New Inroads for Minorities in Medicine

“Affirmative action” programs begun in medical schools in the 1970s have succeeded in dramatically increasing the number of minority group members who become doctors but new obstacles may be cropping up that will keep the number of such physicians disproportionately low, a new Rand Corp. study concludes.

Moreover, while the equal opportunity programs have also made medical services more accessible to residents of ghettos and barrios and have seen large proportions of minority group doctors enter so-called primary care fields, the programs at the same time have been largely able to avoid further segregating medical care.

Benefits Confirmed

In all, the research found evidence to confirm many of the theoretical benefits that had been claimed for equal opportunity admission programs when they were inaugurated. Dr. Robert Ebert, former dean of Harvard Medical School and now an official of the Robert Wood Johnson Foundation, said the study represents the first quantification of a concept that had been accepted almost on faith. “The survey sort of supported everything that everybody wanted,” said Ebert, who also served as chairman of an advisory committee overseeing the Rand project.

But at the same time, the new study concluded that doctors who are minority group members lag significantly behind their white counterparts in academic performance in medical school and in the proportion by which they earn specialty board certification. The Rand group argued that the marketplace for medical services--which, in wealthier communities, tends to equate board certification with minimum competency--may discount the need for such credentials in minority communities.

No Basis of Comparison

The Rand team conceded it could find no way to compare the quality of medical care being provided by minority group and non-minority group members; two of the principal authors conceded it is possible that at least some doctors may have elected to practice in inner-city areas after they were unsuccessful in their attempts to pass board certification examinations.

In the main, though, the Rand study said, equal opportunity admission programs have resulted in vastly increased numbers of inner-city doctors offering care in the crucial fields in general internal medicine, obstetrics-gynecology, pediatrics and family practice.

Such programs were set up in the early 1970s with the intention of raising to 12% the proportion of medical students who are minority group members. That objective was never met, however, the Rand team noted, and by 1976--the year the 12% goal was to have been reached--only 8.2% of medical students were minorities. Many observers believe the growth in minority group enrollment was stunted by two major court cases that undermined the right of medical schools to give admission preference to non-whites.

Today, according to the American Medical Assn., 10.8% of all medical students are black, Puerto Rican, Latino or Native American. Students of Asian descent are not counted as members of a minority group in the calculations.

New Risks Ahead

The Rand report’s authors warned, however, that a variety of factors may pose new risks to further increases in the numbers of minority group doctors. Medicine has entered a period of slight decline in popularity among young people in general as the number of doctors in popular areas reaches or exceeds the saturation point and it becomes more difficult to practice in a geographically desirable place.

Too, the researchers said, financial constraints have already begun to reduce the income doctors can anticipate. That factor, combined with disappearance of public support for medical education and the need for students to rely on loans totaling up to $60,000, will make it more difficult for young people from impoverished backgrounds or families of modest means to consider medicine.

In this atmosphere, agreed two of the Rand study experts, many minority students will likely pursue fields requiring fewer and less expensive years of training and that bring with them a more certain income level. Medicine may find itself unable to compete for many able, intelligent young minority group members, these experts said.

The Rand study is being published today in the New England Journal of Medicine. It was conducted by researchers from Rand, the Charles R. Drew Postgraduate Medical School here and the Washington-based Assn. of American Medical Colleges. The study focused on doctors who graduated from medical schools in 1975 since, because of the time required to complete internship and residency training and get established in practice, a doctor’s actual preferences--as opposed to those he or she may claim during training--cannot usually be determined with certainty until five or 10 years after graduation.

The Rand project traced the practice histories of 12,065 doctors who graduated from medical schools in 1975, of whom 574 were black, 36 were Native Americans, 78 were Mexican-American and 27 were Puerto Rican by birth or of Puerto Rican descent. The graduates also included 9,467 Anglos and 219 persons of Asian descent--all of whom were lumped together in the non-minority group.

Publication of the research report is being accompanied by an editorial in the journal written by Dr. Vivian Pinn-Wiggins of the Howard University College of Medicine. Pinn-Wiggins noted that programs of all types to increase the number of minority doctors have been under attack in recent years.

First Substantial Proof

But the new research, Pinn-Wiggins argued, provides some of the first concrete proof that such programs actually accomplish what they are intended to do. “In spite of the retrenchment in the government, community and institutional commitment to furthering the cause of racial justice and affirmative action programs,” she wrote, “the health status of minorities should still provide an ethical impetus for medical schools to encourage, admit and graduate minority students.

“It is time for (medical schools) to reaffirm their commitment to addressing the inequities in access to quality health care.”

