Transcript has been lightly edited for clarity and readability.
Kerry Whittemore: I'm excited to share the first of two episodes of M.ED Medical Education for the Practicing Clinician on the topic of health equity, diversity and inclusion with Dr. José Rodríguez. Dr. Rodríguez is a practicing family medicine physician and the Associate Vice President for Health Equity, Diversity and Inclusion at University of Utah Health. He is a national leader in the field of diversity in medicine and has a long academic career studying the topic of underrepresented minorities in medicine. Dr. Rodríguez is someone who identifies as a Latino and person of color in medicine, and he will share with us his personal story of how he got into medicine and how he became a leader and accomplished academic in the field of diversity in medicine. Because Dr. Rodríguez has such a depth and breadth of knowledge and experience in this field, this episode will be in two parts. I hope you enjoy my conversation with Dr. Rodríguez and don't forget to go to the RUUTE website for more information, including scholarly articles on the topic and information on how to get free CME credit. Thanks and enjoy.
KW: You have a great depth of knowledge on the subject of diversity in medicine to share with our listeners. So my first question for you is, how did you end up in Utah from Florida, and how did you end up in Florida? Because your family is from Puerto Rico, is that correct?
JR: That is correct. So my family, like many Puerto Rican families left Puerto Rico before I was born, and they moved to New York City and then upstate. I was born in Newburgh, New York, and lived there for 14 years, and then we moved to Florida. And it is from Miami, Florida, that I came to Utah the first time to Brigham Young University, which was a good experience overall, because it was college. When we left Brigham Young University, I was already engaged and my wife is from Ecuador, and we had made a decision that this would be a hard place to raise children of color. Fast-forward 16 years, I went to medical school and all of those places, and then we ended up coming back here because Utah had changed and our kids were older. We were delighted to be here and happy to be working at the University of Utah Health and at Redwood. I really do feel like this is kind of a magical time as well as a very unspeakably difficult time.
I think the magical part of the time is because there has been a nationwide reckoning with systemic anti-black racism. Like I have not seen since, well, since the History Channel content on the Freedom Riders in the 1960s.
KW: As a person of color yourself, what was your medical school and residency training like?
What was your medical school and residency training experience like?
JR: I would say that when I went to Cornell, I was expecting to find a lot more diversity than there was at Brigham Young University and I was pleasantly surprised to see that there was. But at the time, there was a hundred medical students in my class. One-half of the class were women. Or actually 51. There were 101 students, 51 were women and 50 were men. And at the time, 15% of us were considered underrepresented in medicine, which is a huge percentage, because since then it's actually gone up. But at the time, I did find a lot more diversity in the student body than I had been exposed to since leaving Miami for BYU. However, in the patient population, I was surprised that there wasn't as much diversity as you would have thought, and that has to do with Cornell's serving a very specific demographic of very wealthy individuals, and so there were places and patients that I wasn't allowed to see as a medical student, and that was hard. The other hard part about it was that medical school was tough, and there were certain things that happened in medical school that I couldn't understand why they were happening to me, and I always figured that it was some sort of personal failure on my part, the things that were happening to me. Then it became clear to me that I was bucking up against a system that wasn't exactly made to accommodate people like me, and that revelation is what got me started on this diversity path.
KW: Can you give an example of something that happened to you during med school?
JR: I don't want Cornell to look bad. But I will tell you that Cornell was extraordinarily generous with me, and I have to say that like 10 times, because during the time that I was there, I graduated with such a low amount of debt that it was unbelievable, and they actually started forgiving my debt the day I graduated. So Cornell financially was good to me, but you know, there are all sorts of things. The one thing that still stands out in my mind was when I got a test back, saying, "You know you failed, José," and I'm like, "Oh, dammit." I don't need to fail tests. This is Med School. This is bad, but the test that was given to me was not mine. However, it belonged to a similarly named person who was also Puerto Rican, so it's that kind of stuff.
