糖心vlog

Key Points

Question听 How do premedical student advisers at Historically Black Colleges and Universities (HBCUs) describe the barriers to and facilitators of Black premedical students successfully navigating to medical school?

Findings听 In this qualitative study of 26 HBCU premedical student advisers, barriers to and facilitators of students successfully matriculating to medical school were complex relationships between undergraduate HBCUs and medical schools, concern for preferential access to clinical opportunities for students of predominantly white undergraduate schools, and the importance of support networks.

Meaning听 The findings suggest that an opportunity exists for medical schools to build stronger relationships with HBCU undergraduate institutions, which has implications for increasing representation among medical school applicants and the physician workforce.

Importance听 There remains a lack of representation of Black physicians in the physician workforce despite decades of national efforts to increase diversity. Historically Black Colleges and Universities (HBCUs) contribute to increasing representation in the workforce in the US. There is limited literature exploring the experiences of HBCU premedical students navigating the journey to medical school.

Objective听 To examine barriers to and facilitators of medical school matriculation among Black students by exploring the perspectives of premedical student advisers at HBCUs.

Design, Setting, and Participants听 In this qualitative study, HBCU advisers participated in a focus group in October 2019 or in semistructured interviews from January 2020 to March 2021. Using purposive sampling, premedical student advisers were recruited from different educational backgrounds and geographic locations and conducted 1-on-1 interviews. Data analysis was performed from March 2021 to March 2022.

Main Outcomes and Measures听 The main outcome was the experiences of HBCU premedical students navigating to medical school from the perspective of premedical advisers. An inductive approach to generate codes from the interviews and the focus groups was applied by reviewing transcripts and noting concepts and themes associated with advising strategies and student experiences.

Results听 Among the 26 participants, 18 (69.2%) were female, 13 (50.0%) had a doctorate degree, and 8 (30.8%) had more than 10 years of experience as advisers. Participants described 3 major themes: (1) the complex institutional relationship dynamics between undergraduate HBCUs and medical schools, (2) concerns about preferential treatment for students from predominantly white undergraduate schools when accessing clinical shadowing opportunities, and (3) the 鈥渋t takes a village mindset鈥� emphasizing family and peer involvement.

Conclusions and Relevance听 In this qualitative study, barriers to medical school matriculation included concerns for the preferential treatment of students from predominantly white institutions when engaging with medical schools and a lack of access to clinical opportunities for HBCU students. The findings suggest that medical schools should continue to build collaborative partnerships with HBCUs to ensure equitable access to opportunities that prepare students for medical school.

In the US, health disparities persistently affect the Black community, leading to worse outcomes for many major health indicators, including infant and maternal mortality.^1,2 Recent evidence highlights that Black physicians can play a role in mitigating these disparities and other survival-related outcomes.^3,4 The underrepresentation of Black physicians in the workforce may exacerbate health disparities by impeding access to care given that individuals from historically underrepresented backgrounds are more likely to practice in underserved communities⁵ and care for publicly insured and uninsured patients.^6,7 Despite their effects on access to care in marginalized communities and various health outcomes, Black physicians remain severely underrepresented in the physician workforce.⁸ The Association of American Medical Colleges (AAMC) defines individuals as underrepresented in medicine (URiM) if they belong to racial and ethnic groups with less representation in the medical profession relative to the general population.⁹ According to 2023 US Census Bureau statistics, there were 45.3 million Black or African American individuals in the US, which represented 13.6% of the US population.¹⁰ Yet, only 5.7% of physicians in the US self-identified as Black.⁸

Given the recent US Supreme Court decision on race-neutral admissions and the revised Liaison Committee on Medical Education (LCME) standard (Element 3.3) allowing for more leniency in reporting diversity outcomes, there is concern that these changes may further contribute to a decline in racial and ethnic diversity within the physician workforce.^11,12 Previous studies have demonstrated an association of state anti鈥揳ffirmative action policies with decreases in medical student enrollment of URiM students at public medical schools, showing a 32% decline in URiM medical school enrollment following the passage of such policies.¹³ This recent federal decision raises significant concerns about the potential for similar nationwide declines in URiM student enrollment.

