Open Access
Medical Education  |   February 2021
The history of medical education: a commentary on race
Author Affiliations & Notes
  • Yasmeen Daher, OMS IV
    A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, AZ, USA
  • Evan T. Austin, MS IV
    The University of Arizona College of Medicine, Phoenix, AZ, USA
  • Bryce T. Munter, MS IV
    The University of Arizona College of Medicine, Phoenix, AZ, USA
  • Lauren Murphy, MS I
    The University of Arizona College of Medicine, Phoenix, AZ, USA
    The Department of Obstetrics and Gynecology, Banner University Medical Center-Phoenix, Phoenix, AZ, USA
  • Kendra Gray, DO
    A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, AZ, USA
    The University of Arizona College of Medicine, Phoenix, AZ, USA
    The Department of Obstetrics and Gynecology, Banner University Medical Center-Phoenix, Phoenix, AZ, USA
  • Corresponding author: Kendra Gray, DO, MS, A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, AZ, USA; University of Arizona College of Medicine, Phoenix, AZ, USA; and the Department of Obstetrics and Gynecology, Banner University Medical Center-Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006-2612, USA, E-mail: KendraMGray@gmail.com  
Article Information
Medical Education
Medical Education   |   February 2021
The history of medical education: a commentary on race
The Journal of the American Osteopathic Association, February 2021, Vol. 121, 163-170. doi:https://doi.org/10.1515/jom-2020-0212
The Journal of the American Osteopathic Association, February 2021, Vol. 121, 163-170. doi:https://doi.org/10.1515/jom-2020-0212
Abstract

The institution of medicine was built on a foundation of racism and segregation, the consequences of which still permeate the experiences of Black physicians and patients. To predict the future direction of medical inclusivity, we must first understand the history of medicine as it pertains to race, diversity, and equity. In this Commentary, we review material from publicly available books, articles, and media outlets in a variety of areas, including undergraduate medical education and professional medical societies, where we found an abundance of policies and practices that created a foundation of systemic racism in medical training that carried through the career paths of Black physicians. The objective of this Commentary is to present the history of race in the medical education system and medical society membership, acknowledge the present state of both, and offer concrete solutions to increase diversity in our medical community.

The notion that one race may be better than another and therefore more worthy of guidance, resources, formal education, prosperity, and even quality of life is a social and moral toxin constructed from within the trenches of White supremacy. This oppressive and diseased way of thinking has resulted in the chronic asphyxiation of capable and deserving individuals’ dreams, livelihoods, careers, and time. It is no question that the United States was built upon these lethal ideas. Medicine and medical education are no different, intentionally built from a legacy of segregation that haunts our society in both straightforward and insidious ways. This dark history of racial exclusivity set up Black medical students and physicians to be cast out from every facet of premedical education, medical education, and professional work. 
There is a significant body of work in medical literature and history books recognizing the racist policies and practices that prevented Black students from obtaining an undergraduate medical education. Once students were able to attend medical school, continued racist policies prevented them from obtaining society memberships critical to their success as physicians. In a study exploring minority perception of medical school admissions, perceived barriers for admission to medical school included information on admissions, guidance and social support, financial and academic factors, and persistence. 1 There has also historically been a lack of underrepresentated minority (URM) representation in medical school faculty positions, 2 which may have contributed to the lack of encouragement for Black students to obtain a medical education. In addition, in a 1987 study by Bullock et al., 3 30 of 31 Black medical student interviewees divulged having racist experiences during their medical school education. Notably, a study 4 exploring racial disparities in the Alpha Omega Alpha Honor Society (a membership society open to medical students, residents, fellows, faculty members, clinicians, and other leaders) demonstrated that Black medical students were less likely to be members of Alpha Omega Alpha than their White counterparts, reflecting possible bias in selection. Lack of membership in this and similar professional societies could impact career opportunities for any physician. 
