Race Preferences for Medical Practice

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Back in December ’04 UCLA Law Professor Richard Sanders published A Systemic Analysis of Affirmative Action in American Law Schools in the Stanford Law Review which detailed the costs to African-American students of being recipients of Affirmative Action (see here and here for the Cliff Notes versions.) As you can imagine this set off a fire storm of protest, similar in tone, though subdued in fury, to what followed the publication of Rushton and Jensen’s paper Thirty Years of Research on Race Differences in Cognitive Ability. Critics lined up to take their shots at Sanders. A good summary of the ensuing battle can be found at the Volokh Conspiracy, here and here (Be sure to read the comments.)

As with Ruston & Jensen’s paper, the controversy that followed Sanders was a clear case of conflicting Axioms with many of the rebuttals arguing from the Axiom of Equality, the Axiom of Proportionalism and Axiom of Social Justice, and were primarily worried about the decreased African American presence in law schools that would result if Affirmative Action was eliminated. In reading many of these rebuttals I was struck by the game theoretic aspects which argued that if Affirmative Action was eliminated that many African-American students would transfer their ambitions to other Professional Schools that still employed Affirmative Action policies. The critics argued that Law Schools shouldn’t abandon the crutch they’ve provided to minority students thereby foreclosing the prospect of losing these unqualifed students to rival faculties. The critics seemed to completely miss that Sanders was arguing from the Axiom of Merit, which he felt trumped the existing policies of the Law Schools.

After reading through the back and forth volleys I got to wondering why no similar study had been conducted on the effects of Affirmative Action within the medical community. Afterall, the stakes are certainly greater in that a medical student’s performance impacts on the health of patients, rather than simply their well-being (civil law) or freedom (criminal law.) What I really wanted to see was how medical malpractice suits were broken down by race of the physician but I couldn’t find any data at all. If anyone has access to such data, please leave a comment or e-mail me with the particulars.

I’m guessing the data is proprietary to insurance companies and is probably essential in determining insurance rates. After reading some of the data from the National Medical Association, which represents the interests of African-American physicians, it’s clear that obtaining malpractice insurance is a significant problem for its members, but considering that we’re in the middle of a malpractice crisis, it’s imposible to ascertain whether African-American physicians’ rates, and difficulty in obtaining insurance, are any different from the physican community as a whole.


However, even without the medical malpractice data, the consequences of Affirmative Action are evident in how minorities perform in medical school and in subsequent licensing examinations:

The study examined admissions records in two separate years at the five medical schools: the Medical College of Georgia, Michigan State University College of Human Medicine, the University of Oklahoma College of Medicine, the State University of New York’s Brooklyn College of Medicine, and the University of Washington School of Medicine.

[ . . . . . ]

For example, at Michigan State University’s College of Medicine in 1999, the median grade point average (GPA) for white admittees was 3.61, nearly an A-, while the median GPA for black admittees was 2.93, slightly below a B. Furthermore, the median MCAT score for blacks admitted to Michigan State that year was 29 (out of a possible 51 points) compared to 36 for whites.

[ . . . . . ]

These differences in admissions rates mirror the racial disparities in accomplishment on the first stage of the medical licensing exam. Scores from Michigan State averaged over a three year period show that 14% of black students failed the Step 1 of the exam, and 10% failed to take it, while among white students the failure rate was only 1% and the untested rate, 4%. Thus cumulatively, 24% of black medical students at Michigan State failed to complete the first stage of obtaining a medical license compared to only 5% of white students. Among Hispanics the combined rate was 8% and among Asians, 2%.

[ . . . . . ]

These figures are especially stark when one considers that the scores reported by Michigan State are final scores. Medical students are allowed to take Step 1 up to six times, and when a student fails several times, only the final result is reported. Thus the 14% of black students at Michigan State who are noted as failing the exam, may in fact have repeatedly failed to pass the exam and have a failure listed as their final result, and will not be able to obtain a medical license unless they are able to pass Step 1.

More disturbing than even the failure rate of minorities on the licensing exam, Clegg asserted, “is that even among the students who ultimately pass the exam it’s fair to assume that they are not going to be as successful as doctors as students who are academically better qualified would have been.” He continued, “You know one of the responses that we heard to our study was, well, what’s wrong with racial and ethnic preferences because no one’s going to be qualified to become a doctor unless they pass the exam…as far as patients are concerned, not only will there be fewer doctors, but the doctors who finally do become admitted are not going to be as good. The idea isn’t simply to admit students who are able to scrape by with a passing grade after taking the medical exam several times. We should be trying to have the best possible doctors, not doctors who are simply minimally qualified.”

