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AAMC Report Examines How to Increase the

Pipeline of Black Men Entering Medical School

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Medical News & Perspectives

AAMC Report Examines How to Increase the Pipeline

of Black Men Entering Medical School
Julie A. Jacob, MA

nthony Kulukulualani knew from

age 11 years that he wanted to become a physician. Even though he
received support and encouragement from
his family, the road to medical school was
tough at times, he said, especially as an
African American man from a lower socioeconomic background who did not have anyone to coach him on preparing for medical
school.
The majority of my journey to medical
school was self-discovery. I intuitively
guessed at what courses to take and also
pursued the advanced-level versions when
possible, recalled Kulukulualani, now in his
third year at Tufts University School of Medicine. He is also president of the Student National Medical Association.
Kulukulualani said his journey became
easier after he participated in 2 summer

enrichment programs for premed students

from underrepresented demographic
groups. In the Travelers Summer Research
Fellowship Program at Weill Cornell Medical
College, he participated in research and
attended medical lectures, as well as presentations by minority physicians. At the
University of Pittsburgh School of Medicines Summer Premedical Academic
Enrichment Program, he assisted with biomedical research and attended medical
school admissions preparation workshops.

Continued Underrepresentation
Kulukulualanis challenges as a black man
preparing to become a physician, as well as
the support and guidance he received in
the enrichment programs, represent challenges and strategies for success addressed
in a 2015 Association of American Medical

Colleges (AAMC) report, Altering the

Course: Black Males in Medicine (http://bit
.ly/1IH3Bua). The underrepresentation of
minority students in medical schools has
been addressed in previous AAMC reports
in 2008 and 2012 (http://bit.ly/1OjxKDC, http:
//bit.ly/1PgF0iC), but the most recent one
focuses specifically on the challenges facing
black men interested in careers in medicine. It highlights factors that support their
success and addresses the role of academic
medicine in increasing the numbers of
African American men in medical school.
In 2014, only 515 black men matriculated to medical school, less than the 541
who did so 36 years ago in 1978. Black men
constitute the only minority demographic
group to have fewer students starting
medical school in 2014 than in 1978,
according to Jennifer Eliason, a lead
research analyst at the AAMC. Even as the
number of black men entering medical
school in 2014 has slipped compared with
1978, African American women gained
ground in applications and enrollment in
that same time span, with 1016 applying
and 391 matriculating in 1978 and 2200
applying and 712 matriculating in 2014.

The challenges for black males aspiring to

medical school begin early, starting with their
disproportionate representation in underperforming elementary, middle, and high
schools that may not have the finances or
staff to provide a solid educational foundation for premed studies.
Perhaps because of their disproportionate enrollment in underperforming schools,
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Challenges Along the Path

News & Analysis

black students lag behind their white and

Latino peers in college readiness in English,
reading, and math, according to a report on
minority male achievement in community
colleges (http://bit.ly/1OiUt0W).
To better prepare black males for
medical school, its crucial that advanced
placement and enrichment classes be available to minority students in elementary
school and middle school, said Marc Nivet,
EdD, the AAMCs chief diversity officer.
Such enrichment courses may require a
creative use of limited resources in cashstrapped school districts, such as online
programs, he noted.
The perception among school instructors that black males are troublemakers or
have poor academic potential is another obstacle facing black males aspiring to medical careers, the report noted. Furthermore,
negative media images combined with lower
expectations may indirectly perpetuate stereotypes and systemic biases that affect
black boys career aspirations, the report
stated. Adding to these negative perceptions that black boys face, parents of black
children may have lower academic expectations for their sons than for their daughters
(Rowley SJ. Adv Child Dev Behav. 2014;47:
301-332).
Such bias may follow minority students into postgraduate education, according to a research study that found professors were less likely to answer email queries
from prospective doctoral students who had
names signaling that they were female or
nonwhite (Milkman KL et al. Psych Sci. 2012;
23[7]:710-717). Black students may also face
the headwind of stereotype threat, in
which the fear that they may confirm a prevailing negative racial stereotype can cause
students to underperform, even in contexts where active or overt prejudice is unlikely or absent (http://bit.ly/1OiUt0W).
A lack of black male physicians and
medical school faculty members who can
serve as role models, mentors, and coaches
is another hurdle for black men pursuing
medical careers. Only 2% of full-time medical school faculty members are African
American men, according to the AAMC
report, and yet black male medical school
faculty members can provide valuable networking advice and encouragement to
black men applying to or enrolled in medical school, noted Curtiland Deville, MD,
assistant professor of radiation oncology
and molecular radiation sciences at Johns

Hopkins University School of Medicine.

