By 2034, the United States will encounter a workforce shortage of up to 124,000 physicians. 1 This shortage offers an opportunity and creates a sense of urgency to develop a national strategy to recruit diverse talent to medicine. Data reveal notable differences in representation by race, ethnicity, and socioeconomic status among medical students and in the physician workforce. 2–5 These trends have not changed significantly in the past 40 years, and inequities are most dire for Black men and American Indian and Alaska Native communities. 6 No workforce development and management strategy to address the projected physician shortage can be complete without accounting for this lack of diversity in the workforce.
In 2015, the Association of American Medical Colleges (AAMC) released Altering the Course: Black Males in Medicine, a report showing there were more Black men applying and entering medical school in 1978 than in 2014. 6 Despite slight increases since 2014, the representation of Black men in medicine (BMIM) remains a critical issue. 3 Drawing from this work, in 2017, the National Academies of Sciences, Engineering, and Medicine published An American Crisis: The Growing Absence of Black Men in Medicine and Science, the proceedings of a joint workshop with the W. Montague Cobb/National Medical Association (NMA) Health Institute, which underscored that the representation of BMIM is more than just a Black community crisis, it is an American crisis. 7
This American crisis is rooted in a history of systemic racism from slavery to Jim Crow, to Supreme Court cases including Plessey vs Ferguson and Brown vs Board of Education, to redlining practices disregarding the 14th Amendment. Discriminatory and prejudicial policies and practices also created obstacles for aspiring Black physicians. 8 For example, the NMA was founded in 1895 because Black physicians could not join the American Medical Association (AMA) or other medical societies until the 1960s. 9 Being denied AMA membership was significant since it was a prerequisite for securing the hospital privileges needed to practice medicine in the United States. In 1910, the Flexner Report forced the closure of 5 Black medical schools, leaving only Howard University and Meharry Medical College. 10 Despite the opening of 2 additional Historically Black College and University (HBCU) medical schools in the intervening years, Charles R. Drew University of Medicine and Science in 1966 and Morehouse School of Medicine in 1975, the BMIM ratio remains a national issue. 10,11
This history undergirds the deplorable reality that Black men are typically at the bottom ranks of U.S. education, health, and employment statistics. 12 For example, public perceptions and teachers’ mindsets influence the trajectory of Black men starting as early as preschool. 13 In addition, life expectancy for Black men in the United States is the lowest of any population. 14 Black boys and men must often navigate an inequitable system that is rarely called to account for disparities. Research and data affirm that a national systems-based strategy for increasing the representation of BMIM is long overdue to address workforce and health inequities.
Facilitating Systems Changes Through Collective Impact
Since the mid-1960s, federal policies have catalyzed health workforce development in the face of shortages and a lack of diversity. Some examples include the 1963 Health Professions Educational Assistance Act, the Comprehensive Health Manpower Training Act of 1971, and the Special Health Careers Opportunity Grant Program (later the Health Careers Opportunity Program). 15 In addition, the federal government, philanthropy, nonprofits, and academic health centers have sponsored premedical programs that have significantly increased health workforce diversity. 16–18 However, anti-affirmative action laws and the constant threat of federal funding cuts have subverted diversity efforts. 19
Exploring systems-based solutions to mitigate this crisis is essential. Recognizing that no one entity could address this feat alone, the AAMC and the NMA launched the Action Collaborative for Black Men in Medicine in August 2020. 20 The Action Collaborative started with an Organizing Committee of AAMC and NMA leaders. The Organizing Committee identified subject matter experts in the areas of Black men in higher education, equity, diversity, and inclusion, and admissions; leaders in K-12, undergraduate, and medical education and health care; and learners. These experts serve as the Action Collaborative Steering Core Committee. Both the Organizing and Steering Core Committees convened for several months to work through a discovery phase that enabled us to develop the foundational knowledge to inform an action agenda focused on systems change along the medical education continuum. Figure 1 shows the structure of the Action Collaborative, which includes 3 interconnected groups with varied levels of engagement.
