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Barbara A. Noah
Reprinted from: Barbara A. Noah, A Prescription for Racial Equality in Medicine , 40 Connecticut Law Review 675-721 (February, 2008)(186 Footnotes)
[p677] The man who never alters his opinion is like standing water, & breeds reptiles of the mind.
William Blake
The Marriage of Heaven and Hell
Plate 19 (1790)
Statistically, race plays a profound role in health. Estimates suggest that by 2030, well over forty percent of the American population will be members of minority races. A recent Harvard study examining regional and nationwide disparities in life expectancy found an eighteen year gap between the life expectancy for Asian females compared with African American males. Although the causes of such dramatic differences in life expectancy are multiple and complex, evidence suggests that cultural [p678] barriers to doctor-patient communication and resulting disparities in quality of care contribute substantially to the gap. More broadly, a significant body of research demonstrates that race adversely affects the quantity and quality of health care provided to minority patients. In order to tackle this truly odious quality gap, medical educators, individual health care providers, and health care institutions must take active steps to identify its underlying causes and make changes at all levels of health care delivery. This Article focuses primarily on the dynamic between individual provider and patient, and it considers educational and policy mechanisms, consistent with current law, to improve quality of care for patients of color and, ultimately, for all patients.
Research suggests that the quality of communication between physician and patient strongly influences the quality of care that the patient receives, and that social and cultural stereotypes can interfere with communication. Racial and cultural diversity in medical education helps physicians in training to develop crucial communication skills and to break down stereotypes so that all medical school graduates, not only minority physicians, will be equipped to communicate with and provide optimal care for patients whose race differs from their own. The concept of diversity frequently is understood to refer to racial and ethnic diversity, particularly focusing on the inclusion of under-represented minority (URM) groups, but the ideal medical school class should include not only under-represented racial and ethnic minority students, but also students of diverse political viewpoints, religions, and socio-economic backgrounds.
As explained within, diversity in medical education promotes two separate but related goals. First, admitting students of diverse backgrounds obviously opens up the professional field of medicine to members of diverse racial groups. Because URM physicians more often choose to work in medically underserved areas, this in turn increases access to care for underserved patients and provides many patients of color with the opportunity to receive care from a physician with whom they can communicate effectively and whom they trust. Second, diversity in medical education breaks down racial, cultural, and religious stereotypes [p679] by exposing all members of the medical school class to the different perspectives and experiences of their classmates. This immersional experience, together with explicit training in “cultural competence,” can improve the quality of communication between physicians and patients and, ultimately, the quality of medical care.
Because of longstanding societal inequities, the admission of well-qualified medical students from under-represented minority groups continues to pose challenges and, for now, admissions policies that consider race (among other important factors) play an essential role in guaranteeing racial diversity in medical schools. Other commentators have ably presented and evaluated the now-familiar arguments offered by proponents and critics of affirmative action in higher education. Supporters of affirmative action in higher education argue that these admissions programs both atone for past discrimination and provide some counter-balance for ongoing societal bias, and that diverse classrooms enhance the learning experience for students of all races and prepare graduates for work in a racially and culturally diverse world. Detractors of affirmative action in this context suggest that race-conscious admissions policies draw attention to and perpetuate racial differences, stigmatize the intended beneficiaries of affirmative action, and unfairly exclude highly qualified white applicants. This Article brackets and sets aside the larger, complex debate over affirmative action in higher education and instead focuses on the operation and influence of the diversity rationale as a justification for race-conscious admissions programs and its importance to eliminating bias and improving quality in health care delivery.
After a twenty-five year pause, the Supreme Court in 2003 once again spoke on the issue of affirmative action in higher education admissions and affirmed the ability of public colleges and universities to consider race as a factor in the admissions process. The narrowly drawn opinions in Gratz v. Bollinger and Grutter v. Bollinger focused on the specific educational contexts in which they arose-Gratz on undergraduate admissions and Grutter on law school admissions. The Grutter opinion considered and endorsed classroom diversity as a compelling governmental interest justifying the use of race and ethnicity as a factor in higher education admissions, as originally suggested by Justice Powell's well-regarded [p680] opinion in Regents of the University of California v. Bakke.
None of these opinions, however, explored in any depth the question of whether the nature of the compelling state interest justifying the consideration of race in higher education admissions differs from one educational context to another. As with many complex societal issues, broad generalizations work less well than specific and nuanced discourse to promote consensus. Because affirmative action and the diversity rationale will continue to provoke controversy, those who engage in the debate should attempt to make the dialogue more productive. Some skeptics view diversity as a visible manifestation of political correctness run amok, with little intrinsic value. Others see multiple layers of benefit, to minority students, their white classmates, and to society at large. Given this divergence of opinion, it would be helpful to explore the value and function of affirmative action to achieve diversity in specific educational contexts rather than simply as a general concept. Accordingly, this Article considers the operation of diversity as a justification for race-conscious medical school admissions and suggests that, although the rationales offered in support of race-conscious admissions support the use of these strategies to diversify classes in all types of higher education, the diversity rationale in medical education is different in kind and, in terms of its ultimate societal impact, arguably more compelling than in other contexts.
The Grutter decision by no means settled the debate about affirmative action and the value of diversity in higher education. In fact, a couple of recent developments suggest that this issue will continue to receive attention and that universities utilizing race-conscious admissions policies should not become complacent. With recent changes in the Supreme Court's composition replacing the authors of the majority opinions in both Gratz and Grutter, it is not inconceivable that the newly-constituted [p681] Court may seek an opportunity to revisit affirmative action in higher education. In fact, the Court at the end of its most recent term decided a pair of cases invalidating public school district plans that used student race as a primary factor in school assignments in order to maintain racial balance in the classroom.
