How to diversify the dwindling physician–scientist workforce after the US affirmative action ban

Abstract

The US Supreme Court decision on affirmative action will disrupt efforts to diversify the physician–scientist workforce and requires immediate action.

On 29 June 2023, the US Supreme Court ruled that race-based affirmative action in college admissions violates the Fourteenth Amendment’s Equal Protection Clause to the US Constitution (Students for Fair Admissions vs President and Fellows of Harvard University, 2023; Students for Fair Admissions vs University of North Carolina, 2023). The majority opinion asserts that the US Constitution is “colorblind”, despite continuing systemic issues of segregation and racial inequities. This decision affects the biomedical workforce, and we believe will stunt the cultivation of a robust and diverse physician–scientist community. A lack of racial and ethnic diversity in the physician–scientist workforce hinders progress in clinical care and biomedical innovations, and the Supreme Court’s ruling will exacerbate existing disparities.

Historical diversity

The Association of American Medical Colleges (AAMC) and 45 other healthcare organizations filed an amicus brief in the 2023 case supporting race-conscious admissions. The affirmative action legal debate has involved medical and doctoral education for decades. The landmark 1978 Regents of the University of California vs Bakke ruling, which focused on admissions to medical schools, was the Court’s earliest modern precedent on race-based school admissions. In that case, the Supreme Court “upheld generally the right of schools to consider race as one factor in their admission process”, although they abolished the use of racial quotas¹.

The link between affirmative action practices and medical school admissions is quantifiable. Starting in 1997, affirmative action bans by eight states led to a 5.5% decrease in the enrollment of underrepresented students within 5 years². During the affirmative action era, the benefits of a diverse student population on educational experience have been documented. Students describe how having diverse peers enhanced classroom discussions and improved their ability to work more effectively with others from different backgrounds, as well as increased cultural competency, and awareness of healthcare inequity³. Recognizing and celebrating the value of diversity is morally necessary to build a medical and scientific workforce that values patients’ intersectional life experiences. Furthermore, personal identity influences researchers’ approaches to developing hypotheses and methods, as well the types of research questions they choose to pursue⁴. National organizations and dual-degree (MD–PhD and DO–PhD) admission committees must develop complementary strategies to continue to build and train a diverse future physician–scientist workforce in the absence of affirmative action.

Lack of representation

Physician–scientists are uniquely trained to bridge the scientific and medical communities and often pioneer basic, translational and clinical discoveries, yet comprise only 1.3% of US physicians. First-generation college graduates, women, LGBTQ+ people, and people from historically marginalized racial and minority ethnic groups face additional barriers to becoming physician–scientists.

Even before the 2023 Supreme Court ruling, national surveys of the physician–scientist workforce underscored the need to increase diversity⁵. Recent data showed an incremental increase from 2009 to 2018 in the percentage of MD–PhD matriculants from minority racial or ethnic groups, including Black or African American, Hispanic or Latinx, and Native American or Alaska Native students⁶. Such individuals are as likely as their peers to consider an MD–PhD pathway after taking the Medical College Admission Test (MCAT) entrance exam and enrollment, but remain underrepresented in the applicant pool, which suggests barriers to entry⁷. Underrepresented groups made up only 11.4% of MD–PhD program matriculants in 2022 and ultimately make up only 5% of physician–scientist investigators funded by the National Institutes of Health (NIH)⁸. The racial and ethnic makeup of the biomedical workforce does not match that of the country.

A diverse physician–scientist workforce is important for addressing the clinical needs of the population and for advances in research. Lack of representation is a pressing concern because people from marginalized backgrounds experience disparities in the access to and quality of healthcare. Systemic racism has had long-lasting deleterious effects on health outcomes and quality of life over generations. Both the healthcare and biomedical research sectors in the USA have contributed to systemic racism, leading to profound mistrust and limited access to essential preventative and clinical care, as well as participation in research studies. A diverse workforce is essential to build trust with patients who have disproportionately poorer health outcomes, and to improve population-wide health and participation in invaluable biomedical research. Research teams that include people from different ethnicities can produce high-impact work by leveraging multidisciplinary skill sets, and diversity of perspectives with the added benefit of ensuring that advancements benefit patients from all backgrounds.