Historically Black Colleges and Universities (HBCUs) play a crucial role in increasing the diversity of the physician workforce and in training Black physicians.^14-16 Undergraduate HBCUs account for 25% of all Black graduates receiving science, technology, engineering, and mathematics degrees and 25% of all Black graduates receiving baccalaureate degrees despite making up only 3% of all colleges and universities in the US.¹⁷

HBCU medical schools also make a significant contribution to the workforce of Black physicians.¹⁴ According to the AAMC, 9.8% of Black medical school graduates in 2019 completed their training at HBCU medical schools.^18,19 HBCUs are not only a pathway of incoming medical school students, but they also overproduce leaders in academic medicine. HBCU medical schools comprise only 2.4% of all medical schools, but HBCU medical school graduates constitute 31% of all Black department chairs in academic medicine, 10% of all Black academic faculty, and 10% of all Black medical school students.¹⁶

Despite the known benefits of HBCUs, there is a paucity of literature exploring how Black HBCU undergraduate students navigate the process and successfully gain admission to medical school and how premedical advisers support them. In this qualitative study, we aimed to identify barriers to and facilitators of medical school matriculation among Black students by exploring the perspectives of premedical advisers at HBCUs. Greater insights into the barriers to and facilitators of medical school matriculation for Black HBCU students may help identify effective strategies to increase the numbers of Black individuals entering the physician education training pathway, with the goal of increasing the number of practicing Black physicians from 5.7% to parity with the Black US population at 13.6%.^8,10

In this qualitative study using purposive sampling, we recruited advisers whose role allowed for frequent interactions with students seeking admission to medical school.²⁰ During the Yale School of Medicine鈥檚 First Look Immersion Program on October 10 and 11, 2019, the study team conducted 1 in-person semistructured focus group. This event, sponsored by the Office of Diversity, Inclusion, Community Engagement, and Equity, attracted premedical advisers and students from HBCUs to share more knowledge about the Yale School of Medicine as an institution and the medical school admissions process in general. After the event, the study team lead investigator (J.W.) conducted additional 1-on-1 interviews with HBCU premedical advisers from other institutions using video conferencing from January 2020 to March 2021. Using information from HBCU websites, the study team identified additional premedical advisers to participate in the study. Two participants from the focus group also agreed to participate in 1-on-1 interviews. We obtained verbal consent from all study participants, which included permission to publish anonymous quotations. Two advisers who were contacted for interviews declined study participation. The Yale institutional review board deemed this study non鈥揾uman participant research. This study reports our findings using the Consolidated Criteria for Reporting Qualitative Research () reporting guideline.²¹

We developed a semistructured interview guide to evaluate current practices for student advising and how advisers perceived and approached obstacles that students may face along the pathway to medical school (Box). Two physician researchers assisted with interview guide pilot testing. After the initial focus group, the guide was revised based on participant responses and used by the lead investigator (J.W.) to conduct 45- to 60-minute semistructured interviews. All interviews were audio recorded and transcribed verbatim. Each study participant also completed a survey to collect their demographic data (including number of years wanting to serve as a premedical adviser and advisers鈥� level of education). Self-reported race and ethnicity categories of study participants included Asian, Black or African American, Hispanic or Latino, and White. Interviews were completed after achieving thematic saturation (ie, when no new concepts emerged from data collection and all interview data were assigned to codes and categorized into preexisting categories).²²