The Rand team said it hopes eventually to evaluate trends that may have taken shape between the 1975 and 1980 graduating classes. The 1980 group is now making the transition from residency training to practice.

Among the Rand study’s major observations were these:

--Among the 1975 graduates, a larger proportion of minority group members than non-minority physicians--55% versus 41%--went into primary care fields, including the four major specialties for generalists. Twice as many minority group members--12% versus 6%--went into practice in disadvantaged areas.

--Black doctors tended to accommodate a larger proportion (31%) of Medicaid recipients in their practices than all Latino groups combined (24% Medicaid) and whites (14% Medicaid). The program is called Medi-Cal in California, where poor people who rely on it have found care increasingly difficult to find as doctors have quit the program because of reduced reimbursement rates.

--Minority doctors tended to serve more members of minority groups than non-minority colleagues; each subgroup of physicians tended to gravitate to its own ethnic group for the largest proportion of patients. For example, 56.4% of black doctors’ patients were black, and 76.5% of the patients of Anglo doctors were white.

--Despite the tendency of minority doctors to see minority group patients, however, measurable trends in the practices of all doctors indicate greater assimilation is occurring in medicine at large than many physicians had anticipated. Some white physicians are entering practice in minority communities and vice versa, the study found, implying that there has been “substantial integration of the medical marketplace.”

--Minority group doctors had significantly lower academic achievement scores than their Anglo counterparts, but the Rand team attributed this to systematic problems in school systems that serve minority populations. A black elementary school graduate, noted Dr. Stephen Keith of Drew, often enters junior high already so shortchanged in terms of science, reading and writing that he or she can never recover to the level of more fortunate students.

--More important, however, far fewer minority group doctors attained speciality board certification than non-minorities--48% for the minority physicians and 80% for the non-minorities. But Keith and Albert Williams, a Rand economist, said that patient expectations in minority community practices may not accord certification the importance it often attains in other areas.

An Unresolved Question

Keith and Williams agreed that their research was unable to resolve what could be a significant question about the quality of medical services among minority group populations: How many doctors practicing in disadvantaged areas established themselves there because they could not attain board certification?

Board certification means that a doctor has been able to pass a test given by an organization that sets training and competency requirements for an individual medical specialty. The tests are given after a doctor has completed a residency training program in a specialized field--ranging from general internal medicine or pediatrics to such superspecialized areas as orthopedic or cardiovascular surgery.

In all, the Rand team concluded, “minorities were not merely admitted to medical schools in much larger numbers; they also graduated, took residency training and entered practice in much larger numbers.

“Moreover, they entered primary care specialties, chose to practice in . . . health-manpower shortage areas and cared for ethnic minority and poor patients in a greater proportion than did their non-minority counterparts.

“(We) found that affirmative action in medical education made good progress toward its multiple objectives.”

In an interview, Keith and Williams discounted the importance of academic performance measures in comparing minority and non-minority physicians. Williams noted that the more important measure is the extent to which the quality of medical care for the poor and non-whites has improved as a result of production of larger numbers of minority group physicians.

Not a ‘Quality Study’

“We didn’t do a quality study,” Williams said, “but minority doctors are much better trained now.” Keith agreed, noting that “you can infer much higher quality for minority doctors.”

As evidence, Keith noted that in 1970--before the admission preference programs began--while 11.1% of the U.S. population was black, only about 2.1% of doctors were black. Moreover, most of those physicians were trained at two predominantly black medical schools--at Howard in Washington and MeHarry University in Nashville--and that the system amounted to almost de facto segregation in medical training.

But both experts in the Rand study and Ebert of the Robert Wood Johnson Foundation voiced concern that the changing dynamics of the medical marketplace may place at risk some of the gains noted in the new study.

“We’re in a different kind of medical marketplace now,” Williams said. “There always seemed to be a demand for more physicians. That’s not true now.”

Ebert expressed the same worry, noting that in the last year or two the number of applications to medical schools from men and women has begun to decline for the first time in at least two decades, implying that young people are wary of the implications of changes both in economics and practice freedom that have swept medicine in the last 10 years.

At the same time, the debt burden medical students must take on has increased as federal programs that once subsidized medical education have largely disappeared.

“I think there are a number of factors in terms of minorities that are, to me, very worrisome,” Ebert said. “It’s bad enough for everyone, but if you come from a minority family and look ahead to a debt of $50,000 or $60,000, it is very worrisome.

“I have the same worry for white students who come from families of very modest means. I think many of them (potential physicians from poor backgrounds, regardless of ethnic status) will be going into other areas where the training doesn’t take as long.

“Everyone is aware that there is an excess of doctors and getting into medicine isn’t going to be as easy as it was.”