Why Do We Continue to Miss the Mark with Efforts to Improve Diversity?

The Association of American Medical Colleges and other professional organizations such as the AUA have formally committed to increasing diversity in medical training in order to promote a workforce that reasonably resembles the racial, ethnic and gender profiles of the patient populations we serve.^1,2 However, despite decades-long efforts, significant progress is still lacking,³ begging several important questions: Why do we struggle to recruit, train, retain and promote underrepresented physicians in academic medicine? And at what cost? Is diversity in medicine truly important enough to demand our continued, unified commitment to this goal?

Why Do We Fail? The Leaky Pipeline

Structural racism results in disparate opportunities for people of color throughout their education and careers. Educational disparities have historically been used to oppress non-White communities. As a prime example, post-Civil War laws in various states prohibited Black Americans from learning to read, write and seek employment utilizing these skills. Indeed, the landmark Brown v. Board of Education, which overturned the doctrine of separate-but-equal, centered around educational inequality.^4,5

The exclusion of non-White communities remains rooted in our educational system today. Outright racist policies linger as veiled remnants, such as categorically underfunded schools in impoverished areas inhabited predominantly by people of color. Latino and Black children in the U.S. are the most likely to attend high poverty schools.⁵ In turn, research highlights early childhood poverty as a risk factor for low academic performance and school completion, with Black, Latino and Native American students facing the highest rates of expulsion and grade retention.⁶

Ultimately, students who attend impoverished schools are less prepared for the academic rigors of college/university.⁷ Upon entering higher education, many students are braced with large amounts of debt and isolation due to a lack of representation and culturally aware mentorship.⁸ Coupled with the economic burden of pre-medical preparation (eg MCAT^® [Medical College Admission Test^®] preparation), such struggles lead to fewer underrepresented students being accepted into medical school.⁹ In fact, researchers have argued that medical school admission requirements, as they presently exist, systematically discourage underrepresented students from pursuing careers in medicine.¹⁰

Whereas many capable applicants leak out of the pipeline without ever having had a chance, a minority of individuals with a combination of exceptional talent and opportunity (both are required) rise to the challenge, only to encounter additional barriers at every stage. For example, underrepresented residency applicants report experiencing a higher frequency of discrimination during residency interviews.¹¹ Additionally, physicians who are victims of repeated microaggressions from patients and/or colleagues report higher mental distress and functional impairment affecting work performance.¹² Collectively, these experiences lead to fewer diverse individuals present at each stage of the physician pipeline, as exemplified in the figure.

Figure. Leaks in the pipeline contributing to loss of diverse applicants and trainees in academic medicine.

The Costs of Failure to the Physician and the Patient

Although it is convenient to assume that the underrepresented physicians around us, who are visible and successful, are exempt from the negative impact of exclusion, it is more likely that many of the people we consider to be our colleagues, collaborators, mentors and friends often experience discrimination that is ingrained in medicine and leads to career dissatisfaction. The cost–to all physicians–of our failure to foster and promote diversity ultimately becomes our inability to recruit and retain talented individuals whose meaningful contributions to medicine are extinguished by physician burnout relating to macro- and microagressions.^13,14

Equally as important as the underrepresented physicians’ experience is the impact of diversity on patient care. In a conceptual model of health care utilization, Dr. Ronald Andersen framed variables that impact the use of health care within 3 factors: predisposing factors, enabling factors and need characteristics.¹⁵ Predisposing factors comprise social and demographic attributes that influence patients to seek health care. Enabling factors include community dynamics, such as the availability of health care services. Finally, need characteristics are based on an individual’s perception of their health status. Improving diversity can positively influence all 3 of these domains.

Based on historical exploitations, there exists a significant amount of medical distrust amongst communities of color.¹⁶ Additionally, several cultural beliefs influence patients’ medical decision making. Although dismantling medical distrust engendered by systemic racism is a mammoth, complex task, data suggest that patients of color treated by racially concordant physicians report better communication, bring up more issues and are more likely to seek advice follow-through with interventions.¹⁷ As it relates to the quality of care, several studies have also shown that both the objective and patient-perceived quality of care is higher when non-White patients are treated by race-concordant physicians–further exemplifying why increasing diversity is imperative to our society’s overall health.^18,19 As such, fostering a more diverse and culturally aware workforce may represent an important first step in improving medical mistrust by addressing factors which may predispose some patients to avoid care.

Long-standing disparities in routine preventive health and treatments of chronic illnesses are also well described in the literature.²⁰ In fact, data over the past 40 years have shown that non-White patients accessing the health care system have a lower likelihood of receiving appropriate management for their medical conditions.²¹ Furthermore, Black and Latino patients report lower satisfaction with their care than their White counterparts.²² In turn, fewer physicians serve low-income communities made up of these patients.²³

To this end, research demonstrates that members of underserved racial and ethnic groups are more likely to practice in the communities they originate from.²⁴ In the past few decades, data demonstrate underrepresented physicians cared for 53.5% of Black and other non-White patients. Additionally, underrepresented physicians care for 70.4% of non-English speaking communities as well as under- and uninsured patients.²⁵ Thus, increasing diversity in medicine can help mediate physician shortages experienced within communities of color.

Conclusions

The “diversity pipeline” has been a myth for many who are underrepresented in medicine. A variety of systemic factors along the way explicitly target, discourage and prevent Black, Latinx and other non-White, underrepresented individuals from pursuing or continuing medical careers. While these pipeline programs are a good step, initiatives aimed at increasing diversity in medicine must utilize a multi-pronged approach, leveraging the social and political capital of the medical field, in addition to mentorship to address the different sources of attrition. In turn, fostering diversity in medicine will set the foundation for a physician workforce that is more supportive, inclusive and capable of providing equitable care to all patients.