Augustus A. White III, MD, PhD

This special day began by honoring the life and work of Augustus A. White III, MD, PhD, Chief of Orthopaedic Surgery at the Beth Israel Deaconess Medical Center (BIDMC) from 1978 to 1991. Dr. White is a world-renowned clinician, surgeon, educator, visionary, and advocate. He was born and raised in Memphis, Tennessee and received his undergraduate degree at Brown University. Throughout his career, Dr. White was a champion of diversity initiatives and always led by example, becoming the first African-American medical student at Stanford University and first African-American surgical resident and faculty at Yale University. After earning his PhD at the University of Gothenburg and Karolinska Institute, he directed the Engineering Laboratory for Musculoskeletal Disease at Yale before arriving at BIDMC in 1977. There, he mentored 25 outstanding spine fellows through the Daniel E. Hogan Spine Fellowship. At Harvard Medical School (HMS), Dr. White took special interest in teaching cultural competence in medical education and working to eliminate disparities in health care. He was the Founding President of the J. Robert Gladden Society (JRGS) which aspires to advance the ideals of ethnic and gender diversity in the field of orthopaedics. His lifelong dedication to promoting diversity in the field of medicine in general and in orthopaedic surgery in particular culminated in the American Academy of Orthopaedic Surgeons (AAOS) Diversity Award in 2006.

Alvin H. Crawford, MD

The honorary guest speaker for the 2017 White Symposium was Alvin H. Crawford, MD, Professor Emeritus of Orthopaedic and Pediatric Surgery and founding director of the Crawford Spine Center at Cincinnati Children’s Hospital. Like Dr. White, Dr. Crawford was the first African-American medical student at the University of Tennessee College of Medicine and recipient of the AAOS 2007 Diversity Award. He has dedicated his career to treating children with complex spinal disorders and is an expert on spinal deformity in neurofibromatosis.

The symposium was centered on the diminishing representation of African-American men in medicine. In addition to Dr. Crawford, there were three other distinguished guest speakers: Dr. Joan Reede, the Dean for Diversity and Community Partnership at Harvard Medical School (HMS) and – the first African-American female dean at HMS, Dr. Alden Landry who is the Faculty Assistant Director of the Office of Diversity Inclusion and Community Partnership at HMS, and Dr. Daniele Olveczky who is a geriatrician at BIDMC.

What is the problem?

According to an Association of American Medical Colleges (AAMC) report published in 2014 titled “Altering the Course: Black Males in Medicine,” the number of African-American men applying to and matriculating at medical schools across the nation has been declining over the past 36 years. In 2014, there were only 1,337 African-American male applicants, compared to 1,410 in 1978. In 2014, 515 African-American males were enrolled in medical school, compared to 542 in 1978. African-American males compose the only minority group that has had decreasing number of applicants and matriculants from 1978 to 2014. This has occurred despite the inauguration of roughly 20 new medical schools during that same time span. In addition, African-Americans have the lowest ratio of male to female medical school applicants, with 37.8% men and 62.2% women in 2014. Despite the growing number of African-American males graduating from college, it has been puzzling to see why so many young African-American men have shied away from medicine.

It is important to note that the discrepancy in the representation of African-American males exists not only in the medical student body but also in the medical school faculty. According to the 2016 AAMC Faculty Roster, there were 100,318 male faculty members across all US medical schools. However, only 2,239 of them were African-American male (2.2%). “This,” Dr. Reede declared, “is a real crisis. Does this happen by accident? Can this happen by accident? Or is there something within how we do business that excludes and/or limits our ability to gain full value and potential that exist around us?” Why is there such a considerable disparity in the number of African-American male physicians receiving appointments to the faculty of medicine? And what can be done to alter this course?

The speakers clarified that the discussion on lack of representation of African-American men in medicine is not an “either / or” discourse. In other words, just because there is a need for African-American men in medicine does not mean there is not a need for African-American women. In fact, there is a strong need for both, as both groups are still underrepresented. Furthermore, Dr. Reede clarified diversity is not just about race but also about ethnicity, gender, sexual orientation, geography, and socioeconomic status. In discussing the underrepresentation of African-American men in medicine, the speakers reiterated the many forms of inequalities that exist in medicine, let alone in society.

Why is this important?

Why do medical schools need a more diverse student body? Why does the medical profession need more African-American male physicians and a more diverse physician workforce?

