Affirmative Action in Medicine: Improving Health Care for Everyone

VI. Affirmative Action in Graduate Medical Education

118 vi. Affirmative Action in graduate medical education Even more than undergraduate medical education, graduate medical education programs determine the future form and function of the national physician workforce. In recent decades, graduate medical education (GME) has come to rival and surpass the undergraduate system in complexity and size. While in 1940, just under six hundred hospitals offered a total of about five thousand residency training positions, in 1976, approximately seventeen hundred hospitals offered more than sixty-five thousand positions. In 1979 an AAMC survey of graduating students from U.S. schools showed that 93.2 percent intended to finish residency training to complete requirements for specialty certification (AAMC 1980, 115). Of students graduating in 1977, 87.5 percent entered residency training in a teaching hospital in which postgraduate training was provided by “fulltime and voluntary members of medical school faculties” (25). Candidates for graduate training programs are selected by the various clinical departments within a teaching hospital, rather than by an admissions committee representing the whole faculty. The competence of resident physicians who complete the training is determined by outside examiners of the specialty boards who specialize in that field. The training programs also are certified by outside specialists. However, despite this splintering of responsibility, the medical school faculties do in fact control more than 95 percent of all residency training positions through affiliation agreements. Indeed, in most major teaching hospitals, the same faculty member is the head of a given clinical department for both the hospital and the medical school. Even in situations of less close affiliation, the medical school department head will be responsible for the quality of the training program and its director. Despite this medical faculty influence, there is a great deal of variation in quality of training from one special field to another within any teaching hospital. Severe shortages or surpluses of physicians from field to field necessarily lead to different recruitment and selection strategies. Serious current problems for GME to resolve, therefore, are those dealing with the necessity of improving consistency in quality of graduate training programs across the board, to coordinate training programs within a given institution, and to improve and secure future financial support for these important programs. Assuring equity of access to GME programs for all subgroups of our population has attracted less attention than the issue of admission to undergraduate medical schools. Problems of gaining access to graduate education programs within a given institution generally, but not always, follow the pattern of undergraduate medical school admission. In this chapter I present data on the major GME programs that are controlled by the medical schools. PAST RACE PREJUDICE TOWARD BL ACKS IN CLINICAL MEDICAL SET TINGS Black students who attended predominantly White medical schools in earlier decades experienced great problems in their third and fourth clinical years when the time approached for them to go to the wards of the teaching hospital. Until the mid-1960s, Blacks in many parts of the nation had difficulty in gaining entrance to hospitals either as patients, nurses, medical students, residents, or staff physicians. Some of the predominantly White medical schools, with their small number of Black students, arranged in the 1920s and 1930s for these students to be transferred to Howard or Meharry for instruction in their last two clinical years. While this practice gradually had changed by the 1940s, it persisted well into the 1940s for Black students scheduled to do clinical clerkships in obstetrics and gynecology. When I was a student at the University of Michigan during the 1940s, there were no problems in my rotation on the general medicine or surgical clerkships on male or female wards. The University Hospital’s small obstetrics and gynecology service at the University Hospital in Ann Arbor, however, was inadequate to meet teaching needs of all the medical students . Students therefore customarily were divided into sections and rotated through that clerkship in a large hospital for women located in nearby Detroit. Since that hospital did not accept Blacks, the Black medical students were advised to make their own arrangements to do their clerkships anywhere in the nation in hospitals that would accept them. In 1945 I spent a month at Provident Hospital in Chicago, and while it was a productive month, I was the last Black student who had to endure this prejudicial arrangement. This practice continued until 1946, at which affirmative action in graduate medical education 119 time the medical...