Convening with a sense of urgency, the Action Collaborative set its focus on the period from high school through the first 2 years of medical school. Evaluating research, data, current practices, and collective lived experiences, the Action Collaborative members identified systems-based factors influencing the trajectory of BMIM (see Figure 2). These factors are affected by racism, public perceptions, and socially constructed narratives about Black men, and they are interrelated and, in some cases, interdependent. 21–24
In this article, we, as Organizing and Steering Core Committee members, describe the Action Collaborative’s initial focus areas and considerations and future plans that will inform the boundaries of an action agenda for systems change over the next 1 to 5 years.
Navigating premedical systems factors
The Action Collaborative identified the following premedical systems factors that influence the trajectory of BMIM.
Financing and funding.
The average 4-year cost of medical school was $250,222 at a state institution and $330,180 at a private medical school from 2009 to 2019, not including application and interview costs. 25 The median Black family household income was $46,073 in 2019, significantly below the U.S. median of $68,703, so financing and funding stressors cannot be overstated. 26,27
Parsing medical school debt data by race reveals that Black students bear the highest burden of debt, with an average indebtedness at $230,000 for Black graduates compared with $200,000 for White graduates, adding to Black students’ already higher undergraduate education debt. 25 The Action Collaborative explored issues related to access to higher education funding, financial aid and scholarships, philanthropy, debt payoff, and financial literacy skills. Other systems change opportunities include exploring the influence of medical school tuition waivers, rising medical education costs, and the structure of federal financial aid awards and how these opportunities may align with local community and national workforce and health care needs.
The Action Collaborative also explored where, how, and from whom Black men are likely to seek information about pathways to medical school as well as how this information could be more culturally responsive. Providing high school teachers and counselors with improved access to this information may play a critical role in supporting students’ career exploration. 28
At the collegiate level, the Action Collaborative recognized that information sources will vary. Therefore, equipping basic science chairs and faculty engaged in prerequisite courses, academic advisors, career development staff, and leaders of BMIM initiatives with premedical information may improve access for Black students. This includes targeted work with minority serving institutions, community colleges, and grassroots programs. The Tour for Diversity and Black Men in White Coats are good examples of organizations connecting Black men and their communities to resources. 20 Leveraging technology, specifically social media (e.g., #Blackmeninmedicine on Twitter), is also essential to broaden information access.
The Action Collaborative specifically called out the role of pre-health advisors in supporting Black students as a separate systems issue. Advisors often are the first level of gatekeeping in academia. The goal of pre-health advising is to align the hallmarks of academic advising, professional counseling, and career alignment with student competencies. Yet, Black men frequently face challenges with advising. 6 One Action Collaborative concern is the lack of standardized qualifications or preparation for those in the pre-health advising role. In addition, the absence of clear guidelines for pre-health advising and the lack of data explaining the current methodologies used by pre-health advisors undermine developing and evaluating a system of effective, culturally informed practices. 29
Pre-health advising quality is also influenced by the institutions’ strategic priorities, funding, manageable advisor-to-student ratios, as well as student trust and engagement. The pre-health advising community must identify models of success that transcend the influences of both environmental factors and students’ K-12 academic preparedness. Ensuring advisors use a success ideology mindset (focusing on students’ assets) rather than a competitive degradation mindset (focusing on students’ deficits) can affect outcomes for Black men. 30 This approach requires building an infrastructure that is equity-advancing, transformative, and sustainable for diverse communities.
Medical College Admission Test (MCAT).
Standardized test scores that have been used for “educational redlining” in higher education can be an exclusionary metric influencing BMIM. 31 Medical school leaders have reported pressure to continue admitting applicants with the highest MCAT scores to preserve their institution’s U.S. News and World Report ranking. 32 This practice does not take into account how socioeconomic and educational factors can influence MCAT scores. 33 Other key issues include the cost of preparing for and taking the MCAT exam, test intimidation, anxiety, imposter syndrome, stereotype threat, and access to needed accommodations.
