NEJM perspectives (03/09/2023) on “Diversifying the Physician Workforce- From Rhetoric to Positive Action”

[skypilot]

For the good of everyone, both patients and physicians, medical schools and adcoms needs to stop obsessing over gender and race, and start refocusing on merit, fairness, and inclusiveness.

Even as the author suggests that affirmative action measures are necessary to overcome past discrimination, how does fighting past discrimination with reverse discrimination ever make anything better, as our ultimate goal is to end discrimination altogether?

There is value to diversity, but not at the expense of merit. Really, this explanation about URM physicians serving URM communities in rural and underserved communities is hyperbole!

Not using Transparent objective criteria and instead using this opaque holistic criteria undermines meritocracy in medicine. Does a patient really care if a white/black/asian/hispanic doctor has cured his cancer?

Even a cursory reading of SDN posts of WAMC forum for premeds shows there are way too many ORM students who are denied admissions due to factors beyond their control- i.e race. What a pity!

Hoping SCOTUS rules against the unfair race-conscious decision by med schools that penalizes hardworking ORMs while rewarding other candidates with far below stats and EAM-Experiences/Attributes/Metrics, only because they happen to be URMs.

Merit can sometimes be purchased with money. One candidate spent his summer working in an Orphanage in India helping with a project on TB. The other spent the summer working in a warehouse loading trucks.

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[Gern Blansten]

Yeah, I can't speak to that at all. I would have to look to see if the studies I reviewed stratified their black physician populations based on immigration status. That might be interesting, but I am not personally curious enough to do that. If it turned out that only non-immigrant black physicians were reducing the disparity (or immigrant black physicians?) that would potentially impact my policy preferences wrt affirmative action.

But I'm just trying to get people here on board with the idea that this tradeoff for improving underserved populations with a compromise on their meritocratic ideal is a good thing. Affirmative action as the utilitarian choice.

Whether or not we agree on everything, I appreciate your approach to the topic. It seems that you have an open mind but also firmly believe in your argument but with respect to the beliefs of others. You are open to the possibility that you may not be 100% correct and other factors, if they are decided to be true, could influence your decisions. It’s a refreshing approach and is appreciated.

 

[chocomorsel]

This is an opinion piece.
Just as the author has their opinion you can have yours.
Why does this bother you so much?
Perhaps you can write your counter argument and submit it to NEJM.

Always the voice of reason!

 

[chocomorsel]

I used to worry about affirmative action allowing unqualified people into medicine, but after further life experience, I realized that the majority of the stupid people I've worked with in medicine have actually been white males. So why should only stupid white males be allowed into medicine? Dumb people of all races, sexes, and creeds should be allowed an equal opportunity IMO.

I can’t stop laughing! Hilarious. Some of us over here on the colored side have a term for that. “The Mediocre White Male”. Some of us call him Chad!
Thank you for making me laugh! I can’t stop!!!

 

[chocomorsel]

There was unquestionably a dominant ethnic group in my residency and it definitely wasn’t Caucasian. Funnily enough it just so happened to match the dominant ethnic group amongst the faculty.

And this has been the case for Caucasians since the inception of this country. So not surprising. Those in power want to bring in people they have things in common with. People who look and think like them and have similar life experiences.

 

[chocomorsel]

so i guess our healthcare quality will improve soon. we have the most diverse workers. soon to be #1 best healthcare outcome in the world

This is dumb! It’s all driven by Capitalism. Money before people. USA! USA!! USA!!!!

 

[chocomorsel]

Whether or not we agree on everything, I appreciate your approach to the topic. It seems that you have an open mind but also firmly believe in your argument but with respect to the beliefs of others. You are open to the possibility that you may not be 100% correct and other factors, if they are decided to be true, could influence your decisions. It’s a refreshing approach and is appreciated.

Who the heck believes they are 100% correct on discussions?

 

[Dr. Rude]

Who the heck believes they are 100% correct on discussions?

