Wednesday, 2 December 2009

Affirmative Action in US Medicine

From Sally Satel, P.C. M.D. : How Political Correctness is Corrupting Medicine (New York, Basic Books, 2000). Previous extracts posted here. Reference is made in these excerpts to ‘Tuskegee’ - commonly the ‘Tuskegee experiment’ - for a more balanced view than the common one see ‘Tuskegee Re-examined’ by Richard A Shweder.

Rationale for Affirmative Action in Medical School

Whether the quality of health care for minority patients truly depends on producing greater numbers of minority physicians is an unresolved empirical question. If anything, the evidence we have thus far suggests that the answer is no. Nonetheless, proponents of racial preferences in medical school admissions contend that white physicians treat white patients better than minority patients, with whom, it is said, they have difficulty developing a rapport. “This is not a quota born out of a sense of equity or distribution of justice, but a principle that the best health care may need to be delivered by those that fully understand a cultural tradition,” says George Mitchell, the former Senate majority leader and the chairman of the Pew Health Professions Commission.

To be sure, understanding a patient’s cultural tradition is important, but need one be a product of that tradition to have sufficient sensitivity to the patient? Virtually all of the major medical organizations, including the AMA and the federal Council on Graduate Medical Education, say yes. Foremost among them is the Association of American Medical Colleges. When California and Texas were planning to dismantle racial preferences in 1990, the AAMC formed Health Professionals for Diversity, a coalition of major medical, health and educational associations, to lobby for the preservation of preferences. By the time Initiative 200, the Washington State referendum to prohibit preferences by race, ethnicity or sex in public institutions, was on the ballot in 1998, the coalition included fifty-one associations among its membership. According to an association


vice president, the true message of race-neutral policy to minority students is: “We don’t want you.”

Given the relatively small numbers of black, Hispanic and Native American physicians (3 percent, 5 percent and less than 1 percent of the nation’s medical workforce, respectively), compounded by the declining number of minority applicants in the late 1990s, medical schools know they need to rely on racial preferences if they are to boost these numbers in the next few years. Thus, a few weeks before Washington State voters were to cast ballots on initiative 200, the AAMC made a highly visible appeal in newspapers. It ran a full-page ad in which eight doctors appear under a huge banner headline: “The Toxic Side-Effects of initiative 200.”

The AAMC’s ad warned readers that without racial preferences in Medical school admissions, minority Americans will not get the health care they need. After all, the association argued, minority physicians tend to serve black, Hispanic and poor patients more often than white physicians do and are more likely to practice in poor neighborhoods. In addition, the association pointed out, minority medical students often state that they want to practice in medically underserved areas. The ad was also quite specific in predicting that, with fewer minority researchers, less progress will be made in dealing with sickle-cell anemia, prostate cancer and infant mortality - all conditions that disproportionately affect African Americans.

The Current Status of Minorities in Medical Schools

Blacks, Hispanics and Native Americans together represent more than one-fifth of the nation’s population but less than one-tenth of the physician workforce. As such, they are underrepresented minorities, or “URMs,” as the Association of American Medical Colleges refers to them. Asian Americans are not considered a minority because they are well represented among practicing physicians -10 percent versus 4 percent of the general population - and they represent 18 percent of medical school graduates.


Racial preferences have played a role in raising first-year enrolment to the point where, by 1999, it reached 8 percent black and about 7 percent Hispanic, though it remains 1 percent Native American. But recruitment has been difficult. In 1995, when racial preferences in medical schools were nearly universal, only about 12 percent of first-year students were black, Hispanic or Native American. Robert G. Petersdorf, former president of the AAMC, describes the recruitment challenge: “We cannot produce underrepresented minority medical students if there is an insufficient number who are applying to our schools, graduating from college, or even finishing high school with sufficient skill to enable them to survive a premedical course of study.”

Nonetheless, by 2010 the AAMC hopes to attain racial and ethnic representation among physicians that is in proportion to the general population. That goal will be unreachable if current trends continue, according to Donald L. Libby of the Wisconsin Network for Health Policy Research and his colleagues. Based on a minimum requirement of 218 physicians per 100,000 population, Libby calculates that, starting in 1998, the annual number of first-year residents must roughly double for Hispanic and black physicians and triple for Native American physicians if parity is to be attained by 2010. Simultaneously the number of white first-year residents will have to be reduced by about two-fifths and the number of Asian first-year residents by two-thirds.

