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    Transcript for Shades of Opportunity: Exploring Race-Conscious Admissions

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    AARON DILLARD: Welcome everyone to the “Beyond the White Coat” podcast. On today's episode, we're discussing race-conscious admissions, a complex and important topic within higher education. In Part 1 of this discussion, we will explore the legal and admissions impacts surrounding the use of race as a factor in college and graduate school admissions.

    We hope you enjoy our discussion as we delve into the multifaceted dimensions of this practice and its impact on creating a more equitable and diverse educational landscape. Facilitating this in-depth discussion, we have our illustrious host, Dr. David Skorton, president and CEO of the AAMC, which represents the nation's medical schools, teaching hospitals and health systems, and academic societies. David began his leadership here at the AAMC in July of 2019 after a distinguished career in government, higher education, and medicine. In his first year, he had to deal with social issues that affected health. He guided us through a pandemic and built a multiyear strategy to tackle the nation's most intractable challenges in health and health care. working to make academic medicine more diverse, equitable, and inclusive. Welcome, David. Thank you so much for hosting this conversation. And his illustrious guests for today, first is joining us all the way from Spain, is Dr. Mark Henderson, or yes, professor of internal medicine and the vice chair for education and associate dean for admissions of the UC Davis School of Medicine. He previously served as residency program director for internal medicine at the University of Texas Health Science Center San Antonio and at UC Davis. Dr. Henderson has won numerous teaching awards and currently holds the Dean's Endowed Chair in Teaching Excellence. And we thank him for joining us today, especially from Spain, where he is six hours ahead of us. So, thank you so much, Dr. Henderson. 

    And last but certainly not least, Heather Alarcon, JD. Heather is the senior director of legal services at the AAMC, where she provides in-house counsel on litigation, employment law, nonprofit law, standardized testing, inclusion for individuals with disabilities, civil rights laws and national policy issues impacting medical education. Heather was the primary author on the AAMC's amicus brief to the Supreme Court in the Harvard and UNC case recently decided. Prior to joining the AAMC, Heather was an associate general counsel at the Corporation for National Service where she specialized in federal grants and the AmeriCorps program. 

    Thank you, esteemed guests, and David, I'll kick it over to you. How are you feeling today about this race-conscious admissions topic?

    DAVID J. SKORTON: Well, thanks a lot, Aaron. It's great to be on “Beyond the White Coat” again and have these great guests. And Aaron, thanks for organizing this, kicking us off. I'm feeling determined that we are going to continue to do the things we need to do to diversify the medical school classes and the health care workforce, not for any political or ideological reason, but because it's good for the public health. I know we'll get into that a little bit later. And I'm just very, very happy and grateful that both Heather and Mark can join us today and add their expertise. And I must say that, and I'd love to hear from both Heather and Mark about this, I was expecting at least some constraining of our ability to use race as one factor in admissions, but I was disappointed and feel like we've had a pretty big change in our toolkit that we can use to diversify the health care workforce. And of course, we're gonna stay within the law, but we are going to, make no mistake about it, continue to follow our mission and our goals to diversify the health care workforce, because that's what we need to do for the public health. Mark, how are you feeling about this? And how did you feel when this decision came out?

    MARK HENDERSON: I think although I wasn't surprised, I was certainly disappointed in the sense that as you alluded to the purpose of medical schools, the purpose of medical education is a public good. It's to, in a sense, produce a workforce that meets society’s needs. And in order to do that, of course, in all respects, we need to have greater diversity, both from in science, but also in clinical medicine to actualize that mission and to improve the health of the public. So, while disappointing, because I live in California, a state that banned affirmative action over 25 years ago, our institution has operated in this environment for quite a bit of time. And so, I think we've figured out how to stay true to the mission that you began with and that's really been really the bedrock principle of how we've navigated the past 25 years despite a ban on affirmative action.

    SKORTON: Thanks so much, Mark. Heather, your initial thoughts when you heard the decision.

    HEATHER ALARCON: Okay, David, like you and like you, Mark, I was expecting for us to see some constraints to how schools can consider an applicant's — the context of their — racial background and admissions. This was way more of a sweeping change than I expected. And I think that there are some silver linings in the decision, some places that we can lean in and keep doing our work. But it was, it was pretty discouraging to hear our Supreme Court say that the educational benefits of diversity aren't a compelling interest when what we know, what the science tells us, is that they absolutely are. And when I was researching going into this case, it seemed to me, you know, as much as we talk about this as being a sort of a philosophical discussion in medicine, it's absolutely not. I mean, this is a health intervention, diversity. So. For us, it's not an option to set this aside. This is something we have to keep doing because it's what's important for our patients.

    SKORTON: Thank you, Heather. Mark, you've been thinking about this and dealing with it and living in it for a quarter of a century already at Davis. And before we get into some details about what and how you've done things at Davis, which is just fascinating and very admirable, tell me a little bit more about your rationale for wanting to diversify the classes and the health care workforce.

