In Focus: Guest Editorial: Affirmative Action

Medscape, November 2001

By Sally Satel


Affirmative action in medical school admissions is alive and well. Not since the Supreme Court’s 1978 decision on Alan Bakke’s famous reverse discrimination case has there been much open debate regarding the wisdom of racial preferences in medicine. There should be.

The fact that only 10% of the physician workforce comprises minorities has led the Association of American Medical Colleges (AAMC) and other medical organizations to champion racial preferences as a way to reach proportionality with the general population. These proponents offer 2 basic arguments to justify racial preferences in medical school admissions.

The first is that only minority doctors can meet the health needs of a growing minority population. They are, reasoning goes, more sensitive to other minorities and can develop stronger rapport with them than can white doctors. In addition, minority doctors are more willing to work in underserved (eg, minority and/or impoverished) areas. The second argument is that lowering admission standards (grades and MCAT scores) will not affect the quality of medical school graduates because it is noncognitive factors that are equally good, perhaps better, at predicting who will make a good physician.

Choice Care

The first argument revolves around the notion that minority patients will fare better under the care of a doctor of the same race or ethnicity. This has become a much-touted truism, despite the dearth of supporting evidence. “This is not a quota born out of a sense of equity or distribution of justice, but a principle that the best healthcare may need to be delivered by those that fully understand a cultural tradition,” says George Mitchell, the former Senate majority leader and the chairman of the Pew Health Professions Commission. According to Michael J. Scotti Jr. of the American Medical Association, “There is a national health need for physicians who, after the Tuskegee Syphilis Study, for example, are trusted by large segments of our population.”

We can see, then, why so many health organizations became alarmed when California and Texas planned to dismantle racial preferences in 1996. The AAMC formed a coalition called Health Professionals for Diversity to lobby for the preservation of preferences. In his essay “Ethnic Cleansing in the Groves of Academe,” in the American Journal of Public Health, H. Jack Geiger of the City University of New York foresees these “reversals in minority admissions [as] merely the leading edge of a potential public health disaster.”

But is this a public health disaster? Only if there is nothing more important to Americans about their doctors than race. Evidence suggests, however, that advocates like Mitchell and Scotti are more concerned about this than are many minority patients. According to the largest poll on this issue (Commonwealth Fund, 1994), race does not play an especially large role in patients’ attitudes about their doctors. Minority respondents ranked physician’s “nationality/race/ethnicity” 12th out of 13 possible factors influencing doctor choice. Within the subset of the sample indicating that they “did not feel welcome” at their doctor’s office, a mere 2% of African Americans and Hispanics attributed the discomfort to racial-ethnic differences. And of those whose dissatisfaction led them to change doctors, only 2% of blacks did so on the basis of the physician’s race or ethnicity. Less than 1% of those who reported limited choice in care attributed it to racial or ethnic discrimination.

Patient preferences aside, do we have evidence that minority patients fare better with minority docs? Not really. To be sure, data comparing outcomes of patients based on the race of their doctor are sparse. I have found only one study that compares a procedure use by white and black doctors: “Racial Differences in the Use of Cardiac Catheterization After Acute Myocardial Infarction” by Jersey Chen and colleagues (N Engl J Med. 2001;344:1443-1449). Use of catheterization was independent (used somewhat more often in white patients) of doctor’s race. Most important, the Chen study shows that outcomes did not favor whites. In fact, mortality rates were lower among black patients (regardless of treating doctor’s race) than among white patients treated by white doctors.

Performance Anxiety

How do minority students perform? There is no dispute that minorities, on average, enter with lower — sometimes substantially lower — academic qualifications. In California, even after the passing of Proposition 209 (the elimination of affirmative action programs) in November 1996, minority applicants to some of the state’s public medical schools are admitted 2 to almost 3 times as often as whites and Asians who have considerably higher grades. At the University of California at San Diego, for example, the average student accepted through affirmative action had scores comparable to the lowest 1% of his white and Asian counterparts. Nationwide, low-scoring minority students are 3 times as likely to be accepted as low-scoring whites and Asians.

Evidence tells us that attempts to compensate for these deficiencies during the medical education itself are not very effective. Black and Hispanic applicants are overrepresented among students who encounter trouble in medical school. According to the AAMC, they are more likely to repeat their first year or drop out. In 1996, 39% of minority students were unable to graduate with their class, compared with 15% of nonminority students. A 1994 study published in the Journal of the American Medical Association found that 51% of black medical students failed part 1 of the National Medical Boards (taken after the second year of medical school), over 4 times the 12% rate of white students.

Discrepancies persist after medical school as well. “A higher proportion of underrepresented minority students fail to obtain first-year residency positions through the standard process,” according to Gang Xu of Jefferson Medical College in Philadelphia, Pennsylvania, and colleagues. The yearly dismissal rate for black residents (14.4%) was almost double that of other groups (7.7%) from 1996-1999.

These statistics are worrisome, yet they are downplayed by preference proponents who advance the second justification for their policy: that accepting students with weak grades and scores is permissible because those measures are not particularly useful in selection of future physicians. While it is true that college grades and MCAT scores are not consistently associated with performance during the clinical years of medical school, this observation can be misleading. Consider: When students’ grades and scores are high enough and their group’s range narrow enough, the “noncognitive” demands of years 3 and 4 (conscientiousness, maturity, etc) overwhelm raw knowledge as a major determinant of clinical performance. Indeed, some researchers explain the weak association just this way.

Facts and Factors

Racial preference advocates also assert that grades and scores do not predict whether one becomes a good physician once he graduates from medical school. This is a tricky argument, as few data exist concerning the quality of practicing physicians as a function of medical school performance. We do know that: (1) minorities enter medical school with weaker grades and (2) minorities have more trouble in medical school. (Not surprising, the performance of minority enrollees with solid grades and scores is no different from all other students admitted competitively).

Recognizing that minority students are, on average, more likely to have lower grades and scores, the AAMC promotes the use of “noncognitive factors,” like leadership and social conscience. However, empirically, these factors have little relationship to performance in medical school. Research has yet to discover a noncognitive factor that is, alone, highly predictive of good clinical performance in medical school. Granted, establishing good rapport with patients is important — especially in the primary care relationship where management of chronic disease requires ongoing patient compliance — but personal attributes cannot take the place of basic ability.

An informed debate requires more data. We should be asking about the prospects of students admitted with weak numbers: Do they actually practice medicine (vs going into health administration or public health)? Are they more likely to become primary care doctors, pediatricians, and psychiatrists — areas considered, for better or worse, less intellectually demanding than, say, neurosurgery? How many set out to treat underserved populations or end up doing so because their qualifications kept them from practicing in more remunerative venues?

In the end, racial preferences appear inefficient in increasing the number of minority doctors for several reasons. First, despite aggressive admissions policies, minority representation in medical schools remains well below population proportions. Second, minority recruitment has created a 2-tiered system of academic admissions standards. As a result, some potential medical students have been treated unfairly, while others have been propelled into a helping career for which they are ill prepared. Third, we lack compelling evidence that same-race (minority) doctor-patient relationships result in better patient outcomes.

No matter who treats our nation’s poor and minority patients, the fact is that these groups tend to have medical conditions that are often chronic and clinically complicated. They need the best doctors, regardless of race.

Sally Satel, MD, is staff psychiatrist at the Oasis Drug Treatment Clinic in Washington, DC, and is the author of PC, M.D.: How Political Correctness Is Corrupting Medicine (Basic Books, 2000).