The History of Medical Education: a Commentary on Race

J Osteopath Med 2021; 121(2): 163–170

Medical Education Commentary

Yasmeen Daher, OMS IV, Evan T. Austin, MS IV, Bryce T. Munter, MS IV, Lauren Murphy, MS I and Kendra Gray*, DO The history of medical education: a commentary on race https://doi.org/10.1515/jom-2020-0212 The notion that one race may be better than another and Received August 10, 2020; accepted November 24, 2020; therefore more worthy of guidance, resources, formal ed- published online February 12, 2021 ucation, prosperity, and even quality of life is a social and moral toxin constructed from within the trenches of White Abstract: The institution of medicine was built on a supremacy. This oppressive and diseased way of thinking foundation of racism and segregation, the consequences has resulted in the chronic asphyxiation of capable and of which still permeate the experiences of Black physi- deserving individuals’ dreams, livelihoods, careers, and cians and patients. To predict the future direction of time. It is no question that the United States was built upon medical inclusivity, we must first understand the history of medicine as it pertains to race, diversity, and equity. In these lethal ideas. Medicine and medical education are no this Commentary, we review material from publicly different, intentionally built from a legacy of segregation available books, articles, and media outlets in a variety that haunts our society in both straightforward and insid- of areas, including undergraduate medical education ious ways. This dark history of racial exclusivity set up and professional medical societies, where we found an Black medical students and physicians to be cast out from abundance of policies and practices that created a foun- every facet of premedical education, medical education, dation of systemic racism in medical training that carried and professional work. through the career paths of Black physicians. The objec- There is a significant body of work in medical literature tive of this Commentary is to present the history of race in and history books recognizing the racist policies and the medical education system and medical society mem- practices that prevented Black students from obtaining an bership, acknowledge the present state of both, and offer undergraduate medical education. Once students were concrete solutions to increase diversity in our medical able to attend medical school, continued racist policies community. prevented them from obtaining society memberships critical to their success as physicians. In a study exploring Keywords: Black physicians; history; implicit association minority perception of medical school admissions, testing; medical education; minorities; race; segregation; perceived barriers for admission to medical school societies. included information on admissions, guidance and social support, financial and academic factors, and persistence.1 There has also historically been a lack of under- representated minority (URM) representation in medical 2 *Corresponding author: Kendra Gray, DO, MS, A.T. Still University school faculty positions, which may have contributed to School of Osteopathic Medicine in Arizona, Mesa, AZ, USA; University the lack of encouragement for Black students to obtain a of Arizona College of Medicine, Phoenix, AZ, USA; and the Department medical education. In addition, in a 1987 study by Bullock of Obstetrics and Gynecology, Banner University Medical Center- et al.,3 30 of 31 Black medical student interviewees Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006-2612, USA, divulged having racist experiences during their medical E-mail: [email protected] 4 Student Doctor Yasmeen Daher, OMS IV, A.T. Still University School of school education. Notably, a study exploring racial dis- Osteopathic Medicine in Arizona, Mesa, AZ, USA parities in the Alpha Omega Alpha Honor Society Student Doctor Evan T. Austin, MS IV and Student Doctor Bryce T. (a membership society open to medical students, residents, Munter, MS IV, The University of Arizona College of Medicine, Phoenix, fellows, faculty members, clinicians, and other leaders) AZ, USA demonstrated that Black medical students were less likely Lauren Murphy, MS I, The University of Arizona College of Medicine, Phoenix, AZ, USA; The Department of Obstetrics and Gynecology, to be members of Alpha Omega Alpha than their White Banner University Medical Center-Phoenix, Phoenix, AZ, USA counterparts, reﬂecting possible bias in selection. Lack of

