Blog by Kasey Johnson
Students from widening access (WA) backgrounds, contribute unique strengths to medicine and are an investment in the most vulnerable communities, yet recruiting and retaining WA students continue to be a challenge for most medical schools. Association of American Medical Colleges (AAMC) data shows that only 5% of medical school matriculants are from households in the lowest economic quintile. By reviewing demographic data and medical education scholarship, I examine methods and possibilities to increase WA students in medicine. Transformative action being taken by medical education leaders globally reveals close collaboration with communities most affected by healthcare disparities.
Socioeconomic diversity in US medical schools has not changed in 30 years, despite widespread support for diversity and inclusion (AAMC, 2018). American Indian/Alaska Native (AI/AN) populations make up 2% of the US population, yet comprise less than 0.4% of US physicians (AAIP, AAMC, 2018). African Americans make up 14% of the US population, yet only 4% of the physician workforce and similarly, Hispanics or Latinos account for 17% of the US population and 4% of physicians (Talamantes et al. 2019). WA students are more likely to have attended high-poverty schools, leaving them with fewer opportunities and resources (Talamantes et al. 2019, Baugh et al. 2019, 2020). The use of an “othering” lens when describing WA students devalues their contributions, can deepen experiences of marginalization (Cleland and Palma, 2018) and can contribute to low self-efficacy and stereotype threat (Griffin and Hu, 2015).
The social origins of exclusion in medicine are well-documented by such figures as the famous Prussian pathologist Rudolf Virchow who declared in 1848 that medicine is a “social science” and that physicians are “the natural attorney[s] of the poor” (Brown, 2006). Medicine’s role in slavery through the employment of plantation physicians and the medical exploitation of black communities created the conditions under which poor, black communities came to distrust white medical practitioners (Washington, 2008). In 1871 the last treaties were signed guaranteeing trust responsibilities on behalf of the US government to AI/AN persons (Warne and Frizzell, 2014). Yet the history of Indian Health Services is one of underfunding and neglect. In 1910, Abraham Flexner’s report lead to the closing of most black and rural medical schools, further limiting the opportunities of students from these communities entering the profession. In response to Flexner’s call for reform, critics asked if the “poor boy” will fail to be educated in medicine, which indeed has largely played out (Starr, 1982).
In light of the history of exclusion, WA policies attempt to increase the fairness of selection and increase the number of low socioeconomic students (Nicholson and Cleland, 2017). However, a deficit model for such students persists with applicants from non-traditional backgrounds viewed as needing additional support (Cleland et al. 2018). WA students face implicit and explicit bias from within their medical education, which can further contribute to a lack of career fulfillment (Baugh et al. 2019). We must expand the widening access model from admission to include career progression (Fyfe et al. 2020) to address the disparity in cultural capital WA students face (Vasquez Guzman et al. 2020).
Decentering the deficit model involves acknowledging the strengths of WA students. Indeed, WA students are more likely to engage in prosocial behaviors compared to individuals of higher social class (Baugh et al. 2020). Medical students from rural and underserved areas are more likely to practice in those areas (Puddy et al. 2017, AAIP, AAMC, 2018, Mullan et al. 2010). Furthermore, diverse student bodies improve cultural literacy and expand student perspectives (Baugh et al. 2019). Finally, non-white physicians care for the majority of minority and non-English speaking patients, fulfilling the social mission of medicine (Puddy et al. 2017).
Methods for diversifying the physician workforce include using these social mission metrics to incentivize medical schools to accept more WA students (Mullan et al. 2010). The definitive solution offered for increasing widening participation policies that effectively recruit and train more diverse students include “binding minimum requirements” aka quotas as suggested researchers in the UK (Apampa et al. 2010). Japan successfully implemented a regional quota system for its medical schools to address the lack of rural physicians and saw no decline in academic performance (Matsumoto, 2016). New Zealand has initiated equity pathways aimed at recruiting and training Indigenous and rural students in medicine (Curtis et al. 2017).
What might these methods look like in practice? A recent study describes the success of inclusive and targeted admissions and graduation rates of AI/AN medical students in four medical schools using the Medicine Wheel model from traditional Indigenous teachings. The authors use the medicine wheel as a model of supporting students from AI/AN communities in the areas of Mental/Academic, Spiritual/Cultural, Emotional/Social, and Physical/Financial. While the ideal program would be able to incorporate all elements of the medicine wheel in the training of AI/AN medical students, the authors note the strengths that each of the medical schools provide in one of the four main areas. This study points toward culturally rooted, community-based approaches to diversifying the physician workforce (Vazquez Guzman, et al. 2020).
Instituting WA policies require reimagining recruitment, admission, retention, career progression, and promotion of diverse students and faculty. History provides clear examples of alternative framework for addressing medical education’s legacy of exclusion. Student bodies that include WA students allow for a greater exchange of ideas and expanded understanding of diverse lived experiences—a benefit to us all. Medical education leaders globally have outlined and implemented methods to address socioeconomic diversity. The future of medicine and of our health depends upon training a socioeconomically diverse physician workforce and is a global public health imperative.
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Kasey Johnson is a psychiatry resident at the University of North Dakota. She is interested in rural mental health, Indigenous health, public health, addiction medicine, and the medical humanities.