Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools

IMPORTANCE There continue to be low numbers of underrepresented minorities, including African Americans, in academic medicine. Historically Black medical colleges and universities are major sources of training for medical school graduates who are African American or who belong to other underrepresented minority groups. Several historically Black medical schools were closed during the period surrounding the 1910 Flexner report. The implications of these school closures with regard to the number of African American medical school graduates have not been fully examined. OBJECTIVE To examine the consequences associated with the closure of historically Black medical schools for the number of African American medical school graduates. DESIGN, SETTING, AND PARTICIPANTS This observational economic evaluation used steady expansion and rapid expansion models to estimate the consequences associated with the closure of historically Black medical schools for the number of African American medical school graduates. The numbers of graduates from 13 historically Black medical schools that are now closed were obtained through historical records. Data on historically Black medical schools that are currently open were obtained from school-specific reports and reports published by the Association of American Medical Colleges. The study focused on projected estimates of outcomes from the hypothetical continued operation and expansion of 5 closed historically Black medical schools that were included in the Flexner report: Flint Medical College of New Orleans University, Knoxville Medical College, Leonard Medical School of Shaw University, Louisville National Medical College, and the University of West Tennessee College of Medicine and Surgery–Memphis. MAIN OUTCOMES AND MEASURES The main outcome was the estimate of the number of African American students who would have graduated from historically Black medical schools that were closed during the period surrounding the 1910 Flexner report. RESULTS Among the 5 historically Black medical schools that were closed, the estimated mean number of graduates per year was 5.27 students at Flint Medical College, 2.60 students at Knoxville Medical College, 11.06 students at Leonard Medical School, 4.17 students at Louisville National Medical College, and 6.74 students at the University of West Tennessee. If the 5 closed historically Black medical schools had remained open, the steady expansion and rapid expansion models indicated that these schools might have collectively provided training to an additional 27 773 graduates and 35 315 graduates, respectively, between their year of closure and 2019. In the analysis of Leonard Medical School and the University of West Tennessee only, the steady expansion and rapid expansion models indicated that these 2 schools would have provided training to an additional 10 587 graduates and 13 403 graduates, respectively, between their year of closure and 2019. An extrapolation based on the racial and ethnic self-identification of current graduates of historically Black medical schools indicated that if these closed schools had remained open, the number of (continued) Key Points Question What are the projected estimates of the number of African American students who would have graduated from historically Black medical schools that were closed during the period surrounding the publication of the 1910 Flexner report? Findings In this economic evaluation of 13 historically Black medical schools that were closed and 4 historically Black medical schools that remained open after the 1910 Flexner report, an extrapolation based on data from the medical schools that remained open indicated that 5 of the closed medical schools might have collectively provided training to an additional 35 315 graduates by 2019. If these 5 closed schools had remained open, they could have produced a 29% increase in the number of graduating African American physicians in 2019 alone. Meaning The study’s findings suggest that consideration should be given to the creation of medical education programs at historically Black colleges and universities in an effort to increase the number of African American graduates from medical schools and the number of African American physicians in the workforce. + Editorial and Invited Commentary Author affiliations and article information are listed at the end of this article. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(8):e2015220. doi:10.1001/jamanetworkopen.2020.15220 (Reprinted) August 20, 2020 1/10 Abstract (continued)continued) graduating African American physicians might have increased by 355 individuals (29%) in 2019 alone. CONCLUSIONS AND RELEVANCE To increase the number of African American medical school graduates, consideration should be given to creating medical education programs at historically Black colleges and universities. Such programs may start with small enrollment but could have positive consequences for the diversity of the physician workforce. JAMA Network Open. 2020;3(8):e2015220. doi:10.1001/jamanetworkopen.2020.15220


Introduction
Increasing the number of physicians from underrepresented minority groups, including those who are African American or Black, has been an objective of many medical schools. Although an increase in representation has occurred, the number of African American medical faculty remains limited. 1 The shortage of African American faculty can have adverse consequences for the recruitment and retention of minority learners in medical schools. Many medical schools currently use holistic admissions processes, pipeline and outreach programs, and other initiatives to increase the number of students from underrepresented minority groups. 2,3 However, even with an increase in the number of schools that are addressing issues regarding poor and underserved communities, health disparities, and social factors associated with health, 4 the increase in the number of African American students, especially male students, remains slow. 5 Although the opening of additional medical schools may have created additional opportunities for students from minority groups to begin their medical educations, to our knowledge, none of the nearly 30 new medical schools that have opened since 2000 were located at historically Black colleges or universities. 6 Coupled with the increasing number of graduate medical education programs and the ongoing initiatives to increase the number of African Americans attending predominantly White institutions, the creation of new medical schools at historically Black colleges and universities may help to increase the numbers of African American medical school graduates and have positive consequences for the physician workforce.
Historically Black colleges and universities can be an important resource for recruiting students from underrepresented groups to medical programs. 7 These colleges and universities are incubators for young minority talent and often produce positive academic outcomes despite limited funding, negative media images, a history of marginalization, fewer faculty members, and inadequate facilities. [8][9][10] Partnerships between predominantly White institutions and historically Black colleges and universities can be symbiotic, with a sharing of assets that benefits faculty and students. 11 Although fewer in number, historically Black medical schools graduate proportionately more students from underrepresented minority groups than do medical schools at predominantly White institutions. 12 Increased numbers of graduates from minority groups can translate into a more supportive learning environment, in which there is less effort needed for relationship building because of the similarities in culture and background between faculty and students. 10 Black raceconcordant faculty and student environments can promote the personal and social development of students and foster academic gains in writing skills, technology, science, and the arts. 13 Four historically Black medical schools are currently in operation: Meharry Medical College (Meharry), An important factor in the closure of these medical programs was the Flexner report on medical education, which was published in 1910. This report emphasized the importance of education in basic sciences as a prerequisite and a complement to clinical experience in the training of physicians. 16 With regard to the historically Black medical schools operating at the time, the Flexner report recommended that only the Howard and Meharry programs remain operational, as Flexner believed these schools alone had the potential to meet the new requirements for curricula, faculty, and facilities. 5,6 Although historically Black medical schools faced other challenges during this period, including limited funding and facilities, student financial hardship, and the cumulative disadvantage of discrimination and segregation in premedical education, 14,17 the Flexner report represented a turning point. After the publication of this report, all but 2 of the historically Black medical schools, including several that were thriving at the turn of the century (as indicated by enrollment and graduation patterns), 18 closed. In the present study, outcomes of historically Black medical schools that are currently open were used to extrapolate projected workforce estimates of the number of African Americans who would have graduated with medical degrees if the schools that were closed after the Flexner report had been preserved and expanded.

