What Will It Take to Diversify Medicine? — Episode Transcript

From left to right: Jaya Aysola, founder and executive director of Penn Medicine’s Center for Health Equity Advancement, Pierre Johnson, University of Chicago OB-GYN, Madi Sinha, physician and author, and Cesar Padilla, obstetric anesthesiologist

From left to right: Jaya Aysola, founder and executive director of Penn Medicine’s Center for Health Equity Advancement, Pierre Johnson, University of Chicago OB-GYN, Madi Sinha, physician and author, and Cesar Padilla, obstetric anesthesiologist.

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INTRO:

Maiken Scott: This is The Pulse — stories about the people and places at the heart of health and science. I’m Maiken Scott.

Pierre Johnson grew up on the South side of Chicago, in the ’80s … a lot of his early experiences with health care were bad

Pierre Johnson: Like I can remember, as a seven, eight year old kid, sitting in hot clinics in the summer time, waiting for hours to be cared for. Everybody was treated like … a number.

MS: When he was nine, his mother was pregnant and Pierre came to one of her prenatal appointments. The OB-GYN was the first black doctor Pierre ever met …

PJ: He treated my mom like a family member. The treatment and the way he talked to us, and the way he talked to my mom, the way he treated my mom was very different from anything I had experienced. It was much more down to earth …

MS: He says it was the moment that he decided to become an OB-GYN like this doctor.

PJ: It put a little fire in me, that I want to change this, I want to do something about this …

MS: He told me he was one of the top students in his high school — but once he started college things got more difficult

It was, you know, so much that I didn’t know. I had maybe one or two science classes, but I never had physics, I never had any detailed biology or chemistry so everything was brand-new to me.

MS: He was attending Xavier University in New Orleans. It’s a historically Black college that offered a lot of support for students, and he found study buddies — two men who became his best friends …

PJ: In a library, studying hours upon hours and hours a day … Each one of us got pushed to the brink of questioning ourselves, can we really do this, and we all were each other’s backbone, through those bad times

MS: After Xavier, Pierre went on to University of Illinois College of Medicine — which at the time was mostly white. He says the difference was startling..

PJ: I felt like a man on an island, I really just had to navigate things on my own … It was almost depressing at times, just kind of feeling alone.

[MUSIC]

I had to experience a lot of biases, a lot comments that came from a place of ignorance. I pushed for diversity sensitivity training throughout medical school. When I’d hear comments and I would see my colleagues, making comments about patients from underprivileged backgrounds. It really … hurt.

MS: And, it felt heavy. Like a job on top of an already super demanding workload.

PJ: And, I felt that burden. I felt the burden, like the only black kid. I felt the burden of trying to make future doctors aware of the patients they were going to serve, and how you have to be sensitive to people from all walks of life.

Pierre Johnson is an OB-GYN now, but if you think about this burden he felt — to educate his fellow students – that burden may have been easier to carry if his school had been more diverse — an environment where people come from all different backgrounds — and can learn from each other.

Jaya Aysola: There’s so many little lessons just by the saturation of your classroom, and every interaction that you have with your classmates that tees you up to be a better physician later on.

MS: That’s Jaya Aysola, a physician, who researches diversity and inclusion in medicine. She says diversity in med school can lead to better patient care. And it has a broader effect down the road:

JA: When you diversify your student body, you in turn eventually set the stage to diversify your faculty, to diversify clinician investigators that will eventually lead to science that has more diverse perspective.

But getting to this place where med schools truly reflect the populations they serve has been a long road — and there’s still ways to go.

On today’s show: Who makes it into medical school? And what does it take to diversify the student population?

[MUSIC]

SEGMENT 1:

Historically, medicine has been dominated by white men. Over the decades, there have been different attempts to make the field more diverse and to bring in groups that are especially underrepresented like Latinos and Black people.  But, it’s been difficult to move the needle in a meaningful way. Liz Tung takes a look back at one ambitious initiative and what happened to it.

3000 by 2000: A history of the visionary campaign to diversify med schools, and what got in its way

Liz Tung: In 1989, sociologist Tim Ready was perusing the Washington Post, when he came across a job ad that would change his life.

Tim Ready: You know, this is certainly not the recommended way to, to get opportunities and to do this kind of work. But there was a, a classified ad, in the Washington Post. It said that they were hiring. And I said, Hey, I’ll check it out.

LT: “They” being the Association of American Medical Colleges, or AAMC, which is a hugely influential group in the world of academic medicine — they represent the interests of medical schools, and facilitate the application process to both med schools and residencies.