membership in this and similar professional societies never be wholly left to Negro physicians.6” Baker et al.,8 could impact career opportunities for any physician. in an AMA-convened panel, correctly interpreted that Research about the history racial disparity in educa- Flexner’s population-based approach did not separate tion and society membership is crucial to the field of schools that educated Black physicians when he calcu- medicine and medical education, because we must better lated what would be “needed” to care for Black patients 9 understand the past in order to combat these inequalities in Flexner based his opinion on the worthiness of candidates the future. To predict the future direction of medicine with to enter medical schools on multiple criteria, including regard to inclusivity, we must first understand the history (but not limited to) prior postsecondary education of medicine as it pertains to race, diversity, and equity. For (favoring 2 or more years of college vs. a high school this Commentary, we searched various sources for previ- certificate or equivalency test) and standardization of ous publications documenting racism in medicine; these entrance exams for medical schools; both criteria may sources included books, articles, and media outlets. We have been more prohibitive to Black students based synthesized the information we found to present this on other discriminatory practices at that time.8 Baker8 Commentary on the history of race in the medical educa- reported that if Flexner had standardized these population system and medical society membership. In it, we tion criteria, the results would have shown the need for describe the present state of both and offer concrete solu- more medical school openings to train the Black physi- tions to increase diversity in the medical community. cians required by more than 9 million Black Americans in the country.9 Flexner acknowledged that Meharry Medical College Undergraduate medical education and Howard University College of Medicine were, “of course, unequal to the need and the opportunity”6 in admissions educating Black physicians, but neither the report nor professional medical societies like the American Medical Before 1865, American medical schools in the South were Association (AMA) offered any plan or framework for how completely closed to Black students, while a select number to address this discrepancy.9, 10 At the turn of the 20th of northern schools allowed Black students admission.4 century, charity hospitals and those established by the Seven allopathic medical schools were formed between Freedman’s Bureau were often the only access to medical 1868 and 1904 specifically to educate Black students;4 care for Black patients, creating extreme inequalities in this was in alignment with the U.S. Supreme Court’s deci- access to and quality of health care.11, 12 In a review of the sion in Plessy v Ferguson in 1896, which upheld the con- Flexner report 100 years after its publication, Steinecke stitutionality of segregation and provided the legal and Terrell13 described the 2-page chapter of the Flexner foundation for two Americas (one Black and one White).5 report titled, “The Medical Education of the Negro,” saying All but two of these schools (Meharry Medical College and that Flexner “promoted the limited education of the Afri- Howard University College of Medicine) were closed by can American doctor as a service to ‘his own race,’ but also 1923, with the majority of schools closed within five years of for the larger purpose of protecting Whites from the African publication of the Flexner Report,6 a periodical of contro- American population’s potential to spread disease.” Black versial historical merit7 in which Abraham Flexner physicians remained the primary health care providers for assessed the strength of all U.S. medical schools based on Black patients,14 with their numbers decreasing after the their admission standards, faculty, and available learning Flexner report as a result of his ideology; it is estimated that experiences.6 Flexner’s goal was to eliminate the “over- as few as 25 Black physicians were the primary providers production of uneducated and ill-trained medical practi- for Black patients in the entire state of Mississippi prior to tioners,” highlighting that medical education had become the civil rights movement.13, 14 its own for-profit industry lacking quality control As Black students and physicians fought for their space measures to protect the public from inept graduates.6 in allopathic medicine, the world of osteopathic medicine Flexner’s unequal assessment standards led to closures was beginning to take form. In 1892, A.T. Still began that disproportionately impacted Black schools. He educating physicians in Kirksville, Missouri.15 Despite being evaluated the “need” for medical schools based on pop- an active abolitionist outspoken against slavery and a sup- ulation, calculating how many physicians he felt would porter of women pursuing education in medicine,15, 16 Still be needed to serve a given community. Flexner reported could not invite Black students to attend his osteopathic that “the practice of the Negro doctor will be limited to his medical school because admission required an official high own race,” but “the medical care of the Negro race will school degree.17 At the time, Kirksville only offered Black Daher et al.: Race in medical education 165

