Diversity, Equity, and Inclusion and the Impact on Health Equity: Past, Present, and Future

Published October 20, 2023

Diversity, Equity, and Inclusion and the Impact on Health Equity: Past, Present, and Future

In the wake of the COVID-19 pandemic, there is a growing focus on health equity, defined as “the state in which everyone has a fair and just opportunity to attain their highest level of health.”[1] Pursuing health equity requires identifying and addressing “avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”[2]

Among the many factors contributing to continued health disparities is the lack of a diverse physician workforce.[3] Most medical schools have implemented diversity, equity, and inclusion (DEI) initiatives, but building the pipeline to a diverse physician workforce still faces structural biases.[4] Pipeline diversification efforts must continue to evolve to address these biases and the resulting physician workforce inequities.

To understand the current challenges and make impactful forward progress, PYA has compiled compelling research related to healthcare workforce diversification efforts. This research has been organized in a “past, present, future” format to provide context, acknowledge limitations and obstacles, and highlight the importance of continued, intentional efforts to create a diverse physician workforce.

Past: Structural Racism and Underrepresentation

In the early 20^th century, the American medical education system looked significantly different than today. Most medical schools were small, independent, and for-profit with varying curricular criteria. Standardization began with the establishment of the American Medical Association Council of Medical Education (CME) in 1904.[5]

The Flexner Report, published in 1910 by Abraham Flexner, targeted for-profit medical schools, claiming these institutions created a surplus of poorly trained physicians in an effort to make a profit. The report’s impact was significant, as one-third of American medical schools closed following its publication.

Today, the Flexner Report is considered a cover for structural racism.[6] Only two of the seven medical schools that accepted Black students survived the early 1900 closures: Meharry Medical College and Howard University. The Flexner Report opines that curriculum at these schools should “’focus on hygiene rather than surgery’” to serve as sanitarians with a purpose of “’protecting whites’” from common disease.[7] The report defined Black physicians’ role as limited to caring for Black communities only, further reinforcing structural racism in healthcare. The closing of many Black medical schools, coupled with segregation laws and practices which continued in hospital systems until the 1960’s, meant few Black Americans received medical education during the first half of the last century, leaving their communities underserved.[8]^,[9]

We continue to see the impact of the Flexner Report and subsequent closures across America’s medical education landscape today. While Black Americans make up 13% of the U.S. population, they comprise only 5% of practicing physicians. [10]

Black Americans are not the only minority group currently underrepresented in the physician workforce (Fig. 1). According to a 2022 Association of American Medical Colleges (AAMC) report, medical school faculty and the practicing physician workforce are predominately white and male.[11] While nearly 20% of the U.S. population is Hispanic or Latino,[12] only 7% of the physician workforce is Hispanic or Latino. Only 37% of the physician workforce is female.[13] Although approximately 20% of the U.S. population live in rural areas, only 9% of physicians practice in rural communities.[14]^,[15]Further, Black and Hispanic physicians are more likely to provide care to underserved populations when compared to white physicians.[16]

Figure 1[17]^,[18]

Present: Distrust, Bias, and Financial Burden

Though the United States has made many important efforts to curb structural racism within the last 100 years, including but not limited to the civil rights movement, significant inequities still exist.[19] Continued bias has direct impact on our healthcare system and health outcomes of patients in America. The impacts resulting from this bias include the way people access and receive healthcare, the quality of care provided, and the ability to pursue a career within the medical field.

In terms of health outcomes, racial and ethnic minority groups experience worse health outcomes than do white groups, as noted by the Centers for Disease Control and Prevention (CDC). The CDC reports that members of minority groups are more likely to be affected by and die from health conditions such as diabetes, hypertension, obesity, asthma, heart disease, and COVID-19 when compared to their white counterparts.[20] Black infant mortality rates are nearly double the national average, even when controlling for socioeconomic status.[21]

The disparities in health outcomes are attributable, at least in part, to distrust in a healthcare system that does not reflect the population it serves.[22] Recent research shows people of all ethnicities are more likely to visit a doctor if the doctor is the same race. Having the same gender tends to be a lesser factor, though still important. Additionally, Black patients report having a better patient experience if their doctor is also Black.[23] Yet, the current healthcare landscape does not provide patients the opportunity to select a provider of a similar racial or ethnic background. Overall, 53% of Black patients believe it is challenging to find a Black doctor.[24] In addition to improved access, a Howard University article highlights the importance of Black physicians serving as role models and inspiration for young Black students and the future Black healthcare workforce.[25]