What they were looking for was someone to help with a project design to increase diversity in med schools. Tim had experience researching race-related disparities and effective educational programs that serve diverse and economically disadvantaged students.

TR: Discrimination and injustice and how that affects stressors, et cetera.

LT: He’d spent the last few years studying the impact of injustice and discrimination on the health of high school kids of color in South Texas.

TR: And, you know, I saw despite the, uh, aspirations of the Mexican American kids, wanting to go to college and essentially wanting kind of the same American Dream sorts of things as a doctor, lawyer, as everybody else, that wasn’t happening. And there were lots of barriers getting in the way and schools seem to be sorting out who gets opportunity and who doesn’t 

[MUSIC]

LT: Tim had been raised on the Civil Rights movement — including President Johnson’s Great Society programs of the 60s, which placed education at the center of a campaign to eliminate poverty and racial injustice.

TR: Schools were supposed to be the great equalizer and they weren’t working that way.

LT: Tim wanted to be part of the solution. So when he spotted the AAMC’s classified ad, he jumped on it.

TR: To make a long story short, I got hired. And little did I know that it would lead to me having the opportunity to design and direct the national diversity campaign for the 126 medical schools in the country during the 1990s.

[MUSIC]

LT: The job was part of an initiative launched by the AAMC’s president at the time, Robert Petersdorf — who, according to Tim, had decided that med schools had to do something once and for all about how few students of color they were training.

TR: Petersdorf said, you know, ‘this can’t go on. We need to change this trajectory of worsening under-representation.’

LT: Petersdorf wasn’t the first to recognize the problem. Back in the late 1960s, the Civil Rights movement sparked a nationwide push to diversify medicine. (The term used in academic circles then was “underrepresented minorities” — meaning, students who were Black, Mexican-American, mainland Puerto Rican, or American Indian.) Reports were written, recommendations made, departments created — and at first, we did see improvements: from the 1960s into the 70s, enrollment of Black and brown students grew from 2% of the med school population to 9%. But as the years went by, and the country grew more diverse — medical schools didn’t. Progress flatlined. By the time Tim started his job in 1989, there were fewer than 1,500 Black and brown students enrolled in American med schools. Tim says it was clear to him from the beginning that if they were going to solve this problem, they had to start early.

TR: We strongly believe that, that, you know, there was just no way in the world that we were going to reach our goal of parity in actual medical students without doing work, to build the pipeline.

LT: Their goal wasn’t just improvement — it was parity, based on America’s current racial demographics. Which at that time meant enrolling 3,000 Black and brown medical students every year. But here’s the thing: in 1989 — the year before they started — fewer than 3,000 students of color had even applied for medical school in the U.S.

Tim had his work cut out for him. He ended up spending almost a year doing research. He traveled around the country, visiting the medical schools that had the most students of color to see what it was they were doing right. What he found was budding programs — early education initiatives that reached back to high school or earlier. There was Gateway to Higher Education and Bridge to Medicine — science-focused magnet schools in low-income areas that had partnered with medical schools to basically serve as feeder programs.

[MUSIC]

Once they had all the research, Tim and his colleagues carved it into an ambitious 10-year plan. Its name was “3000 by 2000,” which was literally their goal. To enroll a class that contained 3,000 students of color by the year 2000.

It was a bold move — this wasn’t just a bunch of feel-good diversity rhetoric … they were actually naming a hard number that they wanted to reach. Tim even wrote up instruction manuals for medical schools — complete with local data that they could use to develop their own pipeline programs. It was a thoroughly scientific approach to affecting change.

The big announcement came in 1991. The AAMC president, Robert Petersdorf, organized four meetings with medical school deans from across the country.

TR: I mean, this is pretty — a gutsy thing. He said, ‘you know, deans, these people who are incredibly powerful, people who run these massive institutions, you know, show up at this meeting, and we’re going to talk to you about diversity’ and my God, they came.

LT: The next few years were a whirlwind of activity. Medical schools succeeded in helping to set up magnet schools and other early education programs across the country. They also started using what are called articulation agreements — promises between med schools, colleges, and high schools that students who reached a certain academic level would be guaranteed admission.

And almost right away, they saw a jump in the number of Black and brown matriculants — from fewer than 1,500 students in 1990 to more than 2,000 in 1995.

TR: At its peak, we, uh, increased the number of underrepresented students entering medical school by 37% from our starting point.

LT: Then, in the mid-90s, something happened that stopped that progress in its tracks: legal challenges to affirmative action.

