White students attending more racially diverse medical schools consider themselves better prepared to care for patients of racial and ethnic minority groups than are students at less diverse medical schools, according to a study of more than 20,000 graduates.
Attitudes about providing equivalent access to health care for everyone also were stronger among students at more diverse schools. These students' responses were 50% more favorable toward equitable access to care, compared with their counterparts at the least diverse schools.
The associations were particularly strong at medical schools that foster positive interactions and sharing of opinions among students from different backgrounds, Dr. Somnath Saha and colleagues reported in a recent issue of JAMA (2008;300:1135–45).
The investigators also found a “threshold effect” regarding minority student enrollment. Specifically, diversity outcomes were positive among the 118 medical schools in the study if the proportion of underrepresented minority graduates (URMs) exceeded 10%, or the total nonwhite student population was more than 36%. The authors had no disclosures.
Policies and programs devised to achieve racial diversity in medical schools and to increase the numbers of underrepresented black, Hispanic, and Native American students “have come under increasing scrutiny as being unnecessary and discriminatory,” the authors wrote. Dr. Saha is an internist at the Portland VA Medical Center and Oregon Health and Science University.
Affirmative action and addressing prior injustices are the justification for most programs to increase URM student diversity, However, Dr. Olveen Carrasquillo and Dr. Elizabeth T. Lee-Rey wrote in an editorial in the same issue of JAMA, “the well-documented history of widespread racism within organized medicine and the American Medical Association's apology is a reminder of how pervasive and tolerated such practices were only a few decades ago” (2008;300:1203–4).
In the current study, Dr. Saha and colleagues assessed results of the online graduation questionnaires administered by the Association of American Medical Colleges in 2003 and 2004. They assessed anonymous responses from 20,112 individuals, representing 64% of all graduates during those 2 years.
Race and ethnicity were self-reported. The 9% of URM respondents included black, American Indian, Alaska Native, Mexican American/Chicano, mainland Puerto Rican, and Native Hawaiian students. Minorities not considered to be underrepresented in the physician workforce, primarily Asians and non-URM Hispanic or Latino students, comprised the 23% nonwhite/non-URM group. The remaining 68% were white students.
A total of 21% of the 13,764 graduates in 2003 and 22% of the 7,472 graduates in 2004 strongly agreed that “everyone is entitled to adequate care.” Also, 42% of the 2003 graduates and 44% of the 2004 graduates strongly agreed that “access to care is a major problem.”
A total of 59% of the 2003 cohort and 60% of the 2004 cohort indicated they felt prepared to serve diverse populations.
Interestingly, white students at more diverse medical schools did not indicate they were more likely to care for underserved populations. “This may reflect confounding by the urban versus rural location of schools,” the authors wrote. “Rural schools are likely to have both fewer nonwhite students and more students who plan to practice in rural, underserved locations.”
In contrast, a total of 49% of URMs planned to work with underserved patient populations, significantly more than both white (19%) and nonwhite/non-URM students (16%).
“The finding by Saha and colleagues in this issue of JAMA that… increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature,” Dr. Carrasquillo and Dr. Lee-Rey wrote. “Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity.”
“As with all cross-sectional studies, there are important limitations, the most important of which is the inability to address causality,” Dr. Carrasquillo and Dr. Lee-Rey wrote.
Dr. Saha and colleagues noted that they had no measures of student attitude, experience, or plans to practice medicine prior to entering medical school. In addition, schools that actively recruit a diverse student body might be more committed to improving diversity-related outcomes, another possible confounder of the study.
“Acknowledging these limitations, we believe our findings have potential policy implications,” they wrote. “A diverse student body is likely to be necessary but not sufficient. Medical schools may need to actively foster positive interaction among individuals from different backgrounds to derive the benefits of diversity.”
Dr. Carrasquillo is the director of the Center for the Health of Urban Minorities at Columbia University Medical Center and Dr. Lee-Rey is the codirector of the Hispanic Center for Excellence, Albert Einstein College of Medicine, both in New York.