Everyone

 

[FutureInternist]

I used to worry about affirmative action allowing unqualified people into medicine, but after further life experience, I realized that the majority of the stupid people I've worked with in medicine have actually been white males. So why should only stupid white males be allowed into medicine? Dumb people of all races, sexes, and creeds should be allowed an equal opportunity IMO.

Go to any VA… 😂

 

[Gern Blansten]

Who the heck believes they are 100% correct on discussions?

You're kidding, right?

 

[midazzoler]

Late to the thread and didn’t read all the comments. Has anyone brought up the outgoing STS president’s comments?

 

[deleted1156722]

Late to the thread and didn’t read all the comments. Has anyone brought up the outgoing STS president’s comments?

Of course, the STS had to quickly make amends and issue a middle-of-the-night statement denouncing Dr.Calhoon’s comments, saying those were “inconsistent with STS’s core values of diversity, equity, and inclusion.”

 

[chocomorsel]

You're kidding, right?

Y’all are tripping.

 

[deleted1156722]

Have you ever read the IOM's report "Unequal Treatment"? It's over twenty years old now, but it argues for diversity competency on evidence based medicine grounds. Among other recommendations, it argues for promoting diversity hiring and promotion as a means of addressing the disparities in healthcare received by minority populations.

Recommendation 5-3 Increase the proportion of underrepresented U.S. racial and ethnic minorities among health professionals.

Patient and provider relationships will also be strengthened by greater racial and ethnic diversity in the health professions. Racial concordance of patient and provider is associated with greater patient participation in care processes, higher patient satisfaction, and greater adherence to treatment (Cooper-Patrick et al., 1999). In addition, racial and ethnic minority providers are more likely than their non-minority colleagues to serve in minority and medically underserved communities (Komaromy et al., 1996). The benefits of diversity in health professions fields are significant, and illustrate that a continued commitment to affirmative action is necessary for graduate health professions education programs, residency recruitment, and other professional opportunities. This is not intended to suggest, however, that racial concordance of patients and providers should be encouraged as a matter of policy. Rather, it is expected that the benefits of diversity in the health professions will accrue broadly, as this diversity helps to expand the disciplines' ability to conceptualize and respond to the health needs of increasingly culturally and linguistically diverse populations.

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care - PubMed

Racial and ethnic disparities in health care are known to reflect access to care and other issues that arise from differing socioeconomic conditions. There is, however, increasing evidence that even after such differences are accounted for, race and ethnicity remain significant predictors of the...

pubmed.ncbi.nlm.nih.gov

Hiring ethnic minority providers can result in better patient outcomes in some areas of medicine. There's plenty of room to be skeptical of some of the studies in the report (I think the Cooper-Patrick study is a telephone survey) and I haven't kept up with more modern research... But as far as I know, this is where the limited data on physician-patient racial concordance points.

There are evidence based reasons to suggest some preferential minority hiring will result in better patient outcomes in minority populations. Take a look at the Executive Summary if you're curious.

We have to recognize that the above book was written in 2003 by a panel of experts, and the current statistics and demographic data are not factored in it. Nevertheless, it is an interesting read, but definitely limited as it addresses the issues predominantly for the black population without much consideration for the burgeoning Latino minority population, or the Asian American population.

Although the book addresses the insurance status somewhat by stating the insurance status was controlled, it did not fully account for variations among health plans, much less the ACA effects which was passed after this book was written. The book/ panel review does not fully address the fact that Minorities are more likely to be enrolled in more affordable but "lower-end" health plans -- the plans characterized by fewer resources per patient and stricter limits on covered services. The disproportionate number of minorities in these plans is actually a potential source of greater disparities in healthcare than the race/ethnicity of the physicians, which the book fails to address adequately.

Finally, the book acknowledges that the quality of healthcare provided does not appear to be better when minority patients and their providers are of the same racial or ethnic group. Only that the concordance of race is associated with greater patient satisfaction.

