In the December 2015 Supreme Court proceedings addressing race-based admission policies at the University of Texas–Austin, the late Supreme Court Justice Antonin Scalia commented that “African American students might fare better at a ‘slower track’ school.” The case, and his comments, revived national discourse regarding the role of affirmative action in higher education. Justice Scalia’s remarks evoked the concept of “mismatched theory,” which postulates that students admitted because of race-conscious college admissions policies are less likely to be academically successful at prestigious institutions.1
In light of national calls for increased diversity in medicine, it is critical for academic medicine to remain actively engaged in the conversation about student diversification in higher education, specifically for students from backgrounds underrepresented in medicine (URiM). Despite numerous attempts to increase the presence of URiM students entering medical school, this population has remained stagnant.2 Here we posit that to improve the diversity of the medical education pipeline and, ultimately, the physician workforce, academic medicine’s diversity efforts must expand to include the undergraduate premedical experience.
The Premedical Experience for Underprepared Students From Underrepresented Backgrounds
Many URiM students fall out of the medical pipeline during their premedical experiences because they are underprepared to endure the challenges of these critical years. While “underrepresented” and “underprepared” are terms often used synonymously, it is important to make the distinction between these two groups. URiM is defined by the Association of American Medical Colleges (AAMC) as racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.3 Academic preparation depends on a multitude of factors, such as rigor of high school experiences as well as parental income and education levels. First-generation college students are more likely to be underprepared because they have not taken higher-level math and science courses prior to entering college.4 These students may experience challenges with the transition from high school to college because of financial struggles and lack of parental guidance.5–7 First-generation college students are also more likely to be African American or Hispanic and to come from low-income families.4
While African American and Hispanic students enter college with similar levels of interest in science, technology, engineering, and math (STEM) fields as their white and Asian American classmates, they have lower levels of degree completion in these fields.8,9 An examination of 1,056 students at Stanford University found that underrepresented students had a larger decline in interest in continuing their premedical aspirations than students from nonunderrepresented backgrounds.10 In this study, undergraduate students were asked to rate their level of interest in becoming a physician on a 10-point scale at the start of their first year, and again at the end of their second year. Native American (−1.64), African American (−1.44) and Latina (−1.32) students had larger decreases on the 10-point scale of interest compared with the white (−1.05) and Asian American (−0.37) students.10 Qualitative interviews at University of California, Berkeley revealed that underrepresented students identified chemistry courses as the catalyst for their abandoning their hopes of becoming a physician. Of the 28 underrepresented students, 71% cited chemistry as the most discouraging of their courses.11 Data from 15,000 students from six California colleges found that underrepresented students received significantly lower grades in their premedical sciences courses. The mean GPA in these courses was 1.74 for African American students and 1.94 for Latino students compared with 2.57 for white students.12 In only one of these studies10 was a distinction made between underrepresented students from low and high family incomes. Indeed, we know very little about the college experience for students from any background. This is an area that needs further inquiry; however, here we will focus specifically on interventions known to promote success for underprepared, underrepresented students.
High-Impact Practices to Promote Success
Higher education research has demonstrated that students from all backgrounds benefit from intentional first-year programs, frequent interaction with faculty and peers, and career exploration.13 Notably, underprepared students appear to benefit the most from these practices.13 Living–learning communities (LLCs) provide college students with social, academic, and career support. An LLC is a “program in which undergraduate students live together in a discrete portion of a residence hall (or the entire hall) and participate in academic and/or extracurricular programming designed especially for them.”14 There is strong evidence that participation in LLCs is associated with many positive outcomes, including smoother academic transitions to college15 and increased sense of belonging, particularly for students in STEM fields.16 In addition, underrepresented and first-generation students demonstrate particularly increased benefits from participation in LLCs.17
The Health Sciences Scholars Program (HSSP) at the University of Michigan is an example of a partnership between the medical community and an undergraduate LLC with the goal of promoting success for prehealth students. HSSP’s mission is to provide support for exploration of the health sciences and professions within a diverse living and learning community. It is a program funded by the undergraduate College of Literature, Science and Arts. Since its inception in 2001, the director of HSSP has come from one of the health professions schools. The director was a certified nurse midwife from 2001 to 2009, an emergency medicine physician from 2009 to 2013, and an obstetrician–gynecologist physician from 2013 to 2016.
Each year, approximately 120 first-year students are accepted into the program. To identify students who could potentially benefit the most from participation in the program, the admissions team considers demographic factors, such as parental income and education level. In addition, active recruitment efforts target high schools with large proportions of underrepresented students to ensure a diverse student cohort. Of the 1,065 total students who participated in HSSP during their freshman year from 2001 to 2011, 218 (20%) self-identified as black/African American, Hispanic, or Native American. Of these 218 students, 49 (22%) were first-generation college students, and 24 (11%) had family incomes less than $50,000.