    HENDERSON: Sure. I think that when I took over the leadership of the missions at UC Davis in 2006, one of the things that struck me and I had come from, as was alluded to in the introduction, South Texas, which is another majority minority state, where a large proportion of the population is Latino or Hispanic. In that state, a lot of health care workers, including myself, spoke Spanish, and that really improved the care that we delivered at what was a public hospital in San Antonio. When I came to UC Davis, at the time, over 40% of the people living in California were Latino, yet only about 4% of physicians at that time practicing in that state were Latino or Hispanic. So right there, this is one example of a huge disparity or gap between the physician workforce and the population that it aims to serve. So, I think that was one really striking example to me that said, you know, in order to improve the health of the community — again, UC Davis is a public institution. Our mission is to improve the health of California, and when I say California, I mean all of it, all of the communities — that means we have to have greater representation.

    So, at the time, our school was — the percentage, the proportion of entering students who were Latino was less than 10%. So again, I knew we had lots of work to do and I knew we had to, again, think about this, conceptualize the gaps and knowing, again, from my personal clinical experience, how understanding a culture, understanding a language, being respectful of where someone, from where someone comes from, is just really important element of building trust, improving care, closing health disparities.

    SKORTON: So, Mark, as you know not everybody agrees with, well really anything in our country right now, but not everybody agrees that we should do diversity for representation purposes, but you’re focusing on the public health aspects as Heather did as well. So, share with the listeners a little bit more besides feeling like it's the right thing to do and representation and those widely divergent differences between the representation in medical schools and representation in the state population. What difference does it make? How does it actually improve the public health, to have a more diverse workforce? Tell us your thoughts on that if you would.

    HENDERSON: The main way I feel that representation or greater diversity in the health care workforce helps is through understanding shared experience, respect, things that all patients, when they seek out health care, are looking for. If you think about illness in this country, most of it’s chronic illness and most of the treatment of that illness has to do with behavior change, taking a medication, modifying your activity. These things are very difficult to do. And in order to do them, I think principally, you have to trust your health care provider. You have to trust your physician. So, if your physician — if you don't respect your physician, if they don't respect you, if there's no shared human understanding, I think it's very difficult to make progress on diseases like chronic illness, which again is [one of] the biggest epidemics in this country. But even acute illnesses, even, we saw this in the pandemic, right? Trust of the health care system. Does this vaccine really work? Does this vaccine got a microchip in it? Is this, I mean, think about how important, what we saw, the effects of mistrust. And even in an acute illness like a pandemic and something that seems so obvious as vaccination. So, I think it's trust. That's what it boils down to. And I think if you don't have any idea about where a patient comes from, I think it's very hard to earn their trust.

    SKORTON: Well, that makes sense to me. Now, you know, beyond the health care world, of course, there's been a lot of research, a lot of observations, that just diverse teams just do a better job of making decisions. And some of us have followed the work, for example, of Professor Scott Page at the University of Michigan, wrote a couple of books. You guys are probably familiar with them. Maybe many of our listeners are. One was called The Difference. One was called The Diversity Bonus. And in the for-profit sector, not-for-profit sector, military, you name it, diverse teams just make better decisions. So, to me, Mark, the combination of all the things you talked about in terms of trust, listening, plus just a better, broader way of making decisions, sure makes sense to me. Now, Heather, we've got to put you on the spot and take us through a journey in the past of how we got to the point where we are. Some of the legal things that have happened, cases and precedents that have happened in decades before this momentous and unfortunate decision. Can you remind us of some of these cases? Please, Heather, thank you.

    ALARCON: So, David, it's hard to know where to start in American history with that question, but I'm just going to start with 1954, the Brown v. Board case. Mark, David, do you guys know what happened after Brown v. Board?

    SKORTON: We'd like to hear more.

    ALARCON: Well, not much. So, the court had to come back a year later and be like, let me clear my throat. What I said was, I need you to integrate your schools. Because after that initial decision came out, schools dragged their feet, communities dragged their feet. They did not integrate. And in the following years, you see more encouragement from the government. The 1961 executive order is where we get the term affirmative action. And that's where President Kennedy is saying, I'm telling you right now, you need to be integrating your workforce. You need to be integrating. We need to be doing this work. And I was refreshing some history on this recently and you know, the AAMC — it was 1968, so we're like some years down the road — where after the Civil Rights Act, 1968, the AAMC is telling our medical schools, at this point, you need to increase your ethnic and cultural diversity of your student body. You need to do what it takes. We need more doctors generally. We need more. We need people who are prepared for the current patient population. So, it's 1968, not that many months after we have the MLK riots that the AAMC is saying our medical schools need to diversify. 

