Notwithstanding important progress, substantial challenges remain in ameliorating racial inequalities in health and health care in the United States. One enduring challenge is the underrepresentation of minority populations, especially African Americans, among the faculty at academic medical centers (AMCs). At each stage of career development, African Americans remain less likely than other physicians to hold academic appointments. Despite constituting 13% of the American population as of 2014, African Americans accounted for only 7.4% of assistant professors, 3.8% of associate professors, and 1.4% of professors at AMCs.1 The statistics are even more troubling for African American males.2 Such profound underrepresentation comes with substantial negative implications for our health care system, and the nation as a whole.3
In this Perspective, we explore the intrinsic pressures that contribute to African American underrepresentation at AMCs with a focus on their historical roots; review evidence of their effect on physician career development; and consider the implications for AMCs seeking to improve African American representation among their faculties. We conclude by providing specific policy options.
Extrinsic Versus Intrinsic Forces in Shaping Career Development as Factors Contributing to Underrepresentation
Physician career development is shaped by both extrinsic (e.g., educational opportunities, role models, mentorship, financial support) and intrinsic (e.g., intellectual curiosity, community service, altruism) forces.4 Structural impediments in the educational pipeline and training environment for African Americans are numerous—poor education and school quality; lack of role models; financial cost of education and training; and persistent bias, stereotyping, and racism—and impact substantially the extrinsic forces shaping career development.2,5,6 Efforts to ameliorate African American underrepresentation in academic medicine have traditionally been focused on modifying these extrinsic forces through tactics such as undergraduate and graduate outreach, diversity and inclusion initiatives at medical schools, and faculty development programs.
Although these are essential programs, we believe the prevailing focus on extrinsic factors has obscured the role intrinsic forces play on the decision to pursue and sustain a career in academic medicine. America’s ignoble history of violence, racism, and exclusion exposes African American physicians to distinct personal pressures and motivations that shape their professional development and career goals. Whereas similar forces undoubtedly shape career development for other marginalized populations across the lines of race, class, gender, and sexual orientation, the historical specifics of the African American experience render this manifestation unique.
Race-Conscious Professionalism and Intrinsic Motivation
The exceptional nature of the African American experience in the professional realm is not a novel observation. Harvard law professor David B. Wilkins7 has used the term “race-conscious professionalism” to describe the process black professionals confront when attempting to “navigate the competing demands of professionalism, racial obligations, and personal integrity.” Amidst a history of oppression and continued racial injustice, many African American professionals are acutely aware of the implications of their success on racial politics and the well-being of their broader communities. For many, this results in a dual obligation: to achieve professional excellence while working to improve their communities.8
Race-conscious professionalism has been an enduring component of the African American experience in medical practice.9 This began as early as the 1840s, when many of the nation’s first formally educated African American physicians used their positions as community leaders and their scientific credibility to challenge the institution of slavery. After the Civil War, African American physicians built medical schools and hospitals that served not only as a way to care for the African American community but also as conduits to build an African American professional class. The existence of race-conscious professionalism continued in the 20th century, when African American physicians assumed leadership roles in fights against segregation within and outside of the medical profession. African American physician–activists were instrumental leaders in catalyzing reforms such as the Civil Rights Acts, hospital desegregation rulings, the Voting Rights Act, and Medicare/Medicaid legislation.9 For nearly two centuries, African American physicians have used their professional training, and the expertise and stature it affords, to address the contemporary challenges facing their communities.
Understanding the historical precedents of race-conscious professionalism can help clarify the intrinsic forces that African American physicians face in developing their professional identity. Just as the struggles of slavery and segregation drew the involvement of peers from previous eras, today’s African American physicians practice in an environment where they are continually reminded of persistent racial disparities. Most have experienced or witnessed, firsthand, inequalities in the access to, and quality of, health care. These realities are not limited to health care, as evidenced by the recent #BlackLivesMatter campaign and protests at many U.S. medical schools.10 A consistent subtext of disparities and injustice continually reinforces the dual obligations of race-conscious professionalism and, in doing so, shapes professional development. In this climate, African Americans often find themselves not only concerned with clinical excellence and professional advancement but also focused on how their career can most positively impact their community.
