A change to the pathway: The Impact of the Supreme Court of the United States affirmative action decision on clinical pharmacy and a call to action for pharmacists

Overview of the Supreme Court of the United States (SCOTUS) Affirmative Action Ruling

On June 29, 2023, the Supreme Court of the United States (SCOTUS) banned using race-conscious admissions in higher education, ending 45 years of precedent.¹ On the heels of the civil rights movement, the initial goal of affirmative action was one of equity whereby historically disadvantaged groups, specifically racially/ethnically minoritized individuals (REM; groups other than non-Hispanic White individuals) and women, were legally protected from discrimination and given increased access to education and employment.^1,2

From its inception, however, there were challenges to affirmative action--particularly on how race was factored into college admission considerations and the perceived preferential treatment of REM applicants¹. In 1978, the Regents of the University of California v. Bakke was noted as a landmark decision by the SCOTUS, as it upheld affirmative action and allowed race to be one of several factors in college admission.^1,2 The use of affirmative action was also supported in the 2003 Grutter v. Bollinger case, where the court ruled that it was not unconstitutional to consider race as a factor (among others) in assembling a diverse student body.^1,2 While the rulings in these cases continued to allow for race to be considered in admissions policies in some capacity, each decision was followed by a notable shift in the consideration and acknowledgment of the confluence of racism and systemic barriers to the quality of education, opportunities, and college readiness of REM students.¹

Perhaps, the most powerful blow of this 2023 SCOTUS decision to curb affirmative action-- in response to racial discrimination lawsuits against Harvard University and the University of North Carolina--is that it comes following the regression of many diversity, equity, and inclusion (DEI) efforts nationwide.^1,2 Ultimately, without intentional intervention, the pathway for REM individuals into healthcare disciplines--including clinical pharmacy--will likely be impacted.

The Implications of the SCOTUS Ruling on Racial/Ethnic Diversity in Clinical Pharmacy

Even under affirmative action, the enrollment of students from REM groups in colleges/schools of pharmacy (COP/SOPs) remained disproportionately below their respective population representations.³ A 2023 study applying a Diversity Index metric found that despite a 24% increase in PharmD graduates over the past decade, Black/African American and Hispanic/Latino individuals continue to be underrepresented compared to regional and national benchmark populations.³ This same study found that taken together, PharmD programs at Historically Black Colleges/Universities (HBCU) and Hispanic Serving Institutions (HSI) are responsible for approximately 30% of Black/African American and Hispanic/Latino graduates despite comprising a low percentage of PharmD programs nationwide.³

Pharmacists of REM backgrounds are also underrepresented in pharmacy postgraduate residency programs. According to a diversity resource guide presented by the American Society of Health-Systems Pharmacists (ASHP), of the resident candidates who applied for the match in 2022, 56% were white, and 27% were Asian, whereas 6% were identified as Hispanic/Latino and 5% as Black/African American.⁴ However, when considering the final match results, the proportions of all REM groups who successfully matched decreased, while non-Hispanic White applicants experienced a 15.8% increase.⁴ This lack of diversity in postgraduate training is multifactorial but often cited reasons include the lack of representation of REM individuals in COP/SOP and residency/fellowship program leadership and the lack of tailored recruitment efforts for REM trainees.⁵

Without direct and intentional mitigation strategies, these disparities within the profession are poised to become more pervasive, and potentially result in deleterious health outcomes across REM populations. Most importantly, the lack of REM diversity in clinical pharmacy has implications for decreased patient-provider racial concordance and adverse patient clinical outcomes.² Studies have shown that concordance, perceived similarity, or shared identity improves patient-provider communication, patients’ satisfaction with care, and utilization of healthcare services.⁶ Furthermore, the number of healthcare deserts in the nation is increasing; however, REM individuals are more likely to return to these disparaged areas to practice, stimulate research, and advocate for community members.^2,7 This underscores the importance of prioritizing DEI in curating and fostering the pathway to clinical pharmacy in a post-affirmative action country.

Call to Action: Actionable Recommendations for Clinical Pharmacists to Consider

While the SCOTUS ruling is disappointing, it is essential to note that before the 2023 decision, several states (Oklahoma, Michigan, California, Nebraska, Florida, Texas, Nebraska, and Washington) had already banned race-based affirmative action for college admissions and have been able to promote DEI throughout their collegiate recruitment initiatives.⁸ From these examples and others in the literature, we provide recommendations and strategies for clinical pharmacists to address barriers in recruiting REM trainees. See Table 1.