    And what’s wild to me is that we go from a place where we’re having to tell medical schools to diversify, and then 10 years later, we have the Bakke case, which I’ll get into more detail, but this is UC Davis, Mark’s school, had a program. They’re answering the call to diversify and they had a set-aside program, 16 seats for Black applicants. Now, a Black applicant could apply to any seat in the class, but those 16 were reserved for Black applicants. And the school had done that. This was actually not an uncommon way for schools to diversify at the time. This was a pretty common pattern. It was because they felt that if they didn’t reserve those seats, then they weren’t gonna be able to get the diversity they needed. And what’s amazing to me is in that 10 years between 1968 and 1978, schools go from resisting integration to fighting for their lives to keep it. And what happened in that 10 years that made them turn around and say, we need this, I think, is that they saw how amazing it was for their education. They saw the outcomes that were happening. Once they had that diversity in their student bodies, they’re like, oh, we can never, ever lose this. We need this because we’re actually producing better doctors. And we see that in health outcomes in the field all the time. We study this a lot. 

    So, the Bakke decision, I think it came as a crushing disappointment to schools because the Supreme Court said you cannot do what you've done where you have a set-aside program, set aside a quota in your class. So, this sort of proportional rate of balancing of trying to match your class to the proportion of the population, you can't do that. But in the decision, they say you can consider race as one factor among many to achieve the educational benefits of diversity, which was something that California UC Davis argued very hard that we need this to educate our physicians. And that became sort of the law for a long time. 

    In the 2003 Grutter case, this is University of Michigan undergrad in their law school, the court clarifies again, yes, you can consider an applicant's race in furtherance of the educational benefits of diversity. I think it's important to say that anytime you're considering race, the court's really going to push you to answer two questions. One, you need to have an extremely good reason to consider race, a really good reason. And two, the way that you’re considering race has to be very narrowly tailored to meet that reason. So, you have to use race only the very little amount and only in a very specific way to achieve that. And that's what they're saying in Grutter again. Like if you're going to do this, you have to be careful. You can't hurt anyone by doing this. You can only consider it if it's necessary, and it has to be one factor among many. And this is where we start to think really about what [does] holistic review look like. You're looking at the entire person. Yeah, you can think about how race might have impacted that person too. When you're looking at the entire person, race might have mattered for that person. That's okay to think about. 

    In 2016 and 2012, we have Fisher I and II. And again, the court says, yes, we're sticking with what we've told you all this time. Yes, you can consider race as one factor among many in this very limited fashion, because the court was still saying at that time, yes, we see that there are educational benefits at the consideration of race. And that kind of brings us up to where we are today. The big change between 2016 and the Fisher case and the Harvard UNC case, of course, is the makeup of the court. So vocal dissent in the Fisher II and Fisher I decisions, those are now, you know, writing the majority opinion in Harvard and UNC.

    SKORTON: Thanks, Heather. That was a very, very interesting review and sort of a travelogue of where we were and how we got to where we are right now. Mark, I'm sure you, or I imagine you, heard this same kind of question I'm going to ask you right now. And I get asked this question a lot. Staying away from quota, as Heather said, and set asides, but doing more creative holistic admissions, are you giving up the idea of merit? Are you giving up the idea of producing doctors who know their stuff, who are good in science, who are who have the merit to become a physician in favor of diversity? Are those things sort of competing? Merit versus diversity? What do you say when people ask you that? I'm sure they ask you.

    HENDERSON: Well, David, I get that question all the time. And I think, again, it depends on how you define merit. As you all know, medical schools across this country get thousands and thousands of applications every year for no more than a few hundred slots. So really, it's a highly selective process whereby exactly how a school considers or what a school considers to be meritorious is how the students are chosen, essentially. So, but to me, the traditional markers of merit, there are a lot of problems with them. In fact, as you alluded to earlier, greater diversity in scientific teams improves their impact, improves the working environment. There's so much evidence that diversity is a good thing for, again, it's resulted in greater, you know, performance in a lot of different fields. So, to me, having a more diverse health care workforce is, or greater diversity is, value added. 

    And I think, again, it's really obvious in health care is that lived experience of someone who might come from a community that's been marginalized or where there's mistrust of health care — As you all know, health care in this country is not equal. And again, that was, it was really on display in the pandemic. There are many communities that are left out of the system. So, I think when you have an experience growing up where your family, let's say, is on Medicaid, you understand the health care system, not in an abstract sense, you understand what it does to you or what it doesn’t do for you. And that, to me, the conversation in the classroom, the conversation on the wards, is completely different when you have a representative student body or when you actually have people from Compton, you know, an African American kid from Compton or, you know, a white kid from Siskiyou County, which is near the border for us, or a Mexican kid whose parents were farm workers. These kinds of experiences help — they challenge us in medical schools — but they help us to improve care. because they improve understanding of the patient's journey. To me, it's all about the patient and improving their care. I mean, I could go on, but I think —

    SKORTON: That's good — So, Mark, are you saying that just a grade point average and an MCAT® score, that's not enough to define a good physician? 

