The Journal of the American Medical Association recently published an outright defense of racially discriminatory admissions practices at medical schools, under the guise of “affirmative action.” Our chairman, Dr. Stanley Goldfarb, wrote the following response to this disturbing article.
My former colleagues at the University of Pennsylvania Perelman School of Medicine have written a defense of race-based medical school admissions that fails on many levels. (Hamilton RH, Rose S, DeLisser HM. Defending Racial and Ethnic Diversity in Undergraduate and Medical School Admission Policies. JAMA. 2023 Jan 10;329(2):119-120. doi: 10.1001/jama.2022.23124. PMID: 36477254.) They argue that racial diversity of a medical school class leads to more students entering primary care training positions and more working in medically underserved areas. They also point out that studies show that minority patients are more likely to have “positive experiences with race concordant physicians,” meaning physicians who share the patient’s skin color. These claims are not supported by the evidence.
In a study of career choices of medical students cited by the authors, 55% of black medical students chose primary care fields (Pediatrics, Internal Medicine, and Family Medicine) for residency compared to 43% of white students. Of those, 57% of black students did not initially opt for further training in a medical specialty, but we know that many such residents work in a primary care position for a short time and pursue specialty training later. Some 47% of white students remained in a primary care specialty over the same period. That means, at most, that 31% of black graduates enter into primary care positions. Currently, 7.7% of medical students in the US are black. Under the scenario of equal representation compared to population, 13% of students would be black. Thus, if the cohort of black students was raised to 13% of all medical students, a nearly 100% increase, the percentage of black students entering the primary care fields would at most increase from 2% of the graduating medical students cohort to 4%. Given that some 22,000 students graduate from medical school each year, this would increase the number of black primary care physicians to approximately 800 per year.
Despite efforts to recruit more black students into medical school, the number has only reached 7.7% of all medical students even in the face of a commitment to increase qualified applicants to medical school. Thus, by the data cited above, currently only 400 black students initially enter primary care fields. On the other hand, currently, some 3,700 white and Asian medical students enter primary care fields each year without initially opting for specialty training. If this number were raised by only 9%, for example through incentive programs like student debt forgiveness, the same 400 person increase in the primary care cohort could be achieved without compromising the academic standards for admitting students to medical school now envisioned by advocates of race-based admissions.
Does this trade-off help black patients? Hamilton et al point to studies showing black doctors tend to choose to practice in “medically underserved areas (MUA’s)”. This is true, but do the authors realize that West Philadelphia where the august University of Pennsylvania Medical Center and its over 2000 physicians practice is a “medically underserved area” according to the US government? This is because the population characteristics including areas of poverty and high prevalence of elderly citizens count as much as any health care availability to the MUA designation. Therefore, we really have no idea about the practice characteristics of the cohort of black doctors who focus on serving black patients since the designation “medically underserved area” is more a political concept than related to health care availability. Moreover, studies from California show that the vast majority of physicians currently practicing in “medically underserved areas” are white.
The next question the authors address is whether black patients have better medical outcomes if cared for by black physicians – a phenomenon known as “race concordance.” Do No Harm has proven there is no valid evidence that clinical outcomes will improve if black patients have black doctors. In fact, the largest study of the question shows that not to be the case.
The authors nonetheless argue that black patients feel more “comfortable” with black doctors, but do we really want a country where skin color affects physician choice? For instance, would it be acceptable if white patients demanded white doctors? The criterion for entry into a field in which lives are at stake should only be based on the potential for providing the highest level of care. That capacity is independent of skin color.
Gaining entry into medical school is a privilege and not a right. If we begin to redress years of lack of opportunity with years of unearned benefits, we will have a health care system that may be more colorful yet may not fulfill its true mission of providing the American people with the best trained and most capable health care workforce. The job of medical education’s leaders is not to make sure that anyone who wants to be a doctor gets to achieve that goal. Rather, they should put patient well-being as the central output of medical education. If 25% or 50% of the medical students in the US were black or from some other minority group and were the most qualified individuals, that would be a successful physician workforce. It is not a function of skin color.
Contorting the admission process to medical school to improve health outcomes for black patients is a social experiment, not an evidence-based approach to reducing health care disparities. Why not work to improve access to our health care system through providing more community entry points rather than a wholesale re-engineering of the health care system? A successful outcome of the pending Supreme Court case in which Asian American students are seeking to end affirmative action at Harvard and the University of North Carolina could be the restoration of merit as the determining factor for entry into medical school. Patients deserve nothing less.
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