A New Lens

Second Opinion

What’s one way that medical education must change to better address health inequities?

Illustration of Black female doctor with long curly hair amid outlines of additional, faceless people in shades of brown, black and red.
Illustration: Hanna Barczyk; Portraits: Matthew Cook

Illustration in black ink of smiling middle-aged East Asian woman.Dr. Yoon Kang

Senior Associate Dean for Education; Richard P. Cohen, M.D., Associate Professor of Medical Education

Diversifying the physician workforce has been recommended as a critical strategy to address disparities in health care by leading organizations such as the National Academy of Medicine and the American Association of Medical Colleges. This is because there is data showing that physicians from underrepresented and socioeconomically deprived communities, where there is a need for expanded access to care, tend to go back to these communities to practice medicine. It is this diversity in physicians that promotes trust between doctors and patients.

What can medical schools do? Medical schools are the gatekeepers to a career in medicine. We can and must create the pipeline for a physician workforce that better mirrors the patients we serve. To do this, we need to address potential barriers, such as the cost of medical school and the need for mentorship. Ironically, these barriers tend to be amplified in communities with the most significant health inequities.

According to AAMC data, students today graduate from medical school with a median debt of more than $200,000. Combine tuition costs with fees for applying, interviewing, and paying for entrance and licensure exams, and medical school feels out of reach for many, especially those with significant undergraduate debt. Debt associated with medical education also varies by race and ethnicity. Notably, for Black students, not only did a higher proportion graduate with debt (91 percent for Black students, compared to 73 percent for all graduates), but the median debt was higher ($230,000 for Black students, compared to $200,000 for all students). Making medical school training more affordable is critical to creating a more diverse student body.

Medical schools must also enhance mentorship programs. Right now, medical schools primarily offer programs focused on students at the undergraduate level. But college is much too late. Our programs must start earlier. We need to partner more intentionally with middle schools and high schools to provide early exposure and connections to science and medicine, particularly in areas where role models don’t exist at home or in the broader community. And this needs to happen long before pre-medical classes or preparation for the MCAT.

With the health of our nation at stake, time is of the essence to bolster our pipeline.

Illustration in black ink of smiling, middle-aged Black woman in glasses and long hair tied back in cornrows.Dr. Joy Howell

Assistant Dean for Diversity and Student Life; Vice Chair for Diversity, Department of Pediatrics; Professor of Clinical Pediatrics

Medical education and, really, the entire health care community, must acknowledge the role of environmental and socioeconomic factors, or what we now call the “social determinants of health,” on population health. If we want to meaningfully address health inequities, then we must sharpen the lens through which we examine the context of each patient’s health and life.

In no way does this mean deemphasizing physiology and pathophysiology. These foundational sciences are critically important but, sadly, not sufficient to provide comprehensive and effective care. Consider, for example, a patient with hypertension. Following a diagnostic workup, a physician might consider what drug to prescribe. Yet critical questions remain: What is the patient eating? Does the patient exercise? What about alcohol and smoking? And stress? Learning to tease apart the social, societal and environmental contributors to illness has not been adopted evenly across medicine. Structural competence, which can be defined as the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political and economic structures, needs to become an integral part of our training, not only during medical school but also throughout our careers.

After the murder of George Floyd, students nationwide called for curricular changes in medical school and a more hospitable learning environment for students historically underrepresented in medicine. Weill Cornell Medicine responded, launching, among other efforts, the new Equity and Inclusion Initiative, with multidisciplinary subgroups identifying opportunities for improvement in domains like admissions, financial literacy and equity, community engagement and anti-racism in the curriculum. Curricular changes underway include acknowledging race as a social, not a biological, construct; avoiding the reinforcement of biases in patient vignettes; and teaching how diseases manifest across multiple races and ethnicities. As the United States population grows more diverse, these steps are essential to effective care.

Weill Cornell Medicine made the intentional decision not to address health disparities in a single class but to weave them across every unit of study and the clinical curriculum (see Addressing Social Impediments to Health). After all, health care and medicine are not immune to societal problems that generate inequities. Identifying the factors contributing to health inequities must become a core, continuing part of our education and learning.

Illustration in black ink of middle-aged Black man in glasses, short hair and neutral expression.Dr. Kevin Holcomb

Associate Dean for Admissions; Vice Chair of Gynecology; Professor of Clinical Obstetrics and Gynecology

Addressing health inequities involves building a physician workforce representative of our population. To achieve this, medical schools nationwide need to admit more ethnically and racially diverse students who will go on to serve the health care needs of our country for decades to come.

Right now, there just aren’t enough Black or African American, Latino or Hispanic and American Indian or Alaskan Native physicians. And this gap in our workforce comes with consequences, affecting everything from infant mortality rates to the likelihood of patients adhering to their physician’s recommendations. For instance, it has been shown that Black men are more likely to follow preventive medicine recommendations when they come from a Black doctor. This is an easy win: Just by increasing our physicians of color, we can save lives.

Without trusted health care messengers in our communities, health problems will only escalate. Look at what happened with the coronavirus pandemic. Earlier on in the pandemic, higher percentages of Black and Latino people died than white people in the United States. However, according to the CDC, over the past year, the COVID-19 death rate for white Americans has been 14 percent higher than the rate for Black Americans and 72 percent higher than the Latino rate. Why? Experts attribute the shift to the mobilization of trusted messengers encouraging vaccination in Black and Hispanic communities, causing a disparity to entirely flip from one direction to another.

What can medical schools do? They can decrease barriers of entry for underrepresented populations, particularly financial barriers. At Weill Cornell Medicine, we offer debt elimination for those who qualify through a program that uses philanthropic funds to cover gaps between a student’s economic resources and the cost of medical school. We also take a holistic approach to admissions by looking at each candidate’s achievements in context. This means, for instance, that if an applicant spent much of their undergraduate experience working in fast food restaurants to support themselves, we factor that in when we look at their extra-curricular activities and accomplishments. We’re not taking away from other applicants; we want to identify all students who are best prepared to be future leaders in medicine.

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