American College of Physicians: Internal Medicine — Doctors for Adults ®


The backlash against affirmative action

With minority admissions falling, educators consider new options

From the January 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Jennifer Fisher Wilson

Only once did Nadia N. Hansel, MD, feel singled out when she was a black student at Harvard Medical School. That was the time a fellow medical student made what she considered an inappropriate comment linking race and scholarships. Otherwise, Dr. Hansel said that she and the other minority students—many of whom might have been accepted through the school's affirmative action program—received the same treatment as the other students.

Now a first-year internal medicine resident at the University of Pennsylvania, however, Dr. Hansel is more aware of the issue, maybe because attitudes have changed, even in the last couple of years. Sentiment that affirmative action programs are unfair pervades U.S. medical schools, she said, even if it's not often voiced openly.

Recent high-profile legislation—California's Proposition 209—and court verdicts like the one from the Hopwood case have banned affirmative action in California, Texas, Mississippi and Louisiana, bringing the issue of affirmative action in medical school admissions to the front burner.

In turn, the number of medical school applications from underrepresented minority students—defined as blacks, Mexican Americans/Chicanos, mainland Puerto Ricans and Native Americans—dropped 11% nationally this year, and the number of minority entrants dropped 7.4%. This occurred even though affirmative action continues to be legal and used in most states.

As a result, many medical educators are now worried about the future of diversity in the American workforce. Medicine has only become as diverse as it is now because of the special admissions programs that have been in place since the '60s, they say. Moreover, advocates of special admissions programs are quick to point out that underrepresented minorities tend to practice in areas underserved by the medical profession. According to the Association of American Medical Colleges (AAMC), minority medical graduates are nearly four times as likely as other students to plan to practice in underserved areas; once in practice, they tend to see significantly more—and poorer—patients than other physicians.

"We need a culturally diverse group of physicians to serve the population. There is a clear utility function beyond what we call an equity function, some kind of payback for past societal discrimination," said Robert C. Davidson, MD, a professor of family and community medicine at UCD and a member of the UCD admissions committee.

Historically, the goal of affirmative action programs has been to correct some of the imbalances in the physician workforce. While some minorities, such as Asians or Pacific Islanders, have achieved balance, others have not. In 1995, for example, these underrepresented minorities—blacks, Native Americans, Mexican Americans/Chicanos and Mainland Puerto Ricans—made up 21% of the overall population, but they accounted for only 12% of medical student enrollment. Without affirmative action, proponents say improving the imbalance in medical school admissions would be nearly impossible.

Opponents of affirmative action, however, say that it's not fair to screen medical students based on race or ethnicity. In fact, the Hopwood case—a suit brought by a white law school applicant against the University of Texas—declared special admissions programs illegal. In the case, Cheryl J. Hopwood claimed reverse discrimination, that she was rejected by the admissions committee while less qualified minority students were admitted in the name of diversity. In 1996, the courts sided with Ms. Hopwood and outlawed race-based admissions in Texas, Louisiana and Mississippi.

Already, advocates of such programs say, such statewide bans on affirmative action have created a chilling effect among both medical school applicants and educators throughout the United States. Jordan J. Cohen, MACP, president of the AAMC and a staunch supporter of affirmative action, directly links the drop in minority admissions this year to these bans and the growing anti-affirmative action sentiment they are producing. "Based on the trend lines from years past," he said, "a number of students who would have chosen medicine did not because of these new laws."

Medical educators in those states find themselves in a bind. Even as the number of minority applicants drop, they cannot use the special admissions programs of the past. They must instead find new ways to attract minority students.

"Our selection criteria must be race neutral," said Larry Broussard, JD, director of minority affairs at UCD. The university now tries to attract minority students by holding recruitment fairs in locations that are medically underserved. Admissions staff also check to see if applicants come from an underserved community. According to Mr. Broussard, such recruitment tactics are still legal because they're not recruiting candidates based on race or ethnicity.

Admissions staff at UCD are also trying to cope with the new rules by placing more importance on the interviewing process. Mr. Broussard said that interviewers try to uncover if students identify with an underserved population or community.

At the University of Texas Medical School at Galveston, minority admissions have actually improved since the Hopwood case. Some staff even hail the loss of affirmative action as a chance to personalize admissions beyond issues of race and ethnicity. "I don't resent that affirmative action went away. It has no purpose in our school," said Billy R. Ballard, MD, DDS, the associate dean for student affairs and admissions there. He indicated that it wasn't fair to base admissions on race or ethnicity. Instead, he said, "We look at individuals."

Officials at UCD, however, have seen their minority admissions drop. Despite its efforts to cope with the fallout from Proposition 209, which banned affirmative action policies in California in 1996, minority matriculation at UCD fell this year, as it did in other University of California schools. Maria A. Lofftus, JD, the assistant dean for admissions for the University of California, San Diego, School of Medicine, said that her school, at least, now bases more initial admissions decisions on test scores and grades and less on race because of the ban.

Other barriers

For many educators, the current anti-affirmative action sentiment is affecting their ability to recruit minorities, which is making an already difficult job even harder. Educators point out that medicine is not always an attractive option to many minorities, for a variety of reasons.

According to Harold L. Mignott, ACP Member, director of minority recruitment and development at the University of Pennsylvania's internal medicine program, one problem is the delayed gratification that medical school brings. "A lot of people from lower economic classes cannot tolerate looking that far ahead," said Dr. Mignott, who is black. "When I was in college, the folks who wanted to or had to get an economic advantage quickly would take jobs where they could go out and earn something right out of college."

To minimize the degree to which financial issues like medical school debt affect the decision to enter medicine, some educators have proposed offering financial inducements to minority students, who often face other economic stresses. But many question whether medical schools could afford such a plan and whether it would be legal.