Research about the history racial disparity in education and society membership is crucial to the field of medicine and medical education, because we must better understand the past in order to combat these inequalities in the future. To predict the future direction of medicine with regard to inclusivity, we must first understand the history of medicine as it pertains to race, diversity, and equity. For this Commentary, we searched various sources for previous publications documenting racism in medicine; these sources included books, articles, and media outlets. We synthesized the information we found to present this Commentary on the history of race in the medical education system and medical society membership. In it, we describe the present state of both and offer concrete solutions to increase diversity in the medical community. 
Undergraduate medical education admissions
Before 1865, American medical schools in the South were completely closed to Black students, while a select number of northern schools allowed Black students admission. 4 Seven allopathic medical schools were formed between 1868 and 1904 specifically to educate Black students; 4 this was in alignment with the U.S. Supreme Court’s decision in Plessy v Ferguson in 1896, which upheld the constitutionality of segregation and provided the legal foundation for two Americas (one Black and one White). 5 All but two of these schools (Meharry Medical College and Howard University College of Medicine) were closed by 1923, with the majority of schools closed within five years of publication of the Flexner Report, 6 a periodical of controversial historical merit 7 in which Abraham Flexner assessed the strength of all U.S. medical schools based on their admission standards, faculty, and available learning experiences. 6 Flexner’s goal was to eliminate the “over-production of uneducated and ill-trained medical practitioners,” highlighting that medical education had become its own for-profit industry lacking quality control measures to protect the public from inept graduates. 6 Flexner’s unequal assessment standards led to closures that disproportionately impacted Black schools. He evaluated the “need” for medical schools based on population, calculating how many physicians he felt would be needed to serve a given community. Flexner reported that “the practice of the Negro doctor will be limited to his own race,” but “the medical care of the Negro race will never be wholly left to Negro physicians. 6 ” Baker et al., 8 in an AMA-convened panel, correctly interpreted that Flexner’s population-based approach did not separate schools that educated Black physicians when he calculated what would be “needed” to care for Black patients 9 Flexner based his opinion on the worthiness of candidates to enter medical schools on multiple criteria, including (but not limited to) prior postsecondary education (favoring 2 or more years of college vs. a high school certificate or equivalency test) and standardization of entrance exams for medical schools; both criteria may have been more prohibitive to Black students based on other discriminatory practices at that time. 8 Baker 8 reported that if Flexner had standardized these population criteria, the results would have shown the need for more medical school openings to train the Black physicians required by more than 9 million Black Americans in the country. 9  
Flexner acknowledged that Meharry Medical College and Howard University College of Medicine were, “of course, unequal to the need and the opportunity” 6 in educating Black physicians, but neither the report nor professional medical societies like the American Medical Association (AMA) offered any plan or framework for how to address this discrepancy. 9, 10 At the turn of the 20th century, charity hospitals and those established by the Freedman’s Bureau were often the only access to medical care for Black patients, creating extreme inequalities in access to and quality of health care. 11, 12 In a review of the Flexner report 100 years after its publication, Steinecke and Terrell 13 described the 2-page chapter of the Flexner report titled, “The Medical Education of the Negro,” saying that Flexner “promoted the limited education of the African American doctor as a service to ‘his own race,’ but also for the larger purpose of protecting Whites from the African American population’s potential to spread disease.” Black physicians remained the primary health care providers for Black patients, 14 with their numbers decreasing after the Flexner report as a result of his ideology; it is estimated that as few as 25 Black physicians were the primary providers for Black patients in the entire state of Mississippi prior to the civil rights movement. 13, 14  