The Court's initial decision to hear these cases provoked some surprise among commentators who observed that, in December of 2005, with Justice O'Connor still on the Court, the justices declined to hear a challenge to an almost identical school integration plan. In addition, the three federal circuits to hear such challenges since the Gratz and Grutter decisions all upheld the school district plans in question, leaving no circuit split for the Court to resolve. In deciding the public school cases, the Court avoided direct reconsideration of the higher education decisions from 2003, and in fact explicitly distinguished Grutter, but the Court's decision to invalidate these school district desegregation plans certainly opens the door to further discussion and undoubtedly will impact the debate about appropriate means to achieve racial diversity in the classroom and the intrinsic value of diversity as an educational goal. Even if the [p682] Court declines in the future to revisit the constitutionality of higher education affirmative action programs such as the one in Grutter, increasing litigation and legislative activity as well as growing public debate concerning the appropriateness of affirmative action will continue to have an adverse impact on the representation of certain minority groups in medical schools and ultimately in the medical profession. State initiatives prohibiting race-conscious university admissions policies already have chipped away at the practice in a number of states. Organizations such as the United States Commission on Civil Rights have criticized race-blind alternatives to affirmative action for failing to assist students of color who are not at the top of their high school classes and for significantly decreasing diversity in graduate level education. Pro-affirmative action organizations have expressed the well-justified concern that the Michigan decisions will galvanize opponents of the process into action at the state level. Even after the Grutter decision in 2004, eight [p683] anti-affirmative action legislative initiatives were introduced in three states and such efforts continue to this day. In fact, in November of 2006, fifty-eight percent of voters in Michigan approved a ballot initiative to amend the state's constitution to prohibit affirmative action in higher education admissions, public employment, and public contracting. Opponents of the measure immediately filed a legal challenge to the amendment in the U.S. District Court. The battle over affirmative action will continue.
Part II of this Article lays out the evidence documenting racial disparities in the provision of health care that contribute to poorer health outcomes for African Americans and several other minority groups. Part III provides an overview of some of the key constitutional decisions that have recognized and developed the position that racial and ethnic diversity represents a compelling governmental interest justifying the appropriate use of such classifications in higher education admissions. Part IV explores in depth the function of diversity in medical education and its connection with improved quality of care and provides some suggested approaches for tackling these challenges. Finally, Part V acknowledges the unanswered questions that remain in the conversation about race and health care quality.
II. The Race Gap in Health Care Delivery
An enormous body of well-designed scientific research demonstrates that minorities, particularly African Americans, experience a statistically higher likelihood of poorer health, earlier disability, and earlier death, compared to white Americans. Significant health disparities between [p684] minorities and whites persist despite identification of this pattern and repeated calls for responses from the medical community. Certainly cost-driven treatment decisions are an unavoidable reality for most patients, but other longstanding inequities in the delivery of health care services pose formidable problems for patients of color and the health care community continues to struggle to understand the underlying causes of health disparities. The correlation between health disparities and disparities in the quality of health care delivery received by whites versus racial and ethnic minorities is well-documented. As the Institute of Medicine explained in a recent analysis of the issue, “[r]acial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.”
Patients of color have expressed a continuing distrust in the health care [p685] system and in individual medical providers, and with good reason. An astonishing number of studies document health disparities between the races and conclude that factors such as genetic differences, lifestyle choices, and variations in access to medical care fail to account fully for these health disparities. Numerous studies concerning virtually every type of medical care strongly suggest that African American patients do not receive the same care as white patients when they seek medical treatment. For example, the utilization rates of coronary drugs and complex coronary procedures, racial disparities in access to organ transplantation, frequency of knee arthroplasty, and disparities in the [p686] provision and availability of pain medications suggest that African Americans and other minorities receive different care than white patients. Another study documented substantial delays in breast cancer diagnosis and treatment for African American women compared with white women, and yet another found that African American women were significantly less likely than white women to undergo genetic testing for increase risk of breast and ovarian cancer.
Although patient preferences may play a role in certain disparities in the utilization of medical procedures, there is real racial and cultural bias at work as well, at least some of the time. A couple of recent examples starkly illustrate the problem. In one highly publicized study, researchers [p687] found that physicians referred lower percentages of African American patients than white patients for cardiac catheterization, even when all other factors, i.e., age, sex, and severity of disease, were equal. Some studies clearly suggest that even when experts agree on an optimal intervention for a particular medical condition, African American patients may receive that treatment less frequently when they seek care. To take one striking example, several studies have demonstrated that African Americans are less likely to receive surgical treatment of early-stage lung cancer than whites, and, consequently, have a lower overall survival rate for the disease. These differential utilization patterns persist even when investigators control for confounding variables such as income, level of education, insurance coverage, co-morbid conditions, and stage of [p688] disease.
At least some of these variations in quality of care appear to spring from unconscious bias in individual health care providers. Measuring this sort of racial bias and its impact on clinical decision-making presents very real challenges, and designing well-controlled, targeted studies remains difficult. In the most recent study attempting to document the effect of unconscious racial bias on clinical decision-making, researchers found a striking correlation between the presence of implicit negative stereotypes of African Americans and a decreased likelihood to provide appropriate medical treatment. In commenting on the research, one co-author suggested that the physicians studied appeared to have unknowingly internalized racial stereotypes that had a subtle influence on their clinical judgment. As the authors conclude,
[i]mplicit racial biases are prevalent in the United States in general, and as such it should not be surprising that they are prevalent among physicians as well . . . . [Such biases] may affect the behavior even of those individuals who have nothing but the best intentions, including those in the medical professions.