[MUSIC]

Back in 1978, the Supreme Court had upheld the use of race as a factor in admissions — colleges, law schools, med schools — they could all take race into consideration — though the ruling barred the use of explicit quotas. More challenges erupted in the mid-90s … in particular, a case called Hopwood vs. Texas.

It was a federal court case in which four white law students challenged the University of Texas Law school’s use of affirmative action … and they won. This time, the Supreme Court declined to hear the case, which meant that the ruling became the law in Texas, Louisiana, and Mississippi. Around the same time California passed its own referendum outlawing the use of affirmative action by state governmental institutions. But the reverberations went further than just those four states — the movement against affirmative action had a chilling effect on schools in the rest of the country. Basically: No one wanted to get sued. Here’s Jordan Cohen. He was president of the AAMC from 1994 to 2006.

Jordan Cohen: As soon as that anti-affirmative action movement, uh, took root and began to be very successful in, in limiting legally, the ability to use this tool, our progress towards that goal of 3000 by 2000 was abruptly aborted.

LT: Tim agrees. He says one of the effects of the attacks on affirmative action was that institutions seemed less willing to quantify their progress out of fear they’d be accused of using quotas.

The result was that the project never reached its full potential. After a quick increase of students of color, peaking in 1995 at just over 2,000, the numbers crept back down. When the project finished in the year 2000, it fell far short of its goal.

[MUSIC]

For Jordan, the AAMC president, it was a disappointing end.

JC: Well … it was a great frustration not to have been able to continue on the track that we were on. Not that that goal would have been the end of the story. I think it still would have required a great deal more effort to, to achieve true equality with respect to, to these demographic dimensions. But I would say it was a great disappointment that we were unable to make the the goal that was set out.

LT: Tim says the project ended without much fanfare. And his proposal for a follow-up was rejected. So he ended up leaving the AAMC.

TR: I felt sad. But I thought that, uh, it was time for somebody else to, uh, carry the ball and maybe they have better ideas, maybe they don’t. But, I think my, my ideas and my time had kind of run its course.

LT: But that doesn’t mean 3000 by 2000 didn’t leave its mark. I talked with Norma Poll-Hunter, the current director of diversity at AAMC. And she said the project did a lot. It helped establish pipeline programs, and raised awareness, but maybe even more important, it threw down the gauntlet, and said to the medical community — this is a problem that we all need to do something about.

Norma Poll-Hunter: It galvanized the national community to really double down and address this issue of under-representation. And as I mentioned, some of these programs still exist today. So although they’re not under the auspices of 3000 by 2000, there are many, many, physicians of color who have been able to benefit from the programs that have existed as a result of 3000 by 2000.

LT: For Tim, the legacy is a living one … one that has popped up again and again, especially lately.

TR: You know, looking at all the health news, you know, on television these days and COVID, and, you know, you see African-American physicians and scientists speaking up. The system wasn’t working in a way that enabled a lot of those people from those underrepresented groups to be able to do that before. And I think we at least played some small role in changing the, uh, the playing field so that it was a little bit more level.

[MUSIC]

MS: That story was reported by Liz Tung.

We’re talking about med schools today and what it would take to attract and retain a more diverse group of students.

Last year, I saw a post on twitter by a physician named Cesar Padilla. In one picture he’s wearing his white coat and a surgical mask — in the other picture he’s a teenager — trying to look tough.

Cesar Padilla: I’m wearing a basketball Jersey and, you know, I have like whatever, like this gold chain on or whatnot. And, uh, I was just very much, um, sort of a product of my environment. That’s how a lot of kids dressed in, uh, around that time.

MS: Cesar grew up in the Bay area, the son of Mexican immigrants. The high school he went to could be a rough place.

CP: And, you know, I think the backstory to that picture is that I was just trying to survive in that may sound a bit odd to say, I’m just sort of looking at the picture, but the reality was that in an environment where I was from, you had to act tough, you had to show a certain degree of confidence of stoicism, if you will, um, or people to sense the weakness in you. That was what I thought as a 15 year old.

MS: Before high school, he and his friend, Raymundo had been total science nerds …

CP: Our world was, you know, comets and asteroids and you know what, we, we just loved it. We thrived in that.

MS: But that passion was fading away …

CP: And something happened in high school where, you know, our friends started dropping out. There was, you know, our friends started to get incarcerated and we felt sort of ignored by the, by the school system. What I can recall is that I, I just felt like there was a disconnect with what the teachers were telling us and what the reality was in our communities. What I was feeling I felt out of place in school and that reality in school, you know, that disconnection, I feel led to a lack of inspiration.