To enhance a patient’s ability to choose a healthcare provider of a similar background, continued diversification of the population entering the pipeline for medical school is required. The number of Black, Hispanic, and American Indian or Alaska Native medical students has increased in recent years, but the number has increased at a rate slower than the U.S. population, resulting in continued underrepresentation.[26] In 2015, the AAMC published a report highlighting the lack of Black males applying for medical school over the past four decades. Specifically, fewer Black men were applying and being accepted to medical school in 2014 than in 1978. The percentage of Black male enrollment at medical schools has only slightly increased since 2014, from 2.4% to approximately 3% in 2022.[27]

In addition, a recent article discussed bias during the medical school application and admissions process against students who begin their education at community colleges, where 51% of students identify as a race or ethnicity other than white.[28] Further, 60% of community college attendees are women.[29] Even students who attended a community college before ultimately graduating from a four-year institution had a lower acceptance rate to medical school compared to students who attended only a four-year university.[30]

Many students choose a community college education to control the financial burden of higher education.[31] The total average cost to attend a traditional, four-year medical school is currently $300,000, and 70% of students graduate with average debt of $200,000.[32] All minority populations, including American Indians, Alaska Natives, Asians, Black Americans, and Hispanics, are more likely to take out loans to pay for medical school rather than obtain scholarships or rely on personal funds from relatives.[33]

Faced with such indebtedness, minority students are less likely to apply for and matriculate from medical school. A 2023 study found Black and Hispanic students who take the Medical College Admission Test (MCAT) are still less likely to apply to medical school, and Asian, Black, and Hispanic students who take the MCAT are less likely to graduate from medical school when compared to their white counterparts.[34] While several factors contribute to this discrepancy, financial constraints are a significant limiting cause.

Future: Meaningful Progress and Sustainable Change

Looking forward, efforts to diversify the physician workforce and reduce partiality must continue in a dynamic fashion. We must ensure these endeavors are meaningful and durable. To do so, leaders must be willing to pivot strategies and adapt in today’s ever-changing healthcare landscape.

During the last 30 years, organizations have deployed racial diversity programs to curb structural bias. These programs are meant to educate employees about implicit bias, challenge societal stereotypes, and implore people to practice equity in their everyday lives. The efforts are well-intentioned; however, evidence shows they are largely ineffective and rarely create significant change in behavior.[35] Racial diversity programs fail largely because the contained, short-term efforts lead to complacency among leaders, who therefore falsely believe the training is resolving the problem.[36]

To create meaningful, sustainable change, we need to address the structural bias ingrained in our organizational practices.[37] This change begins prior to the medical school admissions process with pipeline programs such as the Area Health Education Center (AHEC). Currently, 44 states have adopted AHEC programs designed to expose pre-college students to a variety of health careers while maximizing diversity, focused in rural and underserved communities.[38] Programs such as these create change at the root of the issue and establish a more diverse pipeline to enhance the future healthcare workforce.

The AAMC and the National Medical Association (NMA) also announced a collaboration to address the underrepresentation of Black men in medicine, called the Action Collaborative for Black Men in Medicine. [39] The Action Collaborative has partnered with primary education, higher education, academic medicine, professional organizations, community-based organizations, and other key stakeholders to “refine a national action agenda and plan for the implementation and evaluation of system-wide solutions.”[40]

The Medical Minority Applicant Registry (Med-MAR) is another example of meaningful progress. Med-MAR increases medical school admission opportunities for students from groups who are historically underrepresented and/or socioeconomically disadvantaged by distributing students’ basic biographical information and MCAT scores to minority affairs and admissions offices of AAMC-member universities and health-related agencies to improve matriculation.[41] The AAMC continues to publish educational materials and resources for medical schools and academic medicine institutions to work toward overcoming unconscious bias and addressing underrepresentation in medicine.[42]

In the 2022 Medical School Graduation Questionnaire, 74.6% of respondents, who were recent graduates of medical school reported receiving some experience related to cultural awareness and cultural competence, and 82.5% of respondents reported receiving experience related to health disparities. The Liaison Committee on Medical Education (LCME) has also considered adopting specific standards requiring DEI competencies in medical education curriculum since 1997, when they adopted accreditation standards related to student diversity.[43]