Empirical evidence supports the role of race-conscious professionalism in shaping career decisions. Resolving the dual obligations to self and community can be accomplished, in part, by choosing careers aimed at caring for minority populations. African American physicians have assumed a central role in caring for minority communities and working to ameliorate racial disparities in health and health care outcomes.9 African American patients are a staggering 23 times more likely to have an African American physician than a white physician.11 Similar research has found that African American primary care physicians are roughly 40 times more likely than white physicians to care for African American patients.12 Finally, researchers have found that African American physicians are more likely to seek out, and remain, in areas where they can care for minority populations.13
Implications for AMCs
Intrinsic motivations introduced by race-conscious professionalism complicate efforts to increase the representation of minorities in academic medicine. Even if extrinsic barriers to advancement are removed, underrepresentation is likely to persist. For many African American physicians, a desire to have their work focused on the community will be at odds with the experiences and outputs required under traditional paths to professional advancement at AMCs. For example, most minority faculty members responding to a large national survey reported that their own values were poorly aligned with those of their institution.14 To counter these trends, there are several strategies that AMCs can employ to leverage race-conscious professionalism in efforts to recruit and retain African American faculty. Doing so will require new opportunities for advancement that lie outside of traditional realms of basic science and clinical research, which is the predominant path to advancement and the one most conflicting with intrinsic motivations for many African American physicians.
Within the context of patient care, AMCs could more proactively and explicitly establish themselves as centers for excellence in caring for underserved and minority populations. Many AMCs serve a critical role in caring for underserved patients, and the potential for innovation around how to do so most effectively and efficiently could be a draw for many African American physicians motivated by race-conscious professionalism. For example, the Johns Hopkins University School of Medicine established the Urban Health Institute, focused on improving the health and well-being of the East Baltimore community through research, engagement, and patient care.15 Within the realm of research, AMCs could establish research centers dedicated to health and health care issues facing African American communities. The Disparities Solution Center at Massachusetts General Hospital coordinates and conducts a broad portfolio of research activities related to minority health that engage research faculty across the nation. And within the realm of education, AMCs can continue to develop programs aimed at the successful recruitment and training of African American physicians. Opportunities for teaching and mentoring the next generation of African American physicians are likely to be significant draws for junior and senior faculty members alike.
AMC leaders should consider establishing centers or institutes dedicated to minority health care disparities that can serve as a locus for these and related activities. Beyond serving an important coordinating function, these structures also act as a signal to faculty members about the values and priorities of the institution. Many AMCs have already taken important steps in establishing such bodies, and it will be important to evaluate the extent to which they promote the retention of African American faculty.
Finally, AMCs should make an explicit commitment to valuing the contributions of physicians working to ameliorate health care disparities and racial injustice. Recently, clinical, education, and health systems innovation paths for tenure have emerged alongside the traditional tracks of biomedical and clinical research.16 By giving faculty credit for the advancement of social justice and the reduction of health disparities within the communities they serve, AMCs can improve faculty retention and communicate the value of these activities.
In addition to AMC leadership, other stakeholders have an important role to play in accelerating necessary change. Funding from federal grant-making bodies such as the National Institute of Minority Health and the Health Resources and Services Administration, as well as private foundations, can help support the research and clinical care activities described above. More active engagement and participation of community board members and patient advisory boards could help direct AMC attention to this area. Finally, local and state legislative activity has been used to incorporate the issue of underrepresented minorities in the health professions into regulatory frameworks.17
There remains a dire need for more African Americans in teaching, research, and leadership positions at AMCs. Achieving this goal will provide role models, mentors, and diversity input into the research, innovation, education, and care delivery missions of AMCs. Careers in academic medicine have tremendous potential for African American physicians to reconcile the dual obligations of race-conscious professionalism through publishing, teaching, research, and influencing students, mentees, colleagues, and other leaders. To be successful, programs and initiatives aimed at addressing the continued underrepresentation of African Americans at AMCs must entertain and address the intrinsic, personal, and intimate realities of the African American experience in medicine. In doing so, race-conscious professionalism will become a draw to a career in academic medicine, rather than a force that diverts commitment elsewhere.
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. Accessed November 9, 2015.
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