Why America’s Minority Doctor Problem Begins in the Third Grade

Written By Sydney Lupkin. Originally published by VICE news on March 16, 2016.

Ashley White-Stern was pouring over a gastroenterology textbook one night when she came across a passage that made her bristle: “In the United States, H. pylori infection is associated with poverty, household crowding, limited education, African American or Mexican American ethnicity, residence in areas with poor sanitation, and birth outside the United States.”

White-Stern, a medical student at Columbia University who is black, says that while she didn’t think the passage was overtly racist, she did think it had the potential to imbue medical students with a subtle bias about blacks and Mexican Americans. So she decided to email the authors of the textbook.

“If we didn’t live in a country or world where being of color predisposed society to look down on a person, the published sentence [would] not raise an eyebrow,” White-Stern wrote in her email to the authors. “My humble belief is that we owe it to people of color to consider how and when we include their identities in lists of ‘undesirable’ characteristics.”

Within 24 hours, the authors called White-Stern, thanked her, and asked her to help them change the passage. The next version of the book will explain each association in a little bit more detail and add that higher rates of infection among black and Mexican Americans are not completely understood.

“Unless you have a diverse [medical school] class, you can’t have that discussion,” White-Stern said.

Today, student groups across the United States are calling attention to the lack of diversity on medical campuses, pushing administrators to recruit and enroll more minority students to help end racial health disparities that have persisted for decades. But creating a more diverse class of doctors-to-be is no easy task; while there has been progress made over the last several decades, there still aren’t enough minority medical school applicants.

“The pipeline itself is just too small,” said Marc Nivet, chief diversity officer of the Association of American Medical Colleges (AAMC). “The barriers exist up and down the continuum to our segregated education system…. Too many of our minority students are in poor-performing or underperforming K-12 school systems.”

https://public.tableau.com/views/Applicants_By_Race/Dashboard1?:embed=y&:toolbar=no&:display_count=no&:showVizHome=no#1

According to the latest data from the US Census Bureau, 62.1 percent of the US population is white, 17.4 percent is Hispanic, 13.2 percent is black, and 5.4 percent is Asian. Meanwhile, 60.1 percent of students entering med school between the 2013-14 academic year and the 2015-16 academic year have been white, 22 percent Asian, 9.8 percent Hispanic, and 7.5 percent black, according to the latest data from AAMC, which runs the MCAT, the standardized test that aspiring physicians (MDs and DOs) must take to get into med school.

Studies have repeatedly shown that this mismatch between the racial breakdown of the population and that of doctors causes problems, even if the biases aren’t explicit. For instance, a 2012 study of primary care physicians in urban areas published in the American Journal of Public Health revealed that increases in “implicit racial bias and stereotyping of patient compliance” was linked to negative experiences for black patients and positive ones for white patients. A 2015 study found that black lupus patients were more likely to perceive racial bias and suffer as a result of it. And in 2008, the American Medical Association issued an apology for a century of racial discrimination in the organization’s past.

Related: Scientists Find Cancer’s ‘Achilles Heel’ — Which the Body Could Be Trained to Attack

White Coats for Black Lives, an offshoot of the Black Lives Matter movement comprised mostly of medical students, has attempted to draw attention to racial injustices in medicine since its first “die in” protest in late 2014. The group has called for an acknowledgment of racism’s role in creating health disparities, including the ongoing segregation of healthcare based on insurance status, which they called “colorblind” racial discrimination in an editorial published last fall in the Journal of Urban Health.

A crucial step toward equality in health care is raising the number of minority doctors, medical students, and medical professionals in leadership positions, they say. But fewer black students applied to and enrolled in medical school in 2014 than in 1978, according to AAMC. The group’s report, entitled “Altering the Course: Black Males in Medicine,” says the problem goes all the way back to grade school math and science courses often offered to black students.

A look at the data suggests the largest proportion of would-be minority physicians are effectively eliminated long before it’s time to apply to medical school.

