The second day of the meeting began with opening remarks by Cato T. Laurencin, M.D., Ph.D.,1 and Benjamin S. Carson, Sr., M.D.2 Laurencin opened the meeting by providing a brief recap of the previous day’s discussions and reasserted his call to action to generate ideas and stimulate action to address the shortage of Black men in medicine. Carson provided
1 Laurencin is university professor, Van Dusen Distinguished Professor of Orthopaedic Surgery, and director, The Raymond and Beverly Sackler Center at the University of Connecticut.
2 Carson is secretary of the U.S. Department of Housing and Urban Development.
opening comments reflecting on his experience as a medical student and physician, as well as in his current role.
Benjamin S. Carson, Sr., M.D. Secretary of Housing and Urban Development
Carson began his remarks by reflecting on his own experience in medical school, the academic challenges he faced, the poor advising, and, ultimately, the realization of how he could best succeed. He spoke of his struggle to learn from lectures and later understanding that he learned better by reading. From that experience, Carson took away the importance of mentoring and tailoring learning to students’ needs, including different learning styles. He said,
When you try to fit yourself into someone else’s shoeprint, and you don’t really work very well there, you are not going to do well. The sooner we recognize that for everybody, the better off we are going to be. . . . It is up to us to develop it in the right way and to recognize that each individual learns in a different way, and to put the right kind of support there to help people along.
Carson next spoke about his experiences as a pediatric neurosurgeon and struggling with being able to influence only his patients’ medical outcomes, especially when they faced challenging life circumstances such as difficult home and family environments outside of the hospital. He expanded on the importance of addressing social determinants and opportunities to intervene on these determinants, such as through housing initiatives. Carson then described initiatives he oversees at the U.S. Department of Housing and Urban Development that can help to improve these social circumstances. He discussed how EnVision Centers, for example, can expose children living in low-income neighborhoods to positive examples of the professions they can aspire to, the many potential pathways to achieving career goals, facilitate mentoring, and provide educational opportunities, including exposure to science, technology, engineering, and mathematics (STEM).3 Describing the goals of these centers, he asserted,
It is really about finding ways to get people out of poverty . . . then when they start climbing that ladder of opportunity, not to yank the support
so quickly. . . . You have to let them climb high up on that ladder and let that be an advantage that other people will see.
Carson finished his remarks by emphasizing the need to tap into the potential of Black boys and men, which is lost as they leak out of the educational pipeline. He suggested that this lost potential makes the U.S. workforce less competitive globally, and declared,
We have a responsibility to study history, to understand it, to understand compassion, and to understand that we only have 330 million people in this country, and we have to compete with countries that have four times that many people. We need to develop all of our people, if we are going to be successful in the future.
The first panel of the day discussed accountability in medicine, or, what medical schools can do to address the shortage of Black men in medicine. David Acosta, M.D.,4 launched the panel by putting forward the objective to address what the responsibility is for organizations in addressing the dearth of Black men in medicine, and asked who holds medical schools accountable. He then described different types of accountability, including
- Social accountability, or, the social contract academic health centers have with local and regional communities;
- National accountability for a sufficient and prepared health workforce;
- Compliance accountability for meeting accreditation standards; and
- Internal accountability of each academic health center to its own mission and values.
Finally, Acosta suggested a need to think about the role of other stakeholders not present in the room—for example, local and regional hospitals, hospital associations, pharmaceutical and other industries, and community agencies.
4 Acosta is chief diversity and inclusion officer at the Association of American Medical Colleges.
5 Wilson is president of Wayne State University.
6 Azar is executive dean of the University of Illinois College of Medicine and senior director of Patient-Centered Innovation at Google/Verily Life Sciences.
versity of Illinois College of Medicine and the potential for technological solutions. William Owen, M.D., FACP,7 described how Ross University holds itself accountable for diversity in its student body. Adrienne White-Faines, M.P.A., FACHE,8 offered reflections on the approach to diversity in osteopathic medicine. Veronica Catanese, M.D., M.B.A.,9 described how an accrediting body can guide schools to achieve national standards for diversity and pipeline programs. Acosta led a brief discussion following the presentations.