[MUSIC]

MS: By 10th grade, he stopped going to class. But his dad found out, and stepped in. He got Cesar transferred to another school. He did better there, and went on to community college, he there he had a completely different experience.

CP: The teachers that I had really believed in me in science and, and an English and writing, and that really led to me believing in myself. 

MS: One day, while on campus, Cesar came across some information that changed his life.

CP: I see a flyer on our community college. It was by our biology laboratory and it was, um, the, the, the flyer said Stanford University Minority Medical Alliance, SUMMA.

MS: The flyer was an invitation for a workshop for students from underrepresented groups, who were potentially interested in medicine, to come to the Stanford campus and meet physicians.

CP: I mean, that was transformative for me because I felt like I belonged. And that’s where I met doctors who would teach me how to write a personal statement, who would teach you how to align your career for becoming a physician. And those workshops that Stanford provided, they gave me the confidence to really structure my, um, my credentials, my academic credentials for the next step.

MS: What do you think would have to happen to, to get more kids like yourself onto a path? Like, like you were able to get on?

CP: I want to take this time to highlight my friend Raymundo Jacquez . So Raymundo, we both went on to community college and then he went to UCLA. And he is now a lawyer. And he works in Oakland and he works for the law firm, Centro Legal de la Raza, and he created a program, Raymundo created a program called the Youth Law Academy. And it’s a pipeline academy in Oakland, California, that mentors kids in high school who are interested in law. That’s what we need. We need professionals in the high school, in the middle school and high school settings. We need physicians, doctors who themselves are minorities to look at these kids and say, I was exactly where you are, and you can do it.

MS: Cesar says more diversity in medicine would lead to better care and deeper relationships with patients.

CP: This happened recently, I’m treating a person who basically had a heart attack and he’s a Latino man and he’s maybe in his 50s and he’s very withdrawn from his environment. You can tell that he’s very stressed out and he just doesn’t want to really talk to people. And then I go up to him and start talking to him and he sees my badge, my name, and it says, Cesar. And he’s like, “Hey, my name is Cesar, too,”, and then we start talking. And he’s a Dominican man. And he starts telling me about his experience as a Latino. And we start talking about food and we start talking about baseball  and boxing. And by the end of our 30 minute conversation, he was a different patient. He opened up, he was a completely different patient. And that’s, to me, that’s the art of healing. The art of healing is seeing ourselves in patients. The art of healing is seen ourselves in students that we’re trying to mentor. We see our struggles in others. And that’s what I try to do every day.

MS: Cesar Padilla is an obstetric anesthesiologist and he will be joining Stanford University schools of Medicine this May.

CP: When I think back as a kid and I look at myself now, there are themes. There are things that I’ve stuck with. One of them was an artist, a hip hop artist named Nas. There’s a song called “The World is Yours” that really encapsulates this … this message of just believing in yourself that you belong. His lyrics really hit home. And it inspires me.

[MUSIC]

SEGMENT 2:

MS: This is The Pulse — I’m Maiken Scott.

What are med schools doing to attract and retain more diverse candidates?

[MUSIC]

Maya Hammoud knew from a young age that she wanted to be a doctor. She grew up in Lebanon, during the civil war in the 1980s.

Maya Hammoud: And when you hid from airplane bombing, we would hide in the hospital, Because typically they would not bomb the hospitals, and I remember seeing children who were injured and being brought in.

Her family came to the U.S. and settled in Michigan. After high school and some time at community college, Maya applied to the University of Michigan for medical school in 1991.

She had to take an entry exam called the Medical College Admission Test — the MCAT.

She says the science parts weren’t too hard for her, but she had some problems with other sections.

MH: There were a lot of passages that are cultural what I would say, for example, jazz music. And I person like me didn’t even know jazz was a type of music [LAUGHS] because I did not grow up in this country.

She ended up with a low score, but she still made it to the interview stage, and since they didn’t have money for fancy clothes, her mother made her a dress for the big day.

MH: Small black and white squares, very, very small black and white. And it was kind of double breasted in front.

She went to the interview, talked to a 4th year student, that went well. Then she had to talk to a faculty member.

