IAMSE Spring 2024 Webcast Audio Series – Week 1 Highlights

Presenter: Mark C. Henderson, MD, MACP, Associate Dean of Admissions, University of California Davis School of Medicine

[The following blog was generated by Susan Ely and Doug McKell]

Creating a Diverse Class of Learners via Socially Accountable Admissions

The Learning Objectives for this first Spring 2024 IAMSE Webinar series on Teaching and Learning in Medical and Health Professions Education include the following: First, evaluate the paradigm of social accountability in medical education, including the relationship of representation of increased diversity of health professionals to health equity of underrepresented, underserved, and marginalized patient communities. Second, examine trends in the composition of the US physician workforce, including the percentage of physicians from underrepresented groups compared to their percentage of the population and the changes over time. Third, discuss the UC Davis holistic admissions process, which has increased the diversity of their medical student population despite the 1977 passing of California Prop 209 banning affirmative action.

Dr. Mark Henderson discussed the underrepresentation of marginalized groups in medical schools and the inequities in medical education, emphasizing the need to address these inequities. He stressed the importance of implementing holistic admissions strategies to increase diversity, including long-term changes in the admissions process, cultural support, and peer mentorship. He spoke about the UC Davis School of Medicine and its process over the last 15 years to admit increasingly diverse medical school students. Dr. Henderson began by discussing the paradigm of social accountability as it applies to medical education, specifically medical school admissions, focusing on the current medical student application process that results in the excess or deficit selection of students from some groups compared to their proportional representation in the general population. This negatively affects health equity access and increases health disparities among several underrepresented patient populations. He presented a conceptual model demonstrating why proportional health professional representation and diversity are essential to health equity since individuals and practitioners from disadvantaged groups are more likely to have cultural and language concordance with their patients. This leads to better communication, better trust amongst marginalized communities, and greater health advocacy for such communities, with more health practitioners working in the communities where they are needed.

Dr. Henderson presented data showing that in the United States, the racial/ethnic background, educational advantages, and family income proportions of the demographic composition of physicians who practice in the United States don’t match the United States population as a whole, except for the white population. For example, for the Latino population, which is now almost 20% of the United States, only about 7% of physicians are Hispanic or Latino. There is a similar disparity with the African American population, although it’s not quite as severe, where 6% of physicians are black compared to 13% of the US population. Finally, there is an overrepresentation of Asian subpopulations, where almost 22% of practicing physicians are from Asian subgroups, while Asian Americans comprise only 6% of the US population. Dr. Henderson pointed out that while the US population became much more diverse, with the number of individuals from underrepresented groups living in the US almost doubling from 66 million to over 105 million, and the number of medical schools grew by over 50% between 1997 and 2017, our future physicians do not reflect the US population. Based on the family income of students in medical school today, your chances of being admitted to medical school based on your family’s income are directly proportional to your family income. This means a lower- income student is less than half as likely to be admitted to medical school as a higher-income student.

Dr. Henderson then paraphrased Dr. Martin Luther King’s statement that as capitalism has grown, there are specific segments of the population that have been left out and, in a sense, have exploited impoverished black and white individuals and communities of color. His point was that the inequities he presented dealing with the lack of a representative physician workforce and diversity in the workforce overall were present before last year’s Supreme Court decision that banned affirmative action in the United States. He stated that based on affirmative action bands in California as well as seven other states after those bands were put in place, the racial and ethnic representation in medical schools got much worse. He expects the same thing will occur across the United States unless there’s attention focused on this issue.

Dr. Henderson then described how to make the necessary changes to create a more diverse and representative medical student population. The most crucial step is to have a sense of urgency. The UC Davis School of Medicine was directly affected by the state-wide affirmative action ban enacted in 1997. In 2005, they began a series of process changes, and the enrollment of underrepresented groups has tripled over about 15 years. Many structural elements are present, as alluded to earlier, e.g., privilege, class, and racism. These elements tend to preserve the status quo. Inertia is another factor, as is the fear of lawsuits, even before the recent SCOTUS decision. What is most important is an institution’s mission. Dr. Henderson stated that it is essential to ask your medical school the following question: What medical education goals is the institution trying to accomplish? He argued that the mission of medical education is to train physicians to meet the health needs of society. Fundamentally, it is a social mission. The first step at UC Davis School of Medicine was to adopt a mission focused on meeting society’s needs: socially accountable admissions. This meant that the mission of the UC Davis School of Medicine was to matriculate future physicians who will address California’s diverse health workforce needs.

