HBCUs and the Production of Doctors

A systematic review of barriers to pursuing careers in medicine among Black premedical students

Among the various etiologies of the exclusion of Black male physicians from the healthcare workforce, it is critical to identify and examine the barriers in their trajectory. Given that most medical school matriculants graduate and pursue residency training, medical school admission has been identified as the primary impediment to a career in medicine. Thus, this work aims to identify barriers in the journey of primarily Black, and secondarily underrepresented minority, premedical students. A systematic review of the medical literature was conducted for articles pertaining to the undergraduate/premedical period, Black experiences, and the medical school application process. The search yielded 5336 results, and 13 articles were included. Most papers corroborated common barriers, such as financial/socioeconomic burdens, lack of access to preparatory materials and academic enrichment programs, lack of exposure to the medical field, poor mentorship/advising experiences, systemic and interpersonal racism, and limited support systems. Common facilitators of interest and interventions included increasing academic enrichment programs, improving mentorship and career guidance quality and availability, and improving access to and availability of resources as well as exposure opportunities. No article explicitly discussed addressing racism. There is a dearth of studies exploring the premedical stage-the penultimate point of entry into medicine. Though interest in becoming a physician may be present, multiple and disparate impediments restrict Black men's participation in medicine. Addressing the barriers Black and underrepresented minority premedical students face requires an awareness of how multiple systems work together to discriminate and restrict access to careers in medicine beyond the traditional pipeline understanding.

Surgeon Intersectionality and Academic Promotion and Retention in the US

Introduction

Efforts have been made to increase the number of women and physicians who are underrepresented in medicine (UIM). However, surgery has been slow to diversify, and there are limited data surrounding the impact of intersectionality.

Objective

To assess the combined association of race and ethnicity and sex with rates of promotion and attrition among US academic medical department of surgery faculty.

Design, Setting, and Participants

This was a retrospective cohort study using faculty roster data from the Association of American Medical Colleges. All full-time academic department of surgery faculty with an appointment any time from January 1, 2005, to December 31, 2020, were included. Study data were analyzed from September 2022 to February 2023.

Exposures

Full-time academic faculty in a department of surgery with a documented self-reported race, ethnicity, and sex within the designated categories of the faculty roster of Association of American Medical Colleges.

Main Outcomes and Measures

Trends in race and ethnicity and sex, rates of promotion, and rates attrition from 2010 to 2020 were assessed with Kaplan-Meier and Cox time-to-event analyses.

Results

A total of 31 045 faculty members (23 092 male [74%]; 7953 female [26%]) from 138 institutions were included. The mean (SD) program percentage of UIM male faculty increased from 8.4% (5.5%) in 2010 to 8.5% (6.2%) in 2020 (P < .001), whereas UIM female faculty members increased from 2.3% (2.6%) to 3.3% (2.5%) over the 10-year period (P < .001). The mean program percentage of non-UIM females increased at every rank (percentage point increase per year from 2010 to 2020 in instructor: 1.1; 95% CI, 0.73-1.5; assistant professor: 1.1; 95% CI, 0.93-1.3; associate professor: 0.55; 95% CI, 0.49-0.61; professor: 0.50; 95% CI, 0.41-0.60; all P < .001). There was no change in the mean program percentage of UIM female instructors or full professors. The mean (SD) percentage of UIM female assistant and associate professors increased from 3.0% (4.1%) to 5.0% (4.0%) and 1.6% (3.2%) to 2.2% (3.4%), respectively (P =.002). There was no change in the mean program percentage of UIM male instructors, associate, or full professors. Compared with non-Hispanic White males, Hispanic females were 32% less likely to be promoted within 10 years (hazard ratio [HR], 0.68; 95% CI, 0.54-0.86; P <.001), non-Hispanic White females were 25% less likely (HR, 0.75; 95% CI, 0.71-0.78; P <.001), Hispanic males were 15% less likely (HR, 0.85; 95% CI, 0.76-0.96; P =.007), and Asian females were 12% less likely (HR, 0.88; 95% CI, 0.80-0.96; P =.03). Non-UIM males had the shortest median (IQR) time to promotion, whereas non-UIM females had the longest (6.9 [6.8-7.0] years vs 7.2 [7.0-7.6] years, respectively; P < .001). After 10 years, 79% of non-UIM males (13 202 of 16 299), 71% of non-UIM females (3784 of 5330), 68% of UIM males (1738 of 2538), and 63% of UIM females (625 of 999) remained on the faculty. UIM females had a higher risk of attrition compared with non-UIM females (HR, 1.3; 95% CI, 1.1-1.5; P = .001) and UIM males (HR, 1.2; 95% CI, 1.0-1.4; P = .05). The mean (SE) time to attrition was shortest for UIM females and longest for non-UIM males (8.2 [0.14] years vs 9.0 [0.02] years, respectively; P < .001).

