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    Transcript: Future MD: A Prescription for Addressing Racism in Medical Education

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    Narrator: The national conversation on systemic and institutional racism is sparking efforts to boost racial and ethnic diversity in the nation’s medical schools. Like the larger society, long-standing discrimination and bias in medical education has led to negative outcomes for Black Americans seeking careers in medicine but also for the communities of color that need health care.

    Of the total number of medical school graduates in the 2019-2020 school year, 7.8% were Black or African American.

    AAMC President and CEO Dr. David Skorton spoke eloquently about the institutional inequities that exist within medical education:

    “It is no secret that as the country has become much more diverse, the medical community has failed to keep up. This is unacceptable. In 1980, Black men made up 3.4% of all matriculants in U.S. medical schools, and today, they remain at 3.4%. Their absence isn’t just unfair, counterproductive, and wrong, it weakens us as a profession.”

    In this episode, Geoffrey Young, the AAMC’s senior director of student affairs and programs, talks with Max Jordan Nguemeni Tiako, a fourth-year medical student at the Yale School of Medicine, on his experience as a learner but also as an advocate for racial equity and equality in medical education and health care.

    This is our conversation with Max on “Beyond the White Coat.”

    Geoffrey Young: I'm Geoffrey Young. I'm the AAMC senior director of affairs and programs. I'm here with Max Jordan Nguemeni Tiako, a fourth-your medical student at the Yale School of Medicine. Max, thanks for being here.

    Max Nguemeni Tiako: Thank you for having me.

    Geoffrey Young: Max, I really appreciate you joining us. Just one thing — I understand that you're a graduate of Howard University.

    Max Nguemeni Tiako: Yep, HU.

    Geoffrey Young: I'm a graduate of Hampton University.

    Max Nguemeni Tiako: Oh man.

    Geoffrey Young: Don't go there. We will just elevate the love of our HBCUs — is that cool?

    Max Nguemeni Tiako: Yeah, that's totally cool.

    Geoffrey Young: OK.

    Max Nguemeni Tiako: I was going to say I'm sorry you had to go to Hampton.

    Geoffrey Young: Yeah, I know, yeah. Yeah, we go back-and-forth with this all the time, but I just wanted to acknowledge that and offer respect from one HBCU graduate to another.

    Max Nguemeni Tiako: I appreciate that.

    Geoffrey Young: I'd like to just, you know, talk with you a little bit about your experiences as you have embarked on your medical career. You've been a leading voice in conversations on these issues. First with your column “White Coats and a Hoodie,” and then you were very engaging — you have a very engaging podcast on health disparities and racial justice entitled “Flip the Script.”

    What led you to have these conversations and what has been the most impactful takeaways for you?

    Max Nguemeni Tiako: I think for me, the — I started the podcasts almost as a way to fill a gap that I saw both in medical education but also, like, just in the lay — you know, lay or general public. So, you know, health equity or even matters of, like, health disparities are not things that are necessarily, like, mainstream — or at least were not when I was going through like the first 18 months of medical school.

    I always find myself, like, having arguments with classmates who are not Black, you know, about issues related to racism and — like, be it in class or outside of class or even having to, like, raise my hand like, “Hey, like, I don't think…” Like, I feel like we need a deeper explanation as to, like, why, for instance, like, Black people have greater risk of, you know, “insert condition.”

    So, on the flip side, like, you know, my family lives in the D.C. area and I'll tell you a little bit about my background too, so it makes sense. I grew up in Cameroon, moved here 11 years ago with my uncle, who married — whose wife, Debra, she is African American. So, this is an African American from D.C. and North Carolina. So, I'm basically, you know, I'm like part of theirs — went to Howard for undergrad. So obviously I talk to Black people all day, every day — Black people who are not in health care, including my family.

    I find that, you know, just by virtue of being Black in this country, we know that there is racism in health care. We know about health inequity, right, but from talking to my friends and family, I felt that among my nonmedical friends and family sometimes, some — you know, we don’t necessarily attribute whatever inequity that we see to, like. some, like, greater social forces and sometimes it can be reduced to just the health care system. But like the health care system itself, you know, while obviously here's, like, a tremendous amount of work to be done in terms of racism, it's only but so much because there's all these other societal structures outside of health care that shape our health before we even show up — and obviously that also interact with the health care system, right, like police and criminal justice, before we show up at the hospital.

    So, I wanted to sort of, like, have a platform that is accessible both to basically folks in and outside of health care to sort of, like, get us into — like you know, where do we — what is shaping all of this, right, all of this inequity that we talk about?