students a K–8 education. If they wanted a high school ed- physicians formed the National Medical Association.19 ucation, Black students had to travel over 30 miles each day Although neither the NMA nor AMA explicitly excluded to a different town that allowed them access to an education members based on race, organized medicine remained past the eighth grade.18 largely segregated, with the AMA consisting of mostly White members and the NMA consisting of mostly Black members.20 Many members of the NMA went on to Professional medical societies participate in the Civil Rights Movement.24 For example, Dr. William Montague Cobb, editor of the Journal of the Black physicians continued to face barriers after National Medical Association ( JNMA) from 1949 to 197725 completing undergraduate medical education programs, and president of the NMA from 1964 to 1965,26 published including injustices perpetrated by professional medical the Integration Battlefront column in JNMA,27 which societies. As Baker et al.19 described in their analysis of covered civil rights issues in the realm of medicine. African American Physicians and Organized Medicine, Meanwhile, as Baker et al. described, “The AMA, in contrast, was widely seen as uninterested in, or even Medical societies were the crucibles in which the organized pro- obstructing, the civil rights agenda.20” Furthermore, the fession of medicine was formed. Within them, physicians met and AMA did not condemn racist policies until 2008.28 developed relationships with professional colleagues and provided a forum to present papers and learn the latest techniques and The barriers faced by Black physicians in academia treatments. After 1900, hospital admitting privileges became and society membership, coupled with the fact that they closely linked to medical society membership, as did relationships were the primary healthcare providers for Black patients with state licensing and regulatory bodies. By the 20th century, living in the South during the civil rights era,13, 14 created a exclusion from these societies often meant professional isolation, system in which Black communities experienced severely erosion of professional skills, and limitations on sources of income.20 limited access to patient care. The catastrophic effects of the Flexner Report,7 discriminatory practices by the AMA, Many medical societies either actively refused to admit and laws that kept medical schools from educating Black Black physicians or allowed for passive exclusion through physicians speak to the deeply-rooted oppression in our failure to adopt nondiscrimination policies. Historically, country’s medical history. It clearly shows that a founda- any medical school or local medical society could send a tion was laid in this country to carefully and systematically delegation the AMA’s national convention, which was the exclude Black men and women from positions of power, primary route to AMA membership. Therefore, member- whether in the form of an easily accessible high school ship in a local medical society was necessary in order to education, admission to medical school, or membership to acquire an AMA membership, yet many of these societies a society arguably needed for successful medical practice. blatantly ostracized individuals on the basis of race.19–21 For example, three Black licensed physicians – Alexander Thomas Augusta, Charles Burleigh Purvis, and Alpheus W. Acknowledging the present state to Tucker – were denied entry into the Medical Society of the District of Columbia “solely on account of color”.22 Thus, improve our future exclusion from the Medical Society of the District of Columbia also meant exclusion from the AMA. To bypass Major systemic changes within medical education and these racist policies and obtain AMA membership, the training are necessary to actively combat the history of National Medical Society (NMS) was formed in 1870, and racism and bias in medical schools and residencies, the the group applied for tributary status in the same year; breadth of which cannot possibly be addressed in this the NMS was racially integrated at its onset.20, 22 However, Commentary. As Welton et al.29 eloquently described, the NMS received numerous ethics complaints at the 1870 “Educational institutions are called such for a reason, AMA meeting and many voters urged exclusion from the because their unspoken norms and social agreements have AMA.20 This movement was put to a vote, which passed 114 a long history that has been ‘instituted’ or developed over to 82;23 the 36 delegates of the Medical Society of the Dis- time, and thus become deeply entrenched into the fabric of trict of Columbia were included in that vote.20, 23 how they operate.” While this serves the purpose of In response to their exclusion from AMA-affiliated allowing for more focus on the education itself over local medical societies, Black physicians founded many of maintaining order, it all too often creates a situation in their own local societies, but they still lacked a national which “…an educational institution’s public commitment organization. This changed in 1895, when Black to racial justice in the end is simply rhetoric or ‘just talk’ 166 Daher et al.: Race in medical education

