Late last year, Cornell made headlines by proclaiming that all qualifying students could now attend its medical school for free. The announcement, which follows in the footsteps of NYU, Washington University in St. Louis, and Columbia, aims to — among other things — address a long-standing and persistent challenge of diversity and access in the medical profession.
The numbers speak for themselves: While Hispanic and Latinx Americans account for 17% of the general U.S. population, they represent just 4% of practicing physicians. Disparities are similar for African Americans (14% of the general population vs. 4% of physicians) and Native Americans (2% of population vs. < 0.4% of physicians). As a recent New York Times article put it, “American medical schools are the training grounds for a white-collar, high-income industry, but they select their students from predominantly high-income, and typically white, households.”
While these disparities have been present for decades, the more disquieting news is that America has actually taken a step backwards in the past 20 years. Despite a 2009 mandate from the Liaison Committee on Medical Education, medicine’s accrediting body, that requires all medical schools to reach “appropriate diversity among its students,” the share of matriculating students from underrepresented groups in medical schools has decreased from 15% in 1997 to 13% in 2017. Almost a quarter of first year medical students are from the top five percent of U.S. household income, while only five percent of medical students are from the bottom twenty percent.
Troublingly but unsurprisingly, this lack of diversity in the classroom — including income, race, and ethnicity, as well as language, culture, gender, religion, and sexual orientation — has a direct impact on the health of diverse populations. There is growing evidence that minority patients report better communication, greater satisfaction, and better adherence to medical recommendations when they are cared for by racially, culturally and linguistically aligned physicians. More diverse classrooms have a positive impact regardless of the background of their students: studies have shown that students who train at diverse schools are more comfortable and equipped to treat patients from a wide range of ethnic, racial, and socioeconomic backgrounds. The data also show that physicians of color are more inclined to practice family medicine in the most under-resourced communities.
Our leading medical schools are understandably attempting to address the high levels of debt that plague new doctors — and dissuade would-be physicians from low-income or historically underrepresented populations from entering the medical profession. But the reality is that eliminating tuition is only within the financial reach of America’s most elite medical schools, and is unlikely to spread much beyond the upper echelon. This solution also assumes that debt is the only problem facing medical schools in their quest to be more diverse.
Expanding opportunities for aspiring medical professionals will take more than big pronouncements from the country’s richest schools. Instead, medical schools around the country should partner with institutions that are addressing a broader set of challenges for students: first, encouraging a more diverse student population to apply in the first place, and second, changing medical schools’ rigid and archaic admissions criteria.
The journey to becoming a physician is long — it requires students to invest four years, and then spend another four years earning little during residency. Medical school presents significant barriers to students without the financial support to purchase textbooks and equipment, not to mention housing and transportation. Schools like the University of California, Davis are addressing this issue by making medical school shorter, accelerating their timeline into the workforce and reducing student debt. UC Davis teamed up with Kaiser Permanente to offer a three-year medical degree for students committed to careers in primary care. Sixty percent of students in the program, launched in 2014, are from underrepresented minority communities and 80% have self-identified as disadvantaged on their applications. The curriculum emphasizes addressing medical disparities in underserved populations. There are now more than 150 graduates of three-year MD or DO programs in the U.S., a staggering jump from just ten in 2013.
Other schools have taken a different approach, providing hands-on mentorship to help students chart pathways into healthcare professions. Morehouse School of Medicine has launched Health Careers Opportunity Program Academy, or HCOP Academy. This program matches economically disadvantaged high school and college students with an interest in medicine with tutors, a mentor, and an opportunity to gain clinical experience during the summer. Unlike free or accelerated programs, these efforts seek to address the challenge by providing support for students earlier in their educational journey.
The challenge more schools should address is their rigid admissions criteria, which typically include high MCAT scores, near-perfect GPAs, and substantial extracurricular activities (often unpaid volunteering and hospital shadowing). These requirements favor applicants with the time and resources to build out impressive resumes; in the words of Dr. David Lenihan, President of Ponce Health Sciences University and CEO of Tiber Health, “Students from high income households have more resources to check off the boxes on the seemingly endless list of volunteering, shadowing, research with access to private tutors and test prep material.”
In an attempt to develop a better set of admissions criteria, institutions could follow the lead of Tiber Health, which is partnering with colleges and universities to develop a better predictor of how applicants will perform on the USMLE (the national qualifying exam also known as “the Boards”). Their new one-year master’s program was designed based on the logic that it’s much easier to access and afford a one-year qualifying program than to commit to an eight-year odyssey. The first students to enroll in this program graduated from medical school last May with impressive results: all graduates passed the board exams, and successfully advanced into competitive residency programs.
As Dr. Lenihan put it, “For years, we had to pass on hundreds of candidates that had the potential to become great doctors. Many of these students came from households well below the poverty line and were denied the opportunity to fully demonstrate their potential. It never meant they wouldn’t be great doctors, it only meant they traveled a different journey and were less competitive on the traditional academic measures.”
Ultimately, 2019 may be remembered as the year of catchy “free medical school” announcements. But it remains to be seen whether free medical school will make a measurable difference in helping to cultivate a truly representative workforce of physicians. Beyond tuition, medical schools will need to adopt a more diverse set of strategies in 2020 and beyond in order to make real and lasting progress.
Corinne Spears is an associate at University Ventures focusing on opportunities within education to employment pathways and healthcare education.