There were other things. We've been in classes where they had called out people. I remember one class where they looked at me and said, "We're gonna volunteer like in the Mexican Revolution." And I'm like, "I'm not Mexican. What are you talking about?" Those are micro-aggressions and that's from individuals that aren't there anymore, but the people who are there, those people who ran that financial aid, they were wonderful.
To give you an idea, I went there and they had told me "Your family contribution is going to be $9,000 for your first year of med school." When I got there, they said, "We got more grant money, so instead of taking it out of the money that we're giving you, we're going to take it out of your loan money, so your loan obligation for the first year is now $4,000 including room and board and food." They were so generous.
KW: Wow. That unfortunately is uncommon, so that's great that you were able to benefit from it.
JR: Very uncommon. But it says a lot about the kind of things that we have to do if we're willing to compete for diversity.
KW: Right. I was looking at the American Association of Medical Colleges (AAMC). In 2018, 64% of full-time faculty identified as White, 19% as Asian, 5.5% as Hispanic or Latino, and 3.6% as Black or African-American. That's when Black people comprise approximately 13% of the US population, 5% of the overall physician workforce and 3.5% in academic medicine, and those who identify as Hispanic or Latino make up 19% of the US population, and only 5.5% of medical faculty. That's pretty insane and I'm guessing when you were in med school it was even worse. I know this is a huge question, but what are the most important things that as educators and medical school deans and folks involved in medicine can do to help that?
How can we increase diversity in the medical field?
JR: One of the things that we should talk about is the fact that that number is the exact same as it was when I was in medical school, essentially, you're talking about 8% underrepresented in medicine, and when I was in medical school, it was 7%. Essentially the same number. And that's 30 years now. We have to look at this and say, "Wait a second, what are we doing that has caused this?" The most important thing that we have to look at is how we select students. You are aware that the AAMC finally took the name Abraham Flexner off of the Medical Education Excellence Award at the meeting just last November, and they did this because this is the father of "modern medical education."
His legacy includes some very good things, such as recommending that medical schools become part of universities. But in the same paper, he also recommended that we should only select from the wealthiest echelons of society. As medical colleges, we have been remarkably good at that. He also recommended the closing of most Black medical schools because of the belief at the time and his personal beliefs were that Black medical schools were designed to be sanitation medical schools to keep Black disease out of the White population. So somebody who was profoundly racist. Now, fast-forward to where we are now, we're on 110 years after that report came out, and we're still doing a lot of the same things. We're still remarkably good at taking the wealthiest Americans into our medical school. We're also remarkably good at using metrics that we like to think are objective, but are used in a way that they were never intended to be used.
One of them is the Medical College Admissions Test (MCAT). Now, the MCAT has gone through lots of iterations, and this most recent iteration was actually, part of it was designed to make it more equitable, but what has happened is that we use it in admissions as some sort of gradation scale with the fantasy that somebody who gets a 511 is going to be a better medical student than somebody who gets a 509 or a 507. There's no evidence to support that. The people who made the test, all they want from the MCAT is to show that the person who took it has a strong enough science base that they will be able to be successful in med school.
But using it differentially was never the intention, and so I'm happy to say that there's a loud voice to say, "Listen, if it's designed just to see what the educational opportunities were that our students had, that's fine." A 501 is no different than a 510, especially today.
KW: I think back to my own time preparing for med school, that summer of the MCAT, I was also working full-time, and I didn't have the money or the time to take a MCAT prep class that costs thousands of dollars and I couldn't spend 40 hours a week doing that. I actually have no recollection of my MCAT score. It was fine, but I just think that that's inherently unfair, is that if you have the resources and the time to devote to full-time study. Who can do that? Not folks who are have other challenges to deal with.
JR: I think about what that really means, because now you can get a guaranteed MCAT score, you can say, I paid Princeton Review, $1,600 or $16,000. They will guarantee that I'll get higher than a 500. Like you, I couldn't afford anything like that. But I took an MCAT class; BYU offered one on Saturdays and it cost me $145. I missed work for six weeks, and I had to make up that work during the week. It was the worst.