The UC Davis School of Medicine admissions office shifted its operation to include input from a diverse group of faculty, students, trainees, and patients. They use multiple mini- interviews blinded to several biasing elements that favor the admission of individuals from privileged backgrounds or those who have had more excellent educational opportunities. Using a holistic review is an important paradigm involving choosing students who fit within a school’s mission. It’s about more than just their grades or test scores, which don’t tend to correlate necessarily to the mission. Dr. Henderson emphasized the importance of previous healthcare experiences, whether personal experiences or work experiences within the healthcare system. 45% percent of UC Davis School of Medicine students are the first in their families to graduate from college, which results from applying more inclusive selection criteria to create a more comprehensive economic representation of enrolled students. Finally, Dr. Henderson explained that UC Davis School of Medicine has developed several partnerships with local high schools, local community colleges, and other medical schools that share a similar mission.

Another critical way the UC Davis School of Medicine has approached its mission is to develop inclusive programs focused on community health needs. The Community Health Scholars program comprises almost a third of enrolled students. Most of these students are first-generation-to-attend-college individuals from low-income backgrounds and are often from underrepresented groups. Admissions criteria for these programs prioritize individuals from these communities. The first one, established in 2007, is called Rural PRIME. It is meant to address the maldistribution of physicians in California. Another program, TEACH-MS, focuses on the underserved urban population. The Central Valley REACH program is concentrated in the Central Valley, the agricultural hub of California. The Accelerated Competency-based Education Primary Care program is a 3-year MD degree pathway for Primary Care physicians and is the beneficiary of several external funding sources. Lastly, a program focused on California Native American/American Indian communities was established in 2022.

Dr. Henderson then described the long-term outcome of the residency program match for UC Davis School of Medicine students. Based on data from 147 students over the last ten years, about 80% come from groups underrepresented in medicine. Most students are matched into specialties of need in California, with 43% going into traditional primary care. If ob-gyn, pediatrics, emergency medicine, and internal medicine are included, about 75% of the students would go into some form of primary care.

Dr. Henderson stressed that this level of success requires looking at your applicant pool differently. UC Davis School of Medicine developed a tool called the data scale, which is a metric derived from each student’s application. It incorporates several socio-economic variables to form a score from zero to 99. A high score on this scale means the student has experienced significant socio-economic distress. A low score would mean they’ve experienced very little hardship. The variables include income, parental education, working during college, or growing up in an underserved area. Because traditional measures of excellence or merit tend to be confounded by educational opportunity, we use this scale to provide context to those other measures. Because it’s a number, it tends to nudge our committee members to be more holistic and dive deeper into every applicant’s application. Dr. Henderson indicated that he believes this correlates to resilience or grit and the ability to overcome obstacles, i.e., essential qualities in future physicians.

Dr. Henderson focused on three programs that help ensure medical student success. The first program is their Community Health Scholar program called ACE PC, which admits eight students a year, all of whom have primary care experience before medical school admission, either as an emergency medical technician, a medical assistant, an ancillary health provider, or someone who worked in a healthcare center. 85% of these students are first-generation college graduates. They are admitted to medical school with lower grades and lower MCAT scores, but they finish in three years instead of four, and almost 90% of them match into a primary care residency. They get a full tuition scholarship because accumulated medical school debt discourages many students from pursuing primary care.

The second program is a community college-to-medical school Pathway Program. It turns out that about half of the Latino family residents came through the community college system, and a third of the black family residents went to community college. This is a significant pathway for underrepresented students. The problem is that many community college students don’t finish, or they don’t transfer, or it takes them quite a bit of time to transfer. About 2.5% transfer within two years of community college, and only a quarter within four years. This program aims to build bridges between community colleges and the UC Davis undergraduate campus. Once the students are at the undergraduate campus, they provide additional health professions career advice and help them address gaps in their educational preparation.

The last program is a partnership with Oregon Health Sciences for a tribal health medical school pathway program called Wy’est. This residential post-baccalaureate program accepts Native American students who have applied to medical school but have been unsuccessful. They spend ten months in Portland. If they meet the requirements of the post-baccalaureate program over this period and the Wy’est program requirements, they receive conditional acceptance into UC Davis School of Medicine, Oregon Health Sciences University School of Medicine, or the Washington State School of Medicine. This program has been quite successful over the last eight years. The students from this track enter the Tribal Health Community Health scholar program when accepted at UC Davis School of Medicine.

Dr. Henderson concluded his presentation by repeating his main point that the mission of medical education is to train physicians to meet society’s health needs. He reported that supporting students with additional academic advising resources and financial aid has additional costs. At the same time, he was optimistic that other advances in medical education, such as AI, may make the holistic admission process more equitable despite concerns about fairness and potential misuse.