    You asked what is the best takeaway for me so far? I mean, I've learned a lot from talking to my guests. I think something that's been really rewarding is there are people you know who, like, teach undergrad — like you know, undergrad, like health courses or, like, medical technology, who have told me, “Oh, I listened to this one. I really liked it. I'm going to add it to my service.” And it's super rewarding to know that I'm doing something that can have some kind of impact on the graduate, like, premedical education.

    Geoffrey Young: Right. So, in many ways, Max, it sounds like your platform enables you to really be a source of information and education for multiple communities. So the health care community, but also the “le,” “le community.”

    Max Nguemeni Tiako: Yeah.

    Geoffrey Young: Okay.

    Max Nguemeni Tiako: And it's funny, I didn't know — or I didn't think necessarily that it would be that I would have as decent a reach beyond, like, just, like, health care and public health space, but, like, my family loves my podcasts. Like, their respond to every — like almost every time I post it or, like, my aunt will forward it to all her friends. It's, like, really rewarding to know that, like — I don't know if she does it because she's my aunt and you support what your folks make— but I appreciate it, you know.

    Geoffrey Young: Yeah, well that's, you know, that's also the strength of community, right? I mean, you know, obviously it sounds like they're very proud of you and what you've accomplished and your work. So, you know, having, like, multiple communities behind you are critically important.

    So, you know, Max, in listening to your story — and thank you for sharing that — do you consider yourself an advocate or an activist as you create these opportunities for these difficult conversations? And if so, in what way?

    Max Nguemeni Tiako: I mean, I think both, right? So, I mean, my podcasting is an activism for sure, or, you know, some of the writing that I do isn't necessarily like activism, so I guess I would more so be like, you know, sort of like going, like, a long way of, like, educating people and hoping that I have some impact, right, for that I can't really quantify. I would call that probably advocacy. But in some settings, right, I engage in acts of activism.

    Like, here in the medical school, I've been super involved in issues related to, like, improving curriculum — you know, like strategical planning from the medical student side in terms of, like, addressing, “Okay, what are we doing in terms of, like, recruitment of minority, low-income students?”

    So, it's a little bit of both, I would say.

    Geoffrey Young: So, you know, this shouldn't really be a surprise or news to anyone, but unfortunately the coronavirus pandemic and the country’s reckoning on the topic of race has drawn into sharp focus the racial health disparities that plague the Black community. You have started the process of applying to residency programs where you have — well, you will have more exposure to the clinical setting. Do you think that you know the biomedical framing of race in medical education leads to physician bias, and if so, how?

    Max Nguemeni Tiako: So, I want to ask you how you think about the biomedical framing before I answer, just so I don't answer — just so I, I'm sure, I make sure I'm, you know, answering the right question here.

    Geoffrey Young: Sure, sure, yeah, that's fair. So, you know, I think when faculty come in and they may focus on race almost as, in my opinion, sort of a biological reality and they may focus on, you know, “Well you know Blacks have X, Y, Z” and sort of present in a way when they present a case that may be extremely focused or — and/or I think bias in sort of their approach to helping a student or learner understand, you know, the complexity of health, you know, health equity and some of the other, I think, social determinants of health. But they say it as if it is a —

    Max Nguemeni Tiako: Intrinsic or yeah.

    Geoffrey Young: Right, yeah, does that help?

    Max Nguemeni Tiako: Yeah, thanks. I just, you know, I — like especially when we use terms that complex, I want to make sure that we have the same understanding of the terms before I answer.

    Geoffrey Young: No, absolutely right, so that's my definition, yeah.

    Max Nguemeni Tiako: Yeah, I think, you know, the biomedical framing or however people call it, but this biomedical what is it model or race-based medicine is another way I've heard it.

    Geoffrey Young: Yes.

    Max Nguemeni Tiako: I think, you know, sometimes the — I think a lot of it is actually from people not knowing, right? So, I remember being at a lecture once and my professor was just talking about glaucoma, right? She listed, you know, risk factors for glaucoma. There was like African American, Hispanic, diabetes, hypertension, right, which is, like — sort of inflates race ethnicity and also, like, the biological factors like that diabetes, right, but, like, also diabetes is more prevalent in these communities. And so, it wasn't like, you know, teased out appropriately.

    So, at the end of the lecture, I walked up to her and I was like, “Hey, this is confusing, right, like is being African American or is being Hispanic, like, intrinsically a risk factor for having a glaucoma, like, separately from having diabetes or is it just that it's the risk factor because they are other conditions that predispose you for the glaucoma?” In other words, like, there have been, like, you know, like, studies that actually identify like a non — I guess a current disease or a societal factor that leads to glaucoma irrespective of one's race or ethnicity. And she didn’t know, right, and we don’t know, right?