 

[rowsdower88]

We have to recognize that the above book was written in 2003 by a panel of experts, and the current statistics and demographic data are not factored in it. Nevertheless, it is an interesting read, but definitely limited as it addresses the issues predominantly for the black population without much consideration for the burgeoning Latino minority population, or the Asian American population.

Although the book addresses the insurance status somewhat by stating the insurance status was controlled, it did not fully account for variations among health plans, much less the ACA effects which was passed after this book was written. The book/ panel review does not fully address the fact that Minorities are more likely to be enrolled in more affordable but "lower-end" health plans -- the plans characterized by fewer resources per patient and stricter limits on covered services. The disproportionate number of minorities in these plans is actually a potential source of greater disparities in healthcare than the race/ethnicity of the physicians, which the book fails to address adequately.

Finally, the book acknowledges that the quality of healthcare provided does not appear to be better when minority patients and their providers are of the same racial or ethnic group. Only that the concordance of race is associated with greater patient satisfaction.

The authors of the report gave an interview in 2021 or so and said not much has changed and if anything they have more evidence of racial disparities existing and the causes for them. I can find a link to their interview if you're curious. I would say the onus is on people skeptical to prove things are better now if that's you're argument. The black population is demonstrably facing these disparities more than the Latino and Asian populations, hence the prioritization on those communities. If you have evidence which suggests otherwise I haven't seen it.

There can be confounding factors like insurance type and status, I don't disagree. The report does list other opportunities to address the disparity apart from physician hiring/selection. I think the authors would agree with you that insurance selection and access are also problems in some minority communities.

The report cites studies that suggest patients are more likely to take their meds, have longer patient interviews, and have greater patient satisfaction like you state. I don't think those are trivial and they definitely impact the quality of healthcare recieved. The report also points to a greater number of minority physicians going to the communities where these physicians are needed most. Where does it say the quality was equivalent between racially discordant and racially concordant pairs? I didn't come away with that impression given recommendation 5.3. In any case, there have been subsequent studies on racial concordance that demonstrate similar findings.

Edit: maybe I can ask a specific question:
If you disagree with recommendation 5.3, why? What evidence would you bring to bear to help address these disparities and why is 5.3 wrong?

 

[deleted1156722]

The reason I disagree with Rec 5.3 is because there is no conclusive evidence to show that racial concordance improves healthcare in minorities.
There are no improved findings in the domains of healthcare utilization, or outcomes. The above book summary from IOM showed some improvement with respect to patient–provider communication, preference and satisfaction, but actual objective metrics of improved quality of healthcare with regards to outcomes is not proven.

Here is an interesting article from Ethnic Health in 2009 ( based on data analysis):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3209820/pdf/nihms272842.pdf

 

[rowsdower88]

The reason I disagree with Rec 5.3 is because there is no conclusive evidence to show that racial concordance improves healthcare in minorities. ( not just to improve perceived subjective patient satisfaction metrics, but actual objective metrics of improved quality of healthcare).

Here is an interesting article from Ethnic Health in 2009 ( based on data analysis):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3209820/pdf/nihms272842.pdf

Yeah, I saw that report as well. I think that's a reasonable take you have, I just disagree because the pros seems significant enough to me regardless and the cons associated with affirmative action are small. Subjective satisfaction is important and I think it would be a mistake to discount it. Someone satisfied with their doc is more likely to follow their instructions on diabetes meds as opposed to someone dissatisfied, simply measuring abstract "healthcare utilization" isn't going to track that very well IMO. We do need better studies on the topic. I don't see this report negating 5.3 so much as caveating it.

Do you have any thoughts on the second part of 5.3? The idea that "under-represented in medicine" physicians are more likely to practice in underserved communities?