Conclusion and Relevance

Results of this cohort study suggest that intersectionality was associated with promotion and attrition, with UIM females least likely to be promoted and at highest risk for attrition. Further efforts to understand these vulnerabilities are essential.

Physician Workforce Diversity Is Still Necessary and Achievable if It Is Intentionally Prioritized

The 2023 Supreme Court Decision from Students for Fair Admissions v. Harvard and Students for Fair Admissions v. University of North Carolina threatens the current progress in achieving diversity within undergraduate and graduate medical education. This is necessary to achieve a diverse healthcare workforce, which is a key to healing historical healthcare trauma, eliminating health disparities, and providing equitable healthcare access for all communities. Although the Supreme Court decision seems obstructionist, viable opportunities exist to enhance recruitment further and solidify diversity efforts in undergraduate and graduate medical education to achieve these goals.

Structural Racism in Psychiatric Research Careers: Eradicating Barriers to a More Diverse Workforce

Investigators from minoritized backgrounds are underrepresented in psychiatric research. That underrepresentation contributes to disparities in outcomes of access to mental health care. Drawing on lived experience, scholarly qualitative reports, and empirical data, the authors review how the underrepresentation of minoritized researchers arises from interlocking, self-reinforcing effects of structural biases in our research training and funding institutions. Minoritized researchers experience diminished early access to advanced training and opportunities, stereotype threats and microaggressions, isolation due to lack of peers and senior mentors, decreased access to early funding, and unique community and personal financial pressures. These represent structural racism-a system of institutional assumptions and practices that perpetuates race-based disparities, in spite of those institutions' efforts to increase diversity and in contradiction to the values that academic leaders outwardly espouse. The authors further review potential approaches to reversing these structural biases, including undergraduate-focused research experiences, financial support for faculty who lead training/mentoring programs, targeted mentoring through scholarly societies, better use of federal diversity supplement funding, support for scientific reentry, cohort building, diversity efforts targeting senior leadership, and rigorous examination of hiring, compensation, and promotion practices. Several of these approaches have empirically proven best practices and models for dissemination. If implemented alongside outcome measurement, they have the potential to reverse decades of structural bias in psychiatry and psychiatric research.

Mitigating the Isolation of Minoritized Faculty in Academic Medicine

Increasing numbers of faculty who are underrepresented in medicine has been a focus of academic health systems. Understanding the experiences of these faculty helps in creating environments that are inclusive and supportive, promoting faculty success. When compared with non-minoritized faculty, minoritized faculty face racism, isolation, diversity efforts disparities, clinical efforts disparities, lack of faculty development, and promotion disparities. While there have been contributions to the literature to better characterize disparities faced by minoritized faculty, little has been written about isolation. Isolation occurs when faculty underrepresented in medicine do not feel like part of the department or institution. They may feel excluded from mainstream culture as if they are invisible. They may be excluded from conversations, group chats, get togethers, or other work-related or social functions. These feelings can manifest as imposter syndrome and impact work performance and decision-making. In this article, the author shares how to recognize and mitigate isolation to promote an inclusive environment for all faculty.