Box Section Ref ID

Data analysis was conducted from March 2021 to March 2022. The study team used an inductive approach to generate codes from the interviews and the focus groups by reviewing transcripts and noting concepts and themes related to advising strategies and student experiences.²³ Both J.W. and M.J.N.T. are graduates of undergraduate HBCUs and predominantly white institution (PWI) medical schools. They are also faculty members with expertise in workforce diversity, equity, and inclusion; advocacy; and medical education. Other team members included physicians, researchers, faculty members, and medical school chief diversity officers. All team members had expertise in qualitative research, health disparities, medical education, and diversity, equity, and inclusion. Some members of the study team (J.W., L.B.) coded and discussed the focus group together to ensure interrater reliability and coded the next 5 interviews independently line by line, meeting regularly to discuss any new codes or redundant codes, and then generated a finalized codebook. Other team members (J.W., N.D.A.) then applied the finalized codebook to all remaining interviews, meeting frequently throughout the process. We analyzed the data using a thematic analysis to generate themes. We used NVivo software, version 12 (QSR International) for data storage and organization.

Twenty-six premedical advisers from HBCUs participated in this study (18 female [69.2%] and 8 male [30.8%]). Table 1 highlights the study participants鈥� demographic characteristics, institutional region, educational background, and years of experience as advisers. Some premedical advisers had other roles at the university, including as course instructors. Among the 26 participants, 4 (15.4%) self-identified as Asian, 19 (73.1%) as Black or African American, 1 (3.8%) as Hispanic or Latino, and 2 (7.7%) as White. Thirteen participants (50.0%) had a doctorate degree, and 8 (30.8%) had more than 10 years of experience as a premedical adviser.

Participants described 3 major themes concerning barriers to and facilitators of premedical students successfully gaining acceptance to medical school: (1) complex institutional relationship dynamics between undergraduate HBCUs and PWI medical schools, (2) concern for institutional bias in access to clinical opportunities, and (3) an 鈥渋t takes a village mindset鈥� (ie, family and peer involvement to incentivize student accountability). Table 2 provides illustrative quotations from each theme.

Advisers reported substantial variability in the degree to which PWI medical schools engaged with undergraduate students. Some relationships were viewed as exploitative.

We鈥檙e very well aware that the AAMC has told them that they need to have diversity admissions at their institution and how they will come to HBCUs to pimp us on pipe dreams that really aren鈥檛 going to allow us to see the traction necessary to increase the number of students鈥�and so they come, they get the students excited, but there鈥檚 no real intention of accepting them unless they have 90th percentile scores. And so it looks great for them鈥搚ep鈥揵ut it still does us no service.

Many advisers highlighted that medical schools would come under the guise of seeking all students who would be a good fit for their program. However, they ultimately would only seriously consider the most competitive applicant, often based on test scores, as opposed to taking a holistic view of an applicant.

Come to our school. We want Black people. Right. So they say it a lot鈥�But you PWI want the ones that everybody wants. That鈥檚 right. The one with that MCAT [Medical College Admission Test] that鈥檚 way up there, 90th percentile, you want that person. Everybody鈥檚 vying for that one person. No, we鈥檝e got to think about this differently if we鈥檙e really committed to increasing numbers of underrepresented minorities, especially Black students.

Some premedical advisers reported tempering their expectations of medical schools that come to recruit students, indicating that they had more faith in medical schools with a track record of admitting their students in the past.

I鈥檝e started鈥�to pull down the metrics on how many of our students have applied [to your PWI medical school] and how many they鈥檝e already accepted. So if you haven鈥檛 shown any promise of doing that previously, I don鈥檛 have any confidence that you鈥檙e going to do it afterward.

In contrast, some advisers perceived that their medical school relationships were more genuine and of mutual benefit. Particularly, a few advisers reported strong relationships with osteopathic schools, Caribbean schools, and HBCU medical schools. As 2 advisers noted:

Our state schools have been pretty supportive of accepting our students through the pipeline鈥�. They offered us a guaranteed interview for all of our students. We have at least 3 students, it seems, that gets accepted there each year, and it鈥檚 an osteopathic medical school. We鈥檝e had really good relationships with those medical schools.