As Black students and physicians fought for their space in allopathic medicine, the world of osteopathic medicine was beginning to take form. In 1892, A.T. Still began educating physicians in Kirksville, Missouri. 15 Despite being an active abolitionist outspoken against slavery and a supporter of women pursuing education in medicine, 15, 16 Still could not invite Black students to attend his osteopathic medical school because admission required an official high school degree. 17 At the time, Kirksville only offered Black students a K–8 education. If they wanted a high school education, Black students had to travel over 30 miles each day to a different town that allowed them access to an education past the eighth grade. 18  
Professional medical societies
Black physicians continued to face barriers after completing undergraduate medical education programs, including injustices perpetrated by professional medical societies. As Baker et al. 19 described in their analysis of African American Physicians and Organized Medicine,

Medical societies were the crucibles in which the organized profession of medicine was formed. Within them, physicians met and developed relationships with professional colleagues and provided a forum to present papers and learn the latest techniques and treatments. After 1900, hospital admitting privileges became closely linked to medical society membership, as did relationships with state licensing and regulatory bodies. By the 20th century, exclusion from these societies often meant professional isolation, erosion of professional skills, and limitations on sources of income. 20

 
Many medical societies either actively refused to admit Black physicians or allowed for passive exclusion through failure to adopt nondiscrimination policies. Historically, any medical school or local medical society could send a delegation the AMA’s national convention, which was the primary route to AMA membership. Therefore, membership in a local medical society was necessary in order to acquire an AMA membership, yet many of these societies blatantly ostracized individuals on the basis of race. 19, 20, 21 For example, three Black licensed physicians – Alexander Thomas Augusta, Charles Burleigh Purvis, and Alpheus W. Tucker – were denied entry into the Medical Society of the District of Columbia “solely on account of color”. 22 Thus, exclusion from the Medical Society of the District of Columbia also meant exclusion from the AMA. To bypass these racist policies and obtain AMA membership, the National Medical Society (NMS) was formed in 1870, and the group applied for tributary status in the same year; the NMS was racially integrated at its onset. 20, 22 However, the NMS received numerous ethics complaints at the 1870 AMA meeting and many voters urged exclusion from the AMA. 20 This movement was put to a vote, which passed 114 to 82; 23 the 36 delegates of the Medical Society of the District of Columbia were included in that vote. 20, 23  
In response to their exclusion from AMA-affiliated local medical societies, Black physicians founded many of their own local societies, but they still lacked a national organization. This changed in 1895, when Black physicians formed the National Medical Association. 19 Although neither the NMA nor AMA explicitly excluded members based on race, organized medicine remained largely segregated, with the AMA consisting of mostly White members and the NMA consisting of mostly Black members. 20 Many members of the NMA went on to participate in the Civil Rights Movement. 24 For example, Dr. William Montague Cobb, editor of the Journal of the National Medical Association (JNMA) from 1949 to 1977 25 and president of the NMA from 1964 to 1965, 26 published the Integration Battlefront column in JNMA, 27 which covered civil rights issues in the realm of medicine. Meanwhile, as Baker et al. described, “The AMA, in contrast, was widely seen as uninterested in, or even obstructing, the civil rights agenda. 20 ” Furthermore, the AMA did not condemn racist policies until 2008. 28  
The barriers faced by Black physicians in academia and society membership, coupled with the fact that they were the primary healthcare providers for Black patients living in the South during the civil rights era, 13, 14 created a system in which Black communities experienced severely limited access to patient care. The catastrophic effects of the Flexner Report, 7 discriminatory practices by the AMA, and laws that kept medical schools from educating Black physicians speak to the deeply-rooted oppression in our country’s medical history. It clearly shows that a foundation was laid in this country to carefully and systematically exclude Black men and women from positions of power, whether in the form of an easily accessible high school education, admission to medical school, or membership to a society arguably needed for successful medical practice. 
