It had been a long shift in the emergency department, and I was in the midst of wrapping up the history and physical exam of my final patient when I noticed a beaming smile from the corner of my eye. I looked up and it was my patient staring at me, giving me the biggest smile in the world. I asked, “Sir, is there something in particular that’s making you so happy today? And if so, I want some of that.” He chuckled a bit, and simply replied, “Son, it’s you! I am so proud of you. I don’t often get to see Black men like myself in white coats. Promise me you will thank your mother for me.”

At that point in my fourth year of medical school, I had taken care of countless patients whose names and conversations have come and gone. However, I continue to reflect on this conversation that I had with this older Black gentleman. Although I have taken care of many other Black men since then, I still remember this particular patient — not only because of the fervor in his eyes and the excitement in his voice, but also because of the poignant significance of his words. He was an elderly gentleman who grew up on the South Side of Chicago, an area in which he was more likely to see Black men in body bags than in white coats.

For me, it had become an accepted norm to be one of a handful, if not the only Black person, in my pre-medical classes and in medical school. When the Association of American Medical Colleges (AAMC) published a report that claimed that the number of Black men in medical school was higher in 1978 than in 2014, I was disturbed by the numbers, yet unsurprised given my personal experience. The most gripping data point of this publication was the fact that 542 Black men across the United States enrolled in medical school in 1978, while only 515 enrolled in 2014. Looking at this another way, Black males represented about 3.0% of medical student enrollees in 2014 despite Black people making up 13.3% of the population of the United States. When looking at male and female Black enrollees in 2014, Black medical students still only made up about 7% of new medical students. Unfortunately, despite the population growth of Blacks in the US between 1978 and 2014, the number of Black trainees, male or female, has remained stagnant for decades.

The practice of medicine in the United States has always been dominated by White physicians. Historically, the Black community has mistrusted doctors because of past and current injustices they faced. Between 1932 and 1972, the bodies of Black men were used as guinea pigs in a study titled, “Tuskegee Study of Untreated Syphilis in the Negro Male.” In this study, Black men were intentionally not informed of or offered penicillin to treat the disease even after it was established as the recommended treatment for syphilis in 1947. Today, Black patients are often undertreated for their pain compared to White patients and may be shown less empathy or less effort to build rapport by the White doctors that take care of them. All patients deserve to have physicians that are equally invested in their care and who will treat them with the same respect and empathy as anyone else. It is likely due to these lived experiences that Black patients often prefer to have Black physicians if given the choice. If we assume that these patients have a better relationship and increased rapport with their Black physicians, this could translate into improved health outcomes for Black patients as well, given the associations between increased medication compliance in patients who demonstrate more trust in their physicians. Unfortunately, most Black patients will not be afforded this option given the substantial lack of representation of Black doctors in medicine.

“The most gripping data point of this publication was the fact that 542 Black men across the United States enrolled in medical school in 1978, while only 515 enrolled in 2014.”

I recently had the opportunity to explore the National Museum of African American History and Culture in Washington, DC. As I walked through the museum with awe and admiration of the design and beauty, I was also quite pensive as I reviewed the difficult and enriching history of Black people in this country. One of the most enlightening parts of the museum for me was the section in which the actions of various athletes from Muhammad Ali to Jackie Robinson were highlighted. This section highlighted the opportunity that sports gave Black men for upward mobility, particularly in the early to mid 1900s. This was a time before Brown vs the Board of Education and other major victories in the Civil Rights Movement, where sports was one of the few ways for Black men to achieve upward mobility. Nowadays, there are fewer legal barriers preventing Black people in this country from pursuing higher education. However, it is important to reflect on how much progress has actually been made given the crippling socio-economic and political barriers that are preventing poor Black children from receiving a proper education.

Unfortunately, the socioeconomic and educational level of one’s family in the US is closely tied to one’s quality of education and future professional prospects. Forced school integration from the implementation of Brown vs the Board of Education yielded the greatest shrinkage of the achievement gap between Black and White students in the 1970s and 80s. Specifically, in the early 1970s, there was a 53-point gap in the reading scores between 17 year old Black and White students; yet by 1988, this gap had dropped to only 20 points. Although this did not do much to change other extraneous factors that affected upward mobility, it did at the very least make the odds more even regarding the quality of education. Since then, the laws around integration have become less stringent, and we’ve seen a further widening in the achievement gap between Black and White students as schools have continued to re-segregate. Due to these realities, in conjunction with targeted policing in poor Black neighborhoods, it is not surprising that Black men who grow up in impoverished neighborhoods are more likely to see the bars of a jail than the walls of a medical school classroom.

From the NAEP 2012 National Report on Education and Mathematics

Moreover, even if one is lucky enough to attend a school district that is academically rigorous, various studies have shown that teachers often have implicit biases against Black students, and these biases manifest as early as in preschool. Recent research studies have demonstrated that Black students are four times as likely to be suspended and two times as likely to be expelled as White students. Additionally, such biases also manifest when White teachers set lower expectations for Black students, in particular Black males students, and refer them to gifted programs less often compared to their White counterparts. These actions have far greater effects than just a Black kid missing school — they can affect the mentality and confidence of impressionable children in a classroom, which could lead to insidious educational ramifications that persist into adulthood.

Recently, a friend of mine who teaches in one of Chicago’s public high schools asked me to visit her biology class for the genetics portion of the course in order to give my perspective as a doctor. After lecturing for a short period of time on genetics, I stuck around the classroom afterwards to help answer any questions the students had during the post-lecture activity. While walking around the classroom, I distinctly remember two extremely curious Black teenage boys who were asking me different medical questions every time I walked by their seat. At one point during our conversation, I recall one of these students giddily saying “I’ve never met a Black doctor before. How do you become one?”

“Due to these realities, in conjunction with targeted policing in poor Black neighborhoods, it is not surprising that Black men who grow up in impoverished neighborhoods are more likely to see the bars of a jail than the walls of a medical school classroom.”

A lot of my peers in medical school were not the first in their family to attend medical school and were privileged enough to have someone guide them along their pathway to medicine. More importantly, they knew someone with shared identities from an early age who demonstrated that it was possible for them to be successful in such a field. The fact that these boys had never met a Black doctor before me emphasizes the lack of representation in the field of medicine. Other than former President Obama, the most well-known Black male figures in the media are those either in entertainment or sports. Sadly, this lack of representation is further emphasized in the media by Hollywood typecasting when the actors casted to play physicians in movies, TV shows, and commercials are not often Black. These subtle cues suggest early on that certain professions are not viable for a specific group when they don’t see anyone else with their features presented in this manner.

Aside from the tremendous barriers that prevent Black men from taking an interest in medicine, the completion of medical training requires a lot of patience, stability, and money that not everyone is blessed with. It takes a minimum of eleven years to complete the education and training to become a licensed physician in the US. If someone is from a wealthy family, then he or she likely has family that will help pay for schooling along the way. However, those from middle and working class families are likely to amass a significant amount of debt in the hopes that the payout will be worth it in the end. In 2015, the Association of American Medical Colleges estimated that the average amount of debt for a graduating medical student, accounting for both undergraduate and medical school debt, was approximately $207,000.

Sadly, the idea of amassing so much debt may