Of course, not all health disparities between the races result from bias in health care delivery or disparities in access to care. As one commentator has observed, “two truths . . . may seem contradictory but aren't: 1) There is epidemic racism in this country. 2) You can find racism where it does [p689] not exist.” A complex interplay between socioeconomic status, education, lifestyle decisions and other behaviors, patterns of utilization of health services, and genetics influences the prevalence of disease in different racial and ethnic groups. Even more broadly, larger inequalities in society, such as discrimination in housing, employment, income distribution, education, and exposure to violence contribute to an increased risk of disease among minority populations. Nevertheless, evidence demonstrates the persistent effects of racial bias on the quality of medical care received by minority patients and the impact of this phenomenon in perpetuating health disparities. As a result, commentators have called for action to prevent bias and its effects on health.
III. The Diversity Rationale in Affirmative Action Case Law
The continued viability or ultimate demise of the diversity rationale in higher education admissions obviously has the potential to exert a significant effect on the representation of different races, cultures, and religions in the student populations of medical schools. The Supreme Court has interpreted the Equal Protection Clause to forbid state-funded [p690] colleges and universities from considering race in admissions unless the admissions policy is narrowly tailored and promotes a compelling governmental interest. In the late 1970s, the Supreme Court began to entertain the idea that racial and ethnic diversity in higher education serves important educational goals and can sometimes justify race-conscious admissions policies.
In its famous 1978 decision in Bakke, the Court considered whether the University of California at Davis's medical school admissions process violated the equal protection clause of the United States Constitution and Title VI of the Federal Civil Rights Act of 1964. Three of the Justices believed that the Davis program ran afoul of Title VI. Four different Justices concluded that the Davis program was permissible under both the equal protection clause and Title VI. Justice Powell, who cast the deciding vote, believed that the program was invalid under the Equal Protection clause and therefore rejected admissions quotas and set-asides used by the University of California. Nevertheless, he concluded that some affirmative action admissions programs could survive constitutional scrutiny by considering race as one of several factors in making [p691] individualized admissions decisions.
Justice Powell's separate opinion offered a different rationale in support of certain affirmative action admissions policies, discussing with approval the university's goal of attaining a diverse student body. The opinion concluded that diversity in the classroom could enhance education by introducing students to the novel opinions and experiences of their classmates. In favorably describing the admissions program at Harvard College, Justice Powell explained that all students benefit from learning in a diverse class setting:
Contemporary conditions in the United States mean that if Harvard College is to continue to offer a first-rate education to its students, minority representation in the undergraduate body cannot be ignored by the Committee on Admissions. . . . [T]he race of an applicant may tip the balance in his favor just as geographic origin or a life spent on a farm may tip the balance in other candidates' cases. A farm boy from Idaho can bring something to Harvard College that a Bostonian cannot offer. Similarly, a black student can usually bring something that a white person cannot offer. The quality of the educational experience of all the students . . . depends in part on these differences in the background and outlook that students bring with them.
Nevertheless, the opinion provided only limited endorsement for the use of racial preferences in higher education admissions, rejecting Davis's procedure of setting aside a specific number of places for racial minorities and preferring Harvard's holistic approach to evaluating candidates, in [p692] which race may serve as a “plus” for an otherwise qualified candidate. In response to Powell's opinion, many institutions of higher education attempted to implement a holistic approach to admissions, including consideration of race.
Interestingly, the Powell opinion briefly explored the operation of diversity specifically in the medical school context, although it also suggested that there may be “greater force to these views at the undergraduate level than in a medical school where the training is centered primarily on professional competency.” Justice Powell explained that, because physicians treat a heterogeneous population of patients, otherwise qualified medical students with diverse racial, ethnic, geographic, or other backgrounds may contribute to medical school ideas and viewpoints that enrich the educational experience for all students, making them better able to “render with understanding their vital service to humanity.” Most of the Powell opinion, however, considered the constitutionality of affirmative action in higher education as a general matter, suggesting that classroom diversity as a compelling governmental interest carries the same force in all higher education contexts.
Finally, Justice Powell also evaluated the university's argument that its special admissions program would improve the delivery of health services to underserved communities. Although he acknowledged that a State's interest in facilitating health care to its citizens may sometimes be sufficiently compelling to justify the use of racial classifications, he noted that the record simply did not support the university's claim that giving a preference to candidates of particular racial or ethnic groups would [p693] advance this goal. Today, this argument in support of race conscious admissions rests on a far more developed record. Recent research evaluating the preferences of URM physicians to provide care to underserved populations now strongly supports the argument that minority physicians are more likely to choose to provide care to minority patients and that these patients prefer to receive care from physicians of the same race or ethnicity.
In two federal decisions following Bakke, the Fifth and Ninth Circuits disagreed about whether to embrace Justice Powell's reasoning and the Supreme Court ultimately addressed the resulting circuit split in the Michigan litigation. In Gratz and Grutter, white applicants who were denied admission to the University of Michigan's undergraduate and law programs respectively challenged the university's use of racial classifications in admissions, claiming that the policies violated both the Equal Protection Clause of the Fourteenth Amendment as well as Title VI of the Civil Rights Act of 1964. The University of Michigan's law school admissions program, as described in Grutter, involved individual evaluation of each applicant in order to admit a class with a “critical mass” of students with diverse viewpoints and experiences and of diverse race and ethnicity.
