Where are all the Minority Doctors?

When one sees the low numbers of minority physicians, it’s easy to jump to the conclusion that there simply isn’t enough college students of color applying to medical school. While this is true, is true, this is a superficial look at the problem.

The reality is, the largest proportion of would-be minority doctors are lost long before they even CONSIDER applying to medical school. The gap starts before college, high school and even middle school. In truth, minority students start to fall behind as early as the third grade, when their standardized test scores fall behind those of their white peers. Sadly, the children who start behind tend to stay behind as they struggle to make up lost ground. That achievement gap not only persists, but tends to widen over time.

What’s critical to note, and a fact that is often overlooked is that minorities as a whole fall behind early not because of inherent ineptitude –a common, racist assumption (albeit one often held implicitly by the general public) but because of forces outside of their control.

The  “Poor” Tax

One large factor is that minority physicians are disproportionately from low socioeconomic backgrounds. This is important to know, because a multitude of studies show the strong relationship between SES and educational attainment, test scores and college attendance and completion (Duncan, Morris, and Rodrigues 2011; García 2015; García and Weiss 2015; Lee and Burkam 2002; Mishel et al. 2012; Putnam 2015). Furthermore, an extensive body of reason has conclusively demonstrated that social class is one of the most –if not THE single most significant predictor of their educational success.

The pool of potential minority medical school applications continues to diminish in high school and college. In 2016, 88.3 percent of white students graduated, compared to 79.3 percent of Hispanic/Latino students and 76.4 percent of Black students, and students. Graduation rates for students with disabilities and English language learners (ELL) is in the mid-60s. Again we see income influencing educational attainment at the high school level. For example, 77.6% of low-income students graduated on time in 2014 compared to 90% of non-income students.

One silver lining is that the national graduation rate is increasing. It was 84.1% in 2016, an-all time high. Much of the gains made in recent years comes from students of color, with Black students increasing 9.4 percentage points since 2011 and Hispanic/Latino students making gains of 8.3 percentage points. While minority graduation rates are moving in the right direction, black high school graduates are still much less likely to enroll in college in the year after graduation compared to whites. According to data from The College Board from 2008 (the most current data available at the time of this writing), 56% of black high school graduates compared to 70% of whites.

As U.S. medical schools rely on applicants with a bachelor’s degree from colleges and universities whose attendees are not evenly distributed across race or income level, the pool of medical school applicants is not evenly distributed across race or income levels. Sure enough, comparing the economic diversity of U.S. medical school matriculants with U.S. Census data reveals that more than three-quarters of medical students come from families in the top quintile of family income, and this distribution hasn’t changed in three decades.

The “Race” Tax

But minorities being from disproportionately economically-disadvantaged backgrounds isn’t the only “hit” to the educational attainment and ability to thrive in America of communities of color. Racism, and the associated structural inequalities built into the fabric of society, unequivocally limit the education opportunities of minorities in unique ways.

For example, non-Black teachers have significantly lower educational expectations for Black students than Black teachers do when evaluating the same students. Black and white teachers also tend to evaluate the behavior of black students differently. The more times a black student is matched with a black teacher, the less likely that student is to be suspended. This is likely because a white teacher is much, much more likely to view black student behavior as problematic compared to black teachers. Put simply, Black teachers have much less negative views of Black students behaviors than do white teachers.

White and Asian students are more likely than African-Americans and Hispanic/Latinos to be exposed to advanced classes. The practice of “tracking”, i.e. offering qualified students the opportunity to take advanced-level courses apart from their fellow students, is much more prevalent in suburban middle class communities and in school systems serving primarily white and Asian students. This practice is less prevalent in urban schools and schools serving predominantly African-American, Hispanic/Latino and/or disadvantaged populations. As a result, disadvantaged and underrepresented minorities are much less likely to be exposed to and benefit from the advanced coursework that would help prepare them for a career in medicine.

The stress of racial discrimination itself also partially explains the persistent gaps in academic performance between non-white students, mainly Black and Latino youth, and their white counterparts. A team of researchers from Northwestern University found that the physiological response to race-based stressors–be they perceived racial prejudice or the drive to outperform negative stereotypes–causes the body to pump out more stress hormones in adolescents from marginalized groups. Not only is there a biological reaction to these stressors, but a psychological response as well. What ultimately results is that Black and Latino students’ very concentration, motivation and, ultimately, learning is impaired by both overt and subscious racism.

The End Result

All in all, we can see that a low medical school applicant pool represents the end result of a lifetime of disadvantage for minority applicants. What plays out afterward, in terms of medical school admissions, is merely a continuation of this disadvantage. In 2015, White and Asian-American students represented over two-thirds of U.S. medical school applicants (47.8% and 19.3% respectively) compared with 7.8% of Black or African-American applicants and 6.1% of Hispanic or Latino applicants. Not only are the pools of Black or African-American and Hispanic/Latino applications low, but they are also less likely to be accepted into medical school compared to their white counterpoints, with this phenomenon most pronounced for black applicants. Specifically, according to AAMC MCAT data from the 2013-2014 to the 2015-2016 application season, 45.2% of white applicants, 44.3% of Latino/Hispanic applicants and 42.1% of Asian applicants were accepted to medical school, compared to only 36.2% of black applicants.

Final Thoughts

Once you understand and recognize the factors that ultimately shape the lack of a diverse physician work-force, it becomes clear that there is no simple solution to the issue. However, one simple fact remains apparent: we won’t move the needle on physician work-force diversity without moving the needle on the systemic forces that create disparities in the first place — namely, structural racism and privilege.

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Dr. Brittani James

Brittani James, MD is an Attending Family Medicine Physician who practices on Chicago's South Side. She co-founded Med Like Me with her twin sister, Dr. Brandi, as a passion project. She is dedicated to working with underserved and vulnerable populations and mentoring the next generation of diverse physicians.

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