    HENDERSON: Well, I think I've said this before. I don't know how — I’ve been practicing internal medicine for 35 years. No one’s ever asked me my grade point average. And I would say that my lived experience working in high school, working in college, understanding what many of our patients face, which again is a struggle. Patients come to us with a health care issue. Usually, they don't know what it is. or they're in pain, they're suffering for some reason, but they also have difficulty just accessing health care. And a lot of that difficulty, I think understanding the plight of people who struggle to get care, again, understanding what it's like for people who work, you know, that can help build that trust I was talking about earlier. But again, the grade point average, the MCAT scores, we all know that those things also are affected by educational resources, by privilege, by coaches, by tutors, by things that many segments of society do not have access to. So, is that right? In my view, no. So, what we've really tried to do at UC Davis is really try to level that playing field in some way. And so, I'm not saying that you don't consider grades and MCATs. Of course, you do. But they have to be put into proper context.

    SKORTON: Yeah, you know, just to share a personal bit about my own background, I came from a family where there was no history of completing college or certainly nobody in medicine. And I was one of those folks who came out, you know, without the very top grades or MCAT scores. A very, very satisfying and wonderful career as a clinician, later on researcher and so on and so forth. So, and I had nothing like, nothing like the barriers to deal with of some of the folks that you're talking about, Mark. But I can tell you even then, the idea that there's some sort of direct correlation with what those numbers say and how you end up practicing medicine, being trusted by your patients, doing the right thing, thinking about those myriad things, the manifold things that go far, far beyond the things you can find out by doing a chemistry test on someone's blood or urine. Those are very, very important things. So, thanks for that.

    HENDERSON: I mean, not to interrupt you David, but I would add communication, again, listening.

    SKORTON: You bet.

    HENDERSON: I mean, these things are not captured by a test score. But yet if you ask people, patients, well, what's wrong with your doctor? They always say the same thing, right? He, she, they don't listen to me. That's not measured on a test. Anyway.

    SKORTON: You bet. You've been, please interrupt away. I love it. The more we mix it up, the better it is from my point of view. Now, Heather, you've given us a great historical sort of account, travelogue, told us what happened in recent weeks. Now, where do we go from here from a legal perspective? I'm going to ask Mark where we go from an educational perspective. But where do we go? What's your advice going to be for those who are out there who are thinking, well, you know, I buy this argument about diversity. I think it's great. But now, what do I do? Heather, help us, will you?

    ALARCON: So, you know, we've had a kind of a lens into how Chief Justice Roberts has thought about the consideration of race and admissions for a while. He's famous for saying the best way to stop discriminating on the basis of race is to stop discriminating on the basis of race. He has a new one-liner in the most recent decision: The best way to eliminate consideration of race is to eliminate it completely. So, we’ve known for a while that this was where he stood on it. So going into this case, the way that I thought about it is that, you know, the question about your house is burning down, what are you gonna save from your house and what's the family photos in this situation? And for me, the family photos are an applicant's ability to talk about their experiences and have those experiences considered. I mean, just like Mark just talked about — absolutely true, your experiences probably tell a school more about what kind of physician you can and will be than those scores do. 

    Now, I'm a believer in the MCAT. I think that every part of the application reflects inequity in your life, and the MCAT is the most standardized, but using it alone doesn’t work. And we know that schools every year, 15% to 18% of people with the top GPA and MCAT score aren't accepted anywhere. And that's because schools see somewhere in the interview or the essay, they're saying, this person cannot be with a patient. So, there are these other skills that are important. And I really wanted for schools to be able to consider an applicant's experiences, even if, and maybe especially if, those experiences related to their racial background, because that can matter. And coming out of this case, we know that schools can continue to do that. 

    Now, if you're in one of the nine states that has an existing ban on the consideration of race in admission, your ability to consider that information in an essay or interview response is not gonna be necessarily the same. You're gonna have to follow whatever your state law is. But for the rest of the country, you can look at a person's essay or interview response, and if they're telling you that they had an experience related to their race, you're allowed to listen to that and consider it and tie it to the metrics that you're considering, the criteria or rubrics you're using for selecting your student body. And I think that that's gonna really be a place where schools are going to have to lean. 

    Now, luckily for medical schools, this is maybe not so much the case for undergraduate campuses, but medical schools have engaged in holistic review for decades and they have a lot of experience already with closely looking at an application, reading that essay. Every accepted medical student gets an interview. So those processes are gonna become all the more important. And I read the majority opinion to be a strong endorsement of holistic review and individualized review. So, while schools aren't able to consider race as a separate factor anymore — they can't use it, they can't make judgments based on the racial status. You have to listen to what that applicant is telling you. But I think that medical schools are already really good at this.