It appears that Affirmative Action’s lenient admission standards weeds out the weaker candidates before the time for placement through the National Resident Matching Program sifts and sorts the nation’s medical school graduates and places them into residency programs. Surprisingly I didn’t find any declarative statements that the program grants any preferential treatment to minorities, so if this is a true condition, we’d expect to see more of a merit-based sorting based on the competitiveness of the various disciplines.

It’s frustrating that the data I’m seeking is not available, for I think it would be informative to get a racial breakdown of medical specialties and compare the results to the difficulty of winning admission into the medical specialties.

I did find this breakdown of Black Physicians in New Orleans, and using the competitiveness data above, 9% belong to the Extremely Competitive specialities, 15% to the Very Competitive, 30% to the Competitve and 46% to the Less Competitive. Again, the corresponding data from the medical community as a whole is difficult to extrapolate without access to more data sources. Here is a datasource on State Health Facts that some may find useful.

So what is the ripple effect of admitting minority students to medical school under preferential quotas? The evidence is clear that a sizable portion of minority students simply won’t get licensed to practice. Of those that do get licensed, I’d dearly like to know how well they perform without institutional favoritism shielding them from the full effects of competition and how well they adhere to professional standards.

Once out of medical school, the results of Affirmative Action can have real consequences:

This debate over the possible benefits of racial preferences at the nation’s medical schools was most famously raised by the 1978 Supreme Court case, Regents of the University of California v. Bakke, in which the Court ruled that the use of racial quotas in admissions was unconstitutional but continued to allow for an applicant’s race to “tip the balance” in his favor.

One famous beneficiary of racial preferences in admissions is Bernard Chavis, whose admission into the University of California’s medical school despite his inferior academic accomplishment prompted Bakke to file suit against the university. Long upheld as an example of the success of racially biased admissions programs, Chavis made a career serving poor minority communities until the Medical Board of California suspended his license to practice medicine in 1997, warning of his “inability to perform some of the most basic duties required of a physician” after one woman died and two more suffered serious complications after receiving liposuction from Chavis.

We also see problems with institutional slipping of standards, as Godless noted the problems facing two black medical schools:

A Courant analysis of disciplinary actions against doctors nationwide found, however, that both Howard and Meharry produce troubled doctors more frequently than most other schools – at rates about 10 times greater than the schools with the lowest numbers. The actions ranged from a simple citation to permanent license revocation for a range of misdeeds including medical incompetence, ethical lapses and criminal behavior.

The findings – controversial and politically sensitive as they are – defy simple explanation. [Really?...]

Howard and Meharry are not offshore schools with little accountability to U.S. regulators. Their programs are regularly reviewed and are subject to the same accreditation standards as all other American medical schools. They graduate many fine doctors.

So what accounts for the higher rates of disciplinary actions?

With the consequences of incompetence being so much greater in the field of medicine than in law, a study similar to the one conducted by Professor Sanders is urgently called for. If the Axiom of Merit loses ground to the Axiom of Proportionalism, we could see calls for increased enrollment under preferential guidelines for minority students as reported in The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in Health Professions by the National Academies Press:

A projection model developed by Libby yielded results indicating that in order to reach 218 physicians per 100,000 persons for each racial/ethnic group, the numbers of first year residents would need to roughly double for Hispanic and black physicians, triple for Native American physicians, and be reduced by two-fifths for white and Asian physicians.

Note how Asians are Honorary Whites in that report.

It’s difficult to model how reduced standards for minority students can be ameliorated if they are not as prepared as their colleagues for the rigors of medical school, have higher failure rates during their education, have a more difficult time passing licensing examinations, and with some schools at least, have a disproportionate presence in disciplinary hearings. Are we to believe that simply practicing their craft on innocent patients will over time increase their competence to the same level of their colleagues who weren’t admitted under preferences schemes?

Related: What do you call a black doctor? and ER Meets Reality and Bell Curve For Doctors

18 Comments

  1. 1) a lot of the rationale for the training of doctors from particular ethnic groups is so that they can go treat those particular ethnic groups (ie; the need for culturally fluent physicians, etc.). so, if black doctors are not as competent on average, i think some of the “bite” is taken out of the issue because they mostly treat black patients. if, for example, there was a “busing” equivalent where black doctors had to be proportionally represented throughout the hospitals of this country, including tony wealthy white enclaves, i think medical college admissions boards would be far less likely to push for diversity even if it meant a possible reduction in standards. 
     