In Grutter, a bare majority of the Court embraced the concept of classroom diversity as a justification for a narrowly tailored race conscious admissions program and provided some additional clarity about the [p694] diversity rationale. Justice O'Connor, writing the opinion for a five-justice majority, made several separate points about the operation of diversity within the university classroom, two of which deserve emphasis here. Not surprisingly, she confined her consideration of the value of the classroom diversity to the law school context. First, Justice O'Connor endorsed Justice Powell's views about the value of classroom diversity as a compelling governmental interest, noting that a mix of students with varying backgrounds and experiences promotes stimulating intellectual discussion and exchange of viewpoints, and shared understanding of different races and cultures. Second, she observed that graduation from an elite law school enhances the graduate's chances of active participation in public life and in positions of power in government, Congress, and judgeships. Essentially, as commentators have noted, diversity in the classroom serves two distinct purposes. From an interpersonal relations perspective, the interaction of students of different races promotes interracial understanding, and from a utilitarian perspective, it creates a graduating body of students who are prepared to succeed in an increasingly diverse global economy and society.
After concluding that classroom diversity constitutes a compelling state interest in legal education, Justice O'Connor next considered whether the law school's admissions program was narrowly tailored to promote that interest. As Justice O'Connor explained, the law school used a highly [p695] individualized evaluation of each applicant, considered race as one of many factors that might promote diversity, considered minority applicants in competition with other applicants, and sought merely to achieve a “critical mass” of racially diverse students but did not have a specific percentage as its goal. For these reasons, Justice O'Connor and the majority concluded that the program appropriately considered race and ethnicity and was narrowly tailored to promote the goal of achieving a diverse classroom experience for its students. Although Justice Kennedy dissented in the case, arguing that the University of Michigan School of Law's particular admissions scheme did not satisfy the narrow tailoring requirement, he agreed with the idea that a diversity rationale could serve as a basis for race-conscious admissions policies.
In its most recent term, the Court once again addressed the question of racial diversity in education, this time in the context of public elementary and secondary schools. In Parents v. Seattle School District 1, Chief Justice Roberts, writing for a divided Court, concluded that school district plans that assign students to schools based on race violate the Equal Protection Clause, despite the fact that the school assignment plans were [p696] attempting to promote racial integration. Interestingly, Justice Kennedy, concurring in part and concurring in the judgment, argued that the plurality opinion inappropriately dismissed the government's legitimate interest in creating a diverse student body, suggesting that school districts could “adopt general policies to encourage a diverse student body . . . without treating each student in a different fashion solely on the basis of systematic, individual typing by race.” Almost immediately after the decision was announced, parent groups resurrected challenges to similar local school district policies. School assignment plans around the country designed to promote de facto desegregation now face renewed legal scrutiny. In the wake of these recent decisions, it is difficult to predict how the newly constituted Court would rule on the diversity rationale in the higher education context, were they to revisit the issue.
The majority opinion in the school assignment cases, in distinguishing Grutter, treats the public school and higher education contexts differently, focusing primarily on the use of race for remedial purposes in public education but allowing for a separate consideration of the value of diversity in the higher education context. Moreover, the race-conscious admissions program in Grutter evaluated each student individually and holistically rather than simply trying to balance the presence ofdifferent minority groups within the school. Nevertheless, it is troubling that the five-justice plurality refused to acknowledge the very different purposes that consideration of race promotes in these modern districting plans compared with the old use of race to segregate schools in the years before Brown v. Board of Education was decided. Whatever the eventual fallout, the decision in the school assignment cases signals a significant adverse shift in racial desegregation policy and a continued erosion of support for [p697] integration in this country which will undoubtedly have a negative impact on higher education as well.
IV. Diversity in Theory and in Practice:the Medical Education Context
The problem of achieving diversity is hardly unique to medical education. Administrators in other professional education contexts, such as law, struggle with some of the same issues. For example, in the past ten years, African American enrollment in law schools has declined, although Asian and Hispanic enrollment has grown, and, as in medical education, law schools wrestle with controversial questions about the purposes of and appropriate means to achieve student body diversity. The focus of the remainder of discussion on the role of diversity in medical education is not intended to diminish its importance in other contexts but rather to make the case for the uniqueness of the diversity rationale in medical education.
In the general affirmative action literature, the term “diversity” usually refers to racial and ethnic diversity with a particular emphasis on underrepresented races compared with population-wide percentages. In current discussions of “diversity” in medical education, much of the debate [p698] centers around racial and ethnic diversity, particularly the under-representation of four minority groups in medical school: African Americans, Mexican Americans, Native Americans, and mainland Puerto Ricans. In addition to acknowledging the impact of racial diversity in the classroom, it is worth adding that religious, socio-economic, and even political viewpoint diversity can play an important role in medical training and in the provision of quality medical care.
A. History and Progress
Medical educators committed to improving the racial and ethnic diversity among physicians have made notable progress in the last forty years, and although the number of African American physicians increased by 50% from 1980 to 2004 African Americans remain underrepresented in the physician workforce. In the 1968-69 academic year, African Americans comprised only 2.2% of the 35,800 total students enrolled in medical schools. Fifty-eight percent of African American students at that time attended either Howard or Meharry, two historically black medical [p699] schools. In the following eight years, medical schools made significant progress toward the goal of integrating the profession. By academic year 1975-76, 6.2% of the 35,800 total medical students were African American. At this point, medical schools had a total underrepresented minority (URM) enrollment of 8.1%, but only 12.45% of these students were enrolled at Howard or Meharry.
Certain minority groups currently remain underrepresented in medical schools. The most recent available figures indicate that in 2004, 6.5% of U.S. medical school graduates were African American and 6.4% were of Hispanic origin. Additionally, African Americans then comprised 3.3% of the current physician workforce and Hispanics 2.8%. As a point of comparison, African Americans comprise approximately 13% of the total U.S. population, while Hispanics also comprise almost 13% of the population. The attacks on affirmative action described above have exerted a direct and marked impact on URM enrollment. In 1995, African American enrollment peaked at 9% with Hispanic enrollment peaking at 7.2% in 1996. During the same period, the Fifth Circuit issued an opinion prohibiting public universities from considering race in admissions, and Proposition 209 was passed in California, banning the *700 use of race in the public universities admissions. Not surprisingly, the percentage of URM medical students began a slow decline.