    SKORTON: Heather, is there anything in this decision, in this ruling, that should make schools decide they're going to give up their diversity goals in general? Is there anything in this ruling that's going to say, you shouldn't have a goal of diversifying the health care workforce or the scientific teams? Is there anything that's anti-diversity in this decision?

    ALARCON: Absolutely not. And the court says these are noble and worthy goals and that the school is the one who gets to pick its own mission. That's for the school to decide. So yeah, there was some scaling back of the deference given to schools and we didn't like to see that — any kind of substitution for judgment. Educators are the experts in educating and I still believe that. And physicians are in the best position to pick who should be the next physicians, not judges. So, it hurt to see the court say that their judgment is better than educators. However, with regard to what the school’s mission is, the pursuit of diversity, that deference is intact and those missions can continue.

    SKORTON: Thank you so much. Mark, can we switch gears a little bit and talk about the research trainees and the research community? I mean, you think about COVID and the many, many lives, countless lives, that were saved. We don't even know how many were saved by vaccines and then eventually antivirals. And that didn't happen just because of the fabulous operation Warp Speed. It was because of 15, 18 years of fundamental research, a lot of it at academic health centers, medical schools, funded by the National Institutes of Health that led to this concept of mRNA being a platform for delivering vaccines. I don't know about you, Mark, we're of different generations, but we didn't talk much about mRNA when I was in medical school, and we sure didn't talk about it being a platform for vaccines. So, I'm very worried about research trainees, and tell me, does this whole business of, you know, more trust in physicians and all those benefits of diversity in health care delivery and the public health, does that go for the research world as well, Mark?

    HENDERSON: Yes, so thanks again, David. I think if you think about the COVID vaccine is an incredible success story. But one of the biggest, most urgent issues identified by all kinds of federal funders of research, the NIH, etc., is the lack of, if you will, diversity amongst clinical trials. We don't enroll a representative sample, if you will, of the United States of America in many clinical trials. And this is, you know, this has been, this is not news to you or me. I mean, it's been true for decades. And I mean, there's progress, right? I think that one of the COVID vaccine trials actually was quite, I think it was, quite representative. And I think that the — it's sad to me that the translation of that, you know, that breakthrough, if you will, was not delivered to as many people who could have benefited from it due to mistrust, due to some of the things we were talking about earlier. I mean, we have —

    SKORTON: You bet.

    HENDERSON: — to have, again, same things I mentioned earlier with clinical medicine, right? To get someone to take a vaccine in order to enroll in a trial of a new therapy, right? We wouldn't be where we are without trials, yet they don't, again, they just don't represent all of America. So, it's just as urgent, if not more so, I think in the research environment, because there needs to be an understanding of what a patient, you know, that, you know, let's say is faced with a new therapy, whether they're willing to take that therapy that might be lifesaving for them. I mean, I can tell you, beyond COVID, we struggled, you know, South Sacramento is where UC Davis, the medical center is located. It's a historically Black neighborhood. Lots of people from the Black community, for good reason, mistrusted the vaccine because they felt it was rushed, because you know it happened so quickly, all true stuff, right? But what helped us to deliver the vaccine to that community, it was actually going to people they trusted. It was pastors from Black churches in our neighborhood standing up on Sunday and saying you know, there are these people from UC Davis here, we think you should talk to them, they're gonna have the vaccine after the service. That kind of thing. Think about that. I mean, that's not what you learn about how you do, I don't know, research or clinical medicine in medical school, right? That's community medicine, right? That's —

    SKORTON: You bet.

    HENDERSON: — very different, boy, but if you're from that community, that's gonna be very obvious to you. Anyway, I think it's at least as urgent or more urgent in the research workforce or in research endeavors.

    SKORTON: You know, thank you. You're both sharing so much wisdom today. And I would just sort of retranslate what you just said, Mark, to say that if you want to find out about a problem in a community, ask the people suffering that problem. If you want to get some ideas about the ways out of that dilemma, ask the people who may have some ideas about the solution. It's great, Mark. 

    Heather, I'm not sure exactly what day this and how quickly this podcast will air. because Aaron and the geniuses who do the post-production, they're gonna try to get it out quickly. But as of right now, this day that we're recording it, what do we expect in terms of any extra guidance from the United States government, from the executive branch? In addition to all the wonderful experience that Mark has shared, will we get any guidance from the feds?

    ALARCON: Yeah, we will. So, a lot of what we understand about programs outside of admission that are also covered by Title VI, things like Pathway programs, financial aid, the understanding that we have now, the legal framework is not based on court cases. It's been based on guidance from the federal government where they've interpreted the legal background for these other programs. And so likewise, this case was about admissions. It wasn't about financial aid. It wasn't about other school programming that might be used to increase diversity. So, we're counting on the executive branch to help us out to understand how they are interpreting this case. And part of the reason it's important that we understand their interpretation is because it will be the Department of Education's Office of Civil Rights that will be investigating complaints that come in about schools. So, we really need to know how are they reading this decision? A decision which I would say is not entirely clear in all of these regards. They said it would be about 45 days, so we're expecting to hear something from them. And hopefully that'll help schools understand how to implement this decision in other contexts moving forward.

