Why America's Minority Doctor Problem Begins in the Third Grade

This story is part of a partnership between MedPage Today and VICE News.

Ashley White-Stern was pouring over a gastroenterology textbook one night when she came across a passage that made her bristle: "In the United States, H. pylori infection is associated with poverty, household crowding, limited education, African American or Mexican American ethnicity, residence in areas with poor sanitation, and birth outside the United States."

White-Stern, a medical student at Columbia University who is black, says that while she didn't think the passage was overtly racist, she did think it had the potential to imbue medical students with a subtle bias about blacks and Mexican Americans. So she decided to email the authors of the textbook.

"If we didn't live in a country or world where being of color predisposed society to look down on a person, the published sentence [would] not raise an eyebrow," White-Stern wrote in her email to the authors. "My humble belief is that we owe it to people of color to consider how and when we include their identities in lists of 'undesirable' characteristics."

Within 24 hours, the authors called White-Stern, thanked her, and asked her to help them change the passage. The next version of the book will explain each association in a little bit more detail and add that higher rates of infection among black and Mexican Americans are not completely understood.

"Unless you have a diverse [medical school] class, you can't have that discussion," White-Stern said.

Today, student groups across the United States are calling attention to the lack of diversity on medical campuses, pushing administrators to recruit and enroll more minority students to help end racial health disparities that have persisted for decades. But creating a more diverse class of doctors-to-be is no easy task; while there has been progress made over the last several decades, there still aren't enough minority medical school applicants.

"The pipeline itself is just too small," said Marc Nivet, chief diversity officer of the Association of American Medical Colleges (AAMC). "The barriers exist up and down the continuum to our segregated education system…. Too many of our minority students are in poor-performing or underperforming K-12 school systems."

According to the latest data from the US Census Bureau, 62.1 percent of the US population is white, 17.4 percent is Hispanic, 13.2 percent is black, and 5.4 percent is Asian. Meanwhile, 60.1 percent of students entering med school between the 2013-14 academic year and the 2015-16 academic year have been white, 22 percent Asian, 9.8 percent Hispanic, and 7.5 percent black, according to the latest data from AAMC, which runs the MCAT, the standardized test that aspiring physicians (MDs and DOs) must take to get into med school.

Studies have repeatedly shown that this mismatch between the racial breakdown of the population and that of doctors causes problems, even if the biases aren't explicit. For instance, a 2012 study of primary care physicians in urban areas published in the American Journal of Public Health revealed that increases in "implicit racial bias and stereotyping of patient compliance" was linked to negative experiences for black patients and positive ones for white patients. A 2015 study found that black lupus patients were more likely to perceive racial bias and suffer as a result of it. And in 2008, the American Medical Association issued an apology for a century of racial discrimination in the organization's past.

White Coats for Black Lives, an offshoot of the Black Lives Matter movement comprised mostly of medical students, has attempted to draw attention to racial injustices in medicine since its first "die in" protest in late 2014. The group has called for an acknowledgment of racism's role in creating health disparities, including the ongoing segregation of healthcare based on insurance status, which they called "colorblind" racial discrimination in an editorial published last fall in the Journal of Urban Health.

A crucial step toward equality in health care is raising the number of minority doctors, medical students, and medical professionals in leadership positions, they say. But fewer black students applied to and enrolled in medical school in 2014 than in 1978, according to AAMC. The group's report, entitled "Altering the Course: Black Males in Medicine," says the problem goes all the way back to grade school math and science courses often offered to black students.

A look at the data suggests the largest proportion of would-be minority physicians are effectively eliminated long before it's time to apply to medical school.

• 56 percent of black high school graduates enrolled in college in the year after graduation, compared with 70 percent of whites, according to 2008 data from the College Board.
• Of the 1.6 million students who received bachelor's degrees in 2010, nine percent were black and 77.5 percent were white, according to the latest data from the US Department of Education. According to 2010 US census data, black people made up 14.4 percent of the population of 20- to 24-year-olds; white people made up 67.3 percent of the same age group.
• The same year, 3,475 black students applied to medical school, making up 8.1 percent of all applicants, according to data from AAMC; there were 46,410 white applicants, accounting for 61.8 percent of the total applicant population.
• Again in 2010, of the 165,000 black students who received bachelor's degrees, 2.1 percent went on to apply to medical school. By comparison, 2.3 percent of the 1.2 million white students who received bachelor's degrees that year applied.

In other words, by the time students receive undergraduate degrees, blacks and whites are on nearly equal footing. The disparity develops earlier.

In fact, minority students start to fall behind on their standardized test scores as soon as third grade, and the gap widens over time, Nivet said. To make matters worse, 17 states don't require students to pass Algebra II to graduate from high school, meaning public school students aren't pushed to take that class or the math and science classes that would follow.