  • 56 percent of black high school graduates enrolled in college in the year after graduation, compared with 70 percent of whites, according to 2008 data from the College Board.
  • Of the 1.6 million students who received bachelor’s degrees in 2010, nine percent were black and 77.5 percent were white, according to the latest data from the US Department of Education. According to 2010 US census data, black people made up 14.4 percent of the population of 20- to 24-year-olds; white people made up 67.3 percent of the same age group.
  • The same year, 3,475 black students applied to medical school, making up 8.1 percent of all applicants, according to data from AAMC; there were 46,410 white applicants, accounting for 61.8 percent of the total applicant population.
  • Again in 2010, of the 165,000 black students who received bachelor’s degrees, 2.1 percent went on to apply to medical school. By comparison, 2.3 percent of the 1.2 million white students who received bachelor’s degrees that year applied.

In other words, by the time students receive undergraduate degrees, blacks and whites are on nearly equal footing. The disparity develops earlier.

In fact, minority students start to fall behind on their standardized test scores as soon as third grade, and the gap widens over time, Nivet said. To make matters worse, 17 states don’t require students to pass Algebra II to graduate from high school, meaning public school students aren’t pushed to take that class or the math and science classes that would follow.

“We don’t have enough minority students taking the right classes early on and becoming successful in those classes early on to make successful applicants to any health professional school,” Nivet said.

Dr. Damon Tweedy, author of the memoir Black Man in a White Coat, said that he credits a teacher for pushing him to apply to a magnet program before he started high school. He got in, and was bused from the school in his predominantly working-class black community to a school in a mostly white neighborhood.

If current medical student Dennis Dacarett-Galeano had finished grade school where he started it, he said he probably wouldn’t be on his way to becoming a doctor at Icahn School of Medicine at Mount Sinai in Manhattan.

Dacarett-Galeano, who identifies himself as Latino, said most of his elementary school in Austin, Texas’s effectively segregated education system was considered economically disadvantaged. At the school, white students are the minority, making up 11 percent of the student body.

But thanks to a move to the suburbs and some luck, Dacarett-Galeano was able to attend the wealthiest public high school in the region, which was predominantly white. He had access to the Advanced Placement classes he needed to get into Columbia University, but he said not all of his underrepresented minority Columbia classmates had the same educational privileges — and it showed.

“When I really started to notice the difference between underrepresented minority experiences and otherwise was when I was in a college biology class there,” he said, explaining that biology is considered a “weed-out” class for pre-med students. “Most of my friends who were pre-med who dropped that track were underrepresented minorities or students from disadvantaged backgrounds.”

More could be done to encourage minority undergraduate students to consider medical school, Nivet and Tweedy said.

For minority students, secondary barriers to getting into medical school continue into their undergraduate careers, which are often at historically minority-heavy schools that do not have a full time medical school advisor to guide pre-med students through their coursework and the medical school application process, Nivet said. Such advisors are commonplace at Ivy League and other elite institutions.

Advice from advisers can range from telling pre-med students not to take organic chemistry and physics the same semester to telling them what’s an acceptable MCAT score. Nivet said he occasionally hears about less-informed advisors who have discouraged minority students from applying to medical school based on their MCAT scores, not knowing that those MCAT scores that would be competitive at most medical schools.

Tweedy said that schools lacking diversity may also be more passive about their recruitment methods. For instance, they don’t go to historically black undergraduate institutions to tell students about scholarship opportunities and fee waivers.

“Medical school is an incredible burden,” said Tweedy, who is a psychiatry professor at Duke University Medical Center. “That alone, the time it takes and the cost itself, may deter people from otherwise even considering it. That’s where someone like a recruiter could talk about various options for financial aid, invite students to at least apply and waive the application fees. All these things make it more accessible.”

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Racial disparities continue throughout the application process. From 2013-14 through 2015-16, acceptance rates were lower for black students compared with other racial groups, according to MCAT and GPA data from AAMC.

Although 45.2 percent of white applicants got accepted into medical school — as well as 44.3 percent of hispanic applicants and 42.1 percent of Asian applicants — only 36.2 percent of black applicants were accepted.

Part of this may be tied to the fact that black students tend to score lower on the MCAT. Of the 2,460 students who earned the lowest scores on the test from 2013-14 through 2015-16, 43 percent were black. Of the 221 top-scoring medical school applicants over the same period, 11 percent were black.