Wayne State University Pipeline Programs
M. Roy Wilson, M.D. President Wayne State University
Wilson described initiatives at Wayne State University to address the low college attendance and graduation rates among African Americans. Wayne State University first implemented a student network, a pilot program that offered support for 50 African American male students. The program provided a physical space for the students to gather, study together, and support each other. The network also connected students to Black alumni, faculty, staff, and peer mentors and hosts events like social gatherings, networking opportunities, invited speakers, and field trips. Wilson summed up the effort, saying, “We provide the infrastructure and the structure for them to get together and support each other . . . where they come and they study together. They form a learning community.” Wilson reported that the network increased the retention rate between freshman and sophomore years from approximately 60 percent to 95 percent. Based on the success of the program, Wayne State University scaled up the initiative to include all Black male students in the Student African American Brotherhood.10
Despite the success of programs like the network and the Brotherhood at Wayne State University, Wilson acknowledged that undergraduate college students are a relatively successful group and that programs at the undergraduate level are late in the pipeline to intervene. Thus, he cautioned that there remains a need to look at the challenges African American boys face before they get to college. To that end, he raised the
7 Owen is dean and chancellor of the Ross University School of Medicine.
8 White-Faines is chief executive officer of the American Osteopathic Association.
9 Catanese is co-secretary of the Liaison Committee on Medical Education (LCME).
conflation of U.S.- and foreign-born Blacks as a challenge, saying, “When we talk about African American, we typically talk about Black.” He proceeded to describe the need to distinguish U.S.-born Black students from foreign-born Black students, because the educational achievement and health disparities experienced by native-born Blacks are the result of a legacy of disadvantage and discrimination in the United States. By contrast, foreign-born Blacks have educational and sociocultural experiences that may not be comparable, and which in some instances may reflect privilege. He noted that a similar situation is seen among Hispanic students, where the educational and life experiences of U.S.-born Hispanic students differs from those from Spain and South America. Thus, he encouraged disaggregating data within racial and ethnic groups to parse and better understand the differences in educational achievement between racial and ethnic subgroups.
University of Illinois College of Medicine Pipeline Programs and Potential for New Technology
Dimitri T. Azar, M.D., M.B.A. Executive Dean, University of Illinois College of Medicine Senior Director of Patient-Centered Innovation, Google/Verily Life Sciences
Azar began by describing the highly diverse student body at the University of Illinois College of Medicine, of which 25 to 30 percent come from underrepresented minority groups. He attributed this diversity to the school’s faculty, a commitment to diversity, a focus on excellence, and the work of the current and past associate deans for diversity and inclusion. Azar also underscored the need to value education:
We have to work on emphasizing the value of education. I notice when I am talking to those kids who, like me, studied in another country, and their parents came here [from another country], that the value of education is engrained in the mind of the students. Somehow, we are not trying to do [this] to our kids at home, and then we find out that they are interested in other stuff than education. None of them want to go to medical school because it may be tough. But it is important, I think.
Azar then described the strategies the University of Illinois College of Medicine employs to strengthen the medical education pipeline. These include postbaccalaureate programs and summer prematriculation programs prior to entering medical and dental schools as well as managing students’ financial issues and wellness programs to address social and economic issues for current medical students. The university also pro-
motes role modeling and mentorship, not only to support students, but by promoting faculty from underrepresented minority backgrounds to become leaders and role models. Finally, for students who do not match into residency programs, the college pays loans and interest for 1 year after graduation. Azar commented that the school has not made any payments to date and that he hopes it will not have to. Instead, the school’s primary focus is on preparing students to transition to residencies. Thus, this program serves as a financial incentive, or a mechanism for the school to hold itself financially accountable for better preparing its students.
