The Death of Diversity
Oct 2022
How Structural Barriers in Healthcare Led to a Shortage of Black Female Physicians
Jillian Martin
In the past 50 years, the Black population of the United States increased from 10.5% to 13.4% (Roberts et al. 598). Conventional logic might suggest that because of this growth, the same increase would be reflected in the number of Black physicians in the country — but that is not the case. Unfortunately, according to the Association of American Medical Colleges (AAMC), Black physicians made up only five percent of the workforce in 2019, with Black female physicians comprising an even smaller number: less than three percent (“Diversity”). Black women face disproportionate health disparities, such as a higher maternal mortality rate than White women. Health disparities like maternal mortality rate are not biologically based — a Black woman is not innately born to be more likely to die during childbirth; she is born with structural and systemic inequities that predispose her to die at a higher rate during childbirth.
Throughout our country’s history, Black Americans were forbidden to partake in the same opportunities as White people, like easy access to education or the opportunity to economically grow, thus gradually creating the systemic racism that not only produces health issues but also a lack of education, poor housing, and policing (Johnson et al. 2397). Combine these inequities together, and they contribute to health disparities in the Black community, racial discrimination in healthcare systems such as implicit biases, and a poor representation of Black physicians.
In this paper, I address how structural barriers in healthcare negatively affect Black female physician representation and retention in the United States, and how to facilitate necessary improvements in medical schools to create a safer, more inclusive environment for Black women. I wish I could state that this representation is greatly improving, but that is not the case. Fortunately, however, there are medical schools advocating and implementing certain practices in their programs to matriculate a percentage of physicians that is representative of the Black population. So, I will examine challenges Black women face in medical schools, residencies, and fellowships, analyzing how those hardships impact both representation and retention in academic medicine. I will then look at the University of Chicago’s Pritzker School of Medicine’s and Boston University’s School of Medicine’s mission statements and commitments to diversity as possible examples for other medical schools to follow.
An equitable work environment for all should be a fundamental standard in contemporary culture. In most workplaces, though, Black citizens face daily microaggressions and racism, overt or hidden, but these actions are often overlooked and downplayed by organizational leadership. These work environments, like clinics, are likely predominantly White, so issues surrounding racism are not of concern since Black employees are in the minority. Hospitals are not exempt from this general description of the contemporary workplace: Black physicians face the same microaggressions and discrimination, but the racism affects both physicians and their patients, which contributes to health disparities. If a Black female doctor faces day-to-day discrimination, she might not want to continue practicing in that hospital in a hostile environment. This discrimination the physician faces then might impact the patient’s care. Mark A. Fleming, University of Virginia surgical resident, and colleagues speak out for racial inequity within surgical training, outlining several action items hospitals should initiate to create a better workspace for Black surgeons. Clearly evident in the article is that there is too much fear to call out others for discrimination because of the possibility of being reprimanded by administration and no repercussions for the discriminators. This fear of speaking out and consequential punishment for speaking out can be defined as “whistleblower stigmatism” (Fleming et al. 1388). Due to the lack of accountability for racist actions, Black women are frightened they will both face repercussions like losing their job or be seen as a whistleblower. In an August 2020 Fortune article about the low percentage of Black female physicians, contributing writer Maria Aspan interviews Dr. Uché Blackstock, a Harvard-educated, former emergency room doctor, assistant professor, and the Office of Diversity Affairs’ faculty director of recruitment, retention, and inclusion at New York University School of Medicine (NYU) for eight years. Dr. Blackstock discusses her experiences at NYU and why she ultimately chose to leave, citing that the medical school was “a toxic and oppressive work environment that instilled in [her] fear of retaliation for being vocal about racism and sexism within the institution” (qtd. in Aspan). Dr. Blackstock experienced whistleblower stigmatism, even as a Harvard-educated doctor (Aspan). Unfortunately, this is important to note — despite attending Harvard for both undergraduate studies and medical school, generally perceived as the most elite university in the country, it does not matter where she attended medical school. She was still treated poorly because she is a Black woman.