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For some minority students accepted to medical school, shaking the “false narrative” in their own minds that they don’t deserve to be there can be difficult, Nivet said. When Tweedy was a first-year medical student at Duke University in the 1990s, his professor mistook him for a handyman, Tweedy wrote in his book. He recalled feeling insecure about whether he was inferior to his classmates at the beginning of medical school once he learned that his MCAT score was “a few points below the class average” and that his classmates had come from Ivy League schools and other prestigious undergraduate institutions. He wrote that he knew his full scholarship to Duke’s medical school was the result of affirmative action, but wondered whether he was about to become an “academic casualty.”

Rowan University School of Osteopathic Medicine in New Jersey has a series of pipeline programs to recruit a diverse class of medical students early, but some students — not just minorities — have test scores or GPAs that indicate they may have trouble later on in their medical education, says Thomas Cavalieri, DO, the school’s dean. As a result, the school has a boot camp–like program that starts before the official school year begins to get these students up to speed. It also has a number of interventions to help struggling students throughout their medical education.

Related: Antibiotic Resistance Is a Public Health Nightmare — And It’s Not Going to Stop

Nivet said it’s especially important for minority students to remember that being near or below the average MCAT score isn’t a big deal — and that they’re hardly the only ones in the bottom half of their class.

“A whole bunch of white kids have lower MCAT scores,” he said. “Duke University is not ‘taking a chance’ on any kid…. Students who go to these elite institutions graduate and have become leaders across this country in medicine.”

https://public.tableau.com/views/Number_of_Black_Students_Per_School_2015/Dashboard2?:embed=y&:toolbar=no&:display_count=no&:showVizHome=no#1https://public.tableau.com/views/Number_of_Black_Students_Per_School_2015/Dashboard1?:embed=y&:toolbar=no&:display_count=no&:showVizHome=no#1https://public.tableau.com/views/Number_of_Black_Students_Per_School_2015/Dashboard3?:embed=y&:toolbar=no&:display_count=no&:showVizHome=no#1https://public.tableau.com/views/Number_of_Black_Students_Per_School_2015/Dashboard4?:embed=y&:toolbar=no&:display_count=no&:showVizHome=no#1https://public.tableau.com/views/Number_of_Black_Students_Per_School_2015/Dashboard5?:embed=y&:toolbar=no&:display_count=no&:showVizHome=no#1https://public.tableau.com/views/Number_of_Black_Students_Per_School_2015/Dashboard6?:embed=y&:toolbar=no&:display_count=no&:showVizHome=no#1Follow Sydney Lupkin on Twitter: @slupkin

TOPICS: health, medical school, doctors, racial health disparities, medical school applicants, white coats for black lives, united states, americas, medical school application, damon tweedy

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The Case for Black Doctors

By Damon Tweedy. Originally published in the New York Times Sunday Review on May 15th 2015
CreditAnthony Gerace

DURHAM, N.C. — IN virtually every field of medicine, black patients as a group fare the worst. This was one of my first and most painful lessons as a medical student nearly 20 years ago.

The statistics that made my stomach cramp back then are largely the same today: The infant mortality rate in the black population is twice that of whites. Black men are seven times more likely than white men to receive a diagnosis of H.I.V. and more than twice as likely to die of prostate cancer. Black women have nearly double the obesity rate of white women and are 40 percent more likely to die from breast cancer. Black people experience much higher rates of hypertension, diabetes and stroke. The list goes on and on.

The usual explanations for these health disparities — poverty, poor access to medical care and unhealthy lifestyle choices, to name a few — are certainly valid, but the longer I’ve practiced medicine, the more I’ve come to appreciate a factor that is less obvious: the dearth of black doctors. Only around 5 percent of practicing physicians are black, compared with more than 13 percent of Americans overall.

As a general rule, black patients are more likely to feel comfortable with black doctors. Studies have shown that they are more likely to seek them out for treatment, and to report higher satisfaction with their care. In addition, more black doctors practice in high-poverty communities of color, where physicians are relatively scarce.