    2) i assume that those who aren’t hemmed in by HMOs and can choose their physicians will simply engage in racial profiling.

  2. a lot of the rationale for the training of doctors from particular ethnic groups is so that they can go treat those particular ethnic groups 
     
    Yeah, this one is trotted out quite a bit. Here is what one doctor, writing on Medscape, had to say: 
     
    As a primary care physician in the Midwest who tries hard to keep up with the medical literature, I am dismayed by the implication of many recent articles that racial differences in medical usage and outcomes in America are due to racism, by which most people assume is meant racial prejudice, in this case by doctors and other healthcare providers.[1] There is no question that there are differences in frequency of medical procedures, hospital days, and health outcomes between different racial groups. However, the reason for these results is usually not clear. Controlling for education, income, and socioeconomic class usually, but admittedly not always, reduces these differences significantly. However, the fact that health outcomes are better for women, and often, Asians, would seem to argue against the simple argument, which some imply, that white doctors who are men are prejudiced in favor of white men and this explains all racial and group differences in intensity of medical interventions. 
     
    The facts that black patients often express a preference for black doctors and that black doctors more often practice in predominantly black neighborhoods are often used as a basis for the recommendation that we need to admit more black students to medical schools and graduate more black doctors. Yet the fact that white patients often express a preference for white doctors and that white doctors more often practice in predominantly white neighborhoods should not make us conclude that we need to cater to the prejudices of white patients, any more than we should to the prejudices of other groups. In addition, I am unaware of any studies that medical outcomes are any better when black patients, for example, are treated by black doctors, as opposed to white doctors. 
     
    As a white doctor who treats white, black, and a few Asian patients, let me make a few points that are obvious to me but are apparently not obvious to many writers on this subject. First, when I make the same points and same recommendations to different patients, some patients enthusiastically accept what I recommend, and some are very hesitant and skeptical. If patient A accepts my recommendation without argument, and patient B refuses my recommendation, despite taking 3-4 times as long to explain and answer his questions, does that prove that I am a racist if patient A is white and patient B is black? In my experience, on average, white patients tend, on average, to be very willing and often eager, to have medical tests and procedures done, whereas many black patients tend to be skeptical, especially about invasive procedures. Since many studies showing difference in procedure rates show little if any difference in clinical outcomes, it is often not clear if certain racial groups, such as blacks, have invasive procedures or surgeries too seldom, or whether other groups, such as middle- and upper-class white patients, have them more often than necessary. (Dr. John Wennberg’s studies have shown marked variation in frequency of surgeries and hospital bed days in different regions across the country, with generally little or no evidence that higher frequencies result in better clinical outcomes.) 
     
    If there are studies that prove that patient clinical outcomes are consistently better when patients are treated by a doctor of their own race, then I would admit that racism may well be a terrible problem in our healthcare system. I am unaware of any such studies. I am aware that lack of health insurance and lack of money to pay for medications are very serious problems in this country, and a major cause of poor clinical outcomes. Trumpeting racial differences in intervention frequency, or even outcome, as due to racism among healthcare providers, when there is no proof of that, is harmful, at least to the extent that it convinces members of certain racial groups, especially blacks, to think that our medical system is stacked against them, personally, because of their race. It is very counterproductive when it contributes to the mistrust of black patients for their physicians, most of whom, in my experience, are working very hard and long hours, while they are drowning in paperwork and constantly threatened with a malpractice suit if there is a bad outcome. It may also be a diversion from the well-documented and significant problem of 43+ million Americans (of all races) who have no health insurance and cannot afford medications or doctor visits.

  3. A friend told me that it was when he was very ill in hospital that he found that he was somewhat racist. The “consultant” (specialist) was due to visit him. “Please”, prayed my friend, “let him be a Scot or a Jew.” He proved to be both.

  4. Physician supply in America is artificially restricted to create a shortage which artificially boosts doctor wages and prestige. 
     
    Simply certify more valid medical schools, then allow the gov’t to guarantee as many medical student loans as they do all other disciplines, and the supply of doctors will boom, resulting in lowered salaries for them, and lowered medical costs for the rest. 
     
    A side effect here would be to lessen the acrimony about the currently unfair, tribally based, distribution of the scarce resource of med school places by increasing the total size of that pool. Ending quotas would also help. 
     