Acknowledging the present state to improve our future
Major systemic changes within medical education and training are necessary to actively combat the history of racism and bias in medical schools and residencies, the breadth of which cannot possibly be addressed in this Commentary. As Welton et al. 29 eloquently described, “Educational institutions are called such for a reason, because their unspoken norms and social agreements have a long history that has been ‘instituted’ or developed over time, and thus become deeply entrenched into the fabric of how they operate.” While this serves the purpose of allowing for more focus on the education itself over maintaining order, it all too often creates a situation in which “…an educational institution’s public commitment to racial justice in the end is simply rhetoric or ‘just talk’ because any real action would cause the institution to break away from the ease of norms it has long benefited from. 30 ” Welton et al. 29 also provided a conceptual framework for antiracist change. In that model, five components of change were identified: context and conditions focus of change, scale and degree, leadership, and continuous improvement cycle. Guidelines were given for how to address each of those on both an individual and systemic level. Some examples of actions to be taken include conducting departmental climate surveys, examining admissions data over the past 10 years, implementing implicit bias professional development, providing professional development for diverse leaders, and asking key questions in the admissions process such as identifying where recruitment is taking place. 30 While much of this change can be broadly applied to all types of postsecondary education, there are key strategies that medical schools and societies can specifically implement to improve the current inequalities in medical school admissions, racially biased medical education, and society membership. 
One possible starting point for change is the adoption of implicit association testing (IAT) at medical schools. IAT measures the strength of associations between concepts (e.g., White people, Black people) and evaluations (e.g., good, bad) or stereotypes (e.g., lazy, hard-working). 31 This form of testing serves to measure attitudes and beliefs that people may be unwilling or unable to report. While explicitly racist attitudes, beliefs, or stereotypes still permeate society, the fact that these are deliberate and reported presumably make them much easier to address and remedy. Implicit attitudes, beliefs, or stereotypes, on the other hand, are relatively inaccessible to conscious awareness or control, theoretically making them much harder to identify or address, even for the very person holding such attitudes, beliefs, or stereotypes. 29 When not accounted for, negative outcomes from these associations (such as choosing to deny medical school entry to a qualified Black applicant) can be just as, if not more, harmful than the outcomes that come along with racist explicit associations. In a research study of implicit bias at the Ohio State University College of Medicine (OSUCOM), 32 the admissions committee took a Black-White implicit association test (IAT) before the 2012–2013 admissions cycle. All groups (men and women, students and faculty) displayed significant levels of implicit White preference. 33 Of admissions faculty surveyed, 48% were conscious of their IAT results when assessing candidates for the next cycle, and 21% reported knowledge that their IAT results affected their admission decisions. This led to a 26% increase in URM matriculation and created the most diverse class in OSUCOM’s history for the admissions cycle immediately after the study was conducted. 33 This is a notable achievement given that in 2019, Black medical students made up only 7.4% of all student physicians. 34  
However, it is not enough to simply admit more racially diverse students into our country’s medical schools, as inequities continue to exist once students have matriculated. There is a growing body of evidence pointing to the disproportionate prevalence and harms of microaggressions toward racial/ethnic minorities in medical school and clinical training. 32, 35, 36 These subtle statements or behaviors that unconsciously communicate denigrating messages negatively affect learning, academic performance, and overall well-being. 32 A recent study examining stress coping and resiliency among Black men in medical school reported that perceived academic inequities such as lower academic expectations, less access to academic resources, and social isolation caused tension for Black medical students, creating an environment in which the general stress of medical school was compounded by additional race-related stress. 37 This was demonstrated in a 2007 report from the AAMC 35 investigating attrition rates in medical schools, in which researches found that Black students had an attrition rate of approximately 7% compared to White students with an attrition rate of less than 1%. 34 Furthermore, only about 60% of Black students graduate by year four of medical school, compared with approximately 90% of White students. 34 To address these microaggressions and other harmful racist behavior, we suggest that schools implement ways to report these incidences that is supported by accountability measures. For example, the Ohio University Heritage College of Osteopathic Medicine has a reporting tool accessible to all students for instances of bias or hate-motivated incidents witnessed or experienced in the academic or clinical setting. 38 Once reported, a triage team assesses and investigates the report to address or implement appropriate accountability measures. Similarly, the Georgetown School of Medicine has a Medical Student Life Advisory Committee which provides multiple avenues to report racist or discriminatory behavior, which is then reviewed by a subcommittee composed of at least two faculty members and one student to review and investigate claims. 39  
