The pervasive oppression of underrepresented minority groups in the United States through inferior education, housing, health care, employment opportunities, and uneven application of criminal injustice has been well established.^1,2,3,4,5,6 In the medical literature, disparities in healthcare outcomes have also been widely documented in minority communities in the United States. These differences are often attributed to genetics,⁷ socioeconomic factors,⁵ and provider implicit bias.⁶ The larger societal conditions in which communities of color navigate are discussed less often. In spite of these circumstances, black and African-American applications to medical school have increased by nearly 1500 between 2002 and 2015.⁸ Unfortunately, the number of acceptances only increased by 215.⁸ Although African-Americans represent approximately 13% of the population, they only compose 4% of the physician
workforce.⁹ Some data suggest that white patients who are able to choose their own doctor are more likely to choose a race concordant provider. Satisfaction was rated higher across all racial groups when the patient and physician were of the same race.¹⁰ Therefore, increasing the numbers of underrepresented minorities entering medical fields is a major priority for an increasingly diverse society.

There are significant challenges to meeting this objective. It is well documented that large segments of the population have been historically underrepresented in medicine and in science and engineering fields. As the National Science Foundation report summarizes,

Byars-Winston et al. report 2014 National Center for Education Statistics data that show that while a majority of underrepresented students enter college with plans to major in a STEM discipline, only about 17% earn bachelor’s degrees in those areas.¹² They conclude “underrepresentation, instead, appears to be a problem of translating the abilities and interests of students from racial/ethnic groups historically underrepresented in the sciences into persistence.”² This disparity is a particularly concerning issue in medicine, as there is good evidence that this may affect patients’ health.¹³

Efforts to increase minority enrollment in medical school that focuses exclusively on undergraduate students are less likely to affect the kind of changes that will be necessary to change the medical workforce significantly. This chapter will argue that increasing medical school enrollment will only be achieved through significant societal change that works to eliminate a racially based academic achievement gap in early education. Thus, the content of this chapter focuses upon improving medical school admission for underrepresented minorities argues for broader societal change.

In 2018 to 2019, women made up 51.6% of matriculants to US medical schools.¹⁴ However, several racial and ethnic groups have not experienced similar gains in representation. African-Americans, Native Americans, and Hispanic students continue to be underrepresented in US medical schools.¹⁵ Morgan et al. cite several studies that show that students from groups underrepresented in medicine (URM) and from underprepared populations abandon premedical preparation at rates much higher than majority and privileged students. There is also evidence that some groups face challenges in the medical school admissions process.¹⁶

While most agree that medical students should be admitted based on “merit,” there is some disagreement as to what this term means. In the United States, the predominant way of quantifying merit is the Medical College Admissions Test (MCAT) and undergraduate grade point average (GPA). These metrics do quantify
academic achievement but do not measure fitness for a medical career. Although subjective, there is some suggestion that exclusive admission of students in the top end of this distribution can result in admission of students poorly suited for a medical career.^17,18 Students in underrepresented groups are often characterized as not having the essential skills to succeed in medical school as quantified by the aforementioned metrics.¹⁹ For example, it is often pointed out that black and African-American applicants have significantly lower MCAT scores than other ethnic groups.²⁰ This type of summary assessment of the data misses significant nuances. When carefully examined, the mean MCAT score for all students is 506 ± SD 9.3. The African-American mean is 497 ± SD 9.1 and white 507 ± SD 8.2. The standard deviations suggest significant heterogeneity within each racial group.

Although there is discussion regarding high-stakes testing such as the MCAT, data suggest that the academic achievement gap between white and underrepresented minority groups begins in childhood.^1,21 The National Assessment of Educational Progress measures performance of students on mathematics and reading tests at the 4th, 8th, and 12th grade levels. This assessment found a significant but stable gap between black and Hispanic scores compared with those of white students in years 2013 to 2015. A socioeconomic component was also notable as children who received free or reduced-cost lunches performed worse than children who did not receive support for lunch.²² Over the past 20 years, average scores have improved for all groups. However, the gap between the average scores of underrepresented groups and those of white students has not changed significantly over this period of time.^23,24

As students consider preparation for advanced studies in science, further gaps emerge as white and Asian students tend to enroll in “rigorous” curricula (4 credits in math [1 credit precalculus or higher], 3 credits in science [with biology, chemistry, physics, all being represented], 3 credits in English, 3 credits in social studies, and 3 credits in foreign language) more often than other racial groups.²¹ At the lowest rung of entry into the workforce, African-Americans graduate high school at much lower rates than their white peers.²⁵ Thus, it is no surprise that underrepresented minority groups abandon premedical preparation at much higher rates than other groups.¹⁶

There are a number of explanatory models for these performance differences. While discrimination has been invoked, it is unlikely to be the only explanatory factor.^26,27,28 One group of authors found that students from underrepresented groups are less likely to have higher social capital, leading to underachievement. This effect could be accentuated by ethnic and religious self-segregation.²⁹ “Stereotype threat” has also been proposed as a mechanism. This phenomenon suggests that actual poor performance is mediated by a societal expectation of poor performance.^30,31 Beyond ethnicity, Grace finds that subjective social status leads premedical students who perceive themselves to have lower social status to have more doubts about their fitness for medical school.^32,33