Reflecting on his experience working simultaneously at the University of Illinois and at Google, Azar noted that the underrepresentation of Black men is common to both settings—academia and technology. Thus, he suggested that efforts to attract, train, and retain underrepresented minorities in both sectors will require systems-based and culturally based solutions, as well as strong role modeling. He commented:
We have discussed several examples of our effort to solve the problems of attracting, retaining, and training minority medical students. They are not different from the other solutions that, as you have seen, I have mentioned earlier. But they are systems based, if you are thinking about ways to combat, for example, racism, cultural based, trying to change the social systems and so on, and focusing on this individual encouragement and role modeling. But they are all grassroots efforts. For every student, it requires the work of 10 other people perhaps.
Azar discussed the potential for solutions from new technologies to address the shortage of Black men in medicine—for example, how pipeline programs can use data and new technologies, virtual programs, and analytics. He concluded his presentation by challenging those in attendance:
How can Silicon Valley help to enhance the solutions that have been proposed in this workshop to address the crisis of the growing absence of Black men in medicine and science? How can Silicon Valley attract more Black men to work in data and technology careers, especially health IT [information technology]? And how can they help us improve the pipeline programs and other strategies to address the medical education system, to address cultural norms and values, and to support individual students?
Elements of Accountability for Diversity at the Ross University School of Medicine
William Owen, M.D., FACP Dean and Chancellor Ross University School of Medicine
Owen opened his talk by presenting his “organizational credo” for the Ross University School of Medicine: “Attending medical school is not a privilege, but a right for all eligible students.” He added that the challenge of this credo is how to define eligibility. At Ross, eligibility is operationalized as using holistic selection criteria. He expanded, “We manage eligibility for admissions to our own expectations. . . . We also treat applying to medical school as an opportunity to prepare the applicant to become a matriculate.” Some of these accepted students are underrepresented minorities with substantially lower Medical College Admission Test (MCAT) scores and grade point averages compared with more traditional and “overwhelmingly Caucasian” applicants. To support them, Ross places these students in a “medical education readiness program” that provides preparatory work during the first few semesters of medical school and also “teaches them how to study.” These students are also connected to mentors from a similar background.
Owen identified commitment from leadership as key to increasing diversity at Ross University. He said,
What is most impactful at Ross for accountability and diversity is that it percolates into the organization from the top, from the board of trustees. [Management consultant] Peter Drucker said eloquently and simplistically, “Trees die from the top.” So the mandate for minority success and access at Ross comes from the top, comes from the board of trustees. It comes from the bosses.
Owen described the inclusion of diversity as a key performance indicator for the school. He added that recruitment and retention of underrepresented minorities are monitored over time, and placement rates are benchmarked and discussed at the highest level of the organization, including among trustees. He added that having accountability at the level of leadership removes the responsibility for increasing diversity at the level of admissions committees, saying
This board of trustees [top]-down approach for accountability mitigates the effect of moral licensing: . . . [the] subconscious justification of an unfair decision by a failure to recognize what are biased and self-indulgent choices occurring by admissions committees.
Owen reflected on his experience being held accountable for diversity. He recalled interviewing as a candidate to become dean when a member of the board of trustees asked, “How do you feel about diversity?” He said,
A school that is tolerant of moral licensing would be okay if I gave a lukewarm response about diversity. But such tolerance at Ross is a virtual prediction of leadership failure, much like the rejection of a foreign tissue because it is in our DNA. Ross trustees would not accept an organizational leader who is anything less than a zealot for inclusion. So in hindsight, I think I gave the right answer to the trustee’s surprising question when I said to him, “Oh, I love diversity.” I see it every day when I look in the mirror.
Reflections on Diversity in Osteopathic Medical Schools
Adrienne White-Faines, M.P.A., FACHE Chief Executive Officer American Osteopathic Association
White-Faines started her talk by proposing that U.S. osteopathic medical schools, with their more holistic philosophy on patient care and abolitionist roots, are well positioned to promote and improve upon diversity within the U.S. physician workforce. She reminded the audience that the growth and evolution of osteopathic medical schools now positions D.O. physicians equitably alongside their allopathic counterparts. White-Faines then encouraged the audience that progress occurs when there is “the will” to change. She offered from personal experience:
In the 1970s, there was such a movement to oppose women being in colleges. But Amherst, like many liberal arts schools, made an intentional decision that they want women in their colleges. It is time for our schools to make intentional decisions. It is not something to think about. You just do it. And so it is about being honest. It is about being authentic. It is about all of us calling it out when we see it. It is about being intentional. And it is not so much of how or what do we need to do. The question is, “Do we have the will to do it?”