Many medical schools have adopted holistic admissions, but the level of implementation varies, which affects outcomes. 34 Historically, the MCAT exam has been one of the primary determinants in measuring applicants’ academic preparedness. However, newer research shows that applicants with a broader range of MCAT scores, specifically the middle third of the score scale (495–504), succeed. Within this score range, applicants are more likely to be first-generation college graduates, from a rural or medically underserved area, or identify as Black/African American, American Indian or Alaska Native, Hispanic/Latino, or Native Hawaiian/Pacific Islander. 32 Implementing holistic admissions and broadening the range of acceptable MCAT scores are viable strategies that medical school leaders should use to increase the number of Black men applicants and matriculants. Taking it a step further, making the MCAT exam pass/fail, similar to the recent changes to the United States Medical Licensing Exam Step 1, may have an even greater effect on increasing medical student diversity. 35
Family, peers, teachers, mentors, community members, coaches, and faith-based groups provide social capital that often enables students’ educational and career success. 6,36 However, research based in 3 U.S. cities showed that Black men were more likely to have smaller networks for jobs, education, and housing. 37 One of the identified difficulties for Black premedical students specifically is a lack of mentors and visible role models. 6,36
HBCUs have been praised as inclusive environments facilitating student self-efficacy, racial pride, psychological safety and wellness, academic development, and persistence. 38 As top feeder institutions to medical schools for Black students, there are lessons to learn from HBCUs, like Xavier University of Louisiana, that may help predominately White institutions foster more culturally responsive and inclusive learning environments for Black men. 6,38 For example, predominantly White institutions can replicate services such as peer- and instructor-led educational offerings for students in high-attrition courses, like general and organic chemistry. At Xavier University of Louisiana, there is a peer- and instructor-led drill system that monitors student progress and provides learning reinforcements. Also, with every student engagement, leadership, starting with the university president, are clear that every student has the capacity to succeed. Predominantly White institutions can take a similar asset-based approach to student messaging about college success rather than highlighting their odds for graduation. 38
Next, fraternal membership and ethnic/cultural student organizations promote positive social and academic integration for Black students. 39 Programs like the Student National Medical Association’s Minority Association of Pre-Medical Students provide peer mentoring through local chapters. 36 In addition, many community colleges and universities sponsor Black/minority male initiatives that can be excellent vehicles for collaboration. 40 For example, in 2017, the African American Male Initiative at Augusta University collaborated with the Medical College of Georgia’s chapter of the Student National Medical Association on a premedical mentoring network for Augusta University students participating in the African American Male Initiative. 20 Following its initial success, Augusta University now leverages this program as a recruiting tool. Rather than siloed approaches, the Action Collaborative is starting to foster an interconnected network of support systems for aspiring BMIM.
Pre-K through high school sets the stage for career success. Yet, research often highlights pejorative themes about Black boys in education, including lower high school and college graduation rates. While such portrayals tend to suggest that Black boys and men choose not to prioritize their academics, that is not the reality. 41 Studies have shown that 5 factors influence the educational and career development of Black men: interests, preparation, experiences, connections, and opportunity. 42 The Action Collaborative explored how influencing federal and local policies tied to improving education quality—including rigorous science and math curricula, teacher preparation, school retention and graduation, and school funding—is essential for systems change. Thus, as academic health centers often serve as anchor institutions in their communities, they should take a more active role in shaping public policies that influence pre-K to high school education quality.
Alternative career paths.
Young Black men have many career options outside of medicine. Engineering, research, data science, technology, and other health professions also offer Black men the opportunity to contribute to science and health. The Action Collaborative underscores the importance of partnering across science, technology, engineering, and the health professions to support Black men who want to pursue a career in any of these fields.
Addressing hurdles in academic medicine
The Action Collaborative also identified 4 areas where medical schools should take action to increase the representation of BMIM.
