Abstract
This chapter presents an example of a diversity educational change initiative at a medical school. A novel premedical program for enlisted members of the U.S. military services was implemented based on mission requirements, analysis of existing data, and evidence-based strategies. The U.S. physician population suffers from a lack of diversity. This has been a long-standing problem which has a significant impact on the health of the nation. Educational leaders have been given a mandate to address this challenge, and efforts have been made over the past decades – with varying levels of success. This chapter discusses the realities of the diversity challenges facing the health professions workforce and highlights elements of programs which have produced successful diversity outcomes. The military's premedical program is described in detail, including the theoretical perspectives for student persistence and how leaders collaborated to create the conditions for student success.
TopIntroduction
Becoming a physician is arguably one of the most difficult career choices a person can make. Aspiring physicians must first complete an undergraduate degree followed by four years of medical school and then a graduate medical education (or residency) program ranging from three to eight years in duration. For most of those who successfully achieve this goal, the process began well before they started college. In its resource guide, the Association of American Medical Colleges (AAMC, 2017, 2019) recommends that aspiring physicians begin preparing in high school by taking the appropriate courses, participating in specific types of extracurricular activities, and partnering with healthcare professionals.
The process of becoming a physician is not only time-consuming; it can also be an expensive undertaking. In 2019, the median education debt for medical school graduates was $200,000, and 73% of graduates reported having education debt (Youngclaus & Fresne, 2020). Nevertheless, each year thousands of aspiring physicians apply to medical school. In the 2020–2021 academic year, 62,443 individuals applied, 23,711 were accepted, and 22,666 ultimately matriculated to U.S. allopathic medical schools (AAMC, 2021e). These figures demonstrate that demand continues to outnumber supply for class seats despite the challenges inherent in achieving a Doctor of Medicine (MD) degree.
While there is no shortage of qualified medical school applicants, historically, U.S. medical schools have been challenged with finding a sufficient number of diverse applicants who met their stringent admission standards. The reasons for this problem are multifactorial, and range from structural racism, legal restrictions, resistance to change, and apathy, to name a few. Many programs have been developed over
DISCLAIMER: The views expressed in this chapter are those of the author and do not necessarily reflect the official position or policy of the U.S. government, Department of Defense, or the Uniformed Services University. The author has no conflicts of interest to disclose.
the years to address these issues with varying degrees of success. These types of programs are opportunities to both improve clinical care and reduce health disparities, but also better prepare students to work in multicultural settings. Medical school is the gateway for new physicians; therefore, medical school leaders have a responsibility to develop strategies to recruit and retain qualified medical students in a highly competitive environment.
Post-baccalaureate premedical (PBPM) programs are one such pipeline that has supported diversity in medicine. In 2014, the leadership of the Uniformed Services University (USU)—in partnership with the U.S. military services—implemented a post-baccalaureate premedical program with the goal of enhancing the diversity of the military medical officer (physician) corps (Green et al., 2021). Known as the Enlisted to Medical Degree Preparatory Program (EMDP2), it is the first PBPM program in the Department of Defense. Academically promising enlisted service members compete for selection to this enrichment program that assists students in making the social and intellectual transition from undergraduate studies to medical school and beyond (Green, 2018).
The military has long been viewed as a vehicle of change for the nation, and this educational partnership has been a model program for diversification of the health care workforce. Since its inception, the EMDP2 has matriculated 163 students from four military services (Uniformed Services University, 2022a). Aside from their prior military service, EMDP2 students differed from typical medical students in that they were more racially diverse; and more likely to be 26 years or older, married with dependent children, and have grown up in households with an annual income below $50,000 (Green, 2018).
Key Terms in this Chapter
Structural Diversity: The simple numerical representation of diverse groups. Structural diversity increases the likelihood that students will encounter others of diverse backgrounds but does not guarantee that the interactions will be meaningful.
Meritocracy: The belief that success in school and work is and should be determined by one’s talents and efforts. Meritocracy undergirds the ideology that individuals can succeed because of their independent decisions and actions and that this success is equally available to everyone regardless of origin or social identity. The U.S. educational system is expected to serve as an incubator in which exceptional ability and talent are identified and nurtured. Internal and external factors such as racial and ethnic background, gender, and SES are immaterial, as are natural abilities, and consistent high performance determines success.
Holistic Review: A flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to that individual’s experiences, attributes, and academic metrics. A holistic review must be clearly linked to a school’s mission and goals. Admissions committees that use the holistic review admissions process (HRAP) consider each applicant’s race as one of many attributes along with other elements of diversity, such as educational background, languages spoken, resilience, SES, and geographic background.
Classroom Diversity: The engagement of diverse peers in the classroom. Classroom diversity provides maximum benefit as it facilitates the intellectual engagement of diverse peers in college classrooms and helps create the conditions that lead students to experience diversity in ways that would not occur in a more homogeneous student body, in addition to intellectual engagement.
Underrepresented in Medicine (URM): Racial and ethnic groups whose numbers in the physician population have been consistently low relative to their prevalence in the general population. Currently, URM groups include Blacks or African American people, Hispanic or Latin American people, Native Americans or Alaska Natives, and Native Hawaiians or Other Pacific Islanders.
Informal Interactional Diversity: Daily interactions outside the classroom—in residence halls, campus events, and social activities—that provide opportunities to interact with diverse peers and encourage active thinking and civic engagement.
Culturally Relevant Care: Care in which providers understand how factors interact with the health care system in ways that may prevent diverse populations from obtaining quality health care. Physicians who are from similar cultural backgrounds are often able to identify better with the supported population and help develop strategies to reduce and monitor potential barriers through interventions.
Student Success Factors: Academic support mechanisms that are important for students to remain and succeed in their academic journey. These factors are economic, organizational, psychological, and sociological.
Student Persistence: The amount of physical and psychological energy that a student dedicates to the academic experience in order to continue their studies. Students who develop a commitment to the institution through academic and social integration experiences are most likely to persist in completing their education.
Diversity: Broad representation not only in race and ethnicity but also elements such as educational background, languages spoken, resilience, SES, and geographic background.