U.S. Supreme Court Ruling Potentially Dampens Diversity

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With rheumatology facing a workforce shortage and lagging diversity compared with some other medical specialties, some rheumatologists worry about the potential lasting effect of the recent U.S. Supreme Court ruling regarding affirmative action.

By a vote of 6 to 3, the June decision ruled that the University of North Carolina and Harvard College admission programs were in violation of the equal protection clause in the Constitution barring racial discrimination by government entities.¹

In the decision, Chief Justice John Roberts wrote for the majority and stated that college admissions programs could allow an applicant to explain how their race influenced who they are if it would have an effect on the school they would attend. However, a student “must be treated based on his or her experiences as an individual—not on the basis of race,” he wrote.

Affirmative action became part of certain government, education and other initiatives beginning in the 1960s to address racial inequalities, thereby increasing diversity. It has faced legal challenges throughout the decades, however.

Like other medical societies, including the American Medical Association, the ACR released a statement regarding the Supreme Court ruling this summer. In part, it reads:²

The American College of Rheumatology is deeply concerned about the U.S. Supreme Court’s affirmative action ruling because of the potentially negative impact on rheumatology patients. Adults and children with rheumatic diseases from historically marginalized and under-resourced communities have greater disease burden and worse disease outcomes. Among other factors, a diverse and culturally responsive workforce plays a critical role in fostering strong patient-provider relationships and a climate for optimal health. In addition, educational environments with diverse perspectives and lived experiences create powerful opportunities for learning and skill building that advance patient-centered care.

The decision by [the Supreme Court of the United States] to prevent undergraduate programs from considering race and ethnicity, among other factors, in their admission policies undermines the valuable progress in addressing health inequities and disparities.

The statement goes on to say that fewer than 15% of ACR/ARP members represent racial and ethnic minority groups that are under-represented in medicine. “This ruling will impede the expansion of a diverse physician and health professional workforce that represents the patients they care for,” according to the statement.

A 2015 workforce diversity report from the ACR found that only eight of 1,011 adult rheumatologists identified as Black, 85 identified as Hispanic, three as American Indian/Alaska Native, 153 as Asian and one as Native Hawaiian or Pacific Islander.³

Although numbers may differ slightly today, research indicates that diversity in rheumatology has been an issue for a long time.

Reactions

Dr. Ramsey-Goldman

Many rheumatologists say they are anxious about the effect the court’s decision will have on their ability to attract a diverse group of medical students into rheumatology.

“The decision will impact the rheumatology workforce if we do not strive to continue to embrace the importance of diversity and identify possible solutions to support diversity while complying with the court’s ruling,” says Rosalind Ramsey-Goldman, MD, DrPH, Gallagher Research Professor of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago. Dr. Ramsey-Goldman chairs the ACR’s Collaborative Initiatives Committee and is a volunteer on the Workforce Solutions Steering Committee.

Dr. Wright

“Any messaging from the Supreme Court that suggests we shouldn’t think about race and ethnicity makes me think we’ll have more challenges in having a workforce that mirrors our patient population,” says Tracey Wright, MD, associate professor and chief of the Division of Pediatric Rheumatology, UT Southwestern Medical Center, Dallas. The impact of diversity, or lack thereof, becomes more obvious in smaller niche areas, such as pediatric rheumatology, she says.

Dr. Blazer

“This decision will make it more challenging to recruit and retain the diverse workforce necessary to care for our diverse patients,” says Ashira Blazer, MD, MSCI, an attending physician at the Hospital for Special Surgery and assistant professor of medicine, Weill Cornell Medical College, both in New York City. Dr. Blazer is also co-chair of the ACR’s Diversity, Equity and Inclusion Committee.

“I worry about whose voices will be missing at the table, especially when we’re a small specialty,” says Irene Blanco, MD, MS, professor in the Department of Medicine-Rheumatology, Northwestern University Feinberg School of Medicine, Chicago. Dr. Blanco co-chairs the ACR’s Diversity, Equity and Inclusion Committee. She ponders how the recent Supreme Court decision will affect recruitment groups and organizations that focus on helping minority candidates, both within and outside rheumatology.

