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.