Methods
Historical records were used to identify the number of graduates from 13 historically Black medical schools that are now closed. Sources of the data included Association of American Medical Colleges (AAMC) reports spanning the 2009 to 2010 through 2018 to 2019 graduation years, 19,20 schoolspecific reports of the number of graduates, 15 and previous research describing historically Black medical schools that were operating before the publication of the Flexner report. Schools that were closed before the Flexner report was published (ie, before 1910) were excluded, as those schools had few graduates and their closure was likely inevitable during that period. Therefore, the study focused  students from Morehouse. The specific numbers of graduates from these schools are summarized in Table 2.
The simulated expansion in the number of historically Black medical school graduates at the closed schools is summarized in Table 3

Discussion
During the first 2 decades of the 20th century, the number of medical schools that provided training to African American students rapidly decreased, a development associated in part with the 1910 Flexner report, which recommended that, among the historically Black medical schools, only the Howard and Meharry programs should remain operational. 14  historically Black medical schools provided training to 1 in 5 Black medical school graduates in the US. 17,29 Although not all US medical schools were formerly segregated, as of 1968, Black students represented only 2% of medical student enrollment. In response to these data, the AAMC announced in 1970 that its goal was to increase the enrollment of Black medical students to 12%. 17 Despite slow progress over the subsequent 50 years, this percentage of representation has not yet been achieved.
The proportion of African American physicians was 6% in 1991 and 7% in 1997, and it had not reached 8% as of 2019. 30 Although various initiatives at the medical schools of predominantly White institutions were undertaken to support the recruitment and graduation of African American students, this lack of expansion suggests that increasing the availability of medical education at historically Black colleges and universities, a strategy last implemented in 1981 with the founding of the Morehouse School of Medicine, could be an important step toward meeting the AAMC's 1970 goal.
Among the principal challenges of historically Black medical schools before the Flexner report was securing the facilities and funding to enable their continued operation. 14 This challenge was compounded by ongoing segregation within the medical profession and the educational system in general. 18,31 The AAMC requirement that medical school matriculants have a 4-year high school diploma, for example, was associated with a decrease in historically Black medical school enrollment that started as early as 1906, 4 years before the publication of the Flexner report. 18

Limitations
This study has several limitations. As with other studies that have estimated projected outcomes from the hypothetical continued operation of historically Black medical schools that were closed in the early 20th century, our analysis was constrained by limited data and incomplete information about the contemporary opportunities and challenges encountered by the schools' administrators. 18 In addition, variable and incomplete data on year-specific enrollment and graduation rates prevented us from performing more complex mathematical modeling (eg, incorporating nonlinearity in the projected rates of expansion). As observed in data from the historically Black medical schools operating today, expansion occurs in stages rather than in a linear manner. Using retrospective analysis to estimate when a school might have, for instance, added 10 more spots to its enrollment class was beyond the scope of available data. Furthermore, our estimates of projected increases in the number of graduates focused on the pattern of the total number of physicians who received training at each school but not specifically on the number of African American physicians who received training. Reliable data on the racial and ethnic self-identification of medical students before the 1970s are limited, and we concluded that jointly modeling changes in the number of graduates and the proportion of African American graduates would have required excessive assumptions given the data available.
The potential consequences of the continued operation of additional historically Black medical schools remain a matter of conjecture and are dependent on the distinct circumstances of each institution. 14 What is more likely, however, is that the closure of these schools, combined with other changes in medical education, curtailed the number of new African American physicians, helping to create a disparity that persisted across generations and continues to have implications for the medical workforce more than a century later.

Conclusions
Our study projected estimates of the number of African American physicians who would have graduated from closed historically Black medical schools if those schools had remained open. Even with the use of conservative assumptions, the continued operation of additional historically Black medical schools after the publication of the Flexner report in 1910 could have changed the course of American medicine, both quantitatively, through a substantial increase in the diversity of the physician workforce, and qualitatively, through an increase in the number of mentors and role models who might have encouraged many African American students to pursue a career in medicine.
Furthermore, because physicians and students from underrepresented minority groups graduating from historically Black medical schools have disproportionately pursued clinical practice, research, and advocacy that target the needs of medically underserved communities, 28