One of the Caribbean schools that鈥檚 been really good about accepting our students鈥�. The students that have attended have come back and told us it was a positive experience. And so if they don鈥檛 get into one of the schools here, we say, 鈥淟et鈥檚 look at [school name].鈥�

Some premedical advisers reported concerns that local medical facilities gave priority treatment to PWI undergraduate students for access to clinical experiences, which were needed for students to be as competitive as possible when applying to medical school.

I鈥檓 5 minutes away from another PWI鈥�and they have agreements with everyone. We have 2 hospitals and鈥�a number of health care facilities, assisted living facilities鈥�they have agreements with all of them鈥�and many of their students, because they have these agreements, their students are already in place. They already have a network, pipeline system set up for their students.... So for many of the students at my particular institution, it鈥檚 impossible for them to be able to secure any type of shadowing experience.

Some advisers attributed the lack of access to opportunities for HBCU students to the limited supply of physicians who identified as historically URiM. Respondents anecdotally described more of a willingness of URiM physicians to create shadowing opportunities for URiM students. 鈥淲ith very few African American doctors, we don鈥檛 have the access that some other groups have to get into the hospital to get that clinical experience.鈥�

Some HBCU advisers viewed student placement for clinical experiences competitively when considering students鈥� opportunities and the opportunities for students at PWIs.

There鈥檚 a PWI 20 minutes from my institution. And this is a major obstacle for me. Trying to get my premed students in the same organization that the students go to for clinical rotations and for clinical hours. It has been a constant struggle for me to get my students there鈥�. I鈥檓 almost in stalker mode鈥�. Literally stalker mode. Trying to get this to happen for my students, so. And then you don鈥檛 want to overload the ones that are providing access.

While access to these direct opportunities posed a challenge for some participants, others created alternative strategies to ensure that students could use clinical experiences to receive credits that would contribute to their progress toward graduation.

When we saw some of the same challenges, [we] developed a major focused in health and health sciences and incorporated an internship course in the curriculum鈥�. By institutionalizing it, it has helped us quite a bit.

Others encouraged students to get other health sciences certifications to serve as both employment opportunities and clinical experiences.

Dual enrollment鈥攎any of the students are graduating with their certified nursing assistant, phlebotomy, and other certifications that allow them the ability to work in those capacities versus actually having a [fast food] job and then trying to shadow on the side.

Table 3 includes additional recommendations from the study participants to combat the barriers that students face.

Many advisers recognized the importance of family, peers, and alumni in a student鈥檚 navigation to medical school. Some found creative opportunities to include families and peers into the academic process for students. One participant noted:

At our institution, we set up sort of a checklist of activities in which students need to complete at every level, and it鈥檚 really telling when the parents come, and we ask students, 鈥淲ell, let鈥檚 pull your folder to see where you are,鈥� and of course, when the parents see they only have 3 or 4 checks on this list of 20 things, then it starts the conversation.

Advisers expressed the importance of on-campus opportunities for families to engage and familiarize themselves with the physician career path. One participant stated:

[We created the] first-ever white coat prehealth induction ceremony鈥�. That was a signal to the support systems, to grandma, to auntie, to everyone. 鈥淵ou know what, this is the career path I want to take.鈥� 鈥�.We see the white coats on campus, walking around, moving around. And now, grandma is calling saying, 鈥淗ey. How鈥檚 my baby doing up there?鈥� Okay, so it鈥檚 sort of a holistic approach to advising.

Participants acknowledged the need for multiple sources of encouragement and accountability in supporting the students in contrast to the adviser serving as the singular source of accountability. One participant remarked:

At the beginning of each year, the new cohorts, we have parent orientation.... It鈥檚 mandatory that they attend orientation. And that鈥檚 where the director will lay out his expectations for the students, and what he expects from the parent.

By providing families with the awareness of the steps needed for successful medical school preparation, families became another source of accountability for students.