Table 1.

Intentional Strategies to Increase Diversity in Clinical Pharmacy

Recommendations	Strategies
1. Integrate Determinants of Deprivation into Race-neutral Recruitment Criteria	Utilize indices known to capture diversity in socioeconomic status and other social factors9 Consider offering scholarships/discounts/fee waivers to applicants from disadvantaged backgrounds to alleviate economic barriers4,9
2. Address Deficiencies in the Current Pipeline	Collect and analyze individual program-specific (school/college of pharmacy, residency, or fellowship) REM disaggregated data4 Prioritize collaborations to engage younger (elementary to high school-aged) REM students8
3. Include Diverse Perspectives in Recruitment Initiatives	Have a diverse team of recruiters2,5,8 Educate admissions/hiring teams about the following:2–5,8 Implicit/explicit biases Importance of diversity Structural barriers applicants face
4. Prioritize Education on Racism and Systems of Oppression	Emphasize cultural and structural humility throughout the pharmacy curriculum and post-graduate continuum4,10 Ensure pharmacist leaders and mentors (preceptors and residency program directors) continue professional development in this area5,10

^*Note: The recommendations and strategies for their integration into postgraduate training program recruitment initiatives are provided in the text.

Utilize Indices that Capture Socioeconomic Status and Social Vulnerability Disparities

The positive correlation between low socioeconomic status or high social vulnerability status and REM identity has long been described and explained throughout the literature.⁹ Therefore, using vulnerability indices to identify applicants impacted by inequities in social determinants of health (SDoH), including socioeconomic status, may provide an alternative approach to increasing the number of REM individuals in pharmacy trainee programs.⁹ The University of Florida School of Pharmacy utilized the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) tool to identify trends among their student body and reported that the REM students in their program were more likely to come from areas of moderate to high social vulnerability than their non-REM counterparts.⁹ Using this as an example, pharmacy training programs can consider integrating indices or other markers of socioeconomic disadvantage to identify ideal areas to focus recruitment efforts and account for barriers that impact students from those communities.

Address Recruitment Challenges in the Current Pathway to Clinical Pharmacy

To address limitations in the recruitment approach, selecting an outcome of focus--which may include examining the number of individuals interviewed by the program or applying to the program and disaggregating the data by race/ethnicity-- is an ideal starting point for training programs. Through race/ethnicity disaggregation, the programs can identify where the disparities exist and where interventions should be focused. Postgraduate training accrediting bodies must keep programs accountable by mandating this collection. Further, prioritizing collaborations for elementary to high school-aged students with pharmacy programs that serve a more significant percentage of REM populations would be a positive initial action to diversify.⁸ This early investment in the education of REM students can impact their trajectory into a college/university and their eventual likelihood of applying to a pharmacy program and subsequent postgraduate training.⁸

Include Diverse Perspectives in Recruitment Initiatives

With a diverse recruitment team, there is an increased opportunity for the perspectives of REM individuals to be included and for the barriers that prohibit their success in the profession to be recognized.³ The limited number of REM pharmacists may complicate many programs and institutions. However, REM individuals who occupy staff or pharmacy technician roles can be engaged to provide meaningful perspectives to the recruitment team. Irrespective of their position, education about implicit/explicit bias and structural racism should be required for all members of the recruitment team.⁵ Full awareness of the structural and cultural barriers REM applicants encounter is essential, as this allows for the implementation of tailored interventions to address this important issue.^3,5

Prioritize Education on Racism and Systems of Oppression for Program Trainees and Preceptors

Multiple pharmacy organizations have recognized the importance of emphasizing increased educational experiences focused on cultural and structural humility.^4,10 Noting the mandate for culturally competent education in ASHP-accredited postgraduate training, individual programs should identify opportunities to incorporate SDoH and equity-based education into the curricula.⁴ This integration of education will potentially aid in developing policies that promote a safe and inclusive training environment suitable for diverse recruits.⁴

Conclusion

The recent SCOTUS repeal of race-conscious affirmative action will undoubtedly impact the pharmacy profession; therefore, deliberate, specific, and targeted interventions will be necessary to ensure an equitable representation of REM clinicians. For postgraduate training and employment, individuals involved in recruitment should continue prioritizing DEI and consider utilizing the recommendations provided as alternative strategies to diversify the clinical pharmacy workforce.