Diversity in the student body composition creates a learning environment that fosters cross-cultural understanding and collaboration. A well-managed diverse team will outperform a well-managed homogenous team during the norming and performing stages of group development. A diverse learning environment also allows better training of medical students. A study of medical students from Harvard Medical School (HMS) and the University of California at San Francisco (UCSF) School of Medicine showed that diversity in the student population enhanced medical educational experiences.¹ Many studies have demonstrated that diversity and inclusion in medical school lead to greater cultural competency and empathy among students. In particular, Saha et al. showed white medical students who enrolled in medical schools with greater student body racial and ethnic diversity felt more prepared to care for patients from diverse backgrounds. These students also expressed greater interest in practicing in underserved communities.²

In light of the growing diversity in the patient population, establishing a more diverse physician workforce will allow better care of patients. The Institute of Medicine (IOM) observed that race and ethnicity continue to be the two most significant predictors of the quality of health care.³ This position is upheld by many national and international organizations including the American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC). Although the root of racial and ethnic health inequities is multifaceted, one of the potential solutions would be to increase the number of underrepresented minority (URM) physicians. Marrast et al. reported nonwhite physicians cared for “53.5% of minority and 70.4% of non-English-speaking patients”.⁴ By 2050, minority groups will compose the majority in the United States,⁵ and unless this problem is addressed, the health care gap will only continue to widen.

As emphasized by the speakers, the goal of this discussion is certainly not to insist that every African-American patient should have an African-American doctor, let alone an African-American male doctor. However, if the US patient population is shifting towards greater racial and ethnic diversity, the medical community must strive towards a greater diversity in the physician workforce than what it is now. This is necessary to improve the delivery of care to patients now and in the future. As the former US Surgeon General Regina Benjamin, MD informed us, “Unless the current trend is reversed, our country will see a growing ethnic and racial disconnect between those who receive and those who provide that care.” Likewise, Dr. Crawford acknowledged that diversity and inclusion must be among the core values to transform the current health system.

What are potential solutions?

Dr. Crawford noted that the root of this problem is multifactorial and complex. He cited the work of Thomas et al. who discerned six factors contributing to African-American men’s success in admission to medical school: social support, education, exposure to the field of medicine, group identity, faith, and social responsibility.⁶ Rao and Flores identified several barriers hindering African-American men and women to pursuing a career in medicine, which includes “financial constraints, insufficient exposure to medicine as a career, little encouragement at home and in schools, lack of role models, and negative peer pressure”.⁷

African-American male youth need more role-models like Drs. White and Crawford. As Dr. Alden Landry explained, “You can’t be what you can’t see.” Given the shortage of African-American male physicians, few African-American male children are exposed to medicine or have access to physician role-models growing up. Even fewer go on to pursue a career in medicine after college. This is a downward spiral. Although 1 out of 5 of African-American high school sophomores aspire to become physicians, few actually go on to achieve their dreams.⁸ African-American children need more African-American physicians to lead and to inspire. They need strong mentoring by people who are genuinely interested and invested in their success. As Dr. Landry pointed out, “People who are in leadership positions cannot be gatekeepers or barriers to success.”

Interestingly, not only are the medical school application and admission rates of African-American men low but there are also low reapplication rates. These students have worked tirelessly to fulfill prerequisite courses, complete the Medical College Admissions Test (MCAT), obtain letter of recommendations, etc. Why are these premedical students so discouraged to reapply? Dr. Landry revealed that these students are the “low-hanging fruits” that the community should focus on to increase enrollment of African-American men in medical school.

From an institutional standpoint, African-American male students in primary and secondary schooling should be encouraged to participate in the science, technology, engineering, and math (STEM) fields. Universities must establish premedical programs to reach out to African-American high school and undergraduate students. For example, the Diversity Recruitment and Enrichment for Admission into Medicine (DREAM) program established in 1986 at the University of South Alabama has been very successful at introducing, exposing, and encouraging “disadvantaged and underrepresented students to consider careers in medicine.” Medical schools across the country must pioneer initiatives to increase student body diversity. Diversity is now an essential component of the mission statement at Harvard Medical School:

“To create and nurture a diverse community of the best people committed to leadership in alleviating human suffering caused by disease.”

In addition, admissions committees must be aware of implicit bias that exists in the admissions process and endeavor to change their policies and practice. Capers et al. showed that following administration of the black-white implicit association test (IAT) to measure inherent racial bias at the Ohio State University College of Medicine (OSUCOM), significant implicit white preference was demonstrated among the admissions committee. This awareness led to OSUCOM matriculating its most diverse class in history at that time the following year.⁹

In conclusion, the speakers emphasized that this is not an issue for only African American men or the African American community. It is an issue for everyone. They challenged the audience and healthcare community at-large to work together to advance diversity and inclusion in medical education and the overall community. Although this seems like an insurmountable task, this campaign is led by great leaders in Drs. White and Crawford and many others. As Dr. Crawford advised, “Life isn’t about waiting for the storm to pass. It’s about learning to dance in the rain”.