Dr. Mignott said that another barrier that keeps minorities from going into medicine is exposure to the field. "How many minorities have the opportunity to see what we really do in medicine?" he asked. "This is a multifaceted career: We have physicians in business-oriented portions of medicine, doing research, doing patient care, teaching. I don't know how many minorities view medicine in that light."

Dr. Hansel, the first-year Penn resident, said she had to go outside her family and friends to learn about medicine. "Nobody surrounding me was doing medicine and I had no idea what type of lifestyle it entailed," she said. "For me to understand what being a doctor was all about took a lot of self initiative to seek out people who were doing it, people whom I didn't even know."

She is not alone. In an AAMC survey, minority students who were admitted to medical school but chose not to matriculate expressed fears about losing their identity in medical school and complained about the lack of role models or peer group.

In a survey at the University of Kentucky Medical Center, black students reported similar feelings. "They said they were uncomfortable with their social life in medical school," said John S. Wiggs, student development director for the office of minority affairs at the University of Kentucky. "They had a sense of isolation."


Ironically, the affirmative action programs designed to help these students can often cause even more stress. At AAMC's annual meeting, a video clip played at a workshop demonstrated the backlash against affirmative action.

In the videotaped dramatization, a female black medical student meets her study group for the first time. A white student in the group verbally accosts the woman, blaming her for getting the scholarship his better qualified friend should have received. He questions whether she deserves to be in medical school at all, let alone on scholarship, assuming that she has only been accepted through an affirmative action.

The racially mixed group of students attending the workshop vouched that such sentiment exists widely at medical schools. But they also said it's more of an undertone, something that is rarely talked about.

Studies have shown that minority medical students do have more academic problems than non-minorities, but advocates of special admissions programs argue that test scores aren't the real issue. What's really important, they say, is whether special admissions medical students ultimately become good doctors.

"A very important issue is what is best for the public," said Herbert S. Waxman, FACP, the College's Senior Vice President for Education. "If special admissions programs lead to capable, compassionate, caring doctors who will be more willing to practice in communities with particularly great need—and this is what studies have shown—then the programs are certainly justifiable."

A controversial study published in the Oct. 8, 1997, issue of the Journal of the American Medical Association attempted to show whether special admissions students—including minority students—become equally good physicians as their regular admissions peers. The 20-year retrospective study found that minorities struggled more in medical school, on medical licensing exams and the boards, but that their residency program directors graded them as comparable to other residents in their practice of medicine.

"Affirmative action students may be less qualified if you look only at MCATs and GPAs, but they may be equally as qualified if you factor in a number of other criteria used by admissions committees. In this study, at least, they merged and did equally well in graduate training as those who came in under regular admissions," said Dr. Davidson from UCD, who was the lead author on the study.

While the study was blasted by critics as biased in favor of special admissions programs, it nonetheless raises questions about the best way to choose medical students. If nothing else, affirmative action and other special admissions programs call into question the importance admissions committees place on test-taking performance.

For example, do students who earn higher grades or score higher on the MCATs or their licensing exam go on to make better doctors than students who earn mediocre grades and test scores?

"Absolute numerical certitude seems to be becoming more and more important to many people," said Faith T. Fitzgerald, MACP, professor of internal medicine and program director for the department of internal medicine at UCD and ACP's Governor for Northern California. She pointed out, however, that most of today's older top-notch physicians didn't take the MCAT, nor did they face the same extreme competition for medical school admission as applicants do today.

"All those things now being demanded of medical students were genuinely not in place at the time that the current greats in medicine were in training," Dr. Fitzgerald said. The advances that these physicians have made in medicine and science in the past four decades can be seen as proof that test scores are not absolute necessities for excellence, she explained.

Test scores, for example, fail to show interpersonal communication skills, intuition, honesty, leadership, curiosity, creativity or sensitivity, all qualities important to being a good doctor, she said. And tests don't indicate what students have surmounted to come this far. Some students enter medicine only by overcoming difficult environmental circumstances while more privileged students enter with comparatively little effort. "If those students do equally well on a test, who's the brighter student?" Dr. Fitzgerald asked.

But in a profession where each step forward is predicated on the ability to take exams, such a discussion may be academic. As Dr. Fitzgerald acknowledged, there are few objective criteria besides test scores to measure medical students' progress.

With affirmative action banned in some places, some say a whole new look at admissions is called for. "I think this is our best opportunity to re-explore the issue of what makes a good doctor and how we should select for them," Dr. Fitzgerald said.

Advocates of affirmative action agree and point to current affirmative action students, residents and practicing physicians who they say are walking examples of what's good about promoting diversity in medicine.

At the UCD internal medicine residency program, for example, residents are not so much discouraged by the backlash against affirmative action as resolute to overcome it, Dr. Fitzgerald reported. In her program, she said, minorities address the possibility that they might not have made it without help, but that because of it, they have succeeded in medicine.

While Penn's Dr. Hansel said that race hasn't been an issue in her interactions with attending physicians or fellow residents during training, she feels compelled to prove that she deserves to be there. "I put increased pressure on myself to prove to people who think that minorities are admitted [to medical school] via affirmative action and aren't as smart as somebody else that I can succeed in medicine," Dr. Hansel said.

She also says her generation is critical to increasing diversity throughout the profession, particularly in training and mentoring roles since there are so few minority physicians in these roles now. Despite Penn's ongoing efforts to increase diversity, Dr. Hansel said all but two of her attending physicians have been white.

"It's not a perfect world," Dr. Hansel said. "I think that while the goal is to not have a need for affirmative action, outlawing it now is premature."

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