White-Faines finished by identifying her perspective on critical factors to address the shortage of Black men in medicine. They include intervention through pipeline programs, harnessing partnerships and collaborations, and leveraging financial resources to expand and maximize opportunities. She especially emphasized the importance of building cohorts and using messengers or champions. In particular, she offered African
American medical school alumni as an underused resource, which should be empowered and engaged in the efforts to increase the representation of Black men in medicine.
Diversity in the Learning Environment: Liaison Committee on Medical Education Guidance Principles
Veronica Catanese, M.D., M.B.A. Co-Secretary Liaison Committee on Medical Education
LCME, co-sponsored by the American Association of Medical Colleges and the American Medical Association, is the accrediting body for medical education programs leading to a medical doctorate, M.D., degree in the United States and Canada. Of note, accreditation directly targets medical education programs (and indirectly the physicians they produce), whereas certification targets individuals. The LCME accreditation process involves self-study and peer review to determine whether a medical school meets nationally accepted standards of medical education program quality. LCME standards are “concise statements of the expected level of quality or attainment” and comprise elements, or “components that collectively constitute a standard; operationally, elements identify the variables that must be examined to determine a medical education program’s compliance with a particular standard.” The LCME evaluates each element as “satisfactory,” “satisfactory with a need for monitoring,” or “unsatisfactory” to inform whether it determines a medical school to be in “compliance,” “compliance with monitoring,” or “noncompliant” with the each standard.
With regard to the LCME approach to diversity, Catanese focused on the LCME’s Standard 3 on academic and learning environments and, specifically, on Element 3.3 on diversity and pipeline programs and partnerships. See Box 7-1 for the LCME Standard 3 and Element 3.3 and Box 7-2 for the criteria by which survey teams assess whether Element 3.3 is satisfactory or not.11 In summary, Catanese described key elements for schools that meet LCME Standard 3 and Element 3.3, including having mission-appropriate policies and practices to recruit and retain diverse students, faculty, and staff; pipelines and partnerships directed to and focused on identified diversity groups; and evaluation and monitoring processes to assess the effectiveness and progress of those activities. She added that, although her presentation focused on the standard and element directly
pertaining to diversity and pipeline programs, diversity also plays a role in other elements of LCME’s accreditation—for example, the elements pertaining to professionalism and curricula on cultural competence and health care disparities. She described the intent of LCME to identify the following:
Diversity practices, policies, and processes [embedded] in an environment that allows them not only to have the desired [diversity] outcomes, but to really have a positive effect on the academic and learning environment of the institution as a whole.
To conclude, Catanese emphasized that LCME seeks to give guidance through its standards and elements, and not to be prescriptive. She said, LCME expects “an institution to really identify its mission-appropriate diversity goals and to direct its resources and attention to achieving them specifically.”
Victoria Mallett, M.D., M.M.M.,12 inquired about the feasibility of achieving the LCME standards when Blacks are underrepresented at every level of academia. Relatedly, Valerie Montgomery Rice, M.D.,13 asked whether schools are currently meeting those standards. In response, Wilson described his experience with LCME criteria at Wayne State University School of Medicine. He noted that the M.D. program did not meet LCME criteria in 2014 and it required changing the entire leadership of the medical school to meet the LCME accreditation standard in 2017. He
12 Mallett is dean of the School of Medicine at Meharry Medical College.
13 Montgomery Rice is president and dean of the Morehouse School of Medicine.
added that, within 2 years, Wayne State University School of Medicine went from having 7 underrepresented minorities in the incoming class to having 61. Acosta suggested that medical schools should think about how they can leverage LCME Element 3.3 to enhance their diversity. He pointed out that, according to the standard, schools are asked to define diversity for their institution and identify which population group they will be targeting. Acosta suggested that this would be challenging for those medical schools located in states where the White population is predominant. He challenged these institutions, arguing,
Many of our schools are land grant public institutions, which means they are not only obligated to their social contract with their local and regional communities and state, but also to the nation itself.