    SKORTON: The way forward will be illuminated by some guidance from the federal government, some guidance from people like Mark, who have been operating in this environment for a long time, quite successfully, I might say, in my view. Other ideas people have in the other eight states that have bans, and some of the data that we'll be able to gather at the AAMC and share with folks. Is there anything else that our listeners can think about besides the guidance? Besides learning from people like Mark, besides learning from other schools, either in states that have bans or states that don't have bans, anything else that people can look forward to for some sort of light at the end of the tunnel? We know where we want to go. We know that it's important to get there, but the question of how — Anything else I forgot to mention, Heather or Mark?

    HENDERSON: I think one thing I would mention, David, is, and this comes from data from the AAMC, which I appreciate very much, which is the economic distribution, if you will, of medical students in this country. What I mean by that is that it's not a rep — most medical students come from the upper echelon of society. So, if 50% of U.S. medical students come from the upper quintile compared to 5%, 10 times from the lowest quintile, I think that's a problem. I mean, that's just on the face of it, not right. And so, I mean, you could slice that data in a number of different ways. I think one in four students come from the U.S. median family income or less, one in four, again, that's not even low income. It's just not representative. And so again, I go back, how can a person understand the plight of a patient? Many of our patients, again, if they're on federal programs, Medicaid, I mean, even Medicare now, you know, how can they understand that patient? So, I guess I would say that, you know, we need to really think about that and how to make it possible for the entire spectrum, economically speaking, to be present in the medical education system. That's actually been fundamental to what we've done at UC Davis, is trying to represent, trying to get that, at least, you know, if you think about health disparities, or if you think about, you know, they cut across race, ethnicity, location, rural, all that. But the one common factor to me is poverty. Poverty cuts across all those disparities. So that's why we have really at least attempted to again address that almost economic segregation I just described in medical school.

    SKORTON: Heather, anything to add to that before we —

    ALARCON: Yeah, I mean, I would build on that to say, one thing that, in researching for this case, I learned is just how generational medicine is. I mean, it's quite like being a plumber or electrician where your likelihood of being in this profession is way higher if you had a family member or even a grandparent —

    SKORTON: You bet.

    ALARCON: — who was also in this profession. And I think that is a call to medical schools to look at what other barriers can we be breaking down? What other support do people need to not be intimidated by the on-ramp into this profession? Can we be building things earlier on in the educational pathways and pipelines to encourage people just to apply to get the preparation they need? So, beyond poverty, I would say, what other barriers could we be removing? Now, of course, when somebody's 24 years old, a medical school is inheriting everything that's happened to that person up to that point. There's only so much you can do to intervene at that point, but we can look at our own applications and think, is there a way that we can improve the way that we're going to do this? And I think that we're going to be seeing a lot of that over the next couple of years, that sort of self-examination to remove those barriers and increase opportunities.

    SKORTON: Thank you so much, Heather. You know, the other day I was meeting with a group of high school students who are a part of a summer program for young people who are interested in health professions careers, medicine, dentistry, public health, nursing, you name it. And in a few formal remarks I made before we had a long Q&A, I mentioned this case. And these high school students, very interested to know what does the future hold for them, especially if they come from these underrepresented groups. And I told them, we want you. We want you in the profession. We want you to not only dream about it, we want you to tell people around you who are not here today, dream about it. And Mark, one of the things that we're doing at the AAMC, through the good work of one of our leaders, Dr. Geoff Young, is going earlier and earlier in the educational pathway, back to middle school, anyway, to try to get people to dream about something that as you and Heather said is not in the family, not in the history, but why not start that history with that particular person? So, I think this idea, it's a little bit late, honestly, when you get to the third year or fourth year of college to try to convince someone from an underrepresented group, you know, way too late, right?

    HENDERSON: Yes, it's way too late, David. I mean, I think I really appreciate what Dr. Young is trying to do. I would say not only we want you, we need you —

    SKORTON: Yeah.

    HENDERSON: Actually, I mean, we need you. The public needs you. And I think to Heather's point, I think this is what came up with the decision, the Harvard decision in particular. Medicine is a bit of a legacy system. Now, the American Medical Association, think about this, one of the most conservative organizations I know of, traditionally just adopts a resolution opposing legacy admissions in medical schools. I mean, again, it's what's Heather’s saying, we should be examining what we are doing to be more inclusive. And we should be examining some of the practices that maybe aren't contributing to health equity in this country. I mean, it's again, critical self-examination is certainly what we have done all along this process at UC Davis over these last 15, 17, 18 years. What are we doing that's working? What are you doing that's not working? I'm very — I'm encouraged by that. I think most Americans would not think that's fair.