There are various opportunities for academic medicine to engage young Black men through their school systems, community organizations, and faith-based organizations. Pathway programs, YMCAs, Boys and Girls Clubs of America, Upward Bound, Area Health Education Centers, and other community-based programs offer viable opportunities to intentionally engage young Black men from a spectrum of socioeconomic, cultural, and ethnic backgrounds (e.g., African American/Black descendants of slaves in the United States, Black men of African or Caribbean descent). For example, Young Doctors DC is a health careers high school program for boys in Southeast Washington, DC, and Mentoring in Medicine leverages the enthusiasm of medical students and residents to provide programming for middle and high school students. 20 Health science academies in public schools are another opportunity for medical school partnerships. 43
Aligned with Liaison Committee on Medical Education requirements, medical schools sponsor premedical initiatives as early as elementary school. 44,45 However, these medical schools do not always interview or matriculate participants from their own pathway programs, missing an opportunity to further support their local community and increase the diversity of their student body. Examining the role of premedical programs, reviewing institutional data more closely, and creating bridges across academic health centers may help to create a system of early identification and engagement for young Black men.
Medical school recruitment.
This is a critical component of the admissions process that heavily influences the applicant pool and ultimately medical school matriculants. Institutional recruitment efforts should be closely aligned with holistic review practices. 46 Thus, the policies, practices, and procedures that guide how medical schools conduct outreach and recruitment must be guided by equity-minded principles, and financial and other support should be commensurate to further diversity, equity, and inclusion goals.
Engaging 2-year and 4-year colleges that have a high representation of Black men can enhance recruitment efforts. Premedical programs at these colleges should be viewed as another recruitment tool. It is also vital that medical schools enrolling few or no Black men evaluate their recruitment policies and practices and identify opportunities to improve. Accrediting bodies, like the Liaison Committee on Medical Education, need to hold schools accountable for making these changes.
Medical school admissions.
Admissions policies, practices, and committees can facilitate or hinder BMIM. Thus, admissions offices can benefit from reexamining their screening criteria; screener experience and diversity; diversity of administrators, faculty, and committee members; standardized interview protocols and rating scales; and application of holistic review. 23 Adding voting members, such as diversity affairs officers and/or local community representatives, and instituting committee term limits may also improve admissions processes and outcomes.
In addition, implicit biases affect 7 out of 10 people in studies of the general population, 47 and negative perceptions of Black people were found among admissions committee members at one of the nation’s largest public medical schools, solidifying the need to acknowledge racial bias and discuss its role in admissions. 48 One effective practice that should be implemented at all medical schools then is bias mitigation training for admissions committee members. 49 Research out of Ohio State University supports the widespread adoption of such training; studies found that (1) implicit bias training resulted in internal medicine department members perceiving an enhanced climate of inclusion 47 and (2) the diversity of accepted students increased. 48
Medical school accountability encompasses several domains, including: (1) social accountability or the social contract between a school and the local and regional communities, (2) national accountability for producing a health workforce to meet the population’s needs, (3) compliance accountability for addressing accreditation standards, and (4) internal accountability to its own mission and values. 8 Structures within these domains that hold schools accountable for the planning, implementation, and evaluation of equity, diversity, and inclusion policies and practices are necessary to increase the representation of BMIM.
Accrediting bodies, like the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education, set expectations and standards for the quality of educational programs and could influence the practices of academic health centers. 50 However, the Action Collaborative observed that this influence can be undermined when accrediting bodies do not critically evaluate a program or the institution’s diversity efforts. For example, one Action Collaborative member noted that a well-written report can often obfuscate an institution’s real investment in diversity. Thus, close scrutiny by accrediting bodies is imperative. Attention is also needed to the influence of rankings and other score cards, like that from U.S. News and World Reports, and the role these lists play in promoting selectivity and exclusionary practices rather than mission-based goals. 32
The Action Collaborative explored how leaders can influence systems change by increasing accountability in the following areas: creating value and rewards for leaders; integrating performance management into faculty tenure and promotion processes; promoting transparency to governing bodies; and leveraging community voices to reinforce the institution’s responsibility to the local community. The Action Collaborative also considered accountability frameworks, structures, and metrics at the varied leadership levels and how they can support BMIM. Governing boards, university presidents, chancellors, and other executive leaders with decision making influence have a responsibility for advancing diversity. However, metrics and reporting mechanisms are not always clear, so leaders must consistently and visibly declare that increasing the representation of BMIM is a priority and not leave this responsibility to diversity leaders alone.