As a psychiatrist, I’ve seen this up close. I’ve frequently been the only black doctor (or one of very few) in clinics with large black populations. Quite often, patients ask to see a black doctor, but the sheer volume of people seeking help prevents me from accommodating most of their requests.

Black patients, compared with those of other races, tend to be far less trusting of physicians and their medical advice. Much of this is rooted in a dark history of experimentation on black people without their consent (the four-decade-long Tuskegee syphilis study is the most notorious modern-day example). Too often, however, this mistrust is to the patients’ detriment. I’ve met countless black people who have either delayed or refused needed treatments because they were skeptical about their physician’s motives and honesty. Some wound up far sicker than they should have been; others died.

Perhaps the most compelling evidence that black patients are more likely to trust black doctors comes from the mental health field, where a patient’s relationship with his or her provider is especially important. Black people have often fared poorly in their interactions with the mental health care system. For example, they are nearly half as likely as whites to receive treatment for diagnosed mental health disorders of comparable severity. When black patients do receive treatment, it is far more likely to occur in an emergency room or psychiatric hospital than it is for whites, and less likely to be in the calmer office-based setting, where longer-term treatment can take place.

In this context, it is easy to understand a 2011 meta-analysis published in the Journal of Counseling Psychology that observed that black people strongly preferred to be matched to black therapists and were more likely to view them favorably, and that these preferences and perceptions translated into slightly better clinical outcomes.

In addition to the issues of trust, there is also a simple geographic explanation for the importance of black doctors. For at least three decades, researchers have found that black doctors are simply more likely to practice in high-poverty communities that are minority-rich and physician-poor. According to a 2012 report by the Association of American Medical Colleges, black medical students are more than twice as likely as white students to express the intention to work in such areas.

My career offers an example. I grew up in a working-class family a generation removed from segregated poverty, a background that influenced my decision to practice in clinics that served a disproportionately poor and minority population, instead of private offices.

CLEARLY, we need more black doctors. In the 2011-12 school year, the most recent for which figures are available, there were 5,580 black students enrolled in medical school, making up about 7 percent of the medical student population, which is roughly half of the proportion of the black population in America.

Nonetheless, when viewed through the lens of history, this recent figure reflects progress: In the 1968-69 school year, 783 black students were enrolled in American medical schools, just 2.2 percent of the overall total. Race-based affirmative action programs, which began to be implemented around this time, undoubtedly played a major role in expanding the number of black students in medical school. By the late 1970s, the number of black students had increased nearly fivefold, with the proportion peaking at 8 percent in the mid-1990s.

Since that time, however, opposition toward affirmative action has grown stronger. Many states have banned race-based admission efforts at public universities, and last year, the Supreme Court ruled that this was permissible. Purely race-based affirmative action is not yet dead, but it appears to be approaching its twilight years.

Even those who are uncomfortable with affirmative action or oppose it outright should consider the potential impact of this trend when it comes to medical school. A recent study in The Journal of Higher Education found that affirmative action bans in six states led to a 17 percent reduction in the enrollment of underrepresented students of color in medical school. Policies resulting in fewer black doctors could lead to even worse health outcomes for a population that is already the least healthy.

Of course, black doctors are not the only physicians who can deliver good medical care to black patients. Nor is every black physician a good one. Over the years, I’ve worked with many white and Asian doctors who are adept at interacting with patients of all races and social classes; indeed, they have been some of my best teachers and colleagues. Yet I’ve also seen the other side, where black patients have received cursory evaluations and callous misdiagnoses based upon negative stereotypes.

When I have been particularly successful at treating black patients, it has often had less to do with any particular talent on my part than with my patients’ willingness to bring up the racial concerns that troubled them.

Several years ago, for example, I met a recently retired black man who had been referred to me for treatment of depression. He had become increasingly dispirited by the fact that the town where he had raised his children had transformed into a community full of poor schools, single mothers and young black men in the criminal justice system.

Rather than prescribe him an antidepressant pill, as another doctor had done, I encouraged him to talk in depth about his early life in the 1940s and ’50s and the positive influences that had helped him succeed. Discussing his life in this way made him feel more confident about his ability to touch other lives, even though he couldn’t fix larger social problems. He helped put together a local program that introduced poor black kids to chess and golf, an endeavor that made him feel better than he had in many years. Periodically, he leaves me messages saying that he is still doing well and thanking me for my help.