"We don't have enough minority students taking the right classes early on and becoming successful in those classes early on to make successful applicants to any health professional school," Nivet said.

Dr. Damon Tweedy, author of the memoir Black Man in a White Coat, said that he credits a teacher for pushing him to apply to a magnet program before he started high school. He got in, and was bused from the school in his predominantly working-class black community to a school in a mostly white neighborhood.

If current medical student Dennis Dacarett-Galeano had finished grade school where he started it, he said he probably wouldn't be on his way to becoming a doctor at Icahn School of Medicine at Mount Sinai in Manhattan.

Dacarett-Galeano, who identifies himself as Latino, said most of his elementary school in Austin, Texas's effectively segregated education system was considered economically disadvantaged. At the school, white students are the minority, making up 11 percent of the student body.

But thanks to a move to the suburbs and some luck, Dacarett-Galeano was able to attend the wealthiest public high school in the region, which was predominantly white. He had access to the Advanced Placement classes he needed to get into Columbia University, but he said not all of his underrepresented minority Columbia classmates had the same educational privileges — and it showed.

"When I really started to notice the difference between underrepresented minority experiences and otherwise was when I was in a college biology class there," he said, explaining that biology is considered a "weed-out" class for pre-med students. "Most of my friends who were pre-med who dropped that track were underrepresented minorities or students from disadvantaged backgrounds."

More could be done to encourage minority undergraduate students to consider medical school, Nivet and Tweedy said.

For minority students, secondary barriers to getting into medical school continue into their undergraduate careers, which are often at historically minority-heavy schools that do not have a full time medical school advisor to guide pre-med students through their coursework and the medical school application process, Nivet said. Such advisors are commonplace at Ivy League and other elite institutions.

Advice from advisers can range from telling pre-med students not to take organic chemistry and physics the same semester to telling them what's an acceptable MCAT score. Nivet said he occasionally hears about less-informed advisors who have discouraged minority students from applying to medical school based on their MCAT scores, not knowing that those MCAT scores that would be competitive at most medical schools.

Tweedy said that schools lacking diversity may also be more passive about their recruitment methods. For instance, they don't go to historically black undergraduate institutions to tell students about scholarship opportunities and fee waivers.

"Medical school is an incredible burden," said Tweedy, who is a psychiatry professor at Duke University Medical Center. "That alone, the time it takes and the cost itself, may deter people from otherwise even considering it. That's where someone like a recruiter could talk about various options for financial aid, invite students to at least apply and waive the application fees. All these things make it more accessible."

Racial disparities continue throughout the application process. From 2013-14 through 2015-16, acceptance rates were lower for black students compared with other racial groups, according to MCAT and GPA data from AAMC.

Although 45.2 percent of white applicants got accepted into medical school — as well as 44.3 percent of hispanic applicants and 42.1 percent of Asian applicants — only 36.2 percent of black applicants were accepted.

Part of this may be tied to the fact that black students tend to score lower on the MCAT. Of the 2,460 students who earned the lowest scores on the test from 2013-14 through 2015-16, 43 percent were black. Of the 221 top-scoring medical school applicants over the same period, 11 percent were black.

For some minority students accepted to medical school, shaking the "false narrative" in their own minds that they don't deserve to be there can be difficult, Nivet said. When Tweedy was a first-year medical student at Duke University in the 1990s, his professor mistook him for a handyman, Tweedy wrote in his book. He recalled feeling insecure about whether he was inferior to his classmates at the beginning of medical school once he learned that his MCAT score was "a few points below the class average" and that his classmates had come from Ivy League schools and other prestigious undergraduate institutions. He wrote that he knew his full scholarship to Duke's medical school was the result of affirmative action, but wondered whether he was about to become an "academic casualty."

Rowan University School of Osteopathic Medicine in New Jersey has a series of pipeline programs to recruit a diverse class of medical students early, but some students — not just minorities — have test scores or GPAs that indicate they may have trouble later on in their medical education, says Thomas Cavalieri, DO, the school's dean. As a result, the school has a boot camp–like program that starts before the official school year begins to get these students up to speed. It also has a number of interventions to help struggling students throughout their medical education.

Nivet said it's especially important for minority students to remember that being near or below the average MCAT score isn't a big deal — and that they're hardly the only ones in the bottom half of their class.

"A whole bunch of white kids have lower MCAT scores," he said. "Duke University is not 'taking a chance' on any kid…. Students who go to these elite institutions graduate and have become leaders across this country in medicine."

Follow Sydney Lupkin on Twitter: @slupkin