In Blackstock’s role as faculty director in the diversity affairs office, she held events like bias training sessions for medical faculty; however, she noticed those unaffected by biases did not care about diversity issues. Frustrated by her failed attempts to promote more inclusion and an overall toxic, racist environment, she left NYU and founded her own consulting firm “Advancing Health Equity” to collaborate with health institutions “to dismantle racism in healthcare and to close the gap in racial health inequities” (Blackstock). Dr. Blackstock notes that the general population “think[s] of medicine as innovative and pushing the limits” but fails to recognize that “[medicine] is probably one of the most conservative environments” and that “it’s very resistant to change” (qtd. in Aspan). Dr. Adia Harvey Wingfield, professor of sociology at Washington University in St. Louis, also writes that people believe medicine is “objective and neutral,” so how can one say medicine is objective and neutral if Black women are “60% more likely than non-Hispanic white women to have high blood pressure,” and 2.9 times more likely to die during childbirth for example (Hoyert)?
This so-called “objectivity” that medicine prides itself on is inaccurate because of the constant barriers the Black community endures in healthcare systems — these barriers carry over to the barriers Black people face regarding medical school. To combat segregation and discrimination, Black medical schools were founded, beginning with Meharry Medical College in 1876. But, in the early 1900s, the Flexner Report, a report outlining reform for medical education, effectively shut down medical schools that could not afford to make the recommended changes (Johnson et al.). The report urged that Black medical schools needed to integrate more expensive labs and clinical practice into its education, but directly stated that “only Meharry at Nashville and Howard at Washington [were] worth developing” (Laws). Because of that stark statement, most Black medical schools lost their funding since they could not implement the directives outlined in the report, were viewed as lesser than Howard and Meharry and were subsequently closed. Today, despite these closures, the last four historically Black medical schools (Howard University College of Medicine, Meharry Medical College, Morehouse School of Medicine, and Charles R. Drew University of Medicine and Science) still produce more Black graduates at a disproportionate rate compared to other medical schools.
Then, the Medical College Admissions Test (MCAT) comes into play. The test scores range from 472 to 528, and the average MCAT score of a general applicant is a 506. On average, Black testers had the lowest average scores, receiving a 497, somewhat below average, whereas White students received an average of 507, which is slightly above average (“Table A-18”). This would prompt some to believe that, stereotypically, Black students received a lower score because they are Black. It is true — Black students do receive lower scores because of their race, but not because they are less intelligent. It is because “associations between race and MCAT scores suggest that racial biases and structural barriers have more influence on low scores than a presumed lack of intellectual ability does” (Johnson et al.). Not only does the MCAT impact admission to medical school, but GPA also affects the rate at which Black students are admitted. The average GPA for an applicant to medical school is 3.59, yet Black students applied with an average of 3.35 and White students applied with an average of 3.66 (“Table A-18”). Once again, Black students’ scores are below the norm, and White students’ scores are above, so White students get into medical school at a higher rate. This is a perfect example of how systemic racism works: coming from a richer, more privileged background leads to having easier access to academic tutoring and MCAT preparation that Black students are not afforded.