because any real action would cause the institution to created the most diverse class in OSUCOM’s history for the break away from the ease of norms it has long benefited admissions cycle immediately after the study was con- from.30” Welton et al. 29 also provided a conceptual ducted.33 This is a notable achievement given that in 2019, framework for antiracist change. In that model, five com- Black medical students made up only 7.4% of all student ponents of change were identified: context and conditions physicians.34 focus of change, scale and degree, leadership, and However, it is not enough to simply admit more continuous improvement cycle. Guidelines were given racially diverse students into our country’s medical for how to address each of those on both an individual schools, as inequities continue to exist once students have and systemic level. Some examples of actions to be matriculated. There is a growing body of evidence pointing taken include conducting departmental climate surveys, to the disproportionate prevalence and harms of micro- examining admissions data over the past 10 years, aggressions toward racial/ethnic minorities in medical implementing implicit bias professional development, school and clinical training.32, 35, 36 These subtle state- providing professional development for diverse leaders, ments or behaviors that unconsciously communicate and asking key questions in the admissions process such as denigrating messages negatively affect learning, academic identifying where recruitment is taking place.30 While performance, and overall well-being.32 A recent study much of this change can be broadly applied to all types of examining stress coping and resiliency among Black men postsecondary education, there are key strategies that in medical school reported that perceived academic in- medical schools and societies can specifically implement equities such as lower academic expectations, less access to improve the current inequalities in medical school ad- to academic resources, and social isolation caused tension missions, racially biased medical education, and society for Black medical students, creating an environment in membership. which the general stress of medical school was com- One possible starting point for change is the adoption pounded by additional race-related stress.37 This was of implicit association testing (IAT) at medical schools. IAT demonstrated in a 2007 report from the AAMC 35 investi- measures the strength of associations between concepts gating attrition rates in medical schools, in which re- (e.g., White people, Black people) and evaluations (e.g., searches found that Black students had an attrition rate of good, bad) or stereotypes (e.g., lazy, hard-working).31 approximately 7% compared to White students with an This form of testing serves to measure attitudes and beliefs attrition rate of less than 1%.34 Furthermore, only about that people may be unwilling or unable to report. While 60% of Black students graduate by year four of medical explicitly racist attitudes, beliefs, or stereotypes still school, compared with approximately 90% of White stu- permeate society, the fact that these are deliberate and dents.34 To address these microaggressions and other reported presumably make them much easier to address harmful racist behavior, we suggest that schools imple- and remedy. Implicit attitudes, beliefs, or stereotypes, on ment ways to report these incidences that is supported by the other hand, are relatively inaccessible to conscious accountability measures. For example, the Ohio University awareness or control, theoretically making them much Heritage College of Osteopathic Medicine has a reporting harder to identify or address, even for the very person tool accessible to all students for instances of bias or hate- holding such attitudes, beliefs, or stereotypes.29 When motivated incidents witnessed or experienced in the aca- not accounted for, negative outcomes from these associa- demic or clinical setting.38 Once reported, a triage team tions (such as choosing to deny medical school entry to a assesses and investigates the report to address or imple- qualified Black applicant) can be just as, if not more, ment appropriate accountability measures. Similarly, the harmful than the outcomes that come along with racist Georgetown School of Medicine has a Medical Student Life explicit associations. In a research study of implicit Advisory Committee which provides multiple avenues to bias at the Ohio State University College of Medicine report racist or discriminatory behavior, which is then (OSUCOM),32 the admissions committee took a Black- reviewed by a subcommittee composed of at least two White implicit association test (IAT) before the 2012–2013 faculty members and one student to review and investigate admissions cycle. All groups (men and women, students claims.39 and faculty) displayed significant levels of implicit Fortunately, the IAT has been shown to be useful not White preference.33 Of admissions faculty surveyed, 48% only for increasing racial diversity in medical school ad- were conscious of their IAT results when assessing missions, but also for decreasing racial bias in medical candidates for the next cycle, and 21% reported knowledge students during their education. In a study of 3,547 stu- that their IAT results affected their admission decisions. dents from 49 U.S. medical schools, participants were This led to a 26% increase in URM matriculation and asked to report their experiences with the amount and Daher et al.: Race in medical education 167