KW: I got an MCAT prep book from the bookstore. That worked.
JR: That would probably cost about what my class did. Let's be honest, it's a different thing. The MCAT is part of it, but also we've been moving towards more holistic admissions, which I think is a very important role here. What we haven't been moving towards is actually recruiting for and selecting for diversity, and this is something that medical schools are coming to reckon with now. Again, if we speak about the Black population, there were more Black men in medical school when I was in medical school than there are today, and the Black population as a whole, was a higher percentage in 1994 in medical school.
We have 40 new medical schools since that time, and still we haven't proportionately increased our numbers of Black students, and that's really because of our focus.
KW: At the University of Utah, we have 125 students that matriculated this past year. Three were African-American, which is 2.4%. Apparently, the population in Utah is only 1.5% African-American. I was surprised at that. Nine Hispanic students, which is 7% of those matriculated in the Utah population of 12% Hispanic. So I'm not sure how that compares nationally to matriculated med students, but I'm guessing for the Hispanic population, it's probably equally poor everywhere and then Black population, it is even worse?
JR: Yes. Nationally, the average matriculation of Latino medical students is 5%. We are a tiny bit better in that class, however if we go through the four years, we are not at 5% yet. And kudos to our admissions team and our people who are working on this at the University of Utah, because in the time that I've been here, they've transformed it. There were three Latino students in that fourth year class, and there's nine in this first year class, that's a 300% increase.
The class before, so the ones that are second years now, had one African-American student and the class before them had zero African-American students.
JR: I think we have to kind of talk a little bit about apples and oranges here. I think at the University of Utah, we have an excellent commitment to our region. We have a certain amount of spaces that must be Utah students, and a certain amount of spaces that must be Idaho students, and a certain amount of spaces that are out-of-state students. I think that we have the diversity necessary to actually increase those numbers within our Utah students, but I think what happens is there are highly qualified students. If you can get into the University of Utah, you can go to Cornell. That's essentially what happened to me except I didn't get in here.
I think that we have to be strategic and careful. We have to make it attractive. One of the things that happened to me is I didn't want to go to Cornell. For one, I thought I was going to Ithaca and I didn't want to go to Ithaca.
KW: That's why I said, Cornell in New York City, because I think a lot of people think that Cornell Medical College is also in Ithaca.
JR: That's right. But I was in at the University of South Florida, I was going to be a primary care doctor for poor people, and I thought that an Ivy League education was just overkill. Which is a stupid thing to think but when Cornell came to me and said, "Are you coming?" I go "I'm not sure." They said, "Well, don't tell me anything else, let me give you my financial aid package." And then. Oh man, there was nowhere else. I was into some Florida schools, I was into some schools in Philadelphia, nothing. Nobody could even come close. But that's because they were competing for diversity.
KW: Isn't it also that they are a private school with a big endowment and have the money, because I feel like that's a harder thing to do at a state school, like the U.
JR: I agree that it's a harder thing to do at a state school, but it's not impossible. You see the headlines, the Huntsman family gave us $150 million to do the Huntsman Mental Health Institute. And if they only gave us $147 million and $3 million went to medical student scholarships, we could triple the Latino population in the school in one year.
So it's harder, but it's not impossible, and some of the other places that I got into were other private schools actually. They did offer money, but they didn't offer as much.
KW: One thing I think about diversity is not just in terms of skin color or background, but also in terms of gender and then socio-economic backgrounds, so I think we need more medical students who are not the children of doctors and are from rural areas and first generation college students. How do you think we attract those people? I feel like it's a little harder objectively on the demographics to say, "What was your parents' income?" It's just kind of harder to break that out and to study it, than perhaps races.