The impact of race-neutral policies in some states will make the 2010 parity goal even more elusive. Within two years after Proposition 209 passed in 1996, there was a 29 percent drop in applications by minorities to six public medical schools in California. This set alarm bells ringing throughout the medical establishment. “There is a national health need for physicians who, after the Tuskegee Syphilis Study, for example, are trusted by large segments of our population.” wrote Michael J. Scotti Jr. of the American Medical Association. “It would be deplorable,” he continued, “if medical schools were not permitted to consider the needs of patients when determining their criteria for selecting the best qualified applicants.”

David M, Carlisle and his colleagues at the UCLA School of Medicine proclaimed it a “tragedy that medical students may think they are not wel-


come . . . within the medical profession.” Randall Morgan, an orthopaedic surgeon and former president of the National Medical Association (NMA), which represents more than twenty thousand of the nation’s African American physicians, said: “War must be declared on any and all attempts to limit access to medical education for students who comprise the under-represented minorities.” In protest of the passage of Initiative 200 in Washington, the NMA pulled its 2001 annual meeting from Seattle.

Perhaps the most overwrought statement came from H. Jack Geiger, a professor of public health at the City University of New York. His essay in the American Journal of Public Health, “Ethnic Cleansing in the Groves of Academe,” foresees these “reversals in minority admissions [as] merely the leading edge of a potential public health disaster.” A public health disaster? Only if there is nothing more important to Americans about their doctors than race.

Academic Performance and Racial Preferences

In 1976 Bernard D. Davis, a Harvard microbiologist, found himself at the epicenter of the debate about racial preferences, That year he published an essay in the New England Journal of Medicine questioning whether “we have been properly balancing our obligation to promote social justice with our primary obligation to protect the public interest.” In his book Storm Over Biology, he elaborated on Harvard Medical School’s Affirmative action strategy. The Medical school dean, Davis said, purposely deprived the medical school faculty of objective feedback on student performance on part of the National Board exam, a test given halfway through medical school: “In the past, the ranking of our students in the National Board Examinations, in each subject, was presented each year at a faculty meeting, and any department that fell below third place in the country virtually apologized. Shortly after the new [minority admissions] program started, the dean’s office quietly dropped this annual report.”

Eventually, Davis reported, even the National Boards (since replaced by an exam called the United States Medical Licensing Examination) became optional in some cases. He cited the specific example of a minority student who failed the boards five times but whom the dean still decided to graduate.

After the publication of his essay Davis was attacked by the Harvard Crimson, picketed by students, roundly criticized by the dean of the medical school and verbally assailed by some of his colleagues. Ultimately, some other colleagues rallied around Davis, pointing out that lowering standards would unfairly put into doubt the qualifications of black and other minorities who would he admitted in the future.

Davis wrote his essay in 1976, but almost twenty-five years later the admissions practices he brought to light still go on in medical schools


around the country. Acceptance rates for minority students have long been higher than for white applicants with similar qualifications, according to the Association of American Medical Colleges. In 1979, for example, a minority student with high grades and board scores had a 90 percent chance of being admitted to medical school, while a white applicant with comparable qualifications had a 62 percent chance. By 1991, the last year for which AAMC has published data, the figures were 90 percent versus 75 percent, Conversely, a low-scoring minority applicant had a 30 percent chance of admission while a similarly low-scoring white applicant had a 10 percent chance.

At the University of South Florida College of Medicine, for example, black applicants with a B-plus grade point average (GPA) had a roughly 13 percent chance of admission between 1995 and 1997, but white and Hispanic applicants with the same GPA had only a 4 to 5 percent chance. Despite the passage of Proposition 209 in 1996 in California, minority applicants to some of California’s public medical schools were two to almost three times as likely to be admitted as whites and Asians with considerably higher grades.

During the years 1987 through 1993, the medical school of the University of California at San Diego was applying racial preferences. Students accepted through affirmative action had far lower premed course grades and MCAT (Medical College Admissions Test) scores than their fellow white and Asian students. More precisely, the average student accepted through affirmative action had scores comparable to to the lowest 1 percent of his white and Asian counterparts. Not among those white students in 1992 was a brilliant computer science major named James Cook. Even though he had graduated Phi Beta Kappa from UC San Diego, he was rejected by its medical school, and all the other public California medical schools to which he applied.