Acosta acknowledged that LCME can only offer guidance, and how it guides medical schools is important. He noted that when LCME cited the medical school he was working at as “satisfactory with a need for monitoring” on Element 3.3, this gave him the leverage to make diversity a priority among leadership. Catanese commented about the importance of thinking broadly about pipelines and the total academic environment, which includes not only students, but also faculty, once these students enter an academic career. Acosta added that this academic environment includes not only students and faculty, but also staff. Finally, White-Faines proposed the need to think longitudinally over time and echoed Acosta’s call to think of failing to achieve LCME elements not as a fault, but an opportunity. She said,
Yesterday’s standards may not apply today. So I think everyone should walk away feeling like they have a right, even though [LCME] says everybody can appeal to the standards review, but really use that leverage to say, here is an opportunity for us. Together, we can work on both sides of the process to bring in and think about what does the faculty of tomorrow look like, and how do we need to redefine it as opposed to you won’t let me. Let’s make it work for us.
George Hill, Ph.D.,14 endorsed funding and dedicating resources to increasing mentoring networks and developing new ideas for mentoring. He also inquired about whether mentors in programs discussed were necessarily Black. Azar said, regarding the importance of the quality of mentors, “There were many mentors who just thought it was a good idea to be a mentor. And so they are lousy mentors. And just because their skin color matches the color of the person they are mentoring is not sufficient.” To address this challenge, he developed a program called “Mentor the Mentor” to guide interested mentors in how best to do so and to ensure that well-intentioned mentors do not inadvertently harm their mentees.
Laurencin reflected on what he took away from the panel. First, he described the need to replicate successful pipeline programs, such as the one Wilson described at Wayne State University. Second, he elaborated on White-Faines’s comment about the need to make intentional decisions to address the dearth of Black men in medicine. Drawing a parallel to the increased awareness about sexual harassment and the #metoo movement, he remarked,
14 Hill is Levi Watkins Jr., M.D. professor emeritus in medical education, distinguished professor of pathology, medicine, and immunology emeritus, and past vice chancellor for equity, diversity, and inclusion, and chief diversity officer at Vanderbilt University.
The fact is, 20 years ago, sexual harassment was around. But it wasn’t on the front page of The New York Times like it is today. And so one of the things that happened was there was a cacophony of discussion that started happening around this. People said this is not acceptable. We are going to call it what it is, and changes are going to occur. We have to have that same concept of having that same cacophony of thought and discussion to bring this to the fore to make a big difference.
Third, he reacted to Azar’s comments on the potential of new technologies and emphasized the need to harness technology and to use it to identify potential students.
In closing, Owen asked Wilson whether there is a need to groom leaders. Wilson responded by describing a program that changes the narrative equating diversity to underperforming students to students who are exceptionally well prepared and already poised to be leaders. He described responding negatively to a proposal that addressed lack of diversity with postbaccalaureate programs, and feeling bothered by the traditional narrative of students in postbaccalaureate programs as being behind or deficient in some way, and having the stigma of needing extra help. In response, he created a program called Med-Direct,15 which offers admission to the undergraduate school and the medical school at Wayne State University for high-performing high school students. The program covers tuition and housing for undergraduate students and tuition for medical students for a cohort of 10 students annually and is intended to lead to an M.D. or a M.D./Ph.D. degree program also at Wayne State University. The program also provides opportunities for research, MCAT and Graduate Record Examinations preparation, and summer enrichment courses including leadership development, as well as seminars, workshops, and clinical training in the School of Medicine during the academic year. In closing, he reiterated the idea that this program challenges the perception that pipeline programs for students from diverse backgrounds are postbaccalaureate programs for students struggling to get into medical schools. Instead, it offers the narrative that they are for high performing students who are well positioned to become future physician leaders.
15 For more information on Wayne Med-Direct, see https://provost.wayne.edu/workforce-diversity/wayne-med-direct (accessed March 9, 2018).
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