Dr. Blanco

Research shows physicians who are under-represented in medicine maintain higher-quality communication with patients who identify as racial or ethnic minorities.⁴ Many patients with rheumatic disease, especially those with systemic lupus erythematosus, rheumatoid arthritis and Sjögren’s disease, are female and represent minorities in the U.S., says Dr. Blazer.

A diverse rheumatology workforce can offer better patient care, create more innovative research, publish higher-quality manuscripts and challenge insular biases that prevent progress, Dr. Blazer says. In short, increased diversity can make a difference in patient outcomes.

Although this ruling focused on race and ethnicity, rheumatologists interviewed for this story point out that other types of diversity are also important to admissions considerations, such as diversity in gender, geographic location (e.g., rural vs. urban) and whether a candidate has immigrant parents.

Dr. Helfgott

However, Simon M. Helfgott, MD, director of education and fellowship training in the Division of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Boston, and a former physician editor of The Rheumatologist, points out the Supreme Court ruling could have less of an impact than some think, at least when it comes to evaluating fellowship candidates. He has already seen a trend of candidates revealing less personal information in their applications, making the selection process more challenging for fellowship programs. As a result, he says, he will focus on personal statements, where their residency was completed and feedback from the residency director to get a fuller picture of potential candidates.

Carving Out Diversity as a Priority

Although the impact of the Supreme Court decision continues to evolve and may take years to work its way through the admissions system, rheumatologists are already looking ahead for ways to increase diversity among candidates and encourage fellows to embrace diversity. Here are some of their ideas:

1. Educate medical students about rheumatology. “A medical student, regardless of their background, can’t think about a field if they’ve never interacted with physicians in that field,” Dr. Wright says. Lectures, rotations and programs that connect undergraduate or medical students with rheumatology can expand awareness of what the specialty offers.

When taking part in such sessions, Dr. Wright hears some common questions: What does a rheumatologist do? What do you find most rewarding? What’s your day-to-day work experience? Some students come away with a greater interest in the specialty and stay in touch with her.

Introducing rheumatology as a potential career option could even begin during elementary and high school years, Dr. Blazer says.

2. Reach out to schools or programs that serve those under-represented in medicine. Partnerships and educational programs geared toward historically Black colleges and universities can create a pipeline of clinical talent that could make its way into rheumatology, says Beth L. Jonas, MD, FACR, Reeves Foundation Distinguished Professor of Medicine and chief of the Division of Rheumatology, Allergy and Immunology, University of North Carolina School of Medicine, Chapel Hill. Dr. Jonas is also a member of the ACR Workforce Solutions Steering Committee.

Dr. Jonas

The Rheumatology Research Foundation and the ACR Committee on Training and Workforce Issues invited and offered scholarships to a group of students under-represented in medicine (URiM) to attend ACR Convergence 2022, Dr. Wright says, which included panels and special networking sessions geared for them. The URiM Convergence Scholarship returns for a second year at ACR Convergence 2023.

The ACR’s Collaborative Initiatives Committee also introduced Project LEAD in 2023, which coordinates roundtables between URiM rheumatologists and medical students from historically Black colleges and universities. Such programs are another way to invite a diverse group of candidates to enter the specialty.

Another possibility is collaboration with such groups as the Latino Medical Student Association and the Student National Medical Association, both of which are open to anyone but focus on those from under-represented groups, Dr. Jonas says.

3. Offer more rheumatology slots. Rheumatology is a more competitive specialty than in previous decades, Dr. Helfgott says. Despite a workforce shortage, there are still not enough fellowship slots to accommodate the number of medical students who would like to enter the specialty. He would like to see funding from industry or other relevant sources to support additional slots and enable more candidates to enter the field. Adding slots in areas of the country that currently don’t have rheumatology programs could also help increase diversity, he explains.

