Diversifying the medical classroom: is more evidence needed?

DESPITE 30 YEARS OF PUBLIC AND PRIVATE INITIAtives to increase physician diversity, the proportion of medical school graduates who are from underrepresented minority (URM) groups has stubbornly remained in the 10% to 15% range. This is at a time when the United States has become more racially and ethnically diverse, with current minorities projected to comprise 54% of the population by 2050. The justification for URM student diversity is often based on the principles of affirmative action and addressing prior injustices. Indeed, the well-documented history of widespread racism within organized medicine and the American Medical Association’s apology is a reminder of how pervasive and tolerated such practices were only a few decades ago. However, there are other compelling reasons for increasing physician diversity. Most notably, thorough and authoritative reviews link physician diversity with better access and quality health care for underserved populations. Minority physicians provide disproportionate care to minority populations; racial-ethnic concordance of patient and physician result in improved communication, trust, and patient satisfaction; and patients prefer physicians who share their own cultural, linguistic, and racial backgrounds. Thus, the Institute of Medicine recommends increased physician diversity as a specific and concrete action that should be taken toward eliminating health disparities. However, in 1978, the Supreme Court ruled that a greater likelihood of serving the underserved is not an acceptable justification for race-based preferences in admissions. An additional compelling reason for medical school URM student diversity is that such diversity results in an improved educational experience for all students. This educational benefits rationale is the only one that to date has been accepted by the Supreme Court as justification for race conscious admissions policies and only if applied at the individual assessment level. The research base supporting this justification has been increasing, particularly at the undergraduate college level. One study of 25 000 undergraduates at 217 colleges found widespread benefits of diversity on the cognitive and affective development of students of all racial backgrounds. A report including a set of 3 longitudinal studies found that the positive effects of diversity on outcomes such as active thinking processes, engagement and motivation, and intellectual and academic skills persisted for several years after leaving college. An in-depth review further concluded that the beneficial effects of undergraduate diversity on measures such as attitudes and feelings toward intergroup relations, institutional satisfaction, cognitive development, and academic growth were most profound for white students. Nevertheless, there has been a need for additional evidence from more rigorously conducted research, particularly in the medical school setting. Thus, the finding by Saha and colleagues 4 in this issue of JAMA that, after adjusting for various school and student characteristics, increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature. Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity. The study is also one of the first that attempts to examine mechanisms. The educational outcomes achieved through increased diversity have been hypothesized to be mediated by increased