favorability of interracial contact during school, as well as solution for medical schools. Such work has already been formal and informal curricula related to race, health care, started by Krishnan et al.,45 who noted inadequate pre- and cultural competence.40 Questionnaires were adminis- sentation of race and culture in the virtual case-based tered during the first and last semesters of medical school courses produced by the nonprofit organization Aquifer to determine whether students changed their implicit racial (formerly MedU), which is currently used by over 95% of attitudes after taking the Black-White IAT.40 Completion U.S. medical schools. In their work, they identified six of the Black-White IAT during medical school was a themes describing common mistakes/pitfalls in the pre- statistically significant predictor of decreased implicit sentation of race and culture in Aquifer cases, then created racial bias. Medical school experiences were also inde- a race and culture guide for systematic case revision that pendently associated with change in student implicit racial works to address each of these themes. As a result of attitudes.40 this work, Aquifer has started to integrate this guide into While the IAT serves as a valuable starting point for their editorial workflow and begun a structural review of change, it is insufficient alone. We also propose that their core cases in pediatrics, internal medicine, family medical schools continue to modify their curricula to medicine, and geriatrics.46 We suggest that medical further emphasize race and racism. For example, an schools take a similar approach to their curriculum and investigation of imagery used in the preclinical curriculum encourage potential use of this guide,45 or at least the at the University of Washington School of Medicine noted principles in it, to revise or modify their current curriculum. that of the 5,230 images that could be coded by race/ Furthermore, we encourage medical schools and so- ethnicity, only 1,130 (21.6%) involved people of color.41 It cieties to acknowledge the role they have played in pro- is easy to foresee how such unequal representation could moting inequity throughout history and fight to correct it further contribute to healthcare inequities and biases, both with actionable, achievable goals. While apologies cannot overt and implicit. Fortunately, some progress has been right prior wrongdoings, they can act as an important first made on this front. When second year medical student step. In 2008, the AMA formally apologized for its long Malone Mukwende of St. George’s University of London history of excluding Black physicians, and in 2019, its first noted the lack of education on clinical findings on darker chief health equity officer was hired to establish the AMA skin, he collaborated with a senior lecturer to create Mind Center for Health Equity to focus on embedding health the Gap – A Handbook of Clinical Signs in Black and Brown equity into the organization.28 More recently, the AMA Skin.42 This handbook was previously only available to St. Board of Trustees pledged action against racism and George’s University students, but now is publicly available police brutality.43 The American Osteopathic Association online.43 (AOA) passed a resolution in 2017 encouraging an increase Curricular programs focused on addressing race and in URM graduates and faculty by 2020.47 The American racism have already been implemented by some medical Association of Colleges of Osteopathic Medicine (AACOM) schools across the country. For example, the University of recently published a statement on racism and injustice in Minnesota Medical School convened a 12-month curricu- which they called for the need to “actively seek out racism– lum informed by Public Health Critical Race Praxis meth- overt and implicit– so that we can change our practices, odology, with an aim to better help students from reshape our focus, and ultimately stamp it out by creating marginalized groups and privileged groups discuss the new ways of doing business.45” These statements and concepts of racism.44 Columbia University School of pledges are important steps, yet we encourage the AMA, Medicine created a racially diverse student-faculty task AAMC, and AACOM to be more concrete in their goals. force dedicated to promoting a bias-free curriculum, which One achievable goal to increase diversity in medicine has led to the development of guidelines for faculty to is to increase the percentage of Black, indigenous, and promote increased awareness of bias in their curricula as people of color (BIPOC) in leadership roles to support Black well as formation of an online portal for Columbia stu- medical students through their academic careers.48 dents, staff, and faculty to anonymously submit narratives Medical schools and professional societies can achieve this of troubling and positive experiences regarding inclusivity by setting concrete metrics and by frequently, trans- and bias.43 parently reporting their progress toward those goals. The While implementing new curricula that address race first Black woman Dean of an osteopathic medical school, and racism is ideal, we acknowledge that this process has Dr. Barbra Ross-Lee, became the Dean of Ohio University’s the potential to be burdensome in time, resources, and Heritage College of Osteopathic Medicine in 1993.49 In an finances. As a result, we also recommend modifying interview with AACOM,50 Dr. Ross-Lee highlighted the existing curricula, which may be timelier and more feasible need for accessible opportunity to increase minority 168 Daher et al.: Race in medical education