Standardized tests making it more challenging for Black students to enter higher education is nothing new. Structural barriers like the MCAT are a major reason as to why Black female representation in healthcare is so poor; in a career that is already perceived as White male-dominated, poor representation pushes Black women to stop pursuing medical school and the path to becoming a physician as a viable career option. In a 2020 study conducted at the University of Pennsylvania Perelman School of Medicine, resident physician Sanford Roberts et al. interviewed sixteen Black medical students to learn about their thoughts surrounding academic medicine and surgery both during and after medical school. Academic medicine is a branch of medicine where doctors clinically practice, conduct research, and teach medical students, and in 2018, only 1.8% of full-time faculty identified as Black women (“Figure 18”). Understandably, these medical students are nervous about their futures in a field clearly misrepresentative of the population — how is it possible to sustain a career in academic medicine with that percentage? What stood out to me the most were the concerns Black female medical students noted: a lack of Black females in leadership roles which leads to a lack of mentorship. One Black female student states, “There is being a Black physician. And then there’s like being a Black surgical physician, and then being a female Black surgical physician. So all those things I have to see, like would this be a hostile environment. Like is everyone in this field very unaware of the issues that I think about?” (Roberts et al. 600). Her description of her internal dialogue summarizes what must run through every Black female medical student’s head — there are so many factors that make being a Black woman in healthcare difficult and not having Black women as mentors in the field makes it even harder.
With an already lack of Black women in healthcare, the discussion of tenure becomes increasingly important for Black female medical students and residents. Tenure is viewed as the most coveted position for someone in academic medicine, as it guarantees that person cannot be fired (barring extenuating circumstances) — it’s essentially 100% job immunity. Most tenured medical school professors are White and Asian, even at historically Black medical schools like Meharry Medical College in Nashville, Tennessee. At Meharry, though, out of 34 tenured professors, eight are black woman, making up 23.5% of tenured professors — an impressive number, and Black female medical students there have more opportunities for mentorship with these women (Williams June and O’Leary). On the other hand, University of Texas Southwestern Medical School in Dallas, Texas has 146 tenured professors and no Black women achieved tenure; additionally, Weill Cornell Medicine in New York City has 123 tenured professors with also no tenured Black women (Williams June and O’Leary). It is unacceptable that some medical schools have no tenured Black women, but it makes me think: why would an accomplished medical school applicant want to pursue programs that won’t support them? This is a crucial reason as to why there are so few Black female physicians; not only is there already a small percentage of them in medical schools, but there also is no incentive to work somewhere where they cannot progress up the leadership ladder. Therefore, the retention of a racially diverse faculty is increasingly difficult because there are no plans by many medical schools’ leadership to improve the representation. Without a plan, it is difficult to keep Black female physicians from leaving after these women endure “social isolation, exhaustion, and overall negative experiences that exacerbate departure” (Johnson et al.). This is how Dr. Blackstock felt in the months leading to her exit from NYU.
So, how can medical schools alleviate the stress these women feel surrounding discrimination and inequities in healthcare? According to Dr. Roberts and colleagues, a racially diverse faculty seems to be the key factor for making Black women feel more comfortable and confident going into academic medicine and achieve high leadership roles. Although efforts to increase diversity in medical school programs has spanned several decades, there has yet to be sustained diversity, as demonstrated by the population increase not translating to a physician increase (Johnson et al.). This means that among hospitals, there is no general agreement about the importance of diversity as a core mission. Diversity is seen as a nagging community service, not something that could service communities for the better.
Boston University’s medical school, however, keeps diversity as a cornerstone of their mission. On the university’s Early Medical School Selection program (EMSSP) page, the school describes itself as “an urban school affiliated with a teaching hospital that serves a patient population that is more than half people of color and more than half underserved” (“Early Medical School”). Their mission statement proceeds to acknowledge that their “primary mission is preparing culturally humble, clinically excellent physicians to meet the healthcare needs of a diverse population” (“Early Medical School”). The school strategically writes these descriptions on EMSSP’s page because the program works with historically undergraduate Black colleges and universities to bring in more Black students with an emphasis on women and support them from their junior year in college through matriculation at Boston University for medical school. Both the description of the medical school and mission statement pride themselves on how diversity is an important cornerstone of the school and cannot be overlooked, demonstrated by EMSSP too. The medical school also offers a one-year paid diversity and inclusion fellowship to a current medical student where they work with the Associate and Assistant Deans of Diversity and Inclusion to create and further diversity initiatives like building anti-racist taskforces for discriminatory issues (“Early Medical School”). The fellow also collaborates with the admissions office to promote programs like EMSSP to interested students and works with Boston University’s Institute for Health System Innovation and Policy. This fellowship displays that the medical school has a continual focus on making their environment more inclusive and equitable for their medical students. What’s more, Rebecca Lee Crumpler, the first Black woman to graduate with a medical degree, graduated from Boston University, which could correlate to why the medical school has such a strong commitment to diversity and improving Black female representation. The administration sends a clear message to their applicants and physicians: they care about facilitating change in diversity, equity, and inclusion efforts.