Increasing Underrepresented Minority Students in Medical School: a Single-Institution Experience

PURPOSE

Underrepresented minority student recruitment initiatives from medical school admissions and diversity offices can bring equity for those learners underrepresented in medicine. Measuring growth of the applicant pool helps determine the impact of such initiatives in helping diversify the healthcare workforce.

AIM

The authors evaluated underrepresented minority applicant pool growth at the Brody School of Medicine to determine whether predominantly White institutions or historically Black colleges and universities have accounted for the most growth in minority applicants in recent years.

METHODS

Outreach outcomes across the state were obtained by comparing applicant and matriculant demographics. Data on all applicants and matriculants were retrieved from the school's institutional records and classified according to student self-identification as underrepresented minority. Using Chi-square tests, authors aimed to determine whether the proportion of minority students increased among applicants and matriculants since 2016, the year of restructuring outreach. In further analysis, the number of graduates from historically Black colleges and universities as compared to minority graduates from predominantly White schools was evaluated.

RESULTS

The authors identified 7,848 applicants and 654 matriculants over the evaluation period. The proportion of learners identifying as underrepresented minority increased from 17% before 2016 (622/3,672) to 20% after 2016 (835/4,176; p = 0.001). The proportion of applicants who did not graduate from a historically Black college or university increased slightly after 2016 (89% of underrepresented minority applicants before 2016 vs. 92% of underrepresented minority applicants after 2016), but this increase was not statistically significant (p = 0.097).

CONCLUSION

Applicant growth has been more significant for underrepresented minority applicants from predominantly White institutions. Graduates of targeted historically Black colleges and universities who applied to Brody School of Medicine were better prepared, resulting in increased chances of admission.

Increasing the Representation of Black Men in Medicine by Addressing Systems Factors

In 2015, data released by the Association of American Medical Colleges (AAMC) showed that there were more Black men applying and matriculating to medical school in 1978 than 2014. The representation of Black men in medicine is a troubling workforce issue that was identified by the National Academies of Sciences, Engineering, and Medicine as a national crisis. While premedical pathway programs have contributed to increased workforce diversity, alone they are insufficient to accelerate change. In response, the AAMC and the National Medical Association launched a new initiative in August 2020, the Action Collaborative for Black Men in Medicine, to address the systems factors that influence the trajectory to medicine for Black men. The authors provide a brief overview of the educational experiences of Black boys and men in the United States and, as members of the Action Collaborative, describe their early work. Using research, data, and collective lived experiences, the Action Collaborative members identified premedical and academic medicine systems factors that represented opportunities for change. The premedical factors include financing and funding, information access, pre-health advisors, the Medical College Admission Test, support systems, foundational academics, and alternative career paths. The academic medicine factors include early identification, medical school recruitment and admissions, and leadership accountability. The authors offer several points of intervention along the medical education continuum, starting as early as elementary school through medical school matriculation, for institutional leaders to address these factors as part of their diversity strategy. The authors also present the Action Collaborative's process for leveraging collective impact to build an equity-minded action agenda focused on Black men. They describe their initial focus on pre-health advising and leadership accountability and next steps to develop an action agenda. Collective impact and coalition building will facilitate active, broad engagement of partners across sectors to advance long-term systems change.

