2020 was undoubtedly a momentous year for medicine. From a global pandemic, to novel methods of treatment, to the development of a groundbreaking vaccine, science and healthcare have been front and center in public discourse. But with the rise of protests for racial justice in America another problem in the healthcare system was laid bare: the lack of racial diversity in American medical schools and the medical profession. According to JAMA, African Americans represent about 5% of all practicing physicians today, despite making up 13% of the population.1 Why have African Americans been so underrepresented in medicine over the last century? A transformative period of American medical education in the early 1900s changed the demographic landscape of medicine for years to come. Despite recognition of this disparity and efforts to promote diversity over the last century, there is still much work to be done to achieve equality in the medical profession.

At the inception of the 20th century there were 155 medical schools throughout the United States and Canada, 10 of which were solely for Black students.2 Some of these Black schools were independent institutions founded by Black doctors, but most were founded by religious groups such as the Presbyterian church and the American Missionary Association.2 Funding at these institutions was precarious, as they survived on meager tuition payments and a small amount of funds raised by missionaries and religious organizations. In comparison to White schools, Black schools were gravely disadvantaged. Religious groups had very little money that could be shunted into medical education, and contributions from philanthropic donors was small. The student body at Black schools was also largely comprised of students from impoverished families that struggled to cover the minimum tuition.2

In the early 1900s it had become clear that new advances in medicine necessitated broad educational reform. Such medical advances included the invention of novel tools for diagnosing such as the ophthalmoscope and laryngoscope. The discovery of specific bacteria causing common diseases lead to the utilization of microscopes as common clinical practice.3 In 1907, JAMA estimated that adequate medical education would now require two to three times the current tuition paid by medical students.2

Given this call to reform, the Council on Medical Education (CME) was established under the American Medical Association to evaluate all medical schools to determine whether they were able to meet this new standard. The evaluation process included both in-person visits to tour individual schools as well as assessment of board scores at each institution.2 On school tours, facilities at Black schools fell far behind those of White schools. Many had old, outdated laboratories that lacked modern equipment. Additionally, Black medical colleges were among those with the highest failure rates on board exams. It became clear that the lack of adequate funding led Black schools to struggle with the upkeep of their facilities. They also struggled to provide an education that was comparable to their White counterparts. Given these findings, Black medical schools were ranked by the CME in the bottom percentiles in terms of the quality of education being offered.

As the CME began presenting robust data regarding the current state of American medical schools, they began issuing distinct guidelines that schools were strongly encouraged to meet. Many of these guidelines were easily met by White schools but posed challenges to Black medical colleges.2 One guideline suggested that prerequisite college coursework be required prior to admission to medical school. This greatly reduced admission to Black schools as most Black students did not attend college prior to medical school.2 Another guideline stated that medical school courses should not be held after 4pm, which made it nearly impossible for students with full-time jobs to attend medical school, also decreasing admissions at Black schools. The urging of schools to adopt these policies made it increasingly difficult for Black universities to maintain their class size, which resulted in less students and hence less revenue.

The curriculum of Black medical schools was also under scrutiny. Many Black medical schools offered far less clinical and laboratory experience than their White counterparts and were taught by an older generation of faculty who were not experienced in the more modern practices of medicine.2 As the CME became increasingly aware of these discrepancies, Black schools faced mounting pressure to reform their curricula at a time in which they were already struggling financially. For some schools, it became clear that they simply did not have the resources to keep up with the rigorous demands of medical education. By 1908, three of the ten Black medical schools closed their doors.

Despite these existing challenges, the main catalyst leading to the closure of the majority of Black medical schools was the publication of the Flexner report in 1910. Abraham Flexner was born to parents of Eastern European descent in Louisville, Kentucky. He attended Johns Hopkins University where he studied classic civilizations, and upon graduation returned to Louisville as a public high school teacher. He then went on to study psychology at Harvard, earning a master’s degree in 1906. In 1908 Flexner published a book called “The American College,” in which he articulated the many failures of higher education in America. Following the publication of his book, Flexner was approached by Henry Pritchett, the president of the Carnegie Foundation for the Advancement of Teaching who hired him to evaluate medical education in the United States. The work done by Flexner following this appointment led to the publication of the highly influential Flexner Report.4

Today, the Flexner Report is regarded as one of the most transformative publications in the history of American medical education. It is responsible for the current state of medical education that emphasizes basic science and research as a foundation for clinical practice. Flexner began his research by studying the medical education system in Germany. He felt that the German model of medical education, focused on basic sciences and laboratory work as a basis for future clinical endeavors, was superior to the current educational model of American schools, less focused on academia and research.5 He traveled across the country to assess the facilities, faculty, and curricula of all 155 American medical and Canadian medical schools and was highly critical of what he observed.6 The Flexner report stated that medical schools in the United states had had an “enormous overproduction of uneducated and ill trained medical practitioners,” considering it a “disregard of the public welfare.”7 He called for “reconstruction” of American medical education in which medical schools would predominantly exist in large cities, have sophisticated laboratory and training facilities, and have an esteemed faculty.7 Those schools unable to meet these reforms, Flexner felt, should close their doors.