 

[deleted1156722]

Yeah, I saw that report as well. I think that's a reasonable take you have, I just disagree because the pros seems significant enough to me regardless and the cons associated with affirmative action are small. Subjective satisfaction is important and I think it would be a mistake to discount it. Someone satisfied with their doc is more likely to follow their instructions on diabetes meds as opposed to someone dissatisfied, simply measuring abstract "healthcare utilization" isn't going to track that very well IMO. We do need better studies on the topic. I don't see this report negating 5.3 so much as caveating it.

Do you have any thoughts on the second part of 5.3? The idea that "under-represented in medicine" physicians are more likely to practice in underserved communities?

The term “URM communities” at this time applies to only Black/ Latino/ Native Americans and this disenfranchises so many underrepresented White / Asians from lower socio-economic status, and from rural & underserved areas.

And that is the singular problem with Affirmative Action as executed by LCME/ACGME as it focuses solely on race/ethnicity as a box to be checked, without regards to any other background information that can be valuable in predicting which of these recruited med students/ residents would actually serve the health care needs of the intended underserved population.

Infact, AAMC states that the number of medical school matriculants from rural areas — who would most likely practice in these areas declined between 2002 and 2017. And that decline came at a time when the overall number of matriculants increased by 30%. In addition, in 2016 and 2017, students from rural backgrounds made up barely 4.3% of the incoming medical student body. To that point, IMGs coming from all over the world, are in-fact making up a large part of that deficiency by practicing in these rural areas as part of their visa requirements. ( Conrad 30 waiver)

Why are we not concerned about these HPSAs which are equally in need of physicians?
Clearly, the “URM” students may not be interested in practicing in these remote and rural areas which may/may not be a culturally-ideal fit for them. Or it is entirely possible that Whites and Asians can also choose to serve in these rural areas? The medical needs of these larger swaths of underserved population is more important than trying to artificially refashion the racial demographics of physicians ratio in med schools to mimic the societal demographics.

Every part of this country has underserved and rural areas and every physician, regardless of their race/gender might want to give back to these rural and underserved communities. No particular race/gender/religion has a cornerstone of service to our diverse population in such a large and diverse country. Everyone is capable of service in medicine, if given a fair chance. When politicians, policy makers and academicians take the cue from social justice activists instead of the actual data, of course, the only answer is Affirmative Action!

Attracting the next generation of physicians to rural medicine

People in rural areas sometimes travel hours for care. Academic medicine is attracting and training future physicians to meet desperate needs in these regions.

www.aamc.org

 

[rowsdower88]

The term “URM communities” at this time applies to only Black/ Latino/ Native Americans and this disenfranchises so many underrepresented White / Asians from lower socio-economic status, and from rural & underserved areas.

And that is the singular problem with Affirmative Action as executed by LCME/ACGME as it focuses solely on race/ethnicity as a box to be checked, without regards to any other background information that can be valuable in predicting which of these recruited med students/ residents would actually serve the health care needs of the intended underserved population.

Infact, AAMC states that the number of medical school matriculants from rural areas — who would most likely practice in these areas declined between 2002 and 2017. And that decline came at a time when the overall number of matriculants increased by 30%. In addition, in 2016 and 2017, students from rural backgrounds made up barely 4.3% of the incoming medical student body. To that point, IMGs coming from all over the world, are in-fact making up a large part of that deficiency by practicing in these rural areas as part of their visa requirements. ( Conrad 30 waiver)

Why are we not concerned about these HPSAs which are equally in need of physicians?
Clearly, the “URM” students may not be interested in practicing in these remote and rural areas which may/may not be a culturally-ideal fit for them. Or it is entirely possible that Whites and Asians can also choose to serve in these rural areas? The medical needs of these larger swaths of underserved population is more important than trying to artificially refashion the racial demographics of physicians ratio in med schools to mimic the societal demographics.

Every part of this country has underserved and rural areas and every physician, regardless of their race/gender might want to give back to these rural and underserved communities. No particular race/gender/religion has a cornerstone of service to our diverse population in such a large and diverse country. Everyone is capable of service in medicine, if given a fair chance. When politicians, policy makers and academicians take the cue from social justice activists instead of the actual data, of course, the only answer is Affirmative Action!