In this qualitative study exploring the perspectives of premedical advisers at HBCUs nationally, we found that complex institutional relationship dynamics between undergraduate HBCUs and medical schools coupled with concerns for the preferential treatment of PWI students in offering shadowing experiences were perceived as important barriers to medical school entry among HBCU students. Among strategies to mitigate these biases and to facilitate progress toward successful enrollment in medical school, advisers highlighted the importance of innovative approaches to cultivate clinical opportunities and to engage students鈥� familial and social networks to help them successfully navigate to medical school.

HBCUs have been instrumental to the training of Black physicians in the US. With the historic 2009 requirements of the medical school LCME diversity standard, it would be intuitive to expect PWI medical schools in close geographic proximity to HBCUs to strengthen their relationships with HBCUs as part of their diversity efforts.²⁴ Although some partnerships exist between undergraduate HBCUs and neighboring PWI medical schools for summer enrichment or shadowing opportunities, our findings suggest that these organizational partnerships are perceived by many HBCU premedical advisers to infrequently result in increased medical school admissions, even for well-qualified, competitive HBCU applicants.

Beyond the lack of reciprocity due to perceived institutional status, it is possible that PWI medical schools discriminate against Black HBCU students, as they may be perceived as less racially acceptable because attending an HBCU signals racial salience,²⁵ defined as 鈥渢he degree to which race and Black culture are [perceived to be] important to an individual.鈥�²⁶ Sociological research has shown that racial salience shapes how racial and ethnic minority groups are hired, promoted, and accepted within organizations.^25,26 At the college admissions level, for example, research has shown that White admissions counselors are more responsive to Black students who appear less concerned about race and racism.²⁷ In the medical school pathway context, admissions officials seeking to increase their schools鈥� enrollment of Black students may similarly favor Black students from PWIs. Furthermore, there is a concern that with the revised LCME Element 3.3 standard, PWIs will place less emphasis on creating new partnerships with HBCUs given that schools have more leniency with measuring their recruitment outcomes for racial and ethnic diversity.¹²

Another institutional factor that may contribute to the perception of preferential treatment is that most medical schools are part of a larger university ecosystem and are affiliated with PWIs. In geographic locations where there is an undergraduate HBCU and a PWI medical school, the undergraduates enrolled at the PWI may have an inherent advantage over their HBCU counterparts through institutional affiliation and physical proximity. This proximity may impact the HBCU students鈥� access to enrichment opportunities that strengthen their medical school application, such as shadowing opportunities, research opportunities, and mentorship programs. With access to these experiences becoming more constrained since the COVID-19 pandemic, our findings highlighted the perception among the premedical advisers who we interviewed that many PWI medical schools engaged little with HBCUs in close proximity, and even those that did engage at times may have done so superficially.

Not only may the proximity of PWIs in relation to large academic medical centers impact access to enrichment activities, but the long-standing history of institutional bias against HBCUs may also exacerbate the differential opportunities available to students. HBCUs, particularly public land-grant institutions designated under the Morrill Act of 1890, have faced funding disparities since their inception. According to the National Center for Education Statistics, multiple states underfunded 18 HBCUs by $12.8 billion from 1987 to 2020.^28,29 These differences between PWIs and HBCUs suggest a manifestation of historic and ongoing institutional bias. Additionally, HBCUs often have smaller endowments than PWIs.³⁰ These funding gaps have led to decreased funding for infrastructure, faculty salaries, and student grants, burdening the institutions with more debt and requiring students to take out more student loans to further their education.^29,31

Our findings highlighted premedical advisers鈥� resourcefulness and creativity in finding the academic enrichment activities needed to help students become competitive medical school applicants despite these challenges. Alternative strategies, such as dual enrollment in interdisciplinary clinical opportunities and institutional-required internships through local partnerships, may offer opportunities for HBCU students to obtain valuable shadowing experiences. HBCUs may seek to establish partnerships with local medical specialty chapters and minority medical organizations (eg, the National Medical Association) to help systematize access opportunities for students.³²