MH: And I must have said many times in my interview, ‘I’m sorry.’ And then he looked at me and goes, ‘you’re quite accomplished, why do you keep saying I’m sorry? You don’t have to apologize for anything.’ And I looked at him and I said, ‘I’ll be honest, when I came in this room, I had just had great interview with the 4th year medical student and you’re intimidating, and I’m kind of a little bit scared.’ And he goes, ‘Oh, I’m sorry.’ And I said, ‘You don’t need to apologize.’ [LAUGHS] Just because he was telling me that. And I remember leaving that interview room and back then there were pay phones, not cell phones. Put a quarter in the pay phone and I called my mom, and I said, ‘Forget Michigan because I just told this guy don’t apologize, and that was probably not good of me to say …’

But she did make it. Now she’s a professor of obstetrics and gynecology at the University of Michigan. And by the way, she still has that dress.

[MUSIC]

MH: It’s with my sister. We used to exchange it. We though that dress brought us good luck and we would wear it anytime we would go for a job interview. So we did keep it because we love that dress.

Lucky dress aside, Maya thinks that if she were applying to med school today, her MCAT score might prevent her from getting in.

This test is required by most medical schools. It’s a daylong exam, question after question. It covers chemistry, biology, physics, and much more. It costs more than $300 just to register.

The test can become a barrier and there’s a debate over whether it’s keeping too many people out.

Alan Yu reports:

Should medical schools require a standardized test for admission?

Alan Yu: Mollie Marr went to school for theatre and psychology. She dreamed of being an actor, director, writer. She had a busy schedule. Her parents could not support her, so she worked multiple jobs to support herself. She was an office assistant, a production technician, and a film projectionist at a campus film center. But in her senior year, she took a neuroscience class to fulfill a requirement, and that got her really interested in science and medicine. She started volunteering at the emergency department of a hospital in New York City, where her shift would start at 8 a.m. on Saturday mornings.

Mollie Marr: I’m not a morning person, and I figured that if I didn’t like it, I would know right away, because I wouldn’t wake up in time. And I started getting up earlier and earlier, and I loved the emergency department I loved the people.

AY: Theatre to ER can seem like a big shift. She says this is what she liked about theatre:

MM: I felt like performance was able to get at something core in terms of humanity that we all share, and I loved that core truth, and that it could transcend language, and it could transcend even what was going on in your own world, and for that one moment, you’re in a room full of strangers and you’re transported somewhere together in this shared experience.

AY: She says she also felt that shared experience in the ER, a group of people working together at what could be the worst moment of someone’s life. She would help with patient transport, drop off lab work, and talk to patients to figure out what they needed.

MM: There was one patient in particular, he came in several times during the years that I was there and I got to know him, and I saw him on the street one time, he was also experiencing homelessness, and he recognized me, and he said ‘hey doc,’ and he smiled and he said I’m always going to look out for you, and I felt the same care for him.

[MUSIC]

AY: She graduated and enrolled in a post baccalaureate program to take several years of science courses she would need for medical school. At the same time, she worked as a research coordinator, as well as three other part time jobs, on top of volunteering at the ER.

MM: And I was okay doing the hard work, because I felt like it was for the right reason and I believed in the goal.

AY: She also needed to take the Medical College Admission Test, or MCAT, so she enrolled in a prep class on the weekend, and finally took the exam.

MM: What I remember most distinctly about that exam is there was a fire alarm towards the end of it. I remember just hoping that the fire drill would end, and that I would be able to get through the rest of the questions.

AY: She scored 28, her faculty advisors and peers all told her she would need 30, that’s out of 45 total possible points.

MM: I was like I’m two points away, I have a lot of clinical volunteering experience, I have great research experience, I’m really passionate, I want to do this, let’s go!

AY: She did a few interviews with med schools, got on some waitlists, but no offers. So she had to take the MCAT again. During this time, one of her research jobs had been grant funded, that grant ended, she lost her job. Her roommate also wanted a new apartment and didn’t renew their lease.

Mollie was out of a job, and out of an apartment. She moved to Chicago and shared a place with a friend. She had few connections, and struggled to find work. She had scheduled to take the MCAT again, but now she was no longer in New York, and needed to take the test soon to stay on top of application deadlines. She looked around for test sites that she could get to quickly and take the test in time. The only one she found was in Oregon.

She scraped together money for a cheap flight and hotel, and flew to Oregon the night before the exam.

MM: And I did not even think about time changes and what it would mean to like fly in the night before, and try and take an exam the next morning. I was like no I want to sleep more, please let me sleep more.

AY: This time she got 27, one point lower than the first time. She did not bother applying. She took the MCAT a third time in Chicago, where she was now living. She got a 29, one point higher than the first time.

MM: I was one step closer, and I felt that you know I’m really close to that 30 cut off. I had a lot more research experience. I had a publication. And so I went for it.