University of Chicago’s Pritzker School of Medicine also displays a devotion to diversity, writing the mission statement and student testimonials on their website to back up claims that sound too good to be true. One student says that the school doesn’t just talk about their efforts to promote diversity and inclusion, they truly believe in what they say and act on their words, noting that diversity in the workforce better prepares [students] for a diverse patient population (“Meet”). Another student writes that no school does diversity perfectly, but the University of Chicago is a forerunner for best diversity efforts (“Meet”). In 2020, university leadership proudly proclaimed that 31% of their incoming medical school class were underrepresented in medicine, 19% higher than the national average (“Pritzker”). Reading both student testimonials and statistics shows that this medical school truly cares about diversity. Not only does the school have a commitment to a diverse student body to better themselves, but they also have a commitment to diversity to provide effective care to communities surrounding them. Located in Hyde Park, six miles south of Chicago, the medical school finds itself in a racially diverse, urban location. Students actively engage with the community by volunteering in student-run free clinics like the Community Health Clinic and the Washington Park Children’s Free Health Clinic to provide great care to those with less access to healthcare because of barriers that cause unequal healthcare access. The medical school also hosts the Chicago Academic Medicine Program, an eight-week research, education, and mentoring program geared toward rising college sophomores, juniors, and seniors who identify as an underrepresented racial minority in medicine (URM means Black, Latinx, or Indigenous). In the program, the wealth of opportunities for students participating is worth mentioning — participants can foster relationships with medical faculty, take courses to prepare for the MCAT, and present their research findings at the conclusion of the program.
What both schools have are, unfortunately, unique opportunities that every medical school should jump at the chance to start as well. Boston University’s Early Medical School Selection, to increase the number of Black medical students in the student body, and the University of Chicago’s student-run free clinics, to engage with diverse patient populations to improve both the students’ providing of care and the patients’ care, are two great ideas that could elevate medical schools’ diversity commitments tangibly. These schools also indicate how increasing racial diversity has psychosocial effects on medical students, physicians, and healthcare systems. Boston University hinted at some of these effects on their “Selection Factors” subtitle on the admissions page, notably stating that a more racially diverse student body translates to more racially diverse physicians in the long run, which consequently reduces racial health disparities, and that “racially, ethnically, and culturally diverse leadership in medicine is critical to progress in healthcare and society as a whole” (“Selection”). Cardiologist Amber Johnson et al. also find that racially diverse students might have similar experiences to those they treat that improves overall patient care. According to the authors, Black and Latinx medical students had higher empathy scores than other races; this empathy translates to patient care once again because these students can empathize with patients who also experience racism and discrimination. Being exposed to people of different races, genders, cultures, and religions will prepare any medical student for a more accurate representation of life — medical schools must recognize the benefits of diversity for the sake of their patient populations.