Fortunately, the IAT has been shown to be useful not only for increasing racial diversity in medical school admissions, but also for decreasing racial bias in medical students during their education. In a study of 3,547 students from 49 U.S. medical schools, participants were asked to report their experiences with the amount and favorability of interracial contact during school, as well as formal and informal curricula related to race, health care, and cultural competence. 40 Questionnaires were administered during the first and last semesters of medical school to determine whether students changed their implicit racial attitudes after taking the Black-White IAT. 40 Completion of the Black-White IAT during medical school was a statistically significant predictor of decreased implicit racial bias. Medical school experiences were also independently associated with change in student implicit racial attitudes. 40  
While the IAT serves as a valuable starting point for change, it is insufficient alone. We also propose that medical schools continue to modify their curricula to further emphasize race and racism. For example, an investigation of imagery used in the preclinical curriculum at the University of Washington School of Medicine noted that of the 5,230 images that could be coded by race/ethnicity, only 1,130 (21.6%) involved people of color. 41 It is easy to foresee how such unequal representation could further contribute to healthcare inequities and biases, both overt and implicit. Fortunately, some progress has been made on this front. When second year medical student Malone Mukwende of St. George’s University of London noted the lack of education on clinical findings on darker skin, he collaborated with a senior lecturer to create Mind the Gap – A Handbook of Clinical Signs in Black and Brown Skin. 42 This handbook was previously only available to St. George’s University students, but now is publicly available online. 43  
Curricular programs focused on addressing race and racism have already been implemented by some medical schools across the country. For example, the University of Minnesota Medical School convened a 12-month curriculum informed by Public Health Critical Race Praxis methodology, with an aim to better help students from marginalized groups and privileged groups discuss the concepts of racism. 44 Columbia University School of Medicine created a racially diverse student-faculty task force dedicated to promoting a bias-free curriculum, which has led to the development of guidelines for faculty to promote increased awareness of bias in their curricula as well as formation of an online portal for Columbia students, staff, and faculty to anonymously submit narratives of troubling and positive experiences regarding inclusivity and bias. 43  
While implementing new curricula that address race and racism is ideal, we acknowledge that this process has the potential to be burdensome in time, resources, and finances. As a result, we also recommend modifying existing curricula, which may be timelier and more feasible solution for medical schools. Such work has already been started by Krishnan et al., 45 who noted inadequate presentation of race and culture in the virtual case-based courses produced by the nonprofit organization Aquifer (formerly MedU), which is currently used by over 95% of U.S. medical schools. In their work, they identified six themes describing common mistakes/pitfalls in the presentation of race and culture in Aquifer cases, then created a race and culture guide for systematic case revision that works to address each of these themes. As a result of this work, Aquifer has started to integrate this guide into their editorial workflow and begun a structural review of their core cases in pediatrics, internal medicine, family medicine, and geriatrics. 46 We suggest that medical schools take a similar approach to their curriculum and encourage potential use of this guide, 45 or at least the principles in it, to revise or modify their current curriculum. 
Furthermore, we encourage medical schools and societies to acknowledge the role they have played in promoting inequity throughout history and fight to correct it with actionable, achievable goals. While apologies cannot right prior wrongdoings, they can act as an important first step. In 2008, the AMA formally apologized for its long history of excluding Black physicians, and in 2019, its first chief health equity officer was hired to establish the AMA Center for Health Equity to focus on embedding health equity into the organization. 28 More recently, the AMA Board of Trustees pledged action against racism and police brutality. 43 The American Osteopathic Association (AOA) passed a resolution in 2017 encouraging an increase in URM graduates and faculty by 2020. 47 The American Association of Colleges of Osteopathic Medicine (AACOM) recently published a statement on racism and injustice in which they called for the need to “actively seek out racism– overt and implicit– so that we can change our practices, reshape our focus, and ultimately stamp it out by creating new ways of doing business. 45 ” These statements and pledges are important steps, yet we encourage the AMA, AAMC, and AACOM to be more concrete in their goals. 