    SKORTON: Got it. Heather, anything to add to Mark's thoughts in that regard?

    ALARCON: No, I'm just thinking about my first year of law school, and it just was crushing me. And I realized pretty quickly that whatever that killer instinct was that some of my classmates had, I didn't have it. I just — I'm not an aggressive person. And I was lucky enough to have a mentor say to me, the law needs people with heart. We don't just need people who have that kind of killer instinct, it needs heart. And you need to keep doing this because the law needs you. And having that kind of — I want for young people to hear that too, that medicine needs lots of perspectives because we’re serving everybody and we need all of that. So, I love what Mark just said. Like we don't just want you, we need you. And I just really loved that. Thank you for that, Mark.

    SKORTON: And I'll tell you something I always share with young people thinking about careers and health professions leadership. We've all — I've certainly had my share of imposter syndrome and it's easier to have imposter syndrome if you're coming from a group that's breaking through that ceiling.

    Well listen, there comes a point in every podcast recording where I live in fear of the producers, that they're going to start giving me the signal. You've been going on and on about this. This can't be a lifetime-long podcast. It has to end. So, I just want to ask our producers, especially Aaron, are there any topics you would like us to touch on?

    DILLARD: One thing I did want to add just for audience context and some of the things that Heather and Mark touched on in terms of just needing more inclusiveness. And Heather, I actually pulled this from your amicus brief, stating, Black and Hispanic medical school graduates are on average likelier, more likelier, than others to consider serving underserved communities. And by graduation, 56% of Black and 42% of Hispanic students expressed interest in practicing with the underserved. So just that alone, I think, speaks volumes to the fact that we need those faces and voices and listening ears in those communities. And you know, Mark, what you mentioned earlier about the number one thing that people say or complain about when they see the doctor is that they don't listen. I think that, like you said, that can't be, that's not on your standardized tests, right? That's not on the MCAT. That's not even in the AMCAS® application. And Heather, you kind of touched on something — and Mark, maybe in your admissions process at UC Davis or even at other schools — when there was the change, was there an expansion on the opportunity for students to provide more for an essay? You know and I know our AMCAS application has a limited number of characters quote-unquote, and I didn't know, Heather, after —

    HENDERSON: Yeah, no. So it's a great — you know, again, this is not theoretical to me. The fact is those individuals from those communities, the Black community, the Latino community, are more likely to want to serve patients who are left out of health care. And so, in our process, we have additional essays that actually speak to what we call workforce development tracks within UC Davis. So, over the 17 years I've been involved in medical school admissions, we've developed — starting with a rural medicine track, we've developed six others — Basically, these are medical school pathways within medical school where students like the ones you mentioned, Aaron, can remain connected to what is their passion, their mission, whether they maybe grew up in a rural community, they might have grown up in a farm-working community, they might have grown up in an urban and inner city community. Each of those programs nurtures that interest and reinforces it and allows those students to have experiences working within their community. Because again, I think that's why they come to medical school. That's what's different about some of the — Again, I go back to the legacy system. A lot of people are in medicine because they think they're supposed to be there. But that's very different from a kid who comes from the inner city. They fought their way to get there. Their family, they know why they're there. They know what the consequences of the lack of health care access are. I mean, it's real for them. So yeah, I mean, we have a lot of — so I mean, I think our processes evolve where we try to draw that out and what we’re trying to draw out, honestly, it's the lived experience of the applicant. Now holistic admissions has been around for a long time, but you know, how you implement that — boy, it's all over the map. You know what I mean? Like what that means —

    DILLARD: Sure.

    HENDERSON: You know, you have to adhere to your mission. So, you have to care about that mission — but everyone seems to have a mission, a social mission, all the stuff we're talking about, I just — how far you go to really operationalize that. Anyway, for us, it's really about their lived experience. And that's really powerful. I see it every day when I see students coming from a marginalized community, encounter a patient from that same community, and just watch the look on the patient's face and their demeanor change and their openness to whatever we're talking about change. And that's with students. They’re not even physicians yet. Again, it's about trust. It's about respect. All the things we talked about earlier.

    SKORTON: That's great, Aaron. Thanks for bringing that up. So I want to thank Mark Henderson and Heather Alarcon for a fabulous discussion today. I want to summarize where I think we are and ask my guests to pitch in on that summary. The Supreme Court, in its recent ruling on the Harvard and University of North Carolina cases, has removed the use of race as an explicit factor in admissions for higher education, including medical school. Nothing in the decision stopped us from having the goal of diversification or the mission of diversification, which, those of us doing this, believe there is abundant and growing evidence to do, both for the learning environment, for peer-to-peer learning, both for the research community and for health care. And so, the way forward is not completely clear. We're expecting some further guidance from the federal Department of Education and perhaps others. Learning more from places like the University of California, Davis, and other institutions in the nine states that have already had bans on race-conscious admissions and those who are finding new ways to diversify their classes even in states that have not had bans. And so stay the course and stay tuned would be my summary. Heather and Mark, anything to add as you summarize? Heather?