    FYI, as I heard it, the AMA has refused to certify any new US med schools since the early 1970′s, despite obvious demand. Med schools’ science demands are no harder, and usually easier, than graduate engineering/science schools. Yet while most 4-year campuses have a graduate engineering program, perhaps 1/4 or less have a med school.  
     
    Also, Congress decides a total # of med school tuitions to guarantee annually thru loan guarantees, thus limiting the total # of med students. They do this not for law, engineering, MBA programs, or any other field, but only for medical education, and at the behest of the medical lobby. 
     
    Stop this racket, and lower medical costs. Artificial market restrictions create artificially higher prices.

  5. Artificial market restrictions create artificially higher prices. 
     
    amen! (and law too!)

  6. Good, the comment thread on that bell curve doctor link hasn’t been trashed yet.

  7. You missed one of the more applicable posts in your related links, TM: The Bell Curve for Doctors.  
     
    Scroll down to the LA Times article on King-Drew. Even without AA, there would still be a race difference in doctor ability because there is still an IQ range for doctors. that leads to the very La Griffe conclusion, you have the best chance with a Jewish doctor. If I remember correctly Jewish hospitals typically cluster at the top.

  8. A good measure of medical doctors’ real market value is what they make, and how they are respected, in other nations with freer supply lines of medical students. 
     
    Most foreign MD’s make a good living, and are respected, approximatley to the level of engineers. They are not close to double (or more) the salaries of engineers, nor do they inflate their egos with superfluous titles. The idea of calling someone Engineer Smith, Lawyer Singh, or Architect Kowalski shows how silly this has gotten. Personally, I will not see an MD a second time who corrects me on using the doctor title in conversation. 
     
    Freeing the supply of MD’s, allowing drug imports, and limiting medical malpractice claims (lower insurance bills) should effectively halve the US healthcare bill in a few short years.

  9. “Artificial market restrictions create artificially higher prices. 
    amen! (and law too!)” 
     
    I think there are enough law degree holders but the good ones are special. 
    Those who cant be a good lawyer end up as paralegals. 
     
    In a few years, sniffing dogs and robo doctors will replace MDs who have memorized their way to graduation. 
     
    MD = memorization + science aptitude. 
     
    Law = memorization + logic + human interest + wit (cunning)  
     
    So I think good lawyers would not be replaced pretty soon but MDs…

  10. Let me play devil’s advocate. If you’re reading this blog you’re probably well aware of the differing distributions of intelligence by race. So we all agree that these differences exist, are significant and often dispositive with respect to qualifications in any given symbol manipulating occupation. 
     
    If the goal is having the best doctors, why not raise the difficulty of the MCAT or state licensing exams to the level where only 2% of those who pass today were able to pass? 
     
    The top 2% of performers are probably going to be much better doctors given the strong cognitive component involved in the practice of modern medicine. So if the goal is, only, to have the best doctors then as long as at least 1 person was capable of passing all of the examination requirements along the path to practicing medicine (thereby satisfying the possibility requirement) such a system should be preferrable to the system we have now. 
     
    So why don’t we have a system that, by virtue of diffulty, excludes all but the best of the best? I think it’s pretty clear that producing the best doctors is not the only goal of the current system of medical education. 
     
    This goal has to be subordinated to practical realities; graduating only 1 doctor a year would leave many people wanting for medical care. Graduating every person who entered medical school would probably produce too wide a variation in the quality of care for a profession. 
     
    So on what’s an admissions committee to do? Set the requirements in such a way as to balance the desire for maintaining certain standards of care against the capability of the native population and the demand for these services. It won’t do to require the brilliance of Einstein because, although this might produce the best doctors possible, the supply of such doctors in the native population is far exceeded by the demand for medical services. So we must, as a matter of practicality, accept less-than-the-best medical care. 
     
    Given that multi-ethnic societies are the norm and racial differences in the distribution of intelligence, the ‘capability of the native population’ component of the tradeoff facing an admissions committee should factor in any sizable portion of the native population. The result is affirmative action; practiced in pretty much every country with large minority populations.

  11. Tangoman, 
     
    Not all black distrust of white doctors comes from lack of resources. I personally tend to take many things a white doctor tells me with a grain of salt. I do trust black doctors more simply because they are black. Being black alone would commend me to a B average doctor over a white A average one. I trust white doctors more if they show they are aware of biological differences between black and whites. If not, I may be tempted to discount his advice in some instances and calibrate for what makes the most sense to be. And in that case, what’s the point of seeing a doctor? 
    You have to understand that in this country, blacks (correctly) tend to regard “general” information as being pertinent more to whites than to blacks. e.g.  
     