    And so, I think when people don't know, there's just like this ease to just, like, fall back on assuming that, “Oh, well it may be genetic,” right? And whether or not that contributes to bias in health care, you know, it's a tough question.

    I will say, for a lot of these conditions that, you know — that get, like, so, like, wrongly attributed to, like, the biology of race for whatever that means, right, because we know, like, race itself isn't quite biological.

    Geoffrey Young: Right.

    Max Nguemeni Tiako: But I'm going to come back to that. People don't … There's an element of just not knowing. I don't necessarily think that, like — how am I going to say this? In medical education, we are exposed — we're so, like, overexposed to some of these characteristics, right? Like, if you take the board exams, like, we all kind of know the joke about how, like, you know if you get a question about, like, a young woman who is Black and who has a dry cough, you immediately think about sarcoidosis.
    But there are just kind of, like, these, like, stereotypes in there — in our, like, you know, question banks or practice material or whatever. You know, I don't know about that in itself, like that has shown any, like, how am I … like, evidence of ultimately, like, leading to bias or to how people make clinical decisions.

    Like, you know where, this is all hypothesizing, what we know leads to or makes people more prone to bias. Just like witnessing, as medical trainees, like, witnessing, you know, supervisors or attending physicians or residents, like, you know, make bad jokes or talk badly about patients of color. This has actually been studied, right, like robustly, so we know that witnessing, you know, sort of like negative remarks about patients of color is something that makes medical trainees, like, first of all, less interested in, like, servicing communities of color or low-income communities and also, like, more bias against those patients.

    So then the — I think the environment in which people are training is probably more of a contributor to, you know, this negative bias. Now, that being said, I think race-based medicine, as people call it, can pigeonhole people such that, you know, perhaps, like, the heuristics make one miss the diagnosis, right? So that's — I'm sure that's a thing where, like, you know — for instance, cystic fibrosis is a classic example of, like — cystic fibrosis having previously been, like, you know, identified as, like, something that's far more prevalent among White children. But again, because race is not, you know, such, like, a such — -a 100%, like, stark or clear, like — there are, there are, there isn't quite like a biological border between race, racial groups. You know, one could make assumptions about who cystic fibrosis affects and then, like, miss the diagnosis in a, like, Black child.

    Geoffrey Young: Right.

    Max Nguemeni Tiako: Vice versa with sickle cell disease, which is more prevalent among Black people and, and obviously, right, there are all these conditions that are more prevalent among certain racial groups because of ancestry, geography, and migration and whatnot that I think, you know, we … that remain relevant. When you think about, like, your, you know…

    When I think about my pretest probability, when I'm, like, working a patient up, but for that, knowing the patient's, like, ancestry or, sort of like … yeah, knowing the patient's ancestry can be useful, right? But for instance, the way race is defined in the United States can be really useless, right? Like being White is, like, from being all of — being from, like, all of Europe. Like from the U.S. Census Bureau, like, you know, being Middle Eastern Europe apparently counts as being White, right, but, like, these — like different countries, different regions, like in Europe and the Middle East and, like, Western and Eastern Europe, like, there are different sort of, like, genetic-related conditions that prevalent across different parts of, like, the whole, like, European Continent and, like, the Middle East.

    So race by itself isn't useful in that context, but, like, knowing that — for instance, like, so, knowing that someone is from the Mediterranean region, that's knowing about their ancestry and as it relates to, like, you know, migration and — how do you call that, as it relates to migration and geography and, like, you know, there are some conditions that are, like, more prevalent in the Mediterranean and, of course, like. one should not necessarily, like, make a decision, right, or, like, a prescription based on where — based on individual origin. But I think from a pretest probability perspective, there is usefulness in that, right?

    Like if, if I see a Black patient who is showing symptoms of what I think might be either related to the sickle cell trait or sickle cell disease, right, knowing that they're Black or knowing that they have Africa — you know, specifically like West/West Central African ancestry, like, would raise my pretest probability that this person may be having, you know — maybe this is sickle cell/maybe this is a sickle cell trait. But that doesn’t necessarily mean that it's like — be treated as a slam dunk, right?

    Geoffrey Young: Right.

    Max Nguemeni Tiako: There's another example where, for instance, when we think about hypertension, hypertensive medications — like there's some studies out there that have shown … So, like the best, you know, sort of, like, top-of-the-line anti-hypertensives are ACE inhibitors, right? But some people...