A portion of the underrepresentation problem stems from the under-supply of minority students from public schools who are academically prepared to succeed as undergraduates and thus are able to apply successfully to medical schools. The after-effects of two centuries of racial discrimination, higher rates of poverty, and lower educational attainment in families of URM public school students reduces the likelihood that these students will have the opportunity to prepare for and successfully apply to medical school. As one commentator noted, “[m]edical schools quite properly will admit only those who are almost certain to graduate, and the substandard educational opportunity available to Black youngsters constricts the pipeline.” Public schools in the United States are re-segregating, despite efforts by many school systems to keep them integrated, and the Supreme Court's school assignment decision from last term will likely hasten this process. Moreover, [p701] African Americans and Hispanics have lower rates of high school graduation than whites, making these minority groups statistically less likely to attend college programs that will prepare them for medical school. Thus, the pool of URM applicants to medical schools who possess the academic credentials to compete successfully with other applicants remains comparatively small.
Some commentators condemn affirmative action programs based on the belief that such programs admit minority candidates whose education has not adequately prepared them for the rigors of medical school, and urge continued funding of outreach programs designed to intervene earlier in the educational process in order to increase the pool of qualified minority candidates for medical school. Programs to improve preparation for medical school undoubtedly facilitate the academic success of under-represented minorities and, ultimately, will increase the numbers of minority physicians. At least for now, however, it seems unlikely that these programs alone will prove effective in ensuring a critical mass of [p702] URM students in medical schools. Outreach programs should be used to enhance the impact of affirmative action in medical school admissions, but, at this point, affirmative action remains a necessary and appropriate tool promote diversity in the medical school classroom and ultimately in the physician work force.
Nevertheless, despite the Court's holding in Grutter, some commentators continue to argue that the basic constitutional principle of racial equality and the concurrent requirement of strict scrutiny create a strong presumption against the use of racial classifications. Given the controversy surrounding affirmative action, race-neutral alternatives to affirmative action, such as socio-economic diversity, continue to receive serious consideration and such alternatives undoubtedly serve as appropriate adjuncts to race preferences. It is not clear, however, whether using exclusively race-neutral preferences will allow for the admission of a “critical mass” of URM students in medical schools. The broader debate about the merits of affirmative action deserves continued attention and will, it is hoped, eventually become moot if the achievement gap between the races diminishes. The remainder of this Article will examine how diversity, whether achieved through affirmative action or race-neutral means, or both, enhances the quality of medical education and [p703] ultimately the quality of care for patients of color.
B. The Value of Diversity in Medical Education and Beyond
In their highly influential book on race preferences in university admissions, William Bowen and Derek Bok make a compelling case, using data from a forty-year longitudinal study on African American and white university students, for the value of diversity as a justification for the continued use of affirmative action. Other data supports the general value of diversity across all types and sizes of colleges and universities. But, as Bowen and Bok have observed, “one problem with much of the debate over affirmative action is that it lumps together a large number of highly disparate areas and programs, ranging from the awarding of contracts to minority-owned businesses to . . . the admissions policies of colleges and universities.” Certain arguments in support of affirmative action to achieve diversity in business, for example, may be less persuasive in a different setting such as higher education.
Even within the context of higher education, diversity serves different functions in various educational settings. The learning experience for [p704] undergraduates, law students, and medical students, for example, differs significantly because the purpose of these programs and the eventual occupations of their participants differ. The educational stakes in medical training are enormous; as in other graduate professional programs, all members of a racially and otherwise diverse medical school class can potentially benefit from the experiences and attitudes of their peers. In medicine, however, this education also directly benefits the patients to whom these physicians provide care. As explained below, there is inextricable connection between physician training and successful communication with patients of different races and cultures, and a connection between communication, eradicating racial biases and stereotypes, and improved quality of care. Classroom diversity plays an essential role in promoting these goals in medical education and must, for now, be continued support through the use of carefully considered race-conscious admissions process.
Consider in comparison the law or business school contexts. Although a diverse class undoubtedly enhances the learning process for students in such programs, the stakes after graduation may be lower. For better or worse, many attorneys or MBAs will enter practices or businesses where they will encounter few minority clients, though issues of cultural competence in lawyers have attracted comment as part of the discourse about how lawyers can provide skilled and effective representation. By [p705] contrast, most physicians will care for some, if not many, patients whose race, ethnicity, religion, and educational level differs from their own, and the quality of care these patients receive can have a significant impact on their health and quality of life. In medical schools, a diverse class serves the interests of the future physicians themselves and, more importantly, their patients.
By definition, medical education requires student interaction that differs in kind from that experienced by undergraduates, law, or business students. In fact, some commentators have observed that the development of physicians' professionalism occurs mainly “outside the domain of the formal curriculum and that such learning involves indoctrination in the unwritten rules of . . . medical practice.” Because so much of medical professionalism centers around the physician's ability to communicate with the patient and because so many physicians provide care for patients whose backgrounds differ from their own, the informal learning that occurs in the interstices of the formal medical curriculum can only be enriched by the interaction of students with diverse backgrounds and experiences. Medical students develop their professional selves through a complex process of acquiring values along with medical knowledge:
It is not sufficient for students to acquire the knowledge, skills, and outward behavior necessary for practicing medicine. Being a physician-taking on the identity of a true medical professional-also involves a number of value orientations, including a general commitment not only to learning and excellence of skills but also to behavior and practices that are authentically caring.