AY: She applied to schools that talked about having a mission, thinking perhaps those schools would focus on her experience and less on her MCAT score. Two interviews, waitlists, but again — no offers.

And now she had a looming deadline.

The science courses she took don’t stay valid forever, and she could not afford to pay more tuition.

[MUSIC]

MM: There was kind of this clear end coming up, and I knew I was going to try one more time, and I didn’t tell people, because pretty much everyone had given up on me at this point. It’s interesting so the first time you re-apply, people are like that’s great, you’re tenacious, you can do it, fight for it, it’s great you’re so resilient, and then the second time you re-apply, people are like well you know maybe if you’re struggling with this exam, you’re not really meant for medical school, maybe that’s a sign, you know go ahead, it’s kind of worth trying, and then by the third time, people just don’t support you, all the conversations I had during that time were about what my plan b was, what are you going to do instead.

AY: But she was not ready to give up. She moved back to New York. She could not afford more prep classes, so she studied on her own, took the MCAT a 4th time.

MM: Did phenomenal on verbal, I did phenomenal on the biological science section and I tanked the physical science section, and so despite having two sections that were in the 95th percentile, I ended up with an overall score of 29, so no better, not even one point better, I was so bummed, I was so upset.

AY: But she knew this was it for her, her coursework was expiring, she had to apply with this score. Finally, schools offered her places. She is now in the 6th year of an MD PhD program.

MM: I don’t normally share the whole story, because there’s a certain amount of shame about not being able to do it, right, I feel like surely if I work hard enough or try hard enough, or keep trying I should have been able to do better, I felt like it was a reflection on my intelligence.

AY: Mollie has thought a lot about the MCAT. She said it was a financial barrier: taking the test was expensive, and she could not afford a lot of prep courses, she was busy working to pay for her education. There’s research that backs up what Mollie says about the financial barrier and it comes from the Association of American Medical Colleges itself, the AAMC, the organization responsible for the MCAT.

Their own research shows that in the past three decades or so, more than 70 percent of medical school students come from families that in 2016 terms, made more than $74,000 a year.

So let’s take a step back. What is the MCAT supposed to do?

The AAMC told me that people apply to medical school from all kinds of backgrounds, all kinds of schools.

The MCAT is supposed to be a standard way to make sure people applying to medical school know all the science they would need to succeed. Because how else would they know what a 3.5 GPA means from one school to another?

They sent me research showing that an MCAT score predicts how well a student will do in medical school, in terms of course work, other exam scores and graduating on time.

But the vast majority of medical school students graduate on time anyway.

And there’s also research showing that students who get into medical school on a parallel track without taking the MCAT or other pre-med requirements do just as well.

I heard from medical students, faculty members, who wonder if the MCAT is useful enough to justify having this expensive, extremely stressful barrier to medical school.

Amy Oxentenko: Having a high test score is not synonymous with being a great physician.

Amy Oxentenko is the chair of internal medicine at the Mayo Clinic in Arizona.

AO: You know, I’ve seen learners who are fantastic at test taking, you know they get some of the highest scores on these standardized tests, but if you then put them in a real-life scenario, you might have a student who scores very high who just does not perform very well clinically or bedside at all. And on the other hand, I’ve seen people who have low test scores who are phenomenal physicians, so I just don’t think it’s predictive.

AY: She worries that the MCAT isn’t the great equalizer it’s supposed to be. Instead, she’s afraid it keeps people out who can’t afford expensive prep courses that cost thousands of dollars.

Inginia Genao is an associate professor of medicine at Yale. She said she still remembers one student, who has a PhD in biomedical engineering and wanted to apply to medical school a few years ago. This student took the MCAT, didn’t do well, took out a loan to pay for review courses.

She took it again, and still didn’t do well.

Inginia Genao: That student just stopped pursuing medical school. There are so many students like this student who after a while is just saying this is not going to work out, and and they give up. That student with a PhD unable to perform in a competitive way on the MCAT, is now not a physician because, and specifically because of that test.

[MUSIC]

AY: Two researchers working with the AAMC, the makers of the MCAT published an analysis.

And they argue that because of structural racism in the U.S. a barrier that keeps out the poor, like the MCAT, would also keep out historically marginalized groups. They explain there’s nothing in the content of the exam that keeps out particular groups. Rather, they say the U.S. has a long history of policies that discriminate against people of color, like housing segregation, differences in access to good public education, which lead to more disparities in terms of what schools people can get into.

I took that to Javarro Russell, senior director for admissions testing at the AAMC, the group that makes the MCAT. He says he understands this argument.