The lack of diversity of US physician–scientists is at odds with the needs of the healthcare system and population. Race-conscious admissions, hiring, training, and mentorship practices remain necessary without stereotyping minority racial groups during the admission process. The Supreme Court decision will increase barriers to entry and contribute to attrition from the already dwindling physician–scientist pipeline.

Recruitment barriers

As leaders of the American Physician Scientists Association (APSA), we believe that physician–scientist trainees are well-positioned to actively combat health inequities, advocate for patients from diverse backgrounds, ensure adequate representation of underrepresented backgrounds in research studies, and promote diversity of research topics.

The APSA released a position statement about the affirmative action ruling and continues to develop initiatives to support prospective applicants to dual-degree programs, particularly through efforts by its Justice, Equity, Diversity, and Inclusion Committee. Institutions should work with groups such as APSA to support people from under-resourced backgrounds during their path to dual-degree programs. Institutions should create policies to hold themselves accountable for recruiting and ensuring the success of a diverse student body. The barriers to recruiting racially and ethnically diverse trainees can be overcome through actions taken by national organizations and dual-degree programs (Box 1).

BOX 1.

Initiatives to increase the diversity of the physician– scientist workforce

1. More dual degree trainee positions

2. More outreach efforts

3. Expand mentorship structures

4. Increase access to research opportunities

5. Implement a transparent, holistic, and accessible application process

More trainee positions

According to the AAMC, the number of MD–PhD students enrolled has increased modestly in the past 9 years (from 5,192 in 2012–2013 to 6,005 in 2022–2023). Completing a dual-degree program takes almost a decade; a constantly increasing supply of trainees is therefore needed to fill the increasing need for physician–scientists that drive biomedical discovery. Expanding the number of available positions at current programs and creating more allopathic and osteopathic dual-degree programs would increase the overall trainee pool and the number of people from underrepresented backgrounds. However, this will ultimately need to be coupled with an augmentation in the number of residency positions across the spectrum of clinical subspecialties, particularly those utilizing the physician–scientist training program or research-in-residency training models that places an emphasis on dual training and the transition to independent funding.

Expanding the number of trainees will require increasing financial commitment by the NIH, training institutions, and private donors to help cover the education and living expenses of trainees, which include stipends, financial support for childcare, and tuition. An expansion of available places must be combined with efforts to retain physician scientists. The attrition rate of Black students from MD or PhD programs is 1.5 times that of their non-Hispanic white peers⁹. This can be attributed to a lack of supportive policies at institutions and experiences of mistreatment, discrimination, imposter syndrome and stereotype threat.

Increasing outreach efforts

From 2012 to 2020, the number of US MD–PhD applicants stagnated, indicating that more outreach is needed to inspire more interest in the physician–scientist pathway¹⁰. Raising awareness of this pathway among undergraduate or post-baccalaureate students may expand the pool of applicants from underrepresented backgrounds.

Institutions and professional organizations can synergize efforts by amplifying each other’s outreach efforts. The APSA, with support from the Burroughs Wellcome Fund, has incorporated diversity efforts into its annual regional meetings by intentionally inviting, and providing travel awards to, diverse speakers, underrepresented students, and individuals presenting on social sciences and humanities topics. These efforts have led to a greater diversity of undergraduates participating in the APSA’s annual meetings, of whom one-third later matriculated into MD–PhD programs¹¹. Dual-degree programs can further expand outreach efforts by hosting or attending events at historically Black colleges and universities, Hispanic-serving institutions, tribal colleges and community colleges, as well as national conferences sponsored by organizations such as the Society for Advancement of Chicanos/Hispanics and Native Americans in Science (SACNAS). Programs can support efforts by the American Association of Black Physician Scientists (AABPS) — an organization increasing awareness of Black physician–scientists through interviews, a membership directory, and virtual events. Institutions can encourage individuals identified through outreach to seek out the APSA and other organizations that provide opportunities for mentorship, resources, and information about the training path.

