Meeting the Challenge of True Representation in US Medical Colleges | Health Disparities | JAMA Network Open | JAMA Network
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Invited Commentary
Medical Education
September 4, 2019

Meeting the Challenge of True Representation in US Medical Colleges

Author Affiliations
  • 1New York Academy of Medicine, New York
  • 2Department of Pediatrics, Psychiatry and Behavioral Sciences, Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, New York
JAMA Netw Open. 2019;2(9):e1910474. doi:10.1001/jamanetworkopen.2019.10474

The article by Lett et al1 is timely and has implications for the development of more-effective policies and practices to promote equity in our training of the physician workforce. The authors pose the question of whether the Standards on Diversity 2009 accreditation guidelines of the Liaison Committee on Medical Education (LCME)2 improved the underrepresentation of minorities in medicine. In other words, did the LCME move the needle in achieving diversity and equitable representation? The short answer is no. The main findings of Lett et al1 are that black, Hispanic, and American Indian and Alaska Native students remain underrepresented among medical school matriculants compared with the US population and that this underrepresentation has not changed significantly since the institution of the 2009 LCME guidelines. The authors’ methods are robust, and their conclusions are insightful.

The driving force for the nearly universal acceptance of the need for diversity and inclusion in the past decade is that diversity and inclusion in the workforce are associated with the quality of our health care system, its research priorities, and its system of health care delivery to ensure that everyone has the opportunity to live a healthy life.3 Thus, the findings by Lett et al1 lead to the question of how to transform the medical educational system to yield the results we seek. Furthermore, what is the potential of the accrediting body to bring about change? What can account for the minimal progress made as assessed by Lett et al?1

The LCME is the accrediting body for medical schools in the United States and Canada. Accreditation is a voluntary, peer-reviewed process meant to serve the general public and medical students. Compliance with 12 standards in 4 categories—institutional, education, medical students, and faculty—is required. The 2019 education standard4 relates to the academic and learning environment, especially element 3.3, “Diversity/Pipeline Programs and Partnerships.” The current standards do include several elements that attempt to change culture (eg, elements 3.3, 3.4, 3.5, 3.6, 6.6, 7.2, 7.5, and 7.6). Element 10.2, which addresses the final authority of admissions committees, is not explicit in its commitment to diversity and inclusion.4

The LCME change in 2009 brought attention to diversity as an expectation for an institution. Institutional standard 16 dictated that, “Each medical school must have policies and practices to achieve appropriate diversity among its students, faculty, staff, and other members of its academic community, and must engage in ongoing, systematic, and focused efforts to attract and retain students, faculty, staff, and others from demographically diverse backgrounds.”2 This is a tall order, calling for fundamental and systemic changes to address all aspects of recruitment, retention, and active support throughout the organization. Superficial changes would be unlikely to yield greater numbers of faculty, students, or staff in designated underrepresented groups. Attention to structural barriers to selection and advancement of traditionally underrepresented groups may, in fact, create tensions within an organization, involving the processes of human resources, legal counsel, and the office of diversity and inclusion. Faculty development to address both overt and implicit biases has received attention, but without a fundamental change in leadership hierarchy and representation and continuous focus in targeted areas, improvement in matriculant numbers is unlikely.5

Complicating the LCME process is the actual selection of the minority group targeted for demonstrating compliance with the standard. Identification of the demographic data of the population served by the medical school is essential. An institution is unlikely to target a particular group for improvement in student selection if its probability of success in faculty and staff recruitment of that minority group is not promising. Demonstrating compliance becomes a goal in itself, rather than creating genuine partnership with the community to address core historical injustices. In addition, a priori established recruitment strategies must be detailed and transparent, with tracking of the applicant numbers, the number of applicants interviewed, number of offers, and number of acceptances. These strategies must be tied to the resources available to support students, faculty, and staff recruited.

Medical student diversity standard 8 states, “Each medical school must develop programs or partnerships aimed at broadening diversity among qualified applicants for medical school admission.”2 This imperative is difficult for schools that do not have a tradition of bona fide partnerships with communities, such as those with predominantly African American, Latinx, and American Indian and Alaska Native populations. Advancing the goal of true and effective partnerships is an institutional commitment that must coincide with the attempts to show compliance with the LCME goal of reaching diversity and inclusion. Programmatic efforts showing activities that reflect some level of partnering are important but may not establish full institutional muster for the development of curricula that both attract, support, and retain classes of students that believe in the authenticity of those efforts.

Where do we go from here? The challenges of changing culture and structural bias and racism are daunting. To meet those challenges, colleges and universities must fully tackle processes that are difficult to remediate and take on the implementation of policies and practices at every level of the organization to address the root causes of underrepresentation. Inviting community leader participation to understand the barriers to improvement and recruitment of staff, faculty, and students would be a first step. Here are some additional proposed solutions for the LCME.

