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In this interview, Utibe Essien, MD, MPH, and Victor Agbafe discuss how to ensure diversity in medicine in light of the Supreme Court ruling against affirmative action in college admissions.

Essien is an assistant professor of medicine at the University of California Los Angeles and a health disparities researcher at the VA Center for the Study of Healthcare Innovation, Implementation, and Policy; Agbafe is a fourth year MD/JD student at the University of Michigan Medical School in Ann Arbor and Yale Law School in New Haven, Connecticut.

The following is a transcript of their remarks:

Agbafe: The data earlier this year, I think in a publication in , showed that in counties with higher numbers of Black primary care physicians, that Black individuals have a higher lifespan.

Now, this is important because when you look at the broader context, part of the health disparities we have is that Black people tend to have a shorter lifespan than whites. Some of that's due to the social determinants of health and, quite frankly, having lower access to healthcare. But there also just seems to be something about when you have a Black provider that is resulting in better outcomes.

In addition to that, when we then also point to other micro issues, one of them being the maternal outcomes in our country, a big part of why maternal outcomes are disappointing for us right now in our country is that there's a big gap between Black women and white women. And it's been shown that when Black women have access to Black maternal providers, the outcomes are better.

So that's on a macro lens and when we specifically look at also maternal health, it bears out the fact that we need more diversity in our healthcare workforce.

Essien: Yeah, absolutely. And those are, like you mentioned, more macro/bigger themes.

We see that having doctors who look like you, referred to as racial concordance, actually results in so many different improved outcomes. We have patients reporting better satisfaction and higher ratings of their experiences in care. We see that patients who receive vignettes, cases where they're being advised by a doctor who looks like them to have recommendations such as cardiovascular surgery or catheterization to look for a clot in their heart, and those patients are more likely to agree to those procedures if they have a doctor that looks like them. We even see lower healthcare utilization when you have racial concordance between doctors and their patients.

So this matters, and the fact that we are so far from achieving racial diversity in our medical field compared to what we see in the country really suggests that this decision that was made by the Supreme Court earlier this year is -- as some of my colleagues have written -- actually going one step backwards when we should be going forward.

We're seeing that clearly strides have not been made, but rather than going forward and being direct and precise with addressing this specific issue of racial diversity in medical education -- as we're talking about today, but also higher education in general -- we are keeping things broad. We're keeping the conversation broad. We're keeping the policies broad.

I think that's the biggest reason why affirmative action policy has been imperfect thus far. And again, it's consistent across the board.

It's September right now, people are getting flu vaccines, people are getting new COVID vaccines. We saw this story play out in COVID when we tried to pinpoint policy to improve access to COVID treatments, provide access to vaccination for the groups that were most deprived and most disadvantaged from the pandemic, which happened to be folks from racial and ethnic minoritized backgrounds. When those policies try to come into place, there is pushback, there are lawsuits, etc. So we see this in education, we see this in healthcare.

The fact that we're hoping to bring policies together to address the education system and the diversity thereof to hopefully address the disparities that we see in healthcare, I think, is why we're having this conversation today.

Agbafe: I think both for us to sort of fix affirmative action, in terms of making it more effective, but now to move forward from it now that the Supreme Court has taken that away, I think it means that we've really got to look at our schooling policies going back to K-12.

We have to get to those foundations, to invest equally in our students because we know that there are gaps even when you are matched for income. Schools that have a higher percentage of Black students and minority students versus schools that are predominantly white in terms of the amount of funding that they get.

We also know that due to the fact that until medical schools had opened up to people of all races, that different communities who have had family and community members around them who've had the opportunity to enter medicine, there are other avenues for them to get informal lines of information in terms of how you approach applications, in terms of getting involved in medical research. We're proposing putting in place partnerships to help close those gaps.

Then when we get to the medical school application period and going into medical school, then thinking about how we can go and recruit people from diverse colleges and universities, not just our HBCUs [historically Black colleges and universities], but other schools like the University of Maryland, Baltimore County that has a record of having high levels of socioeconomic diversity.

Kind of like what the Biden administration has been doing, looking at geography in terms of its links to inequality. Can we emphasize geographic diversity in terms of granting interviews?

Essien: Two points that we didn't make, I'll make, and then I'll allow Victor to expand on anything else that I missed is hopefully addressing this issue of the cost of getting into medical school. So one of the biggest drivers of cost is taking the Medical College Admissions Test, this MCAT exam that affects so many people and really discourages a lot of people from actually attending medical school, as some of my colleagues and I published earlier this year. That exam itself costs money. The prep materials cost money to take the exam.

So we are arguing that we need more early admissions systems and processes, early medical commitment programs for our students who when graduating from high school can actually get into these BA/MD programs where an MCAT is not required. Again, you can help improve the access to medical school with eliminating this very, unfortunately, disadvantaging criteria for individuals of color.

And the second -- and I think a really important piece that we have to make -- is really addressing holistic review. We're no longer able to use race in the admissions process as like a checkbox or criteria according to the Supreme Court.

But how are we able to look at the broad journey of our future physicians as they go through this pathway, whether it's as a pre-med, as a medical student, as a resident, as we meet them in training? What has their journey been towards this field? How did they choose it? What's their background? What are some of their socioeconomic challenges or not? How has race influenced their experience in this world and potentially their decision to pursue a career in medicine? Those are going to be hard things to examine on an interview.

We're in the interview season right now and we're being asked to interview numbers of resident applicants. That takes time, that takes effort, that takes people -- taking people out of clinic, perhaps taking people out of their regular research job -- to be able to do this heavy lifting of reading essays, reading applications, etc. You can't just look at a score and look at a checkbox and say, "Come on in, come and interview."

So really investing resources in that holistic review, teaching reviewers to be antiracist in their review and not have some of the unconscious biases that come to us, all of us, when we're reviewing applications, I think, is really going to be important.

And again, this is an investment that schools need to be making today, not waiting until next year to see how things shape up, not waiting until the year after -- this year to be able to ensure that we're not going backwards with some of the numbers that were already so poor.

Agbafe: We have to think of the end target, right? We want a more diverse and we want a more empathetic medical workforce that will result in a more effective medical workforce in terms of patient outcomes and in terms of cost.

Part of that is making sure that it's not just about getting you to med school. But it's along the whole pathway supporting all our students equally when they get there. Making sure too that when you get to residency, which is that terminal stage of medical training, that you are not being discriminated against, you're not being excluded on the basis of race, because those can have very negative and harmful repercussions in terms of one's ability to get that final certification, to go back to their community and serve. So, I think it's making sure that we all take responsibility for that.

A second point I think I'll make is now that affirmative action -- at least in higher education outside of the military academies -- has been ruled unconstitutional, I think Chief Justice John Roberts made a point that people can still discuss their race in terms of how it has affected them as individuals. So I think it also means that, from a race lens, it's shifting. We're shifting, I guess, away from a paradigm of groups and a checkbox, some could say, to now looking at you as an individual, right?

I think to the point Dr. Essien said, I hope that the resources are put in place and the time is taken to really look at all our students in terms of how all aspects of their lives have shaped them, race being a part of that.

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