Deville mentors minority medical students
by, for example, by giving students tips
about navigating medical school, informally
discussing residency program interviewing
strategies, and connecting medical students to researchers and faculty members
who have expertise in clinical and research
fields of interest to the students.
The cost of medical school can be
another barrier, the report states. While the
price tag for a medical degree is steep for
any student, the cost of tuition may seem
especially daunting to black students, who
are more likely to have families unable to
provide financial support, Nivet noted. A
2013 study determined that black students
were the most likely to report anticipated
medical school debt in excess of $150 000,
which, according to the study authors, may
in part explain why medical school enrollment for African American students dipped
from 7.4% in 2004 to 7% in 2011 (Dugger
RA et al. PLoS One. 2013;8(9):e74693).

Long-term Strategies for Success

Despite the numerous obstacles facing black
men pursuing medical careers, enrichment
and mentoring programs can help, the recent AAMC report notes. The Student
African American Brotherhood, an organization with chapters at more than 200 colleges, as well as middle schools and high
schools, is a mentoring and support program targeted specifically to minority males.
The Summer Medical and Dental Education
Program, jointly administered by the AAMC
and American Dental Education Association, is available for minority undergraduates at 12 medical schools: all costs except
travel are covered, and some sites offer
travel stipends. The program provides prepping for medical and dental school entrance examinations, financial advice, and
opportunities to observe a practicing physician or dentist. At the University of North
Carolina School of Medicine , a targeted program called Minority Men in Medicine (http:
//uncmmm.blogspot.com/) offers mentoring, study groups, a listserv, and social events
for minority men interested in health care careers, explained Claudis Polk, MA, the
schools associate director of the Office of
Special Programs.
As helpful as such programs are, coordination of enrichment and mentoring programs is crucial so students stay the course,
said Nivet. Administrators of science enrich-

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ment, mentoring, and advanced placement programs from elementary school

through college need to work together to ensure that students are referred to such programs at the next grade level. Too often, he
said, after students complete these programs, administrators do not follow up with
the students to refer them to additional enrichment programs. This may be one reason why longstanding enrichment programs have not boosted the number of
African American men attending medical
school, he explained.
We lose too many students simply because they are unaware of these programs, Nivet said. Also, while there are a
few programs targeting black male youth,
there are not enough.
Limited data are available on what types
of outreach programs offered to minority
students interested in careers in medicine
are successful, which may be another factor why existing enrichment programs have
not done more to increase the number of minority medical students, Deville said. More
evidence needs to be gathered, he observed, regarding what works, what doesnt,
and why.
Its also important for medical schools to
reach out to underserved neighborhoods in
the community so that minority children will
be exposed to medicine as a career option,
said Nivet. In Baltimore, for example, several physicians from Johns Hopkins University School of Medicine and the University of
Maryland School of Medicine serve on the
advisory board for Medical Education Resources Initiative for Teens (MERIT), a program that offers 7 years of academic support and mentoring from sophomore year of
high school through college to minority teens
interested in medical careers (http://www
.meritbaltimore.org). Students in the MERIT
program attend weekly academic enrichment programs, receive mentoring, and are
placed in summer internships at hospitals
and laboratories.
More widespread adoption of holistic
medical school admissions policies, which
take into account nonacademic factors such
as a students life experiences and personal
attributes, as well as a schools commitment to increasing the representation of minorities in medicine may also help increase
the number of black men entering medical
school, Deville said. In a 2014 survey, 38%
of medical schools reported using some aspects of holistic review, and 48% indicated

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News & Analysis

they incorporated some aspects of holistic

review into the admissions process. Beyond rethinking admissions policies, cultural competency training for faculty may
also help colleges better serve black male
students who are preparing for medical careers. Such training, which teaches faculty
members to understand and appreciate cultural differences, has been recognized as an
important tool in helping minority male students achieve their educational goals (http:
//bit.ly/1OiUt0W).