First, disaggregation of data may yield information regarding colleges or schools of medicine that actually have substantively changed their cultures with proven results. Examination of methods of improvement may be helpful—that is, the LCME must evaluate the effectiveness of its own policies and practices. As noted by the LCME’s document about the functions and structure of a medical school,4 the LCME does seek feedback on the validity, importance, and clarity of the standards and elements from the medical education community and its sponsoring organizations (eg, the Association of American Medical Colleges). Other authors have examined the meaning and application of medical accreditation standards,6 as well as reasons for severe action decisions by the LCME,7 but the LCME could communicate whether it has assessed the effectiveness of the standards and the process to yield changes in areas such as equity in the physician workforce. In addition, in the face of evident health disparities based on racial/ethnic factors, the LCME could serve an important role in evaluating whether compliance with LMCE standards (eg, standard 6, “Competencies, Curricular Objectives, and Curricular Design”) sufficiently addresses the priority health concerns of communities, regions, or the nation and is associated with improvements in the health status of all populations.8

Second, Lett et al1 might want to analyze whether some schools were more effective than others in achieving broader representation and gaining greater representation of subgroups (eg, African American men) and addressing downward trends. Currently, schools are free to implement the broad mandate of achieving greater diversity and inclusion as they wish. The devil is in the details, and the LCME may want to look more deeply at diversity at the senior leadership level, faculty, student, and staff level, as well as the quality of community–medical school and university partnerships, and require independent evaluations. Specific scores for curricula alignment with social mission and diversity and inclusion could be required as metrics for demonstrating compliance.9,10

The analysis by Lett et al1 suggests that there must be real commitment to long-term goals of achieving equitable representation in the medical workforce to be successful in improving the health of populations. Corollary solutions to achieving the health of all populations relate to the transformation of medical college curricula, grounded in the concepts of social accountability and a reexamination of the criteria for admission to medical schools, both of which merit serious consideration.

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Article Information

Published: September 4, 2019. doi:10.1001/jamanetworkopen.2019.10474

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Laraque-Arena D. JAMA Network Open.

Corresponding Author: Danielle Laraque-Arena, MD, New York Academy of Medicine, 1216 Fifth Ave, New York, NY 10029 (

Conflict of Interest Disclosures: None reported.

Lett  LA, Murdock  HM, Orji  WU, Aysola  J, Sebro  R.  Trends in racial/ethnic representation among US medical students.  JAMA Netw Open. 2019;2(9):e1910490. doi:10.1001/jamanetworkopen.2019.10490Google Scholar
Liaison Committee on Medical Education. Liaison Committee on Medical Education (LCME) standards on diversity. Published 2009. Accessed July 29, 2019.
Laraque  D, Szilagyi  PG.  Disparities in utilization of mental health services: explanations and possible solutions.  Acad Pediatr. 2009;9(2):65-66. doi:10.1016/j.acap.2009.01.001PubMedGoogle ScholarCrossref
Liaison Committee on Medical Education. Standards. Published March 2018. Accessed August 5, 2019.
Pritlove  C, Juando-Prats  C, Ala-Leppilampi  K, Parsons  JA.  The good, the bad, and the ugly of implicit bias.  Lancet. 2019;393(10171):502-504. doi:10.1016/S0140-6736(18)32267-0PubMedGoogle ScholarCrossref
Kassebaum  DG, Eaglen  RH, Cutler  ER.  The meaning and application of medical accreditation standards.  Acad Med. 1997;72(9):808-818. doi:10.1097/00001888-199709000-00019PubMedGoogle ScholarCrossref
Hunt  D, Migdal  M, Waechter  DM, Barzansky  B, Sabalis  RF.  The variables that lead to severe action decisions by the Liaison Committee on Medical Education.  Acad Med. 2016;91(1):87-93. doi:10.1097/ACM.0000000000000874PubMedGoogle ScholarCrossref
Boelen  C.  Coordinating medical education and health care systems: the power of the social accountability approach.  Med Educ. 2018;52(1):96-102. doi:10.1111/medu.13394PubMedGoogle ScholarCrossref
Mullan  F.  Social mission in health professions education: beyond Flexner.  JAMA. 2017;318(2):122-123. doi:10.1001/jama.2017.7286PubMedGoogle ScholarCrossref
Khan  MS, Lakha  F, Tan  MMJ,  et al.  More talk than action: gender and ethnic diversity in leading public health universities.  Lancet. 2019;393(10171):594-600. doi:10.1016/S0140-6736(18)32609-6PubMedGoogle ScholarCrossref
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    1 Comment for this article
    Failed social policies
    Michael Plunkett, MD, MBA | Practice/ teaching
    Good points. But very difficult to solve. This is not a problem of medical school acceptance rates. It’s the culmination of failed social policy from last 50 years. How can you expect a minority student from the south and west side of Chicago and its notoriously poor public schools to compete against immigrant minority students whose cultures worship educational achievement, sacrifice, and hard work?

    It’s truly not medical education’s fault. Medical education is handed this problem and it’s not their problem to solve. They have neither
    the tools nor the resources.

    On the other hand, how about trying this experiment?

    Have CPS select 300 of their best grade school students who evince an interest in becoming physicians and send them on to Northside Prep (or even better, to New Trier). Guarantee them a place in the freshman class at the U of I medical school in eight years if they have met high benchmarks. Give them all the tutoring they need. Guarantee them a coordinated undergraduate university program and continue to support them there so they might achieve the benchmarks.

    It would take eight years. But it would be a wonderful investment in the chosen students and it would show that we as a nation are willing to walk the talk.