Javarro Russell: As an African American, I recall, as even as a young boy, looking at my test scores from state tests, and wondering what was different about me, that I wasn’t performing at the higher levels of those state tests.

AY: But he says that’s not the fault of the test.

JR: A useful way to consider this is thinking about the MCAT as a thermometer measuring the temperature. We do not critique the thermometer because of the weather, rather we adjust our conditions to obtain comfort. The MCAT reflects the educational achievement of those interested in medical education, unfortunately structural racism in this country has adversely impacted opportunities to achieve for underrepresented minorities in medical education, but instead of addressing the complexities of providing more opportunity, it’s much easier to blame the test or in this case the thermometer for telling me what the weather is.

AY: He says even if you took away the MCAT, people who have resources and means, people who have privilege will always find ways to get ahead, so you might as well have more information.

In a strange and kind of tragic way, the pandemic created an ideal natural experiment. Some medical schools, including Stanford and the University of Washington, did not require the MCAT in 2020. Which means a few years from now, people can study the graduates of those schools and figure out, are they worse doctors because they never took the MCAT?

And if they’re not, then why do we have the MCAT to begin with?

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Maiken Scott: That story was reported by Alan Yu.

You’re listening to The Pulse — I’m Maiken Scott. You can subscribe to our show wherever you get your podcasts.

SEGMENT 3:

This is The Pulse — I’m Maiken Scott.

We’re talking about who gets into med school and who are we missing out on, in terms of future doctors.

When Madi Sinha was in medical school she liked to read books, fiction, about people going through the same training.

Madi Sinha: And I started to wonder why I didn’t see a South Asian woman, like myself, reflected in a story about residency and about medicine. It didn’t make sense to me that we weren’t represented in medical fiction so I decided to write that book myself.

And she did. Her novel “The White Coat Diaries,” follows physician in training Norah Kapadia who is balancing the pressures of medicine, with family expectations.

MS: So Nora is the daughter of South Asian immigrants. Her father has passed away and there is no other family to call on for help. It’s just Nora and her brother, Paul. And Nora’s family expects her to help care physically, emotionally, and financially for her mother who has poorly controlled diabetes, and also has depression, and anxiety, and it falls to Nora to be sort to speak “the good Indian daughter”

Maiken: And what does that entail to be “the good Indian daughter”?

MS: So for her family it means being present whenever a family member needs her. It mean putting her family above everything and before everything else including her medical training.

Maiken: I asked Madi to read from the book. In this passage, Nora has just been to dinner at her mother’s house, and her brother Paul corners her on the way out and says that he and his wife Reina need Nora to step up in terms of caring for the mom.

MS: We need help Nora. We need you to help. I draw in my breath. It’s not like Paul to be so direct. This is obviously something Reina put him up to … I do help Paul. I was just over here three weeks ago when she called me like she was having a heart attack and … I’m over here everyday, Nora. Either me or Reina is over here everyday — for hours and thank goodness we are. Who knows how long she would have been lying there the last time if Reina hadn’t checked on her. It’s not fair to ask Reina to take care of Ma and Kai. She didn’t sign up for this.

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The idea that Reina thinks of my mother as a this — an onerous nuisance, a burdensome thing is infuriating. She didn’t sign up for this? She didn’t sign up for what? Paul looks at the sky and rubs his chin. To be Ma’s daughter. Your Ma’s daughter. Not her. You’re Ma’s daughter. Three efficient little words that confer a life times worth of guilt and obligation. You think I should quit. You both think I should quit so I can move in more and help out more with Ma …

Maiken: Talk a bit about the kind of pressure that you wanted to convey here? And, I’m sure a lot of the book was inspired by your own experiences going through medical school and going through residency?

MS: Yes, so my own experiences and the experiences of other South Asian women who I trained with who were immigrants or themselves children of immigrants. There was a young woman that I trained with — she had four children all under the age of 8. She was from a South Asian background where in her particular culture it was expected that women would have children by a certain age and also that women would do most of the child care. She lived in a third floor walk up apartment and every morning at 4:30 a.m. would carry her sleeping children one at a time down three flights of stairs to the baby sitters on the first floor. She would do this all at 4:30 a.m. and would arrive for 5 a.m. rounds on the surgery unit every day. And it was amazing to me that that was something she just did. She just dealt with. So seeing that type of experience really made me want to write this book and show what that is like to have family expectations that are in direct conflict to the expectations that are on you as a medical student or as a resident. Traditionally, medical training is all consuming. It’s designed to be that way. The expectation is that while you are a medical student or a resident that your entire life is consumed by that calling. And medical residencies were established in the late 1800s. They were established for men who were white who were from privileged backgrounds and, ya know, when you are not from that background you just have to find a way to fit yourself and your cultural expectations into that framework.

