Diversity in Medical Education, Part II

Do we need diversity in our medical schools? Let me say again. The answer is emphatically and non-equivocally YES!

In my last blog, (I know it was several months ago. We moved, so I got busy with all that involves) I talked about why a diverse medical student body is important and how the admissions process works against diversity.

The MCAT can be biased against some student groups in several subtle ways. Let’s start with the cost? It is a major investment to take the MCAT ($270 for most students, but to be fair a fee waiver program can lower the cost to $100). Many students take an MCAT prep course, such as the type that Kaplan or Princeton Review offers. Those course are really pricey ($1,699 for Kaplan). How about taking the MCAT more than once? Who can afford that? It is not that uncommon for me to see a med school applicant who got a 30 on their first take who has retaken the MCAT in order to raise their score.

Students from some racial and ethnic groups score lower on the MCAT. Mean total MCAT scores for black students are lower than for white students (20.0 vs. 26.3). The same difference is seen in Hispanic students (21.6 vs. 26.3) There are many reasons for these differences. The authors of this study (1) were quick to point out that just having a difference in means does not equate to test bias. The differences may be related to differences in the students themselves. The problem with this view is that students do not all have the same background, experiences, and opportunities. So, even if the individual items on the test are not biased, there may still be inherit bias in the system that keeps black or Hispanic students from performing at the same level. And if a test is used to decide on admission of students to medical school (or graduate school or business school or law school) students with differing performance will be admitted at different rates.

How about rural students? Performance on the MCAT is somewhat related to amount of higher level science courses that are taken prior to the test. Students from rural counties are more likely to attend community colleges and regional state colleges and universities. These students may not have the same access to upper level Biology and Chemistry classes. (This may also put them at risk in the beginning of the medical curriculum.) I remember having a discussion about requiring undergraduate Biochemistry several years ago. There were several small colleges that did not offer Biochemistry. I asked a simple question—is there any difference in medical school performance for students who have had Biochemistry versus those who had not had it? The interesting response at the time from several of the basic science faculty was-yes, students who take Biochemistry do better.  But it was interesting because they had no real data to back up the statement.  When we actually studied it, we found that there was some very slight improvement their grades in the first module, but it did not affect GPA or USMLE Step 1 scores. (2)

What about students from lower family income brackets? Many schools put emphasis on having a service attitude. One of the ways that we measure this attitude is looking at the amount of service (specifically nonpaid) that a students has done. Not a specific hourly amount but the engagement and commitment to service. Many of our students from poorer families may have difficulty doing this. They are often working two jobs just to survive and they really do not have time to volunteer somewhere. There are reasons that most medical students come from the top quintile of family income. Lower income students do not have the same access to opportunity the richer students have when they apply to medical school.

So, what can we do?  Schools should adopt admissions processes that minimize the inherent advantages that white, urban, wealthy students have.

Blind the admissions committee to MCAT scores.  Set you bar and then only tell the Admissions committee if the student is over that bar.

Give credit to students from lower socioeconomic groups for paid work, particularly when it is done in medical fields. Working as a nurse’s aide in a nursing home is far more useful to an applicant that shadowing a radiologist or orthopedic surgeon.

Give the Admissions committee the explicit charge to seek out the unique characteristics that will bring diversity to the class. The Dean has to tell them, “I don’t care how high their MCAT score is, I want them to make a lasting difference in the world.”

The Admissions process should seek out a diverse student body. Don’t use a set minimum MCAT or GPA that might eliminate amazing students before you even get to interview them.  The school’s average MCAT may be 32, but students with a much lower MCAT will still pass Step 1 and may be the students that will make the difference.

Develop pipeline programs. These must start in junior high and high school. They have to be available to students from a variety of backgrounds. The timeline is very long-12 to 14 years sometimes from when they enter the pipeline until you actually turn out a doctor. That requires a true long-term view.

Lastly, get the right people on the Admissions Committee. You have to stack the committee with passionate voices that will speak out for diversity and a diverse medical student class.

References

1. Davis D, Dorsey K, Franks RD, et al. Do Racial and Ethnic Group Differences in Performance on the MCAT Exam Reflect Test Bias? AcademicMedicine 2013;88(5): 593-602. 

2. Delzell J, Chumley H. Does Prematriculant Biochemistry Exposure Predict Preclinical or Clinical Performance? Family Medicine 2013; 45(Supp 3)

Diversity in Medical Education, Part I

Do we need diversity in our medical schools? Let me say right at the beginning. The answer is emphatically and non-equivocally YES!

One of the important values inherent in this discussion is that the medical school class and then subsequently the graduating physicians should look like the general population of the United States. Right now it does not. Medical students are richer (or at least their families are), more suburban, and they are much more white than the overall population.

Why is this important?  Well for one reason, students may not have had exposures to people that are different than they are when they were growing up. A survey in Academic Medicine  from two medical schools (Harvard and UCSF) found that only 27% of medical students reported having frequent contact with people of different races or ethnicities when they were “growing up”(1). The number increased to 41% by the time they got to college, but the message is clear. Students rarely had contact during their formative years with people that looked or sounded or saw the world differently than they did.

A diverse medical school class will be a better class of students. I would like to define diverse very broadly. It is not just about having more than just white students. Yes, it is important to have black students, and hispanic students, and asian students, and native american students. But other aspects of diversity are important. We need students from rural counties, who grew up on a farm. We need students from low income brackets. We need students from other countries, who see the world differently than I do. We need gay and lesbian students, and older students, and women..... And so on. You get the idea?

But, it does not happen by chance. Every school has to work constantly to make their class diverse.

I have heard many discussions about this during the admissions process. It is not overt racism or classism or urbanism. No, it is more subtle. There are suggestions that it is unfair to put students into a situation where they might fail. There is a suggestion that the students are less prepared or less able to handle the academic rigor of medical school. There is a reminder of other students that have struggled. All of this is said by well-meaning faculty, but the reality is that the variables that they are talking about do not have much to do with how good a doctor a student is going to be. Does the MCAT predict that? Absolutely not! Does USMLE Step I predict that? Again, no. How about performance in their college courses? Still, no.

I heard Darrell Kirsch, MD, the president of the AAMC talking about the new MCAT a while back. The most important statement that he made (from my perspective) was that schools that continue to emphasize the MCAT and GPA will by that very act be anti-diverse. That is a pretty bold statement, but completely defensible. If the admissions committee only looks at numbers (GPA, MCAT) the admissions process is going to be biased against non-white, non-urban, non-wealthy students. I would put forth that for most schools much of the admissions process is biased against minority, rural, and lower income students. 

I will talk about each of these in my next blog and put forth some ideas to make the admissions process better.

References

(1)    Whitla DK, et al.  Educational benefits of diversity in medicalschool: a survey of students. Acad Med. 2003 May;78(5):460-6.