Expanding mentorship and guidance

Potential applicants need access to high-quality information; a qualitative study found that medical students interested in research careers do not apply to MD–PhD programs partly because of a lack of information about physician–scientist careers and the application process¹². Since 2018, APSA has run an undergraduate mentorship program that served 569 mentees in 2022–2023 (52% of whom were from underrepresented backgrounds). The APSA also offers monthly virtual interactive sessions for potential applicants that cover topics such as ‘a day in the life of a physician–scientist’, interview preparation, choosing a program, and navigating the waitlist. Dual-degree programs and the AAMC should work to maintain more up-to-date and transparent resources for applicants and undergraduate advisors. These resources could also be distributed by nonprofits, such as Project SHORT and Prescribe It Forward, that provide additional support for underrepresented individuals aiming to apply to dual-degree programs.

Increasing research opportunities

Dual-degree applicants are expected to have research experiences that generate substantial research output, papers, posters, and/or abstracts. Such opportunities can be challenging for undergraduate students to find, especially without adequate mentorship. Underrepresented students who participate in high-school summer research programs and college laboratory research apprenticeships are more likely to enroll in MD–PhD programs¹³. As a response to the COVID-19 pandemic, APSA started a virtual summer research program to aid participants in developing the research skills needed to pursue a physician–scientist career. A follow-up survey completed one year after the 2020 class showed that 72% continued conducting research the next summer, and 23% continued with the same lab¹⁴. Dual-degree programs can encourage faculty and current trainees to mentor a student through this or similar programs.

Dual-degree programs can create their own virtual or in-person summer research programs, such as the Gateways to the Laboratory program at Weill Cornell Medicine, The Rockefeller University, and Memorial Sloan Kettering Cancer Center, to support people from underrepresented backgrounds. Alternatively, dual-degree programs could financially support existing summer programs at their institution and provide specific mentorship to participants who are interested in pursuing the physician–scientist path.

A holistic and accessible application process

Many dual-degree programs have instituted holistic admissions review processes, which considers the unique lived experiences and background of applicants in addition to traditional academic metrics such as the grade point average and standardized test performance. Programs should send a clear message to applicants that their identities and backgrounds outside of their academic track-records are relevant to their application. Applicants should be encouraged to complete the self-reported disadvantaged status question on the medical school application, and programs should craft standardized secondary application questions that give applicants additional space to share their background, including if they identify as underrepresented in medicine or science.

Similar efforts should be implemented as part of the institution’s interview process. Several rounds of interviews for higher education programs are shown to reward different applicant criteria at each phase of evaluation, emphasizing the need to intentionally consider diversity at the initial phases of review, which often rely heavily on numeric indicators such as grades and test scores. In addition, the diversity of admissions committee members has a direct effect on the outcomes of the review process. For example, when admissions committees are composed of diverse genders, enrolled classes display increased gender parity¹⁵. Therefore, the admissions committee and selected interviewers whenever possible should represent the diverse the institution aims to foster. Transparency of that diversity should be evident on institutions’ public-facing web pages. Finally, funding for applicants, such as the AABPS prospective student scholarship, can ease the financial burden during application to dual-degree programs. Programs should also communicate how applicants can request fee waivers and emphasize that these requests do not affect the admission process.

An equitable training pathway

The 2023 Supreme Court decisions on affirmative action will increase barriers to developing and sustaining a diverse physician–scientist workforce and, as a result, contribute to its continued attrition. The onus for ensuring that the future physician–scientist workforce mirrors the racial and ethnic makeup of the nation cannot fall on applicants and national organizations alone. Medical schools and dual-degree admission committees are key stakeholders in recruitment efforts and in granting entry into training programs. The medical community and admission committees must redouble their efforts to diversify the physician–scientist workforce and counter the negative effect of the Supreme Court’s recent decision.