Environmental Health Information Partnership (EnHIP): Strengthening the capacity of minority serving institutions

The U.S. National Library of Medicine's (NLM) Environmental Health Information Partnership (EnHIP) collaborates with Historically Black Colleges and Universities (HBCUs) and other minority-serving academic institutions to enhance their capacity to reduce health disparities through the access, use, and delivery of environmental health information on their campuses and in their communities. The partnership began in 1991 as the Toxicology Information Outreach Panel (TIOP) pilot project, and through successive iterations it is NLM's longest running outreach activity. EnHIP's continued relevance today as an information outreach and training program testifies to the prescience of NLM director, Donald A.B. Lindberg M.D's initial support for the program. Dr. Lindberg's seeing to its continued success to benefit participating institutions and help achieve the societal goals of environmental justice serve as well to benefit NLM by increasing its visibility, and use of its resources in the classroom, for research, and in community outreach. NLM envisions an expanding role for EnHIP in advancing health equity as the impact of environmental exposure, climate change, and increasing zoonotic diseases disproportionately impact their communities.

Responding to Health Disparities in Behavioral Weight Loss Interventions and COVID-19 in Black Adults: Recommendations for Health Equity

COVID-19 has disproportionately impacted Black adults with high prevalence and mortality rates. Obesity is a central factor in the severity of COVID-19 and related treatment. Behavioral weight loss interventions are an efficacious treatment for obesity, but consistently, Black men and women are minimally represented, and weight loss outcomes are less than clinically significant thresholds. This commentary draws parallels between COVID-19 racial disparities, disparate obesity rates, weight loss treatment outcomes, and underlying systemic racial context. This paper also indicates paths forward to address racialized societal norms in obesity treatment to advance health equity in obesity and reduce acute disease vulnerability. Recommendations for behavioral medicine practice and policy include (1) expanding the research lens to prioritize Black scholars and institutions to generate innovative research questions, (2) creating trustworthy relationships with Black community members to bolster recruitment and retention, (3) employing qualitative methods to facilitate better intervention design and uncover influences of racialized social context, (4) centering Black adults in weight loss interventions, and (5) using multilevel approaches that integrate policy into interventions. Moving forward, this commentary aims to make plain the multilayered form and function of racism, its impact on COVID-19 and obesity, and offer pathways to improve behavioral weight loss interventions that can produce more equitable outcomes.

The Time Is Now: Racism and the Responsibility of Emergency Medicine to Be Antiracist

The COVID-19 pandemic has shed light on the ongoing pandemic of racial injustice. In the context of these twin pandemics, emergency medicine organizations are declaring that "Racism is a Public Health Crisis." Accordingly, we are challenging emergency clinicians to respond to this emergency and commit to being antiracist. This courageous journey begins with naming racism and continues with actions addressing the intersection of racism and social determinants of health that result in health inequities. Therefore, we present a social-ecological framework that structures the intentional actions that emergency medicine must implement at the individual, organizational, community, and policy levels to actively respond to this emergency and be antiracist.

Inclusion and equity: Experiences of underrepresented in medicine physicians throughout the medical education continuum

The mission of pediatric medical education is to train the workforce who will provide and innovate child healthcare, including addressing healthcare inequities for children and adolescents of color. A diverse physician workforce is associated with more equitable outcomes. Therefore, it is imperative that our workforce continue to reflect the ever-growing diverse nature of our society. While diversity has been at the forefront of conversations for increasing the number of underrepresented communities in medicine, inclusion and equity are oftentimes overlooked. It is crucial to recognize that while diversity is an important aspect to the UIM experience, the overall impact of diversity is diluted when it is not paired with inclusion and equity. Therefore, the purpose of this paper is to illustrate the experiences that shape inclusion and equity for UIM physicians along the training continuum and how negative factors may impact the wellness and career longevity of UIM physicians. Our study explored the experiences of UIM physicians throughout their medical education through the lens of inclusion and equity by exploring three common factors: social support, racism and discrimination, and well-being and burnout. There may be a perception that stressors, including racial discrimination, diminish with progression through one's educational career; however, this review suggests that these stressors manifest differently relative to the trials inherent to each career stage. By exploring the interplay between these factors and the UIM experience as a continuum, we are better able to discuss effective solutions to diversity, equity and inclusion for UIM physicians.

