Last week we discussed racial bias in medical curricula. One part of that problem that we didn't discuss is the lack of diversity in medical education and that's the topic of this week's Healthcare Triage.

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A 2021 study in the New England Journal of Medicine reported that among medical school faculty, only 5.5 percent identify as Hispanic, Latinx, or Spanish. Only 3.6 are Black or African American, and only 0.2 percent are Native American or Alaskan Natives.

That's a problem because it's very disproportionate from the racial breakdown of the general population. It's also not improving to a great extent.

Another study examining how these numbers changed between 1990 and 2020 reported only a modest increase of 1.6 percent in medical school faculty members that self-identified as Black or African American.

They found that the increase in Assistant Professors was the largest at a .89 absolute percent-point change, with even smaller increases for Associate and Full Professors. This may suggest disparities in promotion, since Associate and Full Professors are the next step up from Assistant.

Of the medical specialties, obstetrics and gynecology had the most faculty that identified as Black or African American at 8.5 percent, while otolaryngology had the lowest at just under 2 percent.

These are still way beneath the current U.S. population, where Black and African American groups represent 13.4 percent.

Not bad? (?~1:30) in the New England Journal of Medicine rightly pointed out that many institutions over-emphasize recruitment and then neglect retention, failing to create an environment that welcomes and nurtures faculty and students from underrepresented groups.

A survey administered to executives, faculty, employees, and students at six hospitals found that cultures of discrimination were often present at these institutions and created barriers to inclusivity.

They identified several related components including micro-aggressions, favoritism, ineffective reporting systems, and the inaction of bystanders.

For medical schools, the pattern is similar. A 2019 study looked at the proportion of medical students from various racial and ethnic minority groups admitted to medical schools between 2002 and 2017 relative to the general population.

They found that students identifying as Black, Hispanic, Native American, or Alaskan Native were severely underrepresented in medical school. They also reported minimal improvement in enrollment over this time period despite public initiatives to increase diversity.

Institutions have been known to cite a lack of qualified candidates as the primary reason for these disparities while overlooking the root cause of disparities that led to the lack of candidates.

Beyond matters of implicit racial bias among admissions committees, existing structural inequities prevent minorities and non-wealthy students from accessing things and experiences that are nearly essential for admission to medical school.

Admission criteria don't generally take into account structural barriers like high application and test fees and the role of expensive test prep courses.

They also don't take into account who has access to things like high-performing high schools and expensive extracurricular activities or other opportunities that give students a major leg up on applications.

So what can we do? One useful approach involves pipeline programs where students from underrepresented groups receive access to early support and career-development programs.

The most successful of these focus on academic enrichment, particularly in science and math, admission prep, mentoring, financial and psychosocial support, and professional opportunities.

Another approach is called holistic review in admissions, or HRA, and is recommended by the American Medical Association. HRA workshops assist medical schools with strategic changes to their admission processes that help it align with both diversity initiatives and the school's individual goals.

HRA focuses on the experience, attributes, and academic metrics of each candidate as well as the value an applicant would contribute, rather than disproportionately emphasizing singular factors including test scores, science grade point averages, and financial concerns.

There are also approaches to help remove implicit bias, including requiring admissions committees to take implicit bias tests and appointing more minorities to admissions committees.

We can't just stop at medical school admissions. We can't just recruit; retention matters too. This requires things like more visible support from leadership and funding and advancement opportunities shaped with diversity in mind. Specific policies and practices must be created and followed to ensure that diversity is achieved.

And the issues don't exist only for individuals in medical school. A Stat news investigation found that Black doctors either leave or are terminated from training programs like residencies significantly more than White doctors.

Individuals they interviewed suggested measuring and publicizing data on how big these problems really are and improving not only the support but protections for residents so that the people they report problems to are not prioritizing protection of the institution for which they work.

A more diverse medical workforce translates to increased healthcare access, reduced health care disparities, and increased quality of care. It benefits everyone, and it should remain an urgent priority until it's achieved.

Special thanks to Eliot Rapoport, who did the heavy lifting on this episode.

Hey did you enjoy this episode? You might enjoy this previous episode on racial bias in medical education.

We'd appreciate it if you'd like the video, subscribe down below, and go on over to patreon.com/healthcaretriage where you can help support the show, make it bigger and better. We'd especially like to thank our research associates, James Glasgow, Joe Sevits, Edward Liljeholm, and Brian Nam, and of course, our Surgeon Admiral Sam.