    ALARCON: I want to go back to something you said in the beginning, David, which was that we're going to follow the law and we want for schools to undertake their admissions process in a way that reduces their legal risk because, boy, litigation is so distracting from the important work that you're doing. But within this decision, there is plenty of room to remove barriers, to open up opportunities, to emphasize characteristics and traits in your applicants that you're looking for that are tied to the mission that you have for your school. And the AAMC, I believe, is really going to help schools over the next few years to identify those best practices so that we can continue to increase the diversity of our student body and workforce.

    SKORTON: Thanks, Heather. Mark, any last thoughts?

    HENDERSON: Sure. Just again, going a bit off of what we've covered, which is that schools should go back to their mission, why they exist. Medical schools, medical education, is a public good. It’s principally financed by the public. And so again, we have an obligation to produce a workforce, to produce scientific knowledge, to advance the health of the United States. So, to me, if we're trying to do that and if you think about who lives in the United States, right, we have to continue this work because, as I said, many parts of the community, many parts of our country, are left out of health care and suffer because of the lack of inclusion, the lack of representation. So, we can't stop this work. We still have a long way to go.

    SKORTON: Thank you very much. Thanks very much. Aaron, over to you for the last segment, please.

    DILLARD: Thank you, David. As we wrap up today's episode, I truly appreciate, as David said, thanking all of our guests for joining us, making time for us. But we'd like to introduce you to a refreshing segment called The Prescription for Relaxation, where we will dive into the personal interests and hobbies of our hosts and esteemed guests. And then in this segment, we will uncover any TV shows they might love, music that just soothes their soul, or books that they can't put down, or activities that they just engage in because it just helps them with that de-stress process. So, ladies first, Heather, what's your go-to activity or book or just what you're into right now to just help you de-stress after a long day? Like after you got the decision and you just needed to just defuse and just let go, what was your go-to activity?

    ALARCON: It took me a couple of days to let go. But I often connect with people, including my children, over books. I'm in three book clubs. Those are the official ones. And then I just really enjoy reading with my children too. But I have to tell you, for really, really disconnecting, there's not much more than being asked to be the judge of one of my kids' diving board jump competitions where they're like, who's doing the best jump? There's just so much vitality, so much glee, and it's really hard for me to think about anything else when we're just treading water and squealing, jumping off the diving board.

    DILLARD: That's awesome. Thank you, Heather. Mark, how about you? What's your go-to activity or hobby or entertainment currently?

    HENDERSON: Well, I love music, listening to music. My wife and I are huge Bruce Springsteen fans. I think we've seen him 35, and this is a small number of times, over 35 years that we've been married. So, right now he's touring Europe and I wish I could be there, but I'm busy relaxing in Spain — I'm just kidding. I'm actually teaching a class in Spain for UC Davis, which is 20 undergraduate students who are spending a month in the Basque country. So that's a very relaxing experience. But if I had my druthers — and I'm going to go see Bruce Springsteen in New Jersey on Sept. 1st.

    DILLARD: Awesome. I mean, you can't go wrong with Bruce Springsteen. 

    HENDERSON: Now talk about glee — that's glee, for me.

    Aaron: Hey, I totally understand. Thank you so much. And David, last but not least, what about you?

    SKORTON: So, I like to read especially adventure, mystery novels, anything by Frederick Forsyth, Robert B. Parker, John le Carrè, those kinds of things. But I have a love-hate relationship with this thing right here. I'm a failed musician. This is an electronic orchestral tuner. And when I play flute, and Aaron, you can just erase this, you don't have to share this with the public. But when I play flute, I have trouble with intonation sometimes. So, my flute teacher says, use your tuner. You think you're in tune, but if the tuner says you're not in tune, then guess what? You're not in tune. So, at the end of the day, most days that I'm at work here at the AAMC, when everybody clears out, my working day is done, I'll pull the flute out, pull out the tuner, do a little warmup and hang my head because the tuner never lies. Thank you, Aaron.

    DILLARD: Okay, well, we appreciate all of your feedback. I want to thank David for hosting this fantastic conversation and Heather and Mark for your fantastic and wonderful insights, taking the time, spending the time, especially Mark being six hours ahead of us in Spain currently. So, we appreciate you having — and we hope you have a wonderful rest of your evening as we progress on with the rest of our morning here back in D.C. So, thank all of you and thanks for joining us on this first edition of the “Beyond the White Coat” podcast for this year. Join us for part two as we further the discussion on race-conscious admissions and as we delve into the social and advisory impacts and perspectives for students as they move forward with their college careers. I'm Aaron Dillard, your producer. For David Skorton, Heather Alarcon, and Mark Henderson, we thank you for joining us. Have a wonderful day.

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