At an interpersonal level, existing literature highlights the importance of family support along the journey to becoming a physician. In a qualitative study of Black male medical students and physicians that explored contributors to their success in admission to and graduation from medical school, participants emphasized the role of family support throughout their education as particularly important.³³ Black medical students also highlighted lack of support from family as a source of stress due to a lack of understanding of the medical school experience, low resources, and an inability to offer financial support.³⁴ Our study provides insight into how HBCU premedical advisers reported leveraging family involvement and peer support as an advising strategy to help motivate and keep students accountable to their goals through role modeling and messages of encouragement.

Our findings should be considered in the context of several limitations. The premedical advisers in the sample may not represent the views and insights of all HBCU premedical advisers. Data on premedical student enrollment, medical school acceptance rates, and type of medical school attended for graduates (PWIs vs HBCUs) were not available to the study team. Because we focused on premedical advisers from HBCUs, our findings may not be generalizable to the experience of all Black premedical undergraduates. Our study also drew on experiences of premedical advisers during the COVID-19 pandemic, which may have adversely affected students鈥� successful navigation to medical school.³⁵

This qualitative study highlighted the opportunities and challenges that HBCU students faced when navigating the journey to medical school from the perspective of premedical advisers. HBCUs are important to the growth of Black physicians in the US by producing a vast number of medical school applicants and by training physicians. By not addressing barriers for undergraduate students at HBCUs, medical schools and the medical field at large may be missing critical opportunities to welcome unique insights into their communities and the field of medicine. Future studies could compare and contrast the perspectives of premedical advisers at PWIs in the context of Black undergraduate students navigating to medical school as well as the perspectives of Black students seeking admission to medical school from differing institutions (PWIs vs HBCUs).

Accepted for Publication: August 29, 2024.

Published: October 23, 2024. doi:10.1001/jamanetworkopen.2024.40887

Open Access: This is an open access article distributed under the terms of the CC-BY License. 漏 2024 Weiss J et al. 糖心vlog Open.

Corresponding Author: Jasmine Weiss, MD, MHS, Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, 231 MacNider Hall, Campus Box 7225, Chapel Hill, NC 27599 (jasmine_weiss@med.unc.edu).

Author Contributions: Dr Weiss had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Weiss, Keene, Balasuriya, Sharifi, Genao, Latimore.

Acquisition, analysis, or interpretation of data: Weiss, Nguemeni Tiako, Akingbesote, Balasuriya, Sharifi, Latimore.

Drafting of the manuscript: Weiss, Nguemeni Tiako, Balasuriya, Latimore.

Critical review of the manuscript for important intellectual content: Weiss, Nguemeni Tiako, Akingbesote, Keene, Balasuriya, Sharifi, Genao.

Statistical analysis: Weiss.

Obtained funding: Latimore.

Administrative, technical, or material support: Weiss, Akingbesote, Balasuriya.

Supervision: Weiss, Keene, Sharifi, Latimore.

Conflict of Interest Disclosures: Dr Weiss reported being the founder of iDream Enterprise, LLC doing business as Black Med Connect outside the submitted work. Dr Balasuriya reporting receiving support from the US Department of Veterans Affairs (VA) Office of Academic Affiliations through the VA National Clinician Scholars Program and Yale University during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was supported by the Yale National Clinician Scholars Program and by Clinical and Translational Science Award TL1 TR001864 from the National Center for Advancing Translational Sciences, National Institutes of Health (Drs Weiss and Balasuriya).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See the Supplement.

Additional Contributions: Michelle Salazar, MD, MHS (Memorial Sloan Cancer Center), and Louisa Holaday, MD, MHS (Icahn School of Medicine at Mount Sinai), helped pilot the interview guide. There was no financial compensation for these contributions.