Though most organizations understand the importance of diversification, efforts to pass DEI legislation often experience significant opposition.[44] As of July 2023, several states, including but not limited to Arizona, Florida, North Carolina, North Dakota, Ohio, South Carolina, Tennessee, and Texas, have introduced bills restricting DEI efforts.[45] Specifically, Florida passed a bill in April 2023 banning “theories that systemic racism, sexism, oppression, and privilege are inherent in the institutions of the United States and were created to maintain social, political, and economic inequities” in general education courses; although, these ideas may be allowed in higher-level or elective courses.[46] Also in April 2023, North Dakota passed a bill banning any mandatory diversity training at public institutions of higher education, as well as ending the use of diversity statements in hiring.[47]

The challenges faced by proponents of enhancing and enforcing DEI legislative policies were further increased when, on June 29, 2023, the Supreme Court ruled race can no longer be considered as a factor for admissions decisions within colleges and universities. The ruling overturns the long-standing practice of affirmative action, a system that has benefited minority students in higher education for years.[48] This ruling will be closely monitored in the coming years to determine if the decision alleviates or exacerbates physician workforce inequities. Others have speculated how this ruling may bleed over into other legal precedents impacting healthcare, including individual rights and free speech related to online medical advice, the role of state governments, and fraud and abuse policies.[49] In the immediate aftermath of the ruling, we have seen a greater spotlight placed on economic diversity as educational institutions seek avenues to fortify their diversity efforts. Significant racial disparities continue to exist in terms of income and wealth in the United States, meaning economic diversity may likely prove to be a material and worthwhile metric for higher education to consider as a proxy to enhance their student body diversification efforts.[50]

DEI backlash should serve as a reminder to focus on meaningful, effective efforts instead of superficial and short-lived programs. Organizations must address the systemic barriers that are depressing minority participation in the medical education system and the resulting physician workforce.

Minority populations in the United States continue to be underrepresented in the physician workforce resulting in disparities in health outcomes. As we continue forward, armed with a greater understanding of historical inequalities, leading healthcare organizations must continue to educate medical students, healthcare professionals, and the public on inequities and drive efforts for meaningful, sustainable change. The United States medical education system must produce a workforce that can effectively serve the entire population, regardless of racial, economic, geographic, or socioeconomic status.

With thanks

PYA thanks Ernest Yoder, M.D., for his invaluable assistance with, and contributions to, this article. Dr. Yoder is Medical Director for Project Healthy Community in Detroit, MI, and Technical Advisor for Teaching Health Centers, Health Resources & Services Administration (HRSA). He has served in leadership positions at Wayne State University School of Medicine, Ascension Health, Central Michigan University College of Medicine, and Western Michigan University Homer Stryker MD School of Medicine.

Resources

[1] https://www.cdc.gov/nchhstp/healthequity/index.html

[2] Ibid.

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626972/

[4] Ibid.

[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211283/

[6] In 2020, the AAMC renamed its most prestigious award, “The Abraham Flexner Award for Distinguished Service to Medical Education” to the “AAMC Award for Excellence in Medical Education” in recognition of the racist viewpoints of Abraham Flexner and the negative impact of the Flexner Report. https://www.aamc.org/news-insights/aamc-renames-prestigious-abraham-flexner-award-light-racist-and-sexist-writings

[7] https://www.medpagetoday.com/publichealthpolicy/medicaleducation/87171

[8] Ibid.

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690142/

[10] https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018

[11] https://www.advisory.com/topics/physician/2023/05/the-physician-workforce-2023-data-unpacked#accordion-0a3f0943dc-item-bc65205779

[12] https://www.census.gov/quickfacts/fact/table/US/RHI725221

[13] https://www.advisory.com/topics/physician/2023/05/the-physician-workforce-2023-data-unpacked#accordion-0a3f0943dc-item-bc65205779

[14] https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071163/

[16] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5743635/

[17] https://www.visualcapitalist.com/visualizing-u-s-population-by-race/

[18] https://www.census.gov/library/stories/2017/08/rural-america.html#:~:text=Urban%20areas%20make%20up%20only,Census%20Bureau%20%2D%20Opens%20as%20PDF.