WHITCOMB, MICHAEL E. MD
At the AAMC's 2001 annual meeting, Lee Bollinger, then president of the University of Michigan, presented the Herbert W. Nickens Memorial Lecture. President Bollinger used the occasion to discuss the principles underpinning the university's use of race and ethnicity in making undergraduate and law school admission decisions. (A slightly edited version of his presentation appears later in this issue of the journal.) At the time of his presentation, the university's policies governing those decisions were being challenged in two lawsuits then pending in the Sixth Circuit Court of Appeals. Most of the journal's readers are probably aware that the decisions handed down by that court are now under review by the U.S. Supreme Court. Oral arguments were presented before the Court several weeks ago, and its decisions are expected soon.
It is generally believed that those decisions will clarify, perhaps once and for all, how U.S. universities may use race and ethnicity in making admission decisions. Because of the specifics of the cases, the Court's decisions probably will not speak directly to the policies that govern medical school admission. However, there is little doubt that the decisions will affect those policies. At this time, only one thing seems certain—medical schools will not be able to factor race and ethnicity into their admission decisions to a greater degree than is now the case. In this editorial, I focus on the special challenge this presents the medical education community.
First, however, it is important to be clear about the current state of diversity in medical school student bodies: medical schools have not been able to achieve the level of enrollment of underrepresented U.S. racial and ethnic minorities that many had hoped for just a few short years ago. In fact, in the past few years, the number of underrepresented minorities entering medical schools has been declining. The reason why more underrepresented minorities have not been admitted to medical schools is apparent if one examines the academic qualifications of underrepresented minority applicants. In the March 5 issue of The Journal of the American Medical Association, Jordan Cohen, the AAMC's president, presents data comparing the academic qualifications of underrepresented minority applicants with those of white and Asian applicants. The data present in stark terms the magnitude of the challenge that medical schools have been facing in their efforts to create diverse student bodies.
Despite the differences between the academic qualifications of underrepresented minority applicants and those of white and Asian applicants, medical schools have made concerted efforts to create more diversity in their student bodies. First, as Dr. Cohen noted in his JAMA article, medical school admission committees have probably placed a heavier weight on an applicant's race and ethnicity than Justice Powell may have envisioned would be necessary when he wrote the decisive opinion in the landmark Bakke case in 1978. Second, medical schools and their parent universities have for years conducted special programs designed to improve the qualifications of underrepresented minorities interested in a career in medicine. Three of the papers in this month's journal describe examples of those programs. Finally, Carline and his colleagues report in their paper the results of an evaluation of a national project (Health Professions Partnership Initiative) aimed at having health professions schools partner with public school districts for the purpose of increasing the number of academically qualified minorities applying to health professions schools. Twenty of the 27 health professions schools participating in the project are medical schools. The results of the evaluation show how difficult it is to construct the kinds of successful partnerships that the program hoped to catalyze. There is no way to know at this time whether the successful partnerships will result in an increase in the number of underrepresented minorities applying to medical schools.
Given these facts, it is clear that medical schools will continue to be severely challenged in their efforts to create more diversity in their student bodies, even if the Court's decisions have no effect on medical school admission policies. Most who have analyzed the current situation recognize that the schools' efforts will not be more successful until there is a dramatic improvement in the overall academic qualifications of the underrepresented minorities applying for admission to them. In this regard, it is particularly disconcerting to note that an analysis to be published in this journal in coming months suggests that certain societal dynamics are operating in ways that make it unlikely that the number and academic qualifications of the underrepresented minorities applying to medical schools will be more favorable in the future. Thus, there is no reason to expect that there will be any meaningful increase in the number of underrepresented minorities in medical school classes for years to come. So what does this mean for medical education?
In seeking the answer to that question it is important to understand why many believe that medical schools should give explicit consideration to race and ethnicity in making admission decisions. Those in favor of doing so tend to offer a number of reasons to support their views. For our purpose, I focus on only one of those reasons—that is, that diversity in medical school student bodies improves the quality of medical education. Those who hold this view assert that diversity in medical school student bodies adds value to the education of all students because it enhances the likelihood that they will gain an understanding of how differences in race, ethnicity, and other cultural experiences might affect adversely the interactions that occur between doctors and the patients who seek their help. The assumption here is that some of the lessons learned in the classroom, in the clinic, and on the wards, which can be traced in part to the diversity of the students in those learning environments, will have a positive impact on the ability of future doctors to establish effective relationships with the patients they will encounter in their practices, regardless of differences in race, ethnicity, or cultural experiences.
With regard to this issue, the paper by Whitla and his colleagues in this month's journal is extremely important because it is the first published report of data relevant to this issue. The paper describes the results of a study designed to obtain the views of students enrolled at two medical schools—the Harvard Medical School and the University of California, San Francisco School of Medicine—about the educational value of the diversity of their classes. At both schools, the majority of the students, regardless of their own race and ethnicity, believed that the diversity of their class did enhance their ability to interact with patients of different races and ethnic and cultural backgrounds, thus contributing positively to their medical education. There is, of course, no way to know whether or not the students' beliefs will actually translate into how they will practice after they complete their formal education, but the study results suggest that this is likely to happen.
Given that, what should medical schools do to try to achieve the educational value of diversity, realizing that diversity itself may be harder to achieve in the future? In my view, they must be vigorous in integrating cultural competence education into their curricula. Recognizing that cultural competence is a critical determinant of a physician's ability to develop an effective relationship with patients who differ by race, ethnicity, or cultural experience, medical schools must develop innovative approaches for educating their students about the ways that differences in race and ethnic and cultural experiences may affect their ability to develop a trusting relationship with all of the patients they will encounter in their practices. Educating students about the importance of cultural sensitivity and providing them with the knowledge, skills, and attitudes they will need to incorporate this into their practice behaviors is a major challenge for the medical education community, primarily because at present, it isn't clear how best to accomplish this.
Furthermore, improving the cultural competence of medical students only is not adequate. For the foreseeable future, doctors who are already in practice will provide most of the medical care in this country. And those who are most poised to enter practice are the residents currently enrolled in the country's graduate medical education programs. Thus, those in the medical education community who are directly responsible for the continuing education of practicing physicians or for the design and conduct of residency programs must also focus their attention on developing educational experiences that will allow all physicians to become more culturally sensitive when they interact with the patients they care for.
To assist the medical education community in its efforts to meet these challenges, we will continue to publish papers dealing with various aspects of cultural competence education. The March 2002 issue of Academic Medicine contained a set of very thoughtful papers that addressed different aspects of cultural competence education, and next month's issue is devoted largely to this topic. We are all fortunate that there are so many scholars focusing some of their attention on this issue. In the long run, all who seek help from physicians will be better off for it.