The HSSP students are prehealth and have interests that include nursing, pharmacy, physical therapy, and dentistry, and the majority of the students start their college experience as premed. All HSSP first-year students live in the same residence hall and have academic and residential support within the building. In addition, there is a prehealth advisor designated exclusively for all HSSP students. The first-year students participate in a two-semester foundational academic course taught by the director of HSSP. The course includes two structured clinical observations per semester, as well as opportunities for the students to connect with faculty of diverse backgrounds from many of the health professional schools including Pharmacy, Medicine, Public Health, Nursing, and Dentistry. Students also have the opportunity to develop mentorship relationships with faculty and graduate students from the health professional schools. HSSP also provides programming and workshops about the development of effective mentorship relationships. The majority of students stay in the HSSP community for only their first year, although a small number are selected to return as sophomore leaders.
A survey of HSSP participants from 2001 to 2009 was performed in 2014, and 409 individuals responded to the survey (45% response rate). Respondents reported high levels of satisfaction with the program. The vast majority (86%) stated that they would recommend HSSP to an incoming first-year student. The clinical observation opportunities, the supportive residential community, positive interactions with the HSSP prehealth advisor, and the faculty interactions were cited as the most valuable aspects of respondents’ experiences. Graduate school matriculation and graduation data for all students who participated in HSSP from 2001 to 2011 were obtained from the National Student Clearinghouse. Of the 1,065 students, 156 (15%) either had graduated from or were currently attending medical school. Of the 218 students from URiM backgrounds, 81 (37%) were currently enrolled in or had graduated from a health professions graduate program, with 25 (11%) either currently enrolled in or having graduated from medical school. Other health professions degrees included 12 (6%) masters of public health, 4 (2%) doctors of dentistry, and 10 (5%) masters of health administration.
These outcomes are similar to published reports of other pathway programs. The Stanford Medical Youth Science Program is a five-week academic enrichment summer program for low-income high school students (N = 405), predominantly from underrepresented backgrounds (N = 239; 59%). Over 18 years, 54 of their students (13%) had either attended or were attending medical school, and 69 (29%) were attending or had graduated from a graduate school in a health-related field.18 The Summer Medical Program from the New Jersey Medical School is another summer program for high school students from low-income families. Over 26 years, 1,772 students participated in the program, and 638 (36%) have entered graduate school in a health-related field.19 There have been other published reports of positive graduate school outcomes for interventions at various institutions20–22; however, it is difficult to make inferences based on the outcomes data from these programs given the inherent differences in programmatic content and design. There are also likely many other programs that exist, but very few have published their outcomes data.
It is important to note that, although many students from HSSP have graduated from health professions graduate programs, the majority of students from URiM backgrounds did not ultimately enter a health profession. A strength of our outcomes analysis was that graduate school information for all HSSP students was obtained from the National Student Clearinghouse. Information about students who applied and were not accepted into graduate programs, or students who decided not to apply to programs, was not available from this data source. A recent qualitative study by Freeman23 reported that premedical and predental students from underrepresented backgrounds faced multifaceted challenges during their college experiences. These challenges included inadequate institutional resources, such as limited opportunities for clinical experience, and inadequate guidance and mentorship. College programs such as HSSP are able to target these gaps; however, they cannot also address many of the other important issues such as strained personal resources and societal barriers that were also cited in participants’ interviews in Freeman’s23 study. Students will ultimately need multiple “touch points” of support at the college level and beyond to bolster their chances of success along the prehealth pathway.
Academic Medicine’s Role in Diversity in Higher Education
It is critical that leaders in academic medicine continue to stress the educational and societal value of diversity in higher education, as well as in medicine. Improving the racial and ethnic diversity of the physician workforce has the potential to improve access to health care and to reduce health care disparities,24,25 increase patient satisfaction,26 and benefit all medical students.27 In 1997, Jordan Cohen,28 then-president of the AAMC, called on U.S. medical schools to “bridge the appalling diversity gap that separates medicine from the society it professes to serve.” Cohen also stated that “seeking diversity in the medical professions is imperative to achieve just and equitable access to rewarding careers in the medical profession.”28 Nearly 20 years later, AAMC Board of Directors Chair Peter Slavin again called attention to the lack of progress in his 2015 annual national address, stating that “even as our country grows more diverse, our hospital staffs and medical schools have not. In fact, the demographics of medical school classes have only moderately changed in 20 years.”29 We argue that these demographics will not improve if discussions on diversity in medicine exclude the undergraduate experience.
If we are to achieve sociodemographic equity and inclusion in medicine, we must reexamine how we support underprepared, underrepresented students during their premedical experiences. Justice Scalia’s comments serve as a reminder of the tendency to frame these matters as a “mismatch” between underrepresented students in elite colleges and universities. Instead, leaders in academic medicine should be involved in “matching” underprepared, underrepresented students with concrete college experiences that promote their success. The HSSP is one example of how developing innovative collaborations can help to nurture and sustain interest in these promising students.
Acknowledgments: The authors wish to thank Ms. Sarah Block for her assistance with the preparation of this manuscript.
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