4. Look for diversity in personal statements and achievements. Dr. Helfgott recalls a fellowship candidate whose personal statement shared that their first experience with the American healthcare system was serving as a translator at age 6 or 7. The candidate helped his parents, one of whom spoke only Italian and the other who only spoke Spanish. Another personal statement he recalls was from a candidate who shared their fear of monkeys, which stemmed from the necessity of walking to school in India through part of a jungle where monkeys could attack. Stories like these help identify candidates with diverse backgrounds and experiences, as well as candidates who may bring a different perspective to your program, Dr. Helfgott says.

Other ideas include adding adversity scores for applicants to measure hardships they’ve faced to reach medical school or essays to address social justice challenges faced by an applicant on their personal journey to a career in healthcare.⁵

Admissions decision makers also can focus on what fellowship candidates have done beyond research—something many schools find important but that not all candidates may have had the time or resources to concentrate on, Dr. Helfgott says.

5. Aim for diversity in research. Program directors can offer fellows support for, and encourage participation in, research that includes a diverse group of subjects. This can lead to more broadly applicable research outcomes. Teaching about social determinants of health and focusing on diseases that have a greater impact on people of color can also encourage fellows to embrace diversity, Dr. Jonas says.

6. Address diversity among all hires. Although not specific to college admissions, diversity among hires within rheumatology can play an important role in increasing workforce diversity, Dr. Jonas says. In addition to physician hires, consider diversity among other hires, including nurses, advanced practice providers, pharmacists and other staff.

7. Advocate and get involved. “The onus is on us to be vocal and be advocates and push back,” says Dr. Blanco, who was previously associate dean for diversity enhancement at Albert Einstein College of Medicine, New York City. “How can we use our voice as physicians to amplify the voices of our patients and our needs as a community?” By participating in admissions committees, spreading the word about the specialty and finding creative ways to help address the specialty’s workforce shortage, she says.

Shared Backgrounds May Help Build Trust Between Patients & Providers

Pancy Brown, 23, of New York City, became a rheumatology patient at the age of 10, when she began treatment for systemic lupus erythematosus and lupus nephritis.

Ms. Brown

One aspect of care that’s been important to her is connecting with a provider who has a similar racial background. Ms. Brown formed a bond with Alisha Akinsete, MD, a pediatric rheumatologist formerly with Montefiore Medical Center, The Bronx, N.Y., and now with the Hospital for Special Surgery, New York City. “Having a provider with a similar racial or ethnic background is important because … I feel like we can relate to each other. From a patient’s point of view, it’s easier to communicate your questions and concerns because you know you’re around someone who’s willing to listen to you,” Ms. Brown says.

Ms. Brown also appreciates that Dr. Akinsete showed that she cared about her—not just her lab numbers, but as a person overall.

Such connections with patients can play a role in improving care, says Dr. Wright, a pediatric rheumatologist. “There are certain conversations I can have when patients share a similar cultural experience,” she says. “Sometimes, that allows me to get more buy-in.” For example, she may share a personal story with a teen who’s struggling to manage their rheumatic disease or take their medications as they should.

“It’s important for adolescents to see people of color treating them—not only for the fact that they look like them, but for the authenticity of the care they are receiving,” Ms. Brown says.

Having a shared racial or ethnic background also can help when inviting patients to take part in research. This is sometimes a challenge due to egregious research that involved persons of color in the past. “That’s another place where that trust can come into play,” Dr. Wright says.

Vanessa Caceres is a medical writer in Bradenton, Fla.

References

1. Students for fair admissions v. President and fellows of Harvard College. (No.20–1199). Argued Oct. 31, 2022. Decided June 29, 2023.
2. ACR statement on U.S. Supreme Court’s ruling on affirmative action in undergraduate admissions. American College of Rheumatology. 2023 Aug.
3. 2015 workforce study of rheumatology specialists in the United States. American College of Rheumatology. 2016.
4. Shen MJ, Peterson EB, Costas-Muñiz R, et al. The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. J Racial Ethn Health Disparities. 2018 Feb;5(1):117–140.
5. Yancy CW, Barabino G, Bright C, et al. The Supreme Court and the importance of diversity in medicine. N Eng J Med. 2023 Aug 24;389(8):677–679.