    There's some studies out there that suggest that, like, “Black people” respond better to calcium channel blockers. But I feel like one should not just decide that, “Oh, because you're Black, I'm going to put you on calcium channel blockers” — like that's what, that's what's I think that the issue with race-based medicine, right? Because unless you know for sure that this one person is not going to respond well to ACE inhibitors and, like, I don't have — have angioedema or whatever, like, you shouldn't say, “Oh, just because you're Black, I'm going to put you on a calcium channel blocker.”

    Geoffrey Young: Right.

    Max Nguemeni Tiako: That's, like, the nuance there that I think is really important.

    Geoffrey Young: Right. So, Max, you raise several, you know, critical points that I just want to ensure that I'm tracking — and in many ways leads to my next question. So, you know, at some level, you know, understanding, sort of, history becomes critically important, but also recognizing that one's ancestry — I think the language that you used, or genetic, you know, ancestry is just one element, it's not the only element or should not be most prevalent or significant element, because you really have to do a comprehensive assessment. And where we get into trouble is when we assume that if you have a particular symptom in our education, this is what you know Black folks, for example, typically will show up with. It's likely that you may miss something critically important that has nothing to do with, you know, being, you know, an ethnic minority or specifically Black.

    Max Nguemeni Tiako: Yep.

    Geoffrey Young: Right? So okay, good, I just want to make sure that I was hearing that correctly.

    So, you also begin to talk a little bit about, you know, some of the — I think, you know, the historical aspects of Black and Brown communities that may have some level of distrust in medicine.

    Max Nguemeni Tiako: Mm-hmm.

    Geoffrey Young: You know, in part due to, I think, the, you know, history of racism and bias and inequity in health care. So, as our nation really begins to talk about and have conversations about anti-racism and how it needs to be addressed in the academic medicine community, how do you think you and your colleagues, medical school colleagues more specifically, can address that distrust to help promote a better relationship with communities of color?

    Max Nguemeni Tiako: That's a hard question, man. I don't even know where to start. I mean, I don't think people are equipped. Medical mistrust is like a deep, deep issue and I think there are many reasons why, right? Like, and it can start at , like, the small level of the patient encounter. Where, like, providers can be — can literally treat their patients better, right?

    There's evidence that, for instance, like, physicians who are not Black, like especially physicians who are White use, like, fewer words and have like, more or, like, less open body language when they are treating Black patients and there's this sort of, like, feedback — feedback loop in the communication between, you know, patient and provider, such that, you know, if I'm noticing that you're not using a lot of words when you are speaking to me or that your body language isn't so positive, then you're making me, like, feel some type of way about this clinical encounter. I'm sort of like — close off myself.

    Or, yeah, in clinical encounters, it's like a small way to sort of, like, get at whether or not people trust the institution.

    But I think on a larger scale, how do you treat Black people, right, like at an institution — like quite literally? And by that, I don't necessarily mean just in the clinical encounter. A lot of these hospitals in academic medical centers are anchor institutions in their communities, right? So, like, I go to Yale. Yale University and Yale New Haven Hospital are like the two largest employers you have in Connecticut.

    So beyond patient encounters, how do you treat Black people over there? How do you treat the Black people that you employ, right? Because we talk, right, like Black folks will tell you, “Oh yeah, that place is racist” and like, that's based on perhaps how somebody got treated at work and that also translates into how people are — what, like, people's attitude or, like, the physician towards the place might be when they show up for clinical care, right, knowing that you don't treat your Black employees right. Like, how am I supposed to believe that you're going to treat me right as a patient if you don't do your employees right, right?

    So, I think that's something that is, like, critically missing in this conversation of, like, anti-racism and health care. It's especially when I think about it. So, most Black people who work in the hospital are not physicians, right? But this conversation of anti-racism has sort of — of like, focus on, “Oh, we need more Black doctors” — nah, nah, nah, which we do, yes, but, like, I don't think that that is, like, the most — that is not the most anti-racism that a medical center can do, right?

    Hospitals hire the majority of low-wage health care workers who are disproportionately Black and Hispanic, right? Many of them Black women, many of them who live in poverty, especially if they have children and, for instance, are, like, insured on their Medicaid, right? How come if you work for a big … if you work for a hospital, how come you're not insured under the same insurance plan as the other people who work in the hospital, right?

    So, I think there is far more anti-racism to be done than paying lip service to the, you know, the project of diversifying medicine as a profession. You don't even need — I mean, we need Black doctors obviously, but, like, you don't need more Black doctors for hospitals to start paying their Black employees better, you know what I mean?

    Geoffrey Young: Right.