[p706] It is this aspect of professional education that deserves special notice in the context of medical education. Of course, all professional education (law, business, engineering) involves more than simply the acquisition of specialized knowledge. Most professionals in these disciplines acquire values and communication skills along with the rest of their training, but those acquired by future physicians possess a unique significance because they directly affect the physician-patient relationship and thus the patient's health and well-being.
The first four years of medical school are divided into two years of preclinical and two years of clinical training. Medical educators explain that the entire training experience is designed to promote four inter-related goals: basic science and medical knowledge, basic skills such as performing a physical exam, attitudes and values such as professionalism, and a habit of lifelong learning which is necessary for physicians to keep abreast of evolving medical concepts and technologies. Although much of the preclinical curriculum focuses on learning the basic science and principles of disease, medical students also begin, usually in a highly interactive format, to learn clinical practice skills such as learning to take patients' medical histories, and learning to perform basic procedures such as taking vital signs, and performing physical examinations. Often, students practice on each other, or on volunteer actors who play the role of patients. During the following two clinical years, medical students gain experience in all of the major specialties, usually including internal medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry, and neurology. Exposure to these specialties through hospital and outpatient-based “clerkships” gives medical students the opportunity to work with qualified physicians as they learn about the more common [p707] diseases and conditions associated with each specialty and to develop more practical skills. As students begin to participate in actual medical practice, ideally they will learn not only how to diagnose and treat a patient's illness, but also how to care for individuals based on each patient's particular personal environment, financial circumstances, religious beliefs, cultural concerns, and other relevant factors.
In sum, the benefits of classroom diversity in medical schools extend far beyond the classroom. Ideally, the physician workforce will mirror the increasingly diverse society in which it practices. Obviously, training more minority applicants in medical schools guarantees diversity in the future physician workforce. Sheer numbers matter, because major urban and rural areas in the United States remain medically underserved. As a general matter, minority physicians are more likely than their white counterparts to specialize in primary care, and to provide care to patients of color. One study suggests that minority patients are four times more likely than white patients to receive care from minority physicians. Another study found that 22% of physicians provided about eighty percent of primary care to African American patients.
[p708] The Association of American Medical College's Medical School Graduation Questionnaire for 2004 indicated that approximately one-fifth of graduating medical students intended to practice in medically underserved areas. The intent to practice in such areas varied significantly by race; over 50% of African American students, 41% of Native American students, and 33% of Hispanic students intended to locate their practices in underserved areas compared with only 18% of white students. At the same time, recent data suggest that levels of URM physicians continue to drop compared with the diversity of the populations they serve, and without a continued commitment on the part of medical schools to train a diverse population of physicians, the diversity gap between physicians and the patient population will continue to widen.
Some commentators disagree that studies suggesting that minority physicians will provide care for disproportionately high numbers of minority patients can justify affirmative action in medical school admissions. Instead, those who take this position suggest that any medical school applicant who expresses an intention to provide care in underserved areas of the country should receive consideration in the evaluation process for such an altruistic impulse. Admissions committees already consider [p709] each applicant's expressed and demonstrated commitment to service in the medical profession, but the data described above suggest that URM physicians more frequently make this sort of career decision and, because of related concerns about cultural competence described below, minority race ought to work as an additional plus in the applicant's favor.
Separately, however, the workforce diversification argument for affirmative action in medical school admissions rests on a troubling assumption that only URM physicians can effectively communicate with and provide highquality care for minority patients. While it may be true that minority patients trust and communicate more effectively with minority physicians, an ideal of racial concordance between physician and patient is both impractical and short-sighted. The long-term goal is to teach and support communication skills and the exercise of clinical judgment that will foster understanding and trust between physician and patient, regardless of the race of either. In this sense, the diversification of the physician workforce represents a step along a path to improved medical care in which the race of patient and physician ultimately becomes irrelevant.
To achieve this goal, diversity in medical education plays a separate and ultimately more important role, that of breaking down racial, cultural, and religious stereotypes by exposing individual students of all backgrounds to the different perspectives and experiences of their classmates. Whatever the physician's race, the ability of physicians to communicate with patients whose racial, ethnic, or religious backgrounds differ from their own remains crucial to improving quality of care for all patients. Those who have examined cultural barriers to medical care [p710] describe communication barriers in sharply evocative language. As Anne Fadiman explains in her wonderfully informative book about the cultural conflicts between a community of Hmong immigrants and the staff of a county hospital, such conflicts operate as “collisions, which made it sound as if two different kinds of people had rammed into each other, head on.”
Exposure during intensive medical training to the views and perspectives of classmates from varied racial, cultural, economic, and religious backgrounds helps to eradicate stereotypical assumptions and outright bias that may disrupt the physician's ability to make sound medical recommendations or may diminish the patient's trust in the physician. During medical school, students who spend long hours of training with contemporaries of different races and ethnicities develop better communication skills and a finer ability to understand and interact with sensitivity to patients who differ from themselves. In the medical delivery context, commentators refer to such skills as “cultural competence” though the term encompasses much more than simply achieving a passing understanding of, for example, “Black culture” or “Hispanic culture” or “Muslim religion.” In fact, although some [p711] unifying cultural or religious principles may predominate, the key to true cultural competence lies in the ability to communicate with patients as individuals, while being attentive to the potential impact of cultural issues, and to maximize the quality of medical decision-making through a respectful understanding of each patient's individual beliefs, preferences, concerns, and ability to comprehend.