One achievable goal to increase diversity in medicine is to increase the percentage of Black, indigenous, and people of color (BIPOC) in leadership roles to support Black medical students through their academic careers. 48 Medical schools and professional societies can achieve this by setting concrete metrics and by frequently, transparently reporting their progress toward those goals. The first Black woman Dean of an osteopathic medical school, Dr. Barbra Ross-Lee, became the Dean of Ohio University’s Heritage College of Osteopathic Medicine in 1993. 49 In an interview with AACOM, 50 Dr. Ross-Lee highlighted the need for accessible opportunity to increase minority students in medicine. This requires creating equal opportunity for all students, starting as early as elementary school. Exposing children at a young age to opportunities in science, technology, engineering, and mathematics, as well as medicine, opens their eyes to the possibilities available to them. When discussing the subject, Dr. Ross-Lee stated, “The goal of diversity should be to provide opportunities to people who otherwise would not gain access. 49 ” The AOA and AACOM do not currently list the number of BIPOC serving as Deans of Osteopathic medical schools on their websites; we would encourage this subtle but important opportunity for transparency. 
Another achievable goal is to provide financial support for URM students. AACOM has made progress in this endeavor; they provide two scholarships per year to URM students. 51 While this is a step in the right direction, it is quantitatively insufficient to increase matriculation of Black medical students. By increasing the number of scholarships available to Black students, we have to assume that opportunity would be increased. 
Currently, some medical schools are working to change the barriers and biases – both racist and otherwise – that have historically kept some students out. For example, A.T. Still University (ATSU) offers multiple programs to support their mission of creating a culturally-rich community that embraces all forms of difference. One of those programs is called “Dreamline Pathways,” which is a community-based program that works with K-12 students provide them with exposure and access to the healthcare professions and the many programs that ATSU offers. 50 Another such program is called “Prep for Success Intensive,” in which premedical students prepare for the MCAT and learn test-taking strategies. 50 Beyond that, ATSU has multiple committees dedicated to diversity and inclusion efforts in order to keep the conversation going on these important and ever-changing topics in medical education. ATSU also offers a program called the Graduate Health Professions Scholarship Program, which offers scholarships specifically for historically URM groups in medicine. 50  
Overall, the inclusion of BIPOC in leadership positions and implementation of interventions such as the IAT to help medical school admissions committees reflect on their own biases can help decrease racial disparities in medical education by encouraging institutions to admit more racially diverse classes to their schools. Financial support and other resources would increase the matriculation of Black medical students. Once these students are admitted, medical schools have an obligation to continue reflecting on these biases and ensure their curriculum addresses racism by teaching clinical medicine in a racially-unbiased way. Finally, once students graduate and become practicing physicians, they should have the ability to join professional societies that have appropriately acknowledged the past and are actively seeking to create a more racially-inclusive future. 
Conclusion
Medicine and medical education in the United States were constructed on a foundation of racial segregation and careful discrimination, the effects of which continue to plague this country. Insidious early limits on the practice and scope of Black physicians in America created an environment of real consequences for both physicians and the predominantly segregated communities they served. Acknowledging and addressing racism through measures curriculum reform, formal bias analysis, and equitable admissions and scholarship programs are some of the ways the whole body of medical education can work collaboratively to address injustice and the racial divide. We encourage osteopathic and allopathic medical schools to heed these suggestions, and to capitalize on the successes of the example programs included here. We also encourage medical programs to conduct more research into the history of graduate medical education and other racist practices that may have affected Black physicians’ careers outside of medical society membership. 
We are collectively responsible for continuing to actively lobby for equality and systematic change, not only in medical education but in all aspects of the healthcare system. In both our higher education system and our medical community, there is still much work to be done. We must invest in ourselves, in our students, and in the future of medicine by prioritizing and celebrating inclusivity, diversity, and racial equality. This way of thinking and living is created from intentional change-seeking. There is no better time than now to act and commit, seeking deliberate, structural, and revolutionary change making. 
  Research funding: None reported.
 
  Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
 
  Competing interests: Authors state no conflict of interest.
 
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