Medical Student Selection

Medical school admissions committees are tasked with fulfilling the values of their institutions through careful recruitment. Making accurate predictions regarding the enrollment behavior of admitted students is critical to intentionally formulating class composition and impacts long-term physician representation.

Academic redlining in medicine

Despite concerted efforts over the past decade to increase diversity in U.S. medical schools, persistent applicant and enrollment gaps remain for students from underrepresented racial and economic backgrounds. To understand these gaps, we propose a new theory of 'academic redlining' as a widespread practice in medical schools that systematically excludes students from underrepresented backgrounds from entry into medicine through the nearly universal use of Medical College Admissions Test (MCAT) cutoff scores. In this paper, we provide evidence that academic redlining via the MCAT disenfranchises students from underrepresented backgrounds prior to and during the admissions process due to structural racism, and describe the three core mechanisms that cause medical schools to engage in academic redlining: (1) the pursuit of institutional prestige, (2) market competition and pressure, and (3) market bands. Given the persistent lack of diversity in medicine-which contributes to devastating health care disparities-as medical schools redouble their commitments to diversity, equity, and inclusion, structural alternatives within medical schools' admissions and education practices are offered to curtail the practice of academic redlining in medical school admissions and medicine.

Lack of Exposure to Palliative Care Training for Black Residents: A Study of Schools With Highest and Lowest Percentages of Black Enrollment

CONTEXT

The palliative medicine workforce lacks racial diversity with <5% of specialty Hospice and Palliative Medicine (HPM) fellows identifying as black. Little is known about black trainees' exposure to palliative care during their medical education.

OBJECTIVES

To describe palliative care training for black students during medical school, residency, and fellowship training.

METHODS

We conducted a cross-sectional descriptive study using Internet searches and phone communication in September 2019. We evaluated 24 medical schools in three predetermined categories: historically black colleges and universities (HBCUs; N = 4) and non-under-represented minority-serving institutions with the highest (N = 10) and lowest (N = 10) percentages of black medical students. Training opportunities were determined based on the presence of a course, clerkship, or rotation in the medical school and residency curricula, a specialty HPM fellowship program, and specialty palliative care consult service at affiliated teaching hospitals.

RESULTS

None of the four HBCUs with a medical school offered a palliative care course or clerkship, rotation during residency, or specialty HPM fellowship program. Three of four HBCUs were affiliated with a hospital that had a palliative care consult service. Institutions with the highest black enrollment were less likely to offer palliative care rotations during internal medicine (P = 0.046) or family medicine (P = 0.019) residency training than those with the lowest black enrollment.

CONCLUSION

Residents at schools with the highest black medical student enrollment lack access to palliative care training opportunities. Efforts to reduce health disparities and underrepresentation in palliative care must begin with providing palliative-focused training to physicians from under-represented minority backgrounds.

Institutional and Faculty Partnerships to Promote Learner Preparedness for Health Professions Education

By the year 2060, it is projected that 57% of the US population will be members of minority groups, with no one group being the majority. While there is increasing diversity of the population, there remain significant disparities in morbidity and mortality affecting minority groups, and persistent low numbers of underrepresented students in the health professions. Increasing the numbers of underrepresented minority students in health care and decreasing the disparity gap have been a priority for many institutions. Increasing diversity requires an approach that not only involves health professions schools but also involves undergraduate institutions, faculty, and other professionals who provide pre-health training to students. In 2018, a group of academic medicine leaders convened the Innovators, Collaborators, and Leaders conference with faculty at institutions across the state of North Carolina to discuss ways to improve learner preparedness for health professions education and increase numbers of underrepresented students pursuing health careers. In this manuscript, the authors share results from the conference and how institutional and faculty partnerships can promote learner preparedness for health professions education.