Maiken: But it sounds impossible. I mean, it sounds like just not the kind of environment that is any way forgiving when you need something that’s a little different.

MS: I think that’s 100 percent correct. Ya know, there really is no accommodation made for students or residents who have for example young children or dependents or who are economically unable to afford to for example live next door to the hospital which makes your life a lot easier as a resident when you’re on call.

Maiken: And if you have a family member you have to care for a parent that needs your help — you’re out of luck?

MS: That’s essentially correct. Yes. Any time taken out of medical school or residency is time you’ll make up later, but there is no accommodation really made. The train is moving and it will move without you. So if you need to take a break and step away it definitely negatively affects you.

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Madi Sinha is a physician and author, her novel is called “The White Coat Diaries.”

A lot of experts say that training more doctors from diverse backgrounds would result in better patient care and outcomes.

Jaya Aysola: But there’s also literature that shows it doesn’t solve the whole problem.

That’s Jaya Aysola, she’s the founder and executive director of Penn Medicine’s Center for Health Equity Advancement.

JA: And part of that is irrespective of the diversity at the front lines and that engagement, we’re all sort of learning the same language of how to interact with patients. We’re all steeped in the same medical knowledge that may have been generated with, you know, sort of a single culture in mind. And so unless we change also the diversity throughout the organization and generate science with more diverse perspectives, that informs our medical practice and generate sort of leaders in the organization that are designing the models that we’re all operating in and teaching us how to interface with patients. The front line providers alone in diversifying that alone won’t solve this issue.

MS: When you were a student, did you have any faculty who were not white?

JA: No, not not one? No.

MS: Not a single one?

JA: Not a single one. But that was so common. I didn’t expect I didn’t expect to have them.

MS: Let’s say every med school in this country manages to attract a really diverse body of students, one that reflects the actual makeup of this country. Which problems would that not solve? What would be the remaining issues that need to be addressed?

JA: One is simply the relationship between diversity and inclusion. So if you recruit a bunch of students that are diverse, but the environment is not inclusive and they have to assimilate in order to survive and get promoted in advance, and so they have to navigate this predominantly white space as their non authentic self. You sort of stifle the innovation you would have gotten and the whole purpose of diversification in that process, right? So the whole idea of a diverse multicultural perspective lends for greater innovation, greater diversity of thought, greater creativity. All of that is stifled in non-inclusive environments. And that is the first barrier, I think to achieving what a diverse population of students would set the stage for in terms of benefits.

Jaya says for the environment to be truly inclusive and welcoming — the whole tone of medical school has to change — which can be notoriously rough:

JA: We likened it to a military experience. You know, it was very hierarchical, you just did what you were told, you got through it and that’s how you are supposed to do it. And I think, I think, the time has changed. And in our realization that the way we treat each other is critical to our understanding and our improvement of the way we treat our patients. That realization is, is the paradigm shift that we’re trying to put forth now. Inclusively matters, it inclusively matters. The way we treat each other, irrespective of our background and culture, translates and will translate into the way we treat our patients. 

MS: What would a really diverse med school look like? What would be the structures in place that that made it truly inclusive?

JA: Yeah, I love that question. I think for me, a diverse medical school would represent the population that the medical school is serving. So, oftentimes we track diversity based on national demographics. We don’t account for the changing demographics in society. So ,we just look at absolute numbers and see if they’ve improved over time. We don’t do that relative to the growth of that demographic in the population. And we also don’t do it relative to what the environment is around us. So the first step is defining what diversity should look like for any given medical school. And so that’s the first thing. And then it also looks like a diverse faculty. So when you come in as a medical student, you want to see that not only are you diverse, but diversity succeeds in this place.

MS: Jaya Aysola is dean of inclusion and diversity at the University of Pennsylvania, in Philadelphia, and the founder and executive director of Penn Medicine’s Center for Health Equity Advancement.

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That’s our show for this week — The Pulse is a production of WHYY in Philadelphia.

Subscribe wherever you get your podcasts.

Our health and science reporters are Alan Yu, Liz Tung, and Jad Sleiman. Sojourner Ahébée is our health equity fellow. Charlie Kaier is our engineer. Xavier Lopez is our associate producer. Lindsay Lazarski is our producer.

I’m Maiken Scott. Thank you for listening!

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