Need for Diversity in Medicine

Increasing the racial and ethnic diversity
of students entering medical school is
important for 2 reasons, Nivet said. First,

as the country becomes more racially

diverse, it will become more important to
have a physician workforce that mirrors
the US population (http://1.usa.gov
/1M3diky). In fact, ensuring cultural sensitivity of the health care workforce is one of
the objectives listed in the federal Healthy
People 2020 initiative to help eliminate
health disparitie s (http://1.usa.gov
/1McBILs). Thats because nonwhite and
poor individuals are more likely to have
health conditions such as diabetes and
cardiovascular disease, and minority physicians more often opt than their white
peers to care for racial and ethnic minority
patients in medically underserved areas,
noted a Health and Human Services report

(http://1.usa.gov/1tfOAoW). In fact, 54.6%

of black medical school students plan to
practice in underserved areas compared
with 36% of Latino students, 21.4% of
white students, and 19.4% of Asian students, according to the AAMCs 2012
report on diversity in medical education
(http://bit.ly/1PgF0iC).
Sometimes patients want a provider
who looks like them, understands them, and
may have grown up in a similar neighborhood, Nivet said.
Second, its also important not to
waste the talents of black men, Nivet
noted. We cant afford to have any large
segment of the population not reaching
their full potential.

The JAMA Forum

A Healthy Living Wage

Andrew Bindman, MD

2224

Eligible for federal

subsidies to buy
health insurance
in the Marketplace

Financial Eligibility for Marketplace Subsidy

in Association With Hourly Wages
400
350
300
Hourly Wage

250

$15/h

200
$10/h

150

States without Medicaid expansion

The ACA has already had an enormous effect on expanding health insurance coverage, with an estimated 17.6 million people
(http://1.usa.gov/1RIq3Vp) gaining coverage as a result of its passage. This has occurred primarily through an expansion of
Medicaid coverage and the establishment of
state and federal health insurance exchanges, or marketplaces.
In the 30 states that have expanded
Medicaid, individuals with incomes below
133% of the Federal Poverty Level (FPL)
qualify for Medicaid coverage. In 2015, this
corresponds to an annual income of less

expanded Medicaid, federal subsidies to

purchase insurance through a marketplace
are available for those with incomes above
100% of the FPL ($11 670 in 2015).
Even with the federal financial support for coverage expansion as a part of
the ACA, more than 30 million Americans
still lack health insurance. Although the
Congressional Budget Office anticipated
that it would take time to fully implement

States with Medicaid expansion

Expanding Coverage

than $15 556 for an individual (http://bit.ly

/1RIq9fH). Federal subsidies are also available in all states to support eligible individuals with incomes up to 400% of the
FPL to purchase health insurance coverage through marketplaces. In the Medicaid
expansion states, a person with an income
above the Medicaid eligibility threshold
and less than 400% of the FPL qualifies
for these subsidies. In states that have not

Annual Income as a Percentage of 2015 Federal Poverty Level

uring the next year of presidential

campaigning, candidates positions on their support of or opposition to the Affordable Care Act (ACA) will
become shorthand for their health care
policy. Ever since the ACAs passage without any Republican votes in either chamber
of Congress, the law has been a lightning
rod of partisan politics and a political dividing line. But the candidates minimum wage
policies may actually have a more substantial effect than their support of the ACA on
the rates of health insurance coverage
and population health during their time in
office.

100
$7.25/h
50
0
1

No. of People in Household

Annual incomes for each wage level were calculated based on working 40 hours per week and 52 weeks per year.
Dollar values of 2015 Federal Poverty Levels are available at http://obamacarefacts.com/federal-poverty-level.

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