Another time, I worked with a young woman who struggled with her biracial identity. Her black father had been abusive to her white mother when she was a child, and she found herself both afraid of and hostile toward black men. Because she physically resembled her father in many ways, she had also turned these negative feelings inward. Not surprisingly, her initial impression of me was unfavorable, but a friend encouraged her to come back to see me.

Over the next several months, we talked about every aspect of race imaginable, and by the end, she found herself more at peace and better able to see black men as individuals. For the first time, she even met a black man whom she began dating. She no longer felt depressed or severely anxious.

My experience as a patient may also be instructive. I received a diagnosis of high blood pressure as a first-year medical student, and although I knew perfectly well that I needed to change my high-salt, high-fat diet, I just couldn’t do it. Of course, it was hard to give up what was familiar and enjoyable. But an equally important part was my resistance to assimilating and adopting behaviors that I associated with well-to-do whites — eating salads and drinking fruit smoothies, for example — even though I knew that this defiance was ultimately self-defeating.

Only after many failed attempts have I been able to consistently do the right thing with my health. Today I take this experience into the exam room. While patients ultimately have to take responsibility for their own lives, it is helpful to have a doctor who understands, and doesn’t dismiss, behavior patterns that are often rooted in a cultural history.

How do we find more doctors who can share these insights with their patients? The truth is that race-based affirmative action is not an ideal fix. Despite being a beneficiary, I am ambivalent about it. In college in the 1990s, I was a strong student — co-valedictorian of my class — and a good test taker. On these measures alone, I would have gotten into several high-quality medical schools. Yet affirmative action propelled me into a different stratosphere. I was suddenly an applicant worthy of early admissions and special scholarships at some of the most elite schools.

Race might have been my ticket onto this stage, but what really made me different was social class. My mother went to segregated inner-city schools and couldn’t afford college; my father grew up in rural poverty and didn’t finish high school. In contrast, many of my white classmates were the children of doctors, lawyers and professors. A greater emphasis on socioeconomic diversity — one that looks at applicants in the context of their family structure, parental education, childhood neighborhood and quality of grade-school education — is more likely to be seen as fair by a greater number of people (and more likely to survive legal challenge) than one that primarily uses race as a marker for diversity.

Universities — and medical schools in particular — should go out of their way to recruit good students of every race from these less affluent backgrounds. Over time, such efforts could produce a greater cohort of doctors who are better prepared to relate to the patients who need them the most.

In an ideal world, the race of the patient or physician wouldn’t matter; we would all treat each other strictly as individuals. But we’re quite a ways from reaching that exalted goal. For now, we have to attack the problem of racial health disparities from as many angles as possible. Black doctors are an important part of this mission.

First World Problems: Vaccines cause Autism—Seriously?

autism

I just read a post on KevinMD’s blog by Matt Anderson, MD which totally resonated with me. It is titled: IF YOU THINK FAKE NEWS IS BAD FOR POLITICS, YOU SHOULD TRY BEING A PHYSICIAN.

fake-news-md

Okay,  I am so sick and tired of this untruth which has been promulgated like wild fire around the world for 2 decades. It has been debunked by multiple other studies and the paper who published the initial study in 1997 has since retracted it because, it turns out the physician who first published it falsified data. The association between MMR vaccines and Autism has since been COMPLETELY DISCREDITED due to serious procedural errors, undisclosed financial conflicts of interest, and ethical violations.

Andrew Wakefield, the British surgeon who published and initiate this farce has since been discredited and has lost his medical license. Turns out he is no longer a physician but decades later medical doctors are still undoing the harm that was done to the public health community. Check out this page on  debunked myths about vaccines.

Meanwhile in Africa, 1 in 5 children do not have access to life saving vaccines (WHO). An estimated 3 million children under the age of five will die each year in Africa and most of those deaths could be prevented with vaccine administration.