When it came to Black medical colleges, the Flexner Report not only pointed out the shortcomings of individual institutions, but explicitly stated Flexner’s view that medical education at Black medical schools was deficient as a whole. Flexner at one point stated that five of the seven remaining Black medical schools were “wasting small sums annually and sending out undisciplined men, whose lack of real training is covered up by the imposing MD degree”.2 Flexner also suggested that Black physicians were inferior to White physicians in ability and intellect. He stated that the role of the Black physician in society was to care for other Black Americans, and to educate them on hygienic practices in order to prevent the spread of diseases to White Americans.2 When it came to the individual medical schools still in existence, Flexner felt that Howard University in Washington DC and Meharry Medical College in Georgia could reform, but the remaining five should close.2 By 1920 Meharry and Howard were the only schools still open.

It is important to note that the Flexner report not only condemned many Black medical schools, but many other existing medical schools as well. Flexner was highly critical of some of the White medical schools that he felt were not meeting the educational standard that was needed. Many of these schools closed alongside their Black counterparts due to an inability to meet these new demands. There were 148 American medical schools prior to the publishing of Flexner’s report. In the years to follow, as the standard of education rose dramatically, this number dropped to 66.

The Flexner report had a lasting impact on Black medical education throughout the 21st century. In the years following its publication up until the 1960s, Meharry and Howard educated almost all of the Black physicians in the United States.8 By 1968, only 2% of all enrolled medical students were Black, despite the fact that most medical schools were not officially segregated. The American Association of Medical Colleges (AAMC) recognized this disparity. In 1970, the AAMC published a report outlining their plan to tackle the underrepresentation of Black physicians in medicine. Their mission was “to achieve equality of opportunity by reducing or eliminating inequitable barriers and constraints to access to this profession which have resulted in a representation of racial minorities in the medical profession much less than their representation in the U.S. population”.9 At the time of its publication, African Americans made up a mere 2.2% of physicians while they represented 12% of the United States population.9 The goal was to increase the number of minorities enrolled in medical school from 2.8% to 12% over a five-year period. The three main elements of achieving this goal were the retention of minority students in undergraduate education, providing medical students with financial assistance, and recruiting minority students to medical education.

Many medical colleges took action to increase diversity on their campuses. Affirmative action programs were implemented in the 1960s and 1970s to increase the number of underrepresented minorities being granted admissions.10 Many medical colleges established mentorship programs to recruit Black students, particularly those from underprivileged families. They sought to guide Black students through the complexities of pre-medical education and applying to medical school. But despite these efforts, progress over the last 50 years has been slow. In 1991, African Americans still made up only 6% of physicians in America, and by 2019 that percentage was still under 8. A report published by the AAMC in 2014 showed that Black men applying to medical school has actually decreased.

Could this inequality have been avoided if more there were more Black medical colleges dedicated to the education of African American physicians? A study conducted by JAMA in 2020 estimated that had all of the Black medical schools of the early 21st century remained open, the number of graduating Black physicians in the year 2019 alone would likely have been 29% higher. Such data suggests the monumental effect that Flexner had on the demographic landscape of modern medicine.

The lack of diversity in our healthcare system today remains problematic. The most recent report on diversity by the AAMC, published in 2019, states that only 5% of practicing physicians identified as Black, while African Americans make up 13.4% of the total population.1 This disparity not only represents the pervasive nature of racial inequality in America, but it also has implications on the overall care of minority communities. Numerous studies have demonstrated that African Americans feel an increased sense of trust and cultural understanding when being cared for by Black physicians, which in turn leads to better health outcomes. According to one study conducted by the National Bureau of Economic Research in 2017, Black men were 18% more likely to follow preventative health guidelines when cared for by a Black physician. It is clear that increasing Black representation in medicine is imperative for the sake of social justice and as a means of improving the overall health of the Black population.

There is still much work to be done in attaining equality in the medical profession. It is not only important that Black medical schools continue to provide quality medical education to African Americans, but for all medical schools to make diversity and representation a core part of their mission. One example of how medical schools can increase diversity is the Georgetown Experimental Medical Studies program at Georgetown University School of Medicine. In 1977, Georgetown implemented this post-baccalaureate program that provides rigorous preparation and mentorship to underrepresented students interested in the medical profession. 94% of these students have gone on to receive a medical degree at Georgetown University School of Medicine.

The Liaison Committee of Medical Education (LCME) has also played a crucial role in recent efforts to increase diversity. In 2009 the LCME recognized that diversity in medical schools was steadily decreasing. In response, they implemented new policies that would require admissions committees to have policies in place to increase the diversity of their student body.11 Furthermore, the LCME has continued to monitor the progress that individual institutions are making to improve diversity, threatening the accreditation status of those that fail to do so. Since 2009, schools nationwide have demonstrated a drastic increase in the number of minority students graduating from their institutions in direct response to the LCME’s policies. At the University of Missouri-Columbia, for example, the LCME notified the medical school in 2016 that the current demographic breakdown of their student body did not meet diversity standards. Two years later, the number of Black students enrolled had doubled, and the number of Hispanic students increased five-fold.11

Our work in achieving equality in the medical field is far from over. It is imperative that medical schools remain committed to increasing diversity on their campuses until full equality is achieved. This commitment to diversity is an important step towards racial justice and providing every American with the best possible healthcare, regardless of the color of their skin.