This concept of individualized communication nevertheless remains in tension with questions about the relevance of patient race to medical care. A patient's race (and sometimes religion or cultural background) is undeniably relevant in certain instances to making an accurate diagnosis or plan of care. For example, certain diseases occur more frequently in African Americans than in Caucasians, and understanding patterns of disease incidence and risk remains essential to the practice of medicine. On the other hand, while remaining aware of these trends, physicians must take care to avoid racial profiling of their patients because of the risk of stereotyping and excess rates of misdiagnosis by race. As research into the role of genetic variation in disease progresses, race ultimately will become a biologically meaningless term. For now, it serves as a cumbersome and not very accurate predictor of far subtler genetic and [p712] physiologic differences that may or may not manifest along racial lines.
Race, for now, plays a role in diagnosis, but apart from that role, race, as well as religion and other cultural factors, can affect the quality communication between physician and patient. Evidence suggests that most patient complaints arise from communication problems with their physicians. Health care scholars have argued that the minority patient population's lack of trust in the predominately white medical system discourages these patients from seeking early medical attention, even when such care is accessible. In addition to affecting patients' perceptions about the care that they receive and their trust in the medical system, the quality of communication significantly impacts patient adherence to prescribed medical regimens, such as medication and diet. Because patient non-compliance with physician recommendations can contribute to [p713] undesirable therapeutic outcomes, it seems fairly obvious that physicians must ensure that their patients genuinely understand how to “follow doctor's orders.” The lower education and literacy rates among African Americans and other racial minority groups contribute to the challenges of providing quality medical care, impacting various issues such as medication compliance and informed consent. According to data from the most recent census, the correlation between minority race, poverty, and lower educational attainment remains stubbornly constant, making these problems more frequent among patients of color. Patients with low literacy levels have significant difficulty, for example, with appropriate prescription medication use, necessitating careful communication by prescribing physicians to improve the safety and efficacy of drug therapy for these patients. In addition, educational programs to promote cultural competence must acknowledge and address the problem of language barriers where they exist.
The problem of cultural bias and lack of understanding runs in two directions. Apart from the impact of communication problems on patient trust and compliance with recommended medical care, a physician's [p714] stereotypical or biased beliefs can interfere with his or her exercise of decision-making authority in making recommendations among different treatment alternatives. Thus, part of the cultural competence curriculum should address awareness of disparities in health care and the influence that race and ethnicity may exert on clinical decision-making. The discretionary nature of medical decision-making opens the door to conscious and unconscious racially-biased assumptions on the part of health care providers. As Professor Gregg Bloche has explained, most medical decisions lack empirical and scientific support, and, because physicians usually have a variety of diagnostic and therapeutic choices, “wide variations in the incidence of many common medical and surgical procedures have been documented within small geographic areas and between individual practitioners.” Professor Bloche observes that the relatively unconstrained nature of clinical decision-making paves the way for physicians' stereotypical beliefs to influence their judgment about appropriate treatment options for individual patients. Together with “the attenuation of empathy across racial lines in clinical relationships,” physicians' judgment can be distorted, even in the absence of conscious racism. For these reasons, cultural competence curricula should address not only the communication issues described above but should also press physicians in training to identify and confront their own biases and to consider how they may affect their exercise of clinical judgment.
Many medical schools now include a communication skills component in their curriculum, either at the medical college or graduate medical education stage, often as part of a course dealing with the physician-patient [p715] relationship. Most programs cover the subject of patient communication as part of an existing required course, although others offer it as a stand-alone required course or elective. In some medical schools, the “Introduction to Clinical Medicine” or equivalent course includes topics such as patient interviewing and communication, as well as discussions about the interrelationships between race, gender, poverty and health. The Association of American Medical Colleges' accreditation standards do require that both medical school faculty and students have an understanding of diverse cultures and beliefs that may affect health care and that students become aware of their own cultural biases. It is difficult to determine the content of such courses and they apparently comprise a very small percentage of the curriculum in both the four-year program and in residency programs.
Along the same lines, some commentators have urged medical schools [p716] to train students about issues surrounding race and health care, including the development of courses specifically designed to increase sensitivity and improve understanding of diverse ethnic groups. In addition, a relatively recent addition to the medical boards requires prospective physicians to pass a patient interview component. The Clinical Skills component of the United States Medical Licensing Examination is designed to assess whether a medical student demonstrates the fundamental skills necessary for effective diagnosis of and interaction with patients. Finally, as physicians in training learn about the role of cultural issues, they should be prepared to examine their own attitudes and behaviors critically in order to detect their own internal biases and move beyond them to understanding the individual needs of their patients.
The medical education community clearly recognizes the value of cultural competence training but, if medical educators genuinely take such training seriously, they must devote more classroom hours to it. In the same vein, because individual patient's religious beliefs can impact their preferences and their understanding of medical options, medical schools should include, in their efforts at cultural competence training, curricula that assist physicians with understanding and incorporating religious beliefs into patient care. As a corollary to these curricular reforms, [p717] Congress must retain its commitment to encouraging the training of minority health care professionals. Encouraging minorities to enter the health care professions in greater numbers will help to create a culture of trust between the health care system and its minority patients, with the ultimate goal to train all physicians to communicate well with their patients while keeping the gates to careers in medicine open to a diverse population of future physicians.
Moreover, medical educators must recognize that adding cultural competence training without retaining a commitment to diversity in the classroom probably will fail to improve cultural competence. Medical schools need that, admittedly difficult to define, “critical mass” of URM students, as well as students from various religious, socio-economic, and geographic backgrounds, in order to promote open discussion about and familiarity with the impact of racial, religious, familial, and other factors on patients:
In acquiring the necessary skills to provide appropriate care for their diverse patients, all students, irrespective of their individual backgrounds, must gain a firm grasp on how various belief systems, cultural biases, family structures, historical realities, and a host of other culturally determined factors influence the way individuals experience illness and the way they respond to advice and treatment.