The MMR (Measles, Mumps, Rubella) vaccine  is the particular vaccine erroneously linked to causing Autism. Now let’s compare and see what happens if your unvaccinated child gets Measles, Mumps or Rubella.

For some, this is unimaginable. but I grew up with family members who did not receive appropriate vaccines at birth who now have permanent brain damage due to inaccessibility to vaccines. I have seen firsthand what lack of vaccination can lead to and it is not pretty. 

vaccines

Measles: CDC Fact Sheet
-Lifelong brain damage
-Deafness
-Death

Mumps: CDC Fact Sheet

-Meningitis (infection of the covering of the brain and spinal cord)
-Deafness (temporary or permanent)
-Encephalitis (swelling of the brain)
-Orchitis (swelling of the testicles) in males who have reached puberty
-Oophoritis (swelling of the ovaries) and/or mastitis (swelling of the breasts) in females      who have reached puberty

Rubella: CDC Fact Sheet 

-Brain infections and bleeding problems.                                                                                                  -Rubella is most dangerous for a pregnant woman’s unborn baby. As many as 85 out of 100 babies born to mothers who had rubella in the first 3 months of pregnancy will have a birth defect. Infection during pregnancy can cause miscarriage, or birth defects like deafness, blindness, intellectual disability, and heart defects.

measles

Child with Measles.

In summary developing countries have 99 problems and fake news about vaccines and autism is not one of them!

I recognize we are all overworked, over exposed and over stimulated today but if you liked this article, consider liking it and sharing it with a friend, family member, colleague, hater or frenemy!

Share your thoughts below, I can’t wait to hear from YOU!

99-problems-autism

 

Fortune

This quote about fortune provoked an adverse reaction in me. I did not particularly agree with it initially. As I read the quote I recognized that the words somehow seemed familiar but I had attributed that description to “fame”. I must admit I was a little annoyed that fame and fortune were being equated as one. As I pondered that quote at 3 am in the morning on my only bathroom break on night call. I questioned why I was so annoyed by the quote and it was not until hours later that I gained some insight into my initial reaction.

I finally realized that I was irritated because it had been drilled in me that if I worked hard I would reap the results of my hard work later. In other words, I had internalized the idea that hard work guaranteed good fortune but this quote challenged that tenet. Once I had calmed down, I was able to understand that just because I put in the work did not necessarily imply I would be successful. This was a particularly bitter pill of knowledge to swallow because I am a physician in training. Most physicians in training will agree with me that the hardest thing about completing the training process is “delayed gratification”.

Anyone can take a test and will eventually pass it once they get enough time to prepare for it. However, it takes a certain commitment to enter a training process that could last anywhere between 11 – 17 years from the time you leave high school depending on your specialty. When you take into account the rising cost of medical education and decreasing physician salaries. It obviates the idea that most people who go into medicine are doing so to get the proverbial “pot of gold” at the end of the training. What motivated me to pursue Medicine was a desire to improve people’s lives and my love for Science I found that this field allowed me to blend the two.

As I begrudgingly accept the fact that I may sacrifice time with my kids and spouse, my health, my personal time, finances, money and friendships and still not be guaranteed good fortune. I realized that finding or discovering my purpose is the key to a building a successful life. But the caveat with that statement is that your must first have a definition of what you consider a “successful life”. I will leave you with this quote by Louis Pasteur “Fortune favors the prepared mind”.

Enjoy the festivities this season and remember – Jesus is the reason for the season.

fortune

Interview season

Rehearsed lines, perfectly ironed shirts

Lists of strength and weaknesses memorized.

Butterflies fluttering in my stomach.

Artificial smile planted on my face

I prepare myself for the greatest performance of my life.

I must show just the right amount of confidence, the perfect dose of humility, the right amount of ration.

Be well read in most topics, be comfortable for 8 hours in a suit and uncomfortable heels.

Show interest on research I can barely remember.

And some how in a couple of interviews convince everyone that I am fit to be a doctor.

Surely Shakespeare must have felt this way before his first play was performed.

Moliere must have experienced this sick feeling before his first performance.

A matador must have his heart pounding in his chest this hard before going in the ring.

“Hush now” I tell the still voice inside, “I was born to do this!”

Berthina Coleman