A flexible, group-based assessment strategy for Historically Black College and University pharmacy students

BACKGROUND AND PURPOSE

Historically Black College and University (HBCU) students often have diverse educational backgrounds and learning needs. We describe the implementation of a group-based assessment (GBA) strategy within a pharmacotherapy course at a HBCU.

EDUCATIONAL ACTIVITY AND SETTING

Ninety second-year pharmacy students participated in the study, completing eight formative GBAs, two summative exams, and a demographic questionnaire. In this study, GBAs were administered as post-assessments after each topic and prior to an exam. Our pilot study sought to describe mean GBA scores in relation to summative exam performance. Data analysis employed descriptive statistics.

FINDINGS

The majority of students were female (61%), identified as either African American (37.8%) or East Asian (35.5%) descent, and claimed English as a second language. The preliminary analysis described student performance levels on Exam 1 and Exam 2 and means of each corresponding GBA. There was a general upward trend in GBA mean scores across the majority of exam performance levels with the exception of GBA 6. GBAs 1 through 4 had the lowest mean scores across all Exam 1 performance levels.

SUMMARY

This pilot study described a flexible group-based assessment format that encouraged student-paced learning among HBCU students. Frequent GBA may act as an early-warning system for these students and can engage students earlier in the course to improve academic performance on major exams. Future studies with a larger number of subjects are needed to validate the use of this GBA strategy in similar settings.

Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools

IMPORTANCE

There continue to be low numbers of underrepresented minorities, including African Americans, in academic medicine. Historically Black medical colleges and universities are major sources of training for medical school graduates who are African American or who belong to other underrepresented minority groups. Several historically Black medical schools were closed during the period surrounding the 1910 Flexner report. The implications of these school closures with regard to the number of African American medical school graduates have not been fully examined.

OBJECTIVE

To examine the consequences associated with the closure of historically Black medical schools for the number of African American medical school graduates.

DESIGN, SETTING, AND PARTICIPANTS

This observational economic evaluation used steady expansion and rapid expansion models to estimate the consequences associated with the closure of historically Black medical schools for the number of African American medical school graduates. The numbers of graduates from 13 historically Black medical schools that are now closed were obtained through historical records. Data on historically Black medical schools that are currently open were obtained from school-specific reports and reports published by the Association of American Medical Colleges. The study focused on projected estimates of outcomes from the hypothetical continued operation and expansion of 5 closed historically Black medical schools that were included in the Flexner report: Flint Medical College of New Orleans University, Knoxville Medical College, Leonard Medical School of Shaw University, Louisville National Medical College, and the University of West Tennessee College of Medicine and Surgery-Memphis.

MAIN OUTCOMES AND MEASURES

The main outcome was the estimate of the number of African American students who would have graduated from historically Black medical schools that were closed during the period surrounding the 1910 Flexner report.

RESULTS

Among the 5 historically Black medical schools that were closed, the estimated mean number of graduates per year was 5.27 students at Flint Medical College, 2.60 students at Knoxville Medical College, 11.06 students at Leonard Medical School, 4.17 students at Louisville National Medical College, and 6.74 students at the University of West Tennessee. If the 5 closed historically Black medical schools had remained open, the steady expansion and rapid expansion models indicated that these schools might have collectively provided training to an additional 27 773 graduates and 35 315 graduates, respectively, between their year of closure and 2019. In the analysis of Leonard Medical School and the University of West Tennessee only, the steady expansion and rapid expansion models indicated that these 2 schools would have provided training to an additional 10 587 graduates and 13 403 graduates, respectively, between their year of closure and 2019. An extrapolation based on the racial and ethnic self-identification of current graduates of historically Black medical schools indicated that if these closed schools had remained open, the number of graduating African American physicians might have increased by 355 individuals (29%) in 2019 alone.

CONCLUSIONS AND RELEVANCE

To increase the number of African American medical school graduates, consideration should be given to creating medical education programs at historically Black colleges and universities. Such programs may start with small enrollment but could have positive consequences for the diversity of the physician workforce.