Finally, payors also have a role in supporting accountability structures and addressing health inequities. In 2004, 11 major health plans joined under the National Health Plan Collaborative to explore ways to improve the quality of care for diverse populations. 51 In addition, the financial costs of health inequities, including those driven by the disproportionate burden of chronic disease in Black men, fall to society. For example, a 2018 WK Kellogg Foundation study reported that U.S. health disparities led to $93 billion in excess medical care costs and $42 billion in unrealized productivity. 52 Thus, health insurers have a business interest in promoting health equity and physician workforce diversity.
Next Steps: Coalition Building and Action Agenda Development
The Action Collaborative’s structure and operations leverage equity-mindedness, collective impact, and coalition building, centering the voices of Black men. Equity-mindedness is characterized by personal and institutional accountability and the principles of race consciousness, institutional focus, evidence-based, systemic awareness, and action orientation. 53 Collective impact has demonstrated promise for systems change in science, technology, engineering, and medicine, 54 and the Action Collaborative integrates 5 key elements from this work: (1) building a common agenda, (2) shared measurement, (3) mutually reinforcing activities, (4) continuous communication, and (5) having a backbone organization(s) (in this case, the AAMC and NMA) involved in planning processes. 55 Working with a coalition of partners, the Action Collaborative’s approach is critical to reducing silos along the education continuum and fostering coordinated action that addresses the factors identified in Figure 2.
Based on the identified systems factors, the Action Collaborative Steering Core Committee prioritized 2 areas for systems change—pre-health advising and leadership accountability. The pre-health advising workgroup first engaged leaders and members of the National Association of Advisors for the Health Professions and the National Association of Medical Minority Educators, who solidified the need for standardized pre-health advising training. Using the Action Collaborative’s preliminary research and key informant interviews, this workgroup is now adapting competencies and formulating learning objectives to develop a standardized set of equity-minded pre-health advising microlearning modules. The process of developing these learning resources and the outputs are the beginning steps toward creating national standards and an interconnected system for pre-health advising. Next, the leadership accountability workgroup started planning forums and additional scholarly work with the goal of developing a framework for use at medical schools. While supporting these workgroups, the Action Collaborative is also focusing on infrastructure development, planning, and coalition building that will set the stage for expanding its membership and implementing a process for co-designing a national agenda. See Figure 3 for specific goals that align with each of the collective impact elements listed above.
Increasing the number of BMIM is one strategy to address workforce shortages and reduce health inequities, especially for Black men. 56–58 Over the past decade, 3 of the top 5 undergraduate institutions supplying Black men applicants to medical school have been HBCUs. 6 However, HBCUs cannot be the sole avenue to engage BMIM. 59 The Action Collaborative urges leaders at every medical school to reflect on their responsibility and social obligation in creating a diverse physician workforce. All the premedical and academic medicine factors we have identified here are critical to enduring systems change. Through collective impact and coalition building, over the next 1 to 5 years, the Action Collaborative will continue with key informant interviews and listening sessions with systems actors to build collective knowledge and will engage more action partners, voices, and allies to further coalition building. The Action Collaborative will also convene action partners to identify mutually reinforcing activities and co-create a common action agenda and associated metrics to measure progress over time.
Addressing the representation of BMIM as a workforce issue means that academic medicine and its partners must tackle the social determinants of both health and education, which undermine the educational and career success of Black men. This must be done using a racial equity and social justice lens. Public policies, like the Commission on the Social Status of Black Men and Boys Act enacted in 2020, offer promise to advance systems-based solutions across sectors. 60 We are excited about the next phase of coalition building through the engagement of action partners and diverse voices and allies to leverage our strengths and act collectively to facilitate broader systems change in medicine.
The authors thank Valerie Montgomery-Rice and Shaun R. Harper for their insights during the initial Action Collaborative discussions; M. Oscar Platero, James L. Moore III, Joon Kim, and the members of the Action Collaborative for their active engagement and contributions; Jim Nuttle for his artistry in the development of Figure 2; and Alysia Rieves for her ongoing administrative support that helped bring this work to fruition.
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