Attracting the next generation of physicians to rural medicine

People in rural areas sometimes travel hours for care. Academic medicine is attracting and training future physicians to meet desperate needs in these regions.

www.aamc.org

I'm worried you don't understand what the disparity is that we're concerned about. It means that even after you account for socioeconomic status of white people, asian people, latino people and black people; there is still a problem with healthcare outcomes affecting black people specifically.

We can absolutely be concerned about the cause of poor Asian and white communities, but in general, even those communities are having better healthcare outcomes than poor black communities.

We can be concerned about HPSAs as well. Being pro-affirmative action doesn't mean I don't care about supporting HPSAs.

Clearly, the “URM” students may not be interested in practicing in these remote and rural areas which may/may not be a culturally-ideal fit for them.

What are you basing this on? Because the studies I've seen suggest URMs tend to go to areas of higher need than non-URM docs.

AAMC states that the number of medical school matriculants from rural areas — who would most likely practice in these areas declined between 2002 and 2017

That could be causing a problem, absolutely. I could conceivably be moved to support programs that support affirmative action for rural students if it demonstrated population level benefits.

To that point, IMGs coming from all over the world, are in-fact making up a large part of that deficiency by practicing in these rural areas as part of their visa requirements

I'm in favor of allowing more IMGs to practice in the US. This doesn't negate any support for AA.

When politicians, policy makers and academicians take the cue from social justice activists instead of the actual data, of course, the only answer is Affirmative Action!

I like to think I'm looking at the data. I see a healthcare disparity and I'm supportive of steps to address it. No one is saying AA is the only answer, just one among many. Didn't you see that 5.3 was only a small part of the total list of recommendations from the Unequal Treatments report? There were like a couple dozen other evidence based recommendations aimed at addressing the disparity as well.

 

[deleted1156722]

That could be causing a problem, absolutely. I could conceivably be moved to support programs that support affirmative action for rural students if it demonstrated population level benefits.

And that exactly is the point. So how many quotas and preferred categories would the admissions process create in the name of Affirmative Action, in order to accommodate so many diverse groups and needs of the society? Like it or not, the Admissions process is a Zero sum game, and when one category is favored, another is disfavored. Subjective criteria and holistic admissions cannot be fair to everyone.

I do sincerely respect and appreciate your thoughtful, well-informed and intellectual discourse on this subject.

 

[rowsdower88]

And that exactly is the point. So how many quotas and preferred categories would the admissions process create in the name of Affirmative Action, in order to accommodate so many diverse groups and needs of the society? Like it or not, the Admissions process is a Zero sum game, and when one category is favored, another is disfavored. Subjective criteria and holistic admissions cannot be fair to everyone.

I do sincerely respect and appreciate your thoughtful, well-informed and intellectual discourse on this subject.

Enough to address the disparities? If the disparities didn't exist, I wouldn't be in favor of affirmative action on these grounds. (I know others will argue for affirmative action on the basis of historic disadvantage or existing prejudice in the education system but that's not the argument I'm making here.) The argument I'm making is predicated on "the needs of society", it's a utilitarian argument. We should prioritize addressing societal ills to a very small degree over the supposed meritocratic ideal. I think in another post I pointed out just how little affirmative action programs actually hurt white students, it's something like the equivalent of getting one or two more questions wrong on the MCAT or getting a B instead of a B+. Which seems trivial to me at least.

The stat I thought was most interesting was that an average white student is more likely to lose their spot to another white student with a lower score than to a black student regardless of any affirmative action.

As far as I know, racial quotas haven't been allowed in any university for a long time. I think the conservatives on SCOTUS are arguing that there exist "pseudo-quotas" but the university admins deny this. At the very least, I think it's debatable that quotas are a thing currently.

 

[RemyMcswain]

Man, I just went down a Twitter rabbit hole. There are some truly toxic people on both sides of this topic. I need to take a walk…