students in medicine. This requires creating equal oppor- practicing physicians, they should have the ability to join tunity for all students, starting as early as elementary professional societies that have appropriately acknowl- school. Exposing children at a young age to opportunities edged the past and are actively seeking to create a more in science, technology, engineering, and mathematics, as racially-inclusive future. well as medicine, opens their eyes to the possibilities available to them. When discussing the subject, Dr. Ross- Lee stated, “The goal of diversity should be to provide Conclusion opportunities to people who otherwise would not gain access.49” The AOA and AACOM do not currently list the Medicine and medical education in the United States were number of BIPOC serving as Deans of Osteopathic medical constructed on a foundation of racial segregation and schools on their websites; we would encourage this subtle careful discrimination, the effects of which continue to but important opportunity for transparency. plague this country. Insidious early limits on the practice Another achievable goal is to provide financial support and scope of Black physicians in America created an for URM students. AACOM has made progress in this environment of real consequences for both physicians and endeavor; they provide two scholarships per year to URM the predominantly segregated communities they served. students.51 While this is a step in the right direction, it is Acknowledging and addressing racism through measures quantitatively insufficient to increase matriculation of curriculum reform, formal bias analysis, and equitable Black medical students. By increasing the number of admissions and scholarship programs are some of the ways scholarships available to Black students, we have to as- the whole body of medical education can work collabora- sume that opportunity would be increased. tively to address injustice and the racial divide. We Currently, some medical schools are working to change encourage osteopathic and allopathic medical schools to the barriers and biases – both racist and otherwise – that heed these suggestions, and to capitalize on the successes have historically kept some students out. For example, A.T. of the example programs included here. We also encourage Still University (ATSU) offers multiple programs to support medical programs to conduct more research into the his- their mission of creating a culturally-rich community that tory of graduate medical education and other racist prac- embraces all forms of difference. One of those programs is tices that may have affected Black physicians’ careers called “Dreamline Pathways,” which is a community-based outside of medical society membership. program that works with K-12 students provide them with We are collectively responsible for continuing to exposure and access to the healthcare professions and the actively lobby for equality and systematic change, not only many programs that ATSU offers.50 Another such program is in medical education but in all aspects of the healthcare called “Prep for Success Intensive,” in which premedical system. In both our higher education system and our students prepare for the MCAT and learn test-taking strate- medical community, there is still much work to be done. gies.50 Beyond that, ATSU has multiple committees dedi- We must invest in ourselves, in our students, and in the cated to diversity and inclusion efforts in order to keep the future of medicine by prioritizing and celebrating inclu- conversation going on these important and ever-changing sivity, diversity, and racial equality. This way of thinking topics in medical education. ATSU also offers a program and living is created from intentional change-seeking. called the Graduate Health Professions Scholarship Pro- There is no better time than now to act and commit, seeking gram, which offers scholarships specifically for historically deliberate, structural, and revolutionary change making. URM groups in medicine.50 Overall, the inclusion of BIPOC in leadership positions Research funding: None reported. and implementation of interventions such as the IAT to Author contributions: All authors provided substantial help medical school admissions committees reflect on their contributions to conception and design, acquisition of own biases can help decrease racial disparities in medical data, or analysis and interpretation of data; all authors education by encouraging institutions to admit more drafted the article or revised it critically for important racially diverse classes to their schools. Financial support intellectual content; all authors gave final approval of the and other resources would increase the matriculation of version of the article to be published; and all authors agree Black medical students. Once these students are admitted, to be accountable for all aspects of the work in ensuring medical schools have an obligation to continue reflecting that questions related to the accuracy or integrity of any on these biases and ensure their curriculum addresses part of the work are appropriately investigated and racism by teaching clinical medicine in a racially-unbiased resolved. way. Finally, once students graduate and become Competing interests: Authors state no conflict of interest. Daher et al.: Race in medical education 169

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