Although the percentage of Black female physicians is extremely low and the odds are always stacked against them, Black women have still accomplished incredible feats in medicine. Dr. Rebecca Lee Crumpler not only graduated as the first Black female doctor in the United States (during the Civil War), but she also pub-lished Book of Medical Discourses, a medical advice handbook for women and children (“Rise”). Dr. Marilyn Hughes Gaston became the first Black female director of the Bureau of Primary Health Care under the U.S. Department of Health and Human Services in 1990 after she created a nationwide sickle-cell disease screening program for newborns in 1986 (“Rise”). Finally, in 1982, Dr. Vivian Pinn became the first Black women to be an academic pathology chair, holding the position at Howard University College of Medicine. In 1991, she then become the first director of the Office of Research on Women’s Health at the National Institutes of Health. Here, her focus is on increasing the number of women in scientific leadership positions (“Rise”). As demonstrated by these incredible women, diversity is nothing but beneficial. It makes a person more empathic, culturally competent, and a better physician overall. Improving Black female physician representation in medical schools only has good consequences, and their presence in university-based health institutions will make working in healthcare safer and more inclusive.
Works Cited
Aspan, Maria. “Black Women Account for Less than 3% of U.S. Doctors. Is Health Care Finally Ready to Face Racism and Sexism?” Fortune, 9 Aug. 2020, fortune.com/2020/08/09/health-care-racism-black-women-doctors/amp/.
“Diversity in Medicine: Facts and Figures.” AAMC, 2019, aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018.
“Early Medical School Selection Program Overview.” Boston University School of Medicine, 2022, bumc.bu.edu/busm/about/diversity/emssp/program-information/.
Fleming, Mark A., II, et al. “The Risk and Reward of Speaking Out for Racial Equity in Surgical Training.” Journal of Surgical Education, vol. 78, no. 5, 2021, pp. 1387-1392,
doi:10.1016/j.jsurg.2021.01.015
“Heart Disease and African Americans.” U.S. Dept. of Health and Human Services Office of Minority Health, 2021, minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=19.
Hoyert, Donna L. “Maternal Mortality Rates in the United States, 2020.” Centers for Disease Control and Prevention, 23 Feb. 2022, cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm.
Johnson, Amber E., et al. “Racial Diversity among American Cardiologists: Implications for the Past, Present, and Future.” Circulation, vol. 143, no. 24, 14 June 2021, pp. 2395–2405, doi.org/10.1161/circulationaha.121.053566.
Laws, Terri. “How Should We Respond to Racist Legacies in Health Professions Education Originating in the Flexner Report?” AMA Journal of Ethics, vol. 23, no. 3, March 2021, pp. E271-275.
“Meet Our Students.” The University of Chicago Pritzker School of Medicine, 2022, pritzker.uchicago.edu/node/1751.
“Pritzker School of Medicine Makes Diversity and Inclusion Central to Its Mission.” The University of Chicago Office of the Provost, 17 Feb. 2020, diversityandinclusion.uchicago.edu/news/article/pritzker-school-of-medicine-makes-di-an-ongoing-priority/.
“Rise, Serve, Lead! America’s Women Physicians.” U.S. National Library of Medicine, National Institutes of Health, 2019, nlm.nih.gov/exhibition/riseservelead/collection-1.html.
Roberts, S.E., et al. “Pursuing a Career in Academic Surgery among African American Medical Students.” The American Journal of Surgery, vol. 219, no. 4, 2020, pp. 598–603, doi.org/10.1016/j.amjsurg.2019.08.009.
“Selection Factors.” Boston University School of Medicine, bumc.bu.edu/busm/admissions/typical-interview-day/.
“Table A-18: MCAT Scores and GPA for Applicants and Matriculants to U.S. MD-Granting Medical Schools by Race/Ethnicity.” Association of American Medical Colleges, 2021, aamc.org/media/6066/download.
Williams June, Audrey, and Brian O’Leary. “How Many Black Women Have Tenure on Your Campus? Search Here.” The Chronicle for Higher Education, 27 May 2021, chronicle.com/article/how-many-black-women-have-tenure-on-your-campus-search-here.
Wingfield, Adia Harvey. “Systemic Racism Persists in the Sciences.” Science, vol. 369, no. 6502, 24 July 2020, pp. 351–351, doi.org/10.1126/science.abd8825.
Jillian Martin studies in the College of Arts & Sciences at Washington University in St. Louis.