    Osteoporosis – All the TV adverts urging all women to drink milk fail to mention that I as a black female am not very likely to get osteoporosis, while milk fat could contribute to my health problems. 
     
    The point is, living as a minority who is biologically very different from the general populace, I need the psychological comfort of a doctor who looks like me. I think it may yield in better healthcare for minorities, not because there is a higher quality of care, but because my psychological comfort makes me more likely to follow the advice of a doctor. And that is the crucial piece for achieving good health……

  12. Graduating every person who entered medical school would probably produce too wide a variation in the quality of care for a profession. 
     
     
    a friend of mine who graduated from medical school says this is precisely what does happen. the reason is that medical schools and the loans industry have an investment in students that they allow to take out loans. if that student doesn’t become a doctor the chances of them repaying the loans are pretty low. so, not letting someone who gets into medical school become an MD is a real drag on the bottom line.  
     
    ina, you make good points, but those aren’t the only considerations at play here. i am skeptical that a B average doctor is going to be as competent as an A average doctor even assuming that the former has a cultural fluency advantange. it is also contingent upon speciality, cultural fluency is probably more important for gatekeeper professionals (internists, family docs, etc.). doctors should know about intergroup differences, but i don’t think that that would be at the top of the list in terms of what the doctor should know (ie; some doctors are probably much better at reading and absorbing the latest literature, and that is the most important issue for a lot of smart people who dislike having to regurgitate their own literature reviews for someone who is charging them $50-100/hour). i will grant that on average a same race doctor might have a marginal amount of extra affinity for the patient (i think this depends on the race), but, i think this issue is dwarfed by the self-interest of less than bright docs who want to keep their lucrative livelihood going even if they are giving their charges substandard care.

  13. Looks like a good source of information about medical school application, matriculation and graduation rates is http://www.aamc.org/data/facts/start.htm 
     
    From a rough scan the matriculation rates (~16.4k) hover about a thousand or so higher than the graduation rates (2000 – 2004). 
     
    Heh, that’s a pretty high graduation rate for any kind of grad school – if I recall something like half the people who enter grad school drop out.

  14. “I need the psychological comfort of a doctor who looks like me.” 
     
    Apparently many of every race feel like that.  
    Also very appropo when one is looking for a GYN or proctologist (no matter how good the opposite sex practitioner may be.)

  15. Alephnull: I followed everything you said up until the bit about affirmative action, but then you lost me. It’s clear that you can’t set unreachably high standards for doctors, teachers, or any other profession for which there’s a large demand. It’s clear that it matters what your local talent pool looks like, and that places with better educated or smarter people will end up able to impose higher standards on medical school entrance. But where does affirmative action enter into this logic? 
     
    Suppose we have a big multiethnic population, in which some groups get consistently better test scores and grades than others, and there’s some reason to think that this translates into being better at learning the stuff taught in medical school, and ultimately in being better doctors. Why would it not make sense to just set the bar for medical school entrance so that you got the necessary sized pool of doctors, and ignore the ethnic makeup of the doctors?

  16. It would be scary having a black doctor because as soon as you finish describing your symptoms he’d start rapping back his conclusions.

  17. “It would be scary having a black doctor because as soon as you finish describing your symptoms he’d start rapping back his conclusions.” 
     
    That’s lame. stop stereotyping blacks.

  18. I am an African American pre-medical student and I do plan on going to medical school . While surfing the net I happen to come across your comments and I was somewhat surprised at what I read. The author seems to be putting this iformation out as to dicourage medical school from accepting blacks into thier schools. What the author of this article fails to realize is that the majority of the black students who are entering medical school are coming from disadvantaged backgrounds. Sure that might sound like an age old excuse but at the same time this is the reality that we live in. How can one compare one student who has gone to the best school and one that simply didn’t. The color of my skin does not determine how I will do in college but the enviroment that I was raise in does. I am very sure that if there were a way to experimentally put some white children in bad schools all there lives and then put black children in the best schools the results would prove the very opposite of the findings stated in the article. So my point is simply this to whoever wrote this article. Don’t simply sit back and discourage african americans form going to medical school help them. What was truly the benefit of putting out such statistics? Was it to raise awarness and find ways to correct the problem or simply to bash a whole race you obviously know nothing about. If you see this as a big enough problem to do such extensive research on then what will you do to solve it. 
     
    Future African American Doctor Of America

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