JR: Yes and no. To give an example, I got into Cornell, and in order for me to qualify for any financial aid income, I had to provide tax records for both my mother and my father. I was married at the time. I had been independent and receiving Pell Grants for years, but they simply did not care. After they got the tax records, they made the calculation and they decided, this is how much you can get. That kind of equity calculation is what we have to do because that makes a big difference. Fast-forward to this year, my 18-year-old son got into another Ivy League school, and they calculated his need the exact same way. In fact, they calculated his need from the FAFSA form, and then he calculated his need from his parents income, and it became clear that he was not going to get offered any money, but that's fair, because if he wanted to go, I'd find a way to pay for it, because we've been blessed that way.
So how do we do that going forward is going to be really important, but we must get family information, and that's one thing we're not doing in many, many schools. I'm not sure about the University of Utah, but I think most schools don't ask for parents' information because these are not children. We're taking students in their twenties, but I think we need to look at family income because that's an equity thing.
KW: What about pipeline programming? So you're talking about students that are already at the point of applying to med school. After they've done all that work, have the GPA, the MCAT, all that stuff. What about getting students even to the point where they think it's possible that they can go to med school?
What about pipeline programming?
JR: That is a bigger question. I will say that, you brought up rural students and first generation students. Our undergraduate institution actually does a great job with first-generation students. I think that it's over 50% are first generation students in that undergraduate pool. So that's a big deal. Now, rural students, as you know, that's a harder thing to define, and I don't have those statistics memorized. I do know that the rural population of this state is less than the Latino population of this state.
KW: In terms of just diversity?
JR: In raw numbers, there's 350,000 people that come from rural or frontier counties, and there are 450,000 Latinos in this state. Which is actually 14%, but the census probably estimates that closer to being 18%, and we'll see what it comes out to this year. It's a smaller proportion of the underserved students, that doesn't mean that they're not very needy people because they're absolutely very needy. And we know that if we can actually recruit someone from the rural area of Utah, train them in that area, that they are much more likely to stay in that area. And there's a great need not just for the majority population, because I think we have this idea that these rural areas are mostly White, and some of them are but we have to remember that agriculture and petroleum are the number one and two industries of those areas, and the people that work in that are overwhelmingly Latino.
KW: I think that is a misconception that people have about rural parts of not just Utah but of the country in general.
JR: We recruit for diversity, and we recruit for diversities that are visible because they protect that invisible diversity. So for example, a place where there's lots of Black and Latinx and Native American students will help that first generation White student who's from a rural area feel at home because they understand some aspects of diversity. And so I think that's part of the message that we have to get out. Visible diversity protects invisible diversity, and we need to figure out how to work with partners across the state. Not everybody can come directly to Salt Lake if they're from Price. But maybe they can go to Price first do two years there and say, "Oh, I can do this." And then move to Salt Lake City.
KW: Right. Part the RUUTE program is try to get more students from community colleges and the rural parts of the state up here who are interested in the medical school or other health sciences after that. So another jargony word is the LCME, which is the Liaison Committee on Medical Education, which I essentially think as the accreditation board for medical schools, so they have standards on diversity that medical schools have to fulfill in order to retain accreditation. How is the University of Utah doing with those and compared to our counterparts, other Pac-12 schools, for example?
JR: For the most part, it's element 3.3, that's diversity and inclusion. Across the country, it is the most cited area of inadequacy in medical schools, and I know this because of talking to people on the LCME. A friend of mine who was a dean at a different school, told me that that's what happens. I've also heard of places where they have high numbers of Black and Latino students. Places that have been top 10 for Latino students, places that have more Black students than any other non-HBCU in the country have still gotten citations on diversity. So I think as far as we're concerned, I'm sure that the LCME will identify equity, diversity and inclusion as an area of improvement for our institution.
KW: Well, thank you so much. Lots of interesting conversation and information to digest. Really appreciate you chatting with me today.
JR: Oh, it's my pleasure. And if you want to do this again I'll come back. Really happy to do it.
KW: In our next episode with Dr. Rodríguez, we will discuss his role as AVP strategies to recruit for diversity and discuss patterns of diversity and inclusion throughout the country and abroad.