Medical students do not truly understand these concepts from reading textbooks. There is a direct correlation between classroom diversity and these pedagogical goals-a critical mass of students from various backgrounds normalizes frank and open discussion about these issues and makes them more difficult to dismiss. Having only a small number-one [p718] or two or three-of students of color in a class may place undue pressure on those few students to serve as the “voice” of their racial or ethnic group. Even when a student is willing to speak about his or her understanding of a particular racial or cultural issue, instructors should take care to emphasize that individual members of the group in question may not share that particular perspective. By contrast, a “critical mass” of racial minorities makes classroom discussion of issues in which race or ethnicity plays a role more difficult for white students to dismiss.
For all of these reasons, many physicians and commentators have made a strong case for continuing the practice of affirmative action in medical school admissions. As Justice O'Connor explained in Grutter, classroom diversity “better prepares students for an increasingly diverse workforce and society and better prepares them as professionals,” and “skills needed in today's increasingly global marketplace can only be developed through exposure to widely diverse people, cultures, ideas, and viewpoints.” The application of such reasoning to health care delivery seems obvious. Even so, critics have observed that “the whole argument over what whites will learn from the presence of a critical mass suggests that ‘diversity’ is for the educational benefit of whites,” which some students of color may find offensive. In the context of medical education, it is hoped that the interplay between cultural understanding, communication, and quality of care described throughout this Article transcends this superficial critique of the value and effect of diversity.
V. Final Thoughts and Future Challenges
Affirmative action remains a controversial and inconsistently effective solution to a complex problem in higher education. Professor Charles Lawrence, for example, has argued that diversity as a justification for [p719] affirmative action fails to remedy deeper societal discrimination and, instead, preserves the current flawed university admissions process. By relying on the diversity rationale as a justification for affirmative action, Lawrence argues that defenders of diversity such as Bowen and Bok “defend the integration of an existing elite without questioning that elite's participation in the reproduction of institutional racism.” The debate about the merits of the diversity rationale coupled with the rapidly developing literature on “race-neutral” preferences receives fuller treatment elsewhere, but medical schools should take whatever steps necessary and consistent with current law to achieve diversity of race, religion, and socioeconomic background in their student bodies.
This Article does not attempt to summarize and discuss the entire debate about affirmative action in higher education. Instead, it considers the practice of race conscious admissions practices as permitted after the Grutter decision and examines the special merits of the practice in medical school education. The Grutter decision affirming racial diversity in the classroom as a compelling governmental interest represents an important first step in the process of eliminating bias in health care delivery. The commitment to diversity can and should remain steadfast in all higher educational contexts, but the conversation about the value and purpose of affirmative action will prove more productive if it is context-specific. Although a diverse class undoubtedly enhances the learning experience for students in undergraduate programs, law, and business schools, the stakes are simply different in medical education. The trickle down effect of under-representation of racial minorities in health care delivery has a far greater impact on society than similar under-representation in law services or business enterprises. It would be indefensible to return to essentially de facto segregated medical education in this era of rapid minority population growth in the United States and continued health disparities between whites and racial minorities. Medical schools must remain committed to social justice as a key component of the ethic of professionalism that students develop during their training.
The United States government has acknowledged the vexing and [p720] seemingly intractable problem of health disparities between the races. Although inadequate access to care contributes to much of these health disparities, the dearth of minority physicians in general and the larger problem of inadequate training to improve the ability of physicians to communicate with patients of different racial or ethnic backgrounds makes progress difficult to achieve. Minority physicians remain more likely than white physicians to treat minority patients, and minority patients continue to express a preference for physicians of the same or similar racial background. Ideally, the medical education system will train all physicians to provide high quality care, with respect and compassion, to all patients, regardless of the race of the physician or patient. Proponents of integrated medical education clearly have made significant strides in the last quarter century, but the continued evidence of racial disparities in health care delivery, racial bias and communication problems between physicians and patients demands an ongoing commitment to the inclusion of substantial numbers of underrepresented minority students in medical school.
Many challenges remain. Continued efforts at diversification of medical school classes and cultural competence training represent only the first step in transforming the health care delivery system in ways that will improve the overall health of Americans and particularly of racial and ethnic minorities. Although it is clear that communication issues and unconscious bias negatively affect the quality of care that minority patients receive in a variety of circumstances, recent evidence suggests that interpersonal discrimination is only one piece of a larger puzzle. The lasting effects of societal discrimination and residual segregation also appear to impact the quality of care that minority patients receive. Moreover, although the evidence suggests that training more URM physicians will actually improve quality of care for URM patients, and that non-minority physicians will benefit from education in a racially diverse setting, it will be difficult to measure directly the actual impact of such reforms on quality of care.
[p721] Ultimately, high quality medical care happens in an environment that encourages meaningful one-on-one interactions between individual health care providers and individual patients. This goal-truly meaningful communication, genuine respect, trust and mutual understanding between patient and physician-if achieved, ultimately can transcend matters of race and culture. An important step toward this goal begins with medical education that trains physicians not only in the science and art of medicine but also in the more universal and essential art of communication. In a society that continues to struggle with matters of race, and in a health care system that continues to deliver health care that is infected with bias, racial diversity in medical education remains an essential tool to train all new physicians to bridge the divide with patients who are different than themselves. Overall, progress is evident and it is heartening. In the past couple of decades, health quality research has moved from recognizing the deeply troubling evidence of racial disparities, to acknowledging that such disparities present challenging ethical and legal dilemmas, to attempting to understand the causes of these disparities and, ultimately, to devising strategies to address them. This final step will undoubtedly prove most challenging. At the very least, graduating classes of new physicians who are aware of and attentive to these issues represents an essential step along the path to equality in health care.
Associate Professor, Western New England College School of Law; J.D. Harvard Law School.