    Max Nguemeni Tiako: Like, you know, how are you paying the janitors? It's like, what are, like, opportunities in this place in terms of upward mobility, right? Like, can someone, like — are there some kind of, like, I don't know, tuition remission benefit? Like what does that package look like? Do people that work in this building or in this hospital, in this medical school, feel like they can progress economically?

    I think I'm more interested in that personally. Like, and from a, like, you know, health care workforce diversity perspective, obviously that is incredibly important, but like, there are — you know, I mean, you're not going to get all of a sudden more Black doctors tomorrow, right, just by releasing statements.

    Geoffrey Young: No, no, I appreciate that, because I think, you know, what I'm hearing you say is, you know, we can talk about increasing diversity of our health care professionals, but we can't do that in isolation. That we have to look at the hospital, right, the hospital system, if you will, and the community that it serves and then those that work within that system.

    Max Nguemeni Tiako: Right.

    Geoffrey Young: And you're right that the ball —

    Max Nguemeni Tiako: It's the same people, right?

    Geoffrey Young: That's right.

    Max Nguemeni Tiako: Like, the people who work here as janitors have family members who might come for care.

    Geoffrey Young: That's right.

    Max Nguemeni Tiako: It's like, if I work here and I tell you, “Oh my God, this place is racist,” right, like as my family member — like, when you go there seeking care, you're already like, “Oh, I don't know about this place,” right? Like —

    Geoffrey Young: Right. So it's really, it's really about, if I hear you correctly, addressing culture and climate.

    Max Nguemeni Tiako: Mm-hmm.

    Geoffrey Young: And —

    Max Nguemeni Tiako: With finances.

    Geoffrey Young: With finances, right, exactly right. That it really does take a real effort to change multiple systems in order to address, you know, issues that — that will enable, I think, an institution or an enterprise if you will, the medical enterprise, to really begin to address issues around anti-racism.

    Max Nguemeni Tiako: Mm-hmm.

    Geoffrey Young: So that leads me to another question, Max. So, you know, there are standards set in medical schools for how and what students are taught in medical school curriculum.

    Max Nguemeni Tiako: Mm-hmm.

    Geoffrey Young: And, you know, one of those standards that many are seeking is now this concept of anti-racism, and in doing that, looking to actively — you know, working to chain systemic in institutional racism and I think that's what we were in many ways just talking about with regards to, you know, the folks that then work in a medical enterprise.

    So, you know, based on all of your experiences and all the great work that you've done, how do you think medical education, right, the house of medicine specifically in terms of educating physicians, can do a better job of teaching cultural competency and anti-racism in curricula?

    Max Nguemeni Tiako: You know I have a cynic answer to this. I don't think — I mean, the stuff doesn't work, right, it's been tested. The cultural competency trainings…

    Like, there's a — so there is, and I mentioned this cohort in this study earlier, but they have multiple studies coming out of this cohort, the changes cohort — this is, like, a study of, like, 5,000 medical students who were tracked from, you know, follow-up from their first year of medical school. Now I think many of them are PGY-3s or like 4 or done with residency, and what the evidence is showing and, you know, this was charted when, you know, implicit bias was like really hot, right, like the sort of, like, “Oh, let's think about our implicit biases.” And basically, some of the evidence from that study shows that the trainings don't work, like it doesn't change people's attitudes.

    What changes people's attitude is the silent curriculum, right? How do people conduct … Again, how do people conduct themselves towards Black patients? How are Black people treated, right? And I think, and this is the crux of — on this issue of, like, diversifying the health care workforce.

    Like, a lot of people come into medical school never having had Black friends. Like right, like there's this, like, sort of — like, race and class and, you know, multiple sort of, like, axis of oppression here, where basically, right, the majority of medical students come from, like, upper-middle-class families.

    Geoffrey Young: Wealth.

    Max Nguemeni Tiako: Right, come from wealth. And if, you know … And especially, the majority of White medical students come from wealth. You know, whereas a minority of Black medical students come from wealth, for instance, right? And if we know anything about how segregated this country is both in terms of, like, housing, education, and then like, even like, social networks, like, you know, most wealthy people go to wealthy school districts where most people are … Well, like, school districts are incredibly segregated now. If they don't go to public school districts, they go to, you know, private schools. If it's in the South, people call those “segregation academies,” because they're, like, incredibly White.

    So, I mean, people show up in medical school having had very limited, substantial contact with Black people, even though, like, I feel like college is — college right now is probably the most, like, diverse setting in this country, right? Like, once you leave college, you go back to somewhat — you go, you know — somewhat segregated neighborhoods, segregated workplaces and whatnot. But still, like, people show up with different experiences and not necessarily having, how am I going to say this, like, having, like, interact — I mean interacted substantially with a lot of Black people from various backgrounds.