Cook’s parents were dumbfounded by their son’s across-the-board rejection in his home state - especially since he was accepted by the Harvard Medical School. Moved to action, his father obtained copies of the academic records of the students who were admitted to San Diego’s medical school over a period of several years. (The race but not the names of the students were made available to Mr. Cook.) With the scatterplots of


student scores spread out before him, Cook saw that minority students with lower grades were distinctly favored over white and Asian students with higher grades. In 1994, when he presented the data to a regent of the University of California named Ward Connerly, he touched off the anti-affirmative action campaign that ultimately rocked the state.

Not only are black and Hispanic applicants favored in medical school admissions, but they are over-represented among students who encounter trouble in medical school. According to the AAMC, they are more likely to repeat their first year or drop out. For the medical school class admitted in 1984, over 20 percent of minority students did not graduate four years later, as is typical. Among white and Asian students, 8 percent did not graduate that year. In 1996 the picture worsened across the board: 39 percent of minority students were unable to keep pace, compared with 15 percent of non-minority students. A 1994 study published in the Journal of the American Medical Association found that, in 1988, 51 percent of black medical students had failed part 1 of the National Medical Boards (taken after the second year of medical school), over four times the rate of white students, which was 12 percent. (Failure rates for Hispanic students were 34 percent, and for Asians 16 percent.)

The typical path for students after graduating from medical school is application to a residency program in their chosen specialty. At this level there have also been different outcomes. “It has been documented consistently over the past decade that a higher proportion of underrepresented minority students failed to obtain first year residency positions through [the standard process],” writes Gang Xu of Jefferson Medical College in Philadelphia and colleagues. Also, the yearly dismissal rate for black residents (14.4 percent) was almost double that for other groups (7.7 percent) from 1996 to 1999. Reasons for dismissal from a residency program can include persistently unprofessional behavior, chronic absenteeism and lack of aptitude or interest.

The problems encountered by black and Hispanic students result from having been under-qualified when admitted to medical school. When black students were compared with whites who had similar academic credentials, the failure rates were similar. A 1987 Rand study found that only about one-half of black physicians obtained board certification com-


pared with 80 percent of white physicians. Yet African Americans were more likely than white physicians to obtain board certification in a recognized medical specialty if their grades in college and on the Medical College Admissions Test were strong enough to get them admitted on a competitive basis in the first place.


An Honest Debate

Instituting racial preferences to achieve the goal of diversity for its own sake or in the spirit of compensation for historical mistreatment are


philosophical abstractions for debate in courtrooms, classrooms and legislatures. Instituting preferences in order to enhance minority health, however, is a practical proposition that can be tested using real-world data. Thus far, the case has yet to be made that improving minority health depends on having more minority doctors.

It appears that racial preferences represent an inefficient way to increase the number of minority doctors - and thus minority health - for a number of reasons. First, minority representation in medical schools remains well below their representation in the general population, despite aggressive admissions policies. Second, minority recruitment has resulted in a two-tiered system of academic standards for admission. This has created attendant problems: some potential non-minority medical students have not been treated fairly, while some minority students have embarked upon a career for which they are ill prepared. Third, we lack compelling evidence that same-race (minority) doctor-patient relationships result in better patient outcomes.

No matter who treats our nation’s poor and minority patients, the fact is that they tend to have multiple , chronic medical conditions and are often clinically complicated. They need the best doctors they can get, regardless of race. Fortunately, inner-city poor and minority patients are most likely to get their care in high-volume municipal hospitals that are associated with academic medical centers and thus have better access to resources and technical support. They employ experienced physicians who perform hundreds of the same operations each year. Over half of all patients hospitalized in major teaching hospitals in 1995 were uninsured, poor or minority, a Rand evaluation found. Black and poor patients received better care in urban teaching hospitals than white and more affluent patients received in rural or nonteaching hospitals.


The racial disparities in health are real, but data do not paint convincingly to systematic racial bias as a determinant, Nor does the evidence suggest that racial preferences in medical school admissions are the remedy for health disparities.


1 comment:

Anonymous said...

Satel also thinks segregated hospitals in the South during Jim Crow were just fine and that lesbians are to blame for domestic violence among other stupid notions. The only reason she gets published is her contrarianism and her M.D. which she hardly uses. Really want to be associated with her on your blog? Oh and she also attacks veterans as faking PTSD. Nice person, really.