incarnation, but previous incarnations, that purposely tried to constrict the number of people that could even become doctors in this country.

And if you kind of read literature and economics and stuff and by law professors, they actually use the medical profession and sometimes analogize it to a cartel, because there are just so few people allowed in it. And I just mentioned this because I think it ties into racial inequity. It exacerbates it, because if there are fewer slots, there's more and more people fighting over fewer and fewer resources and more chances to create racial inequity. And I think this is a good time to question why this scarcity assumption in medicine that I think often goes unquestioned.

De Maio: Well, I want to thank you all for your authenticity, for the energy that you brought to the conversation, for the insight based on your expertise that you taught us. Thank you all for your time and for this really engaging conversation.

In closing, I want to highlight an upcoming event, which is a National Health Equity Grand Rounds virtual webinar that we are hosting on October 10. It is titled "Creating Accountability Through Data: From Racism and Neglect to Transparency and Repair," where you can listen into an engaging discussion with leading experts on this topic. We urge you to register today at Thank you again to all of our panelists and all the listeners of today's episode.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

Table of Contents

  1. Panel
  2. Moderator
  3. Transcript