    So as much as, like, they read the book and there's, like, social media now that connects a little bit more — like people may be more, like, apt and sort of, like, the language of social justice and, like, being racially aware. I still feel like, you know, there are gaps in terms of this issue of diversifying the health care workforce or like diversifying the physician workforce. That starts before people even get to medical school. Like, I feel like it's, like, a larger societal issue.

    I went to graduate school — it was similar.

    Geoffrey Young: Georgia Tech?

    Max Nguemeni Tiako: Yeah. So, I mean, it's a broader issue of, like, inequality and people and, like, just — like, people from different backgrounds live in very, like, separate lives and so then some of us come to medical school and we have classmates who have never interacted with people like us and so they act funny.

    Geoffrey Young: Right. So, Max, do you think — I'm sorry, I didn't mean to cut you off.

    Max Nguemeni Tiako: No, you're good.

    Geoffrey Young: So, I mean I hear you and I think that we know — is that everything that you stated, I mean in terms of, you know, the percentage of those that ultimately matriculate into medical school come from the two upper quintiles, the highest quintiles in terms of the socioeconomic status.

    Max Nguemeni Tiako: Mm-hmm.

    Geoffrey Young: And so, we know that they — that there is a certain socioeconomic class of learner. So again, and I appreciate, you know, your cynicism, because I think, you know, if you live long enough, you'll understand, right? I mean, if you've seen enough, if you've been subject enough to various experiences, one may have a better appreciation.

    Do you think that it is a responsibility, you know — or how might a school really begin to address these issues? Recognizing that a student may be coming into a medical school environment, you know, having the experiences that you laid out. What then might be — how might a school start to at least address some of those issues in a way that, you know, may not change attitudes, but hold them accountable behavior? Does that make sense?

    Max Nguemeni Tiako: Yeah. I mean, and I think that there are ways to do things that will change attitudes, right, but I just don't think it's coming, it's going to happen in the classroom setting. I don't — and by that, I mean I don't think it's going to happen from teaching people.

    I think we can be intentional. Like, there is no — like, we come here being adults, right? There is, I mean, in the concept of cultural competent itself is self-instruct, because, like, you can't quite be, like, “competent” in, like, one other person's culture, but I think that, you know, there are elements of being humble and knowing that, like, you don't know, you know what's best and you've got to ask questions.

    But one, the way med school is structured can be a little bit of an individualistic culture, and we can change that and make it more a group focus and be intentional about creating diverse groups. This is actually something that business schools do.

    So many business schools have this thing where you have, like, learning clubs or, like, study sections — whatever one might call it — and, like, you do everything together as a large group. And these groups, UVA for instance, intentionally — they make these groups, like, you know, diverse in different ways. But, you know, businesspeople, they always think about the diversity as, like, from a productivity perspective, like diverse groups are more productive or — and whatnot.

    So, like, there is intentionality in how these groups are created, right? I mean, we already do some things in group in medical education. We do anatomy in groups. We do some, you know, workshops in groups. But I think there should be more intentionality in how these groups are formed, such that when we're in small group settings we hear other people's perspectives. But of course, in addition here is, what is the current state of diversity among medical students?

    The next thing is, like, being intentional about recruiting students from low socioeconomic backgrounds, rural backgrounds, right? Like, so few medical students these days come from rural backgrounds.

    Recruiting medical students from HBCUs, right? HBCUs produced — so like Howard and Xavier, right — produced, like, the highest number of, like, Black medical — Black people who go to medical schools, but many of them go to Howard and Meharry and Morehouse. So, you know, I want medical schools like mine to be intentional about, like, showing up at Howard's doorstep and like, “Hey, we want to recruit Howard honor grads to come to Yale for medical school,” or to come to Penn or NYU or, you know, you name it. Like, I want there to be more intentionality about recruiting not only, you know, like the Black people who are going to Harvard. You know what I mean? Like, I want there to be more intentionality around this sort of, like, diversity of Black, Browns as well.

    Geoffrey Young: Okay, all right, that's very helpful. So, let's, you know, I just have — just really one more question for you. You know, just as we're talking about diversity, increasing diversity, you are likely very aware, Max, that, you know, there are roughly, you know, over the past few years — you know, 3.9% matriculants are Black males.

    Max Nguemeni Tiako: Mm-hmm.

    Geoffrey Young: And that, you know, just a couple of things and maybe what you attribute that to. You may have sort of talked a little bit about — just in terms of access, in terms of, you know, resources and so forth. I don't want to put words in your mouth, but I'd love to just hear a little bit about what you attribute that to, and then also it would be great just to talk about, you know, your experiences and what got you to the point that you currently are at. Was there anything that potentially deterred you or could have deterred you from achieving your goals?

    Max Nguemeni Tiako: Yeah, I — so I think you're right — right, the last time that there was some kind of parity in the grad, in, like, gender parity among Black medical graduates was like 1988, right? In 1988, 52% of Black med school graduates were men, and then the year after, it was like 47% and it's just been sort of, like, going down since. And since like '98, it's been somewhere between 30% and 40% , right?

    So yes, I think there are so many different things that probably contribute to this. One of them that it's pretty obvious now is that, in college, being premed is not among the top 10 majors sought by Black men, compared to Black women. So Black women in college are more likely to be premed than Black men. I think some of it — and I'm only speculating because this is an association, not causation — but premeds have the lowest earning income immediately after college. Like, if you don't go to medical school, then your earning potential is not great if you study biology in college, right?

    So among the top 10 majors of Black female medical students, being premed is — it's the one with the lowest earning potential.

    And on the flip side, right, the top majors of Black men in med school are engineering, I think there's, like, a performing, visual and performing arts, and computer and information sciences. But like, overall, Blacks — like, this mess is like the — when you combine men and women in college, like, business is like the top major among Black college students.

    So, I think what are we studying in college probably is a contributing factor, but obviously there's also, within college landscapes, like, this sort of, like, disappearance of Black male college students, right? Like Black men have, like, far fewer — have lower, like, four- and five-year graduation rates compared to Black women in college. Lower enrollment rates in the first place, right? Black women have been going to college at a much higher rate.

    So, you already have this thing where, like, out of high school, Black women are more likely to go to college than Black men. And then when the smaller proportion of Black men that are in college are even less likely to be premed compared to the many more Black women who are in college. That's why, like, there are twice as many Black women in medical school as there are Black men, right? I think that's part of it, I mean.

    And what may contribute to this, because obviously, like, Black male and female students, like, come from just, you know, similar environments — I think my theory is that mass incarceration probably actually plays a role into this. I think there are probably some certain pressures and expectations of masculinity that make it such that perhaps the men are less interested in majors that one, like, you know, it takes several years to get to med school. I mean it takes several years to get to becoming a physician, and otherwise, there's that low earning potential, you know, if you don't make it through. It's daunting, right, it makes the activation energy and biochemistry a lot higher if there are subtle expectations of what is it to be a man. Like, do you need to like hurry up and earn money to be a provider?

    Geoffrey Young: Right, get in the job market and being —

    Max Nguemeni Tiako: Yeah, exactly, and so I think that potentially could be a contributor. I already talked about mass incarceration, which — like, in the school-to-prison pipeline which disproportionately affects Black men.

    I mean, obviously, it also does affect Black women, but, like, we know that, like, you know, disproportionately high rates of, like, incarceration in high school and in college, like, affect Black men. So those are just ______ [crosstalk].

    Geoffrey Young: If you had to give a message to young Black men —

    Max Nguemeni Tiako: Oh my God. [Chuckles]

    Geoffrey Young: Yeah, just given your experiences, just given that pathway that you have followed, would there be any — any, you know, pearls of guidance or advice or wisdom that you would want to share?

    Max Nguemeni Tiako: That's such a hard question.

    Geoffrey Young: And yeah, I mean it's — it is a hard question. I'm just curious. I'm just thinking about your experiences and your wealth of knowledge and insight.

    Max Nguemeni Tiako: Yeah, I hate to get preachy about … You know, how, like, people get on the soapbox to, like, talk to Black men or whatever. Like, I don't like to because I think a lot of these issues aren't like — young Black boys and men are not going to fix these issues, right? Like, this is a huge societal problem that needs to be addressed that I don't feel like the responsibility.

    But like, if you fix a lot of this — like a lot of Black, young Black boys and men's problems will go away.

    Geoffrey Young: Yeah, I respect that, I respect that.

    Max Nguemeni Tiako: Yeah, I don't want to — get preachy [crosstalk] about this.

    Geoffrey Young: I respect that. No, Max, I respect that. We can't, you know — I mean, what I'm hearing is you can't sort of expect the target, if you will, or the victim even, of systemic racism to solve systemic racism.

    Max Nguemeni Tiako: Right, exactly.

    Geoffrey Young: Right, so I — I hear what you're saying, and I appreciate that, okay.

    You know, I think we're coming sort of down to the end of our conversation and, you know, I appreciated also, you know, you talked about, you know, making more formal connections between, say, HBCUs and, say, medical schools where they can, you know, establish a pathway program. Do you have a similar thought with, you know, our HBCU medical schools as well? Or do you do think we need more HBCU medical schools to —

    Max Nguemeni Tiako: Um, that's a good question. I mean, I don't know that we need more medical schools, period, I don't know. HBCUs are historical, right? Like, it's like they serve the purpose and continue to serve a tremendously important purpose in educating Black people and providing a path like — sort of, like, a path to upper mobility, you know, to the middle class. To this day, right, HBCUs, like, are producing — either through undergraduate education or graduate or going to med school — are an engine for producing Black physicians.

    Geoffrey Young: PhDs as well.

    Max Nguemeni Tiako: Right, PhDs definitely, like, Howard University is, like, doing it and many HBCUs.

    Geoffrey Young: Hampton, yeah. [Laughter]

    Max Nguemeni Tiako: But the issue with, you know, I saw this study that showed, like, if after the Flexner Report — it closed, I don't know, seven medical schools at the time, seven Black medical schools at the time — yeah, I think it was seven, yeah?

    Geoffrey Young: Yeah, seven, yep.

    Max Nguemeni Tiako: That they would have trained 35,000 physicians, Black physicians. I mean, it's a huge, it's a huge number, right, and it's a projection. Who's to say what the landscape of residencies would have looked like? Because, like, people always talk about opening new medical schools. No one wants to talk about creating more residency slots. There's a —

    Geoffrey Young: Yeah, yeah.

    Max Nguemeni Tiako: And specifically, residency slots in the places where these medical schools are being opened. You know, Black students have like 0.6 adjusted odds of matching into residency compared to their White counterparts. Like, you know, at the four-year mark, which is, like, when most people go to residency after med school.

    So yes, I — you know, I love that the existing medical schools are doing what they're doing, but I really want to also think about beyond medical school, right? Like, what are … But like, can't we expand residencies, right? We know we're facing a loop, like a physician shortage by 2030 that's going to be pretty dire. And so, like…

    Yeah, I want there to be a greater conversation around expanding residency slots.

    Geoffrey Young: Okay.

    Max Nguemeni Tiako: When I think of — because the residencies also help train medical students, right? Like, I remember not too long ago in D.C., there was this conversation about opening a hospital in Southeast that was going to be, like, held by — it was going to be, like, a contract between, like, this hospital in the city and, like, Georgetown or George Washington — one of the two — and, like, not Howard. Like, Howard Hospital is where most Black people in D.C., especially from Southeast, like, get their care.

    And so, like, that would have funneled — I mean, you know, that would have had impact on the education of Howard medical students as well as the people who are doing residency at Howard. And so, in my mind, I was like, “How come the city, which has a majority Black City Council, or like — didn't think of this issue of Howard being this engine, right, for one, supporting the Black community of Southeast and Northeast D.C. and Northwest really, and also supporting these medical students?”

    Or, like, in Nashville, where the city is deciding to close Nashville General, which is the hospital that's affiliated with Meharry — Meharry Medical College, right? Like, Meharry Medical College students, like, need greater opportunity in terms of clinical training.

    So, I don't think opening new medical schools … I want the clinical experiences of medical students at HBCUs to be even better based on what I've seen and based on conversations that I've had with friends, and I want opportunities for training in residency for Black med students at HBCUs and Black med students in general to be better, yeah.

    Geoffrey Young: Okay. Well, Max, I just really want to say thank you for joining me today. I am, you know, just so humbled and thankful that you are pursuing your dreams and accomplishing — and that you have a strong voice advocating for racial justice and the issues that you so eloquently discuss and offer. So, I just want to just say thank you and I — I wish you ongoing success and hope that, as you make that transition to your residency, to faculty, or practice, that I would love to ask you to come back and share some of your insights and visit them with us again.

    So, I just want to just take an opportunity to — just on the behalf of the Association of American Medical Colleges — to say thank you for your time. I know you're incredibly busy and enjoyed the conversation.

    Max Nguemeni Tiako: Thank you so much. I did too. It's a pleasure to talk to a fellow HBCU alum.

    Geoffrey Young: Yeah, yes sir.

    Max Nguemeni Tiako: I actually, you know, I didn't know … You know, it's like, Zoom these days, you don't know, you exchange emails with people, you don't know who you're going to meet. I was like, “Oh, he is Black. He went to Hampton, that's so cool.”

    Geoffrey Young: Yeah right.

    Max Nguemeni Tiako: So, thank you. This was a pleasure. Thanks for having me. I really appreciate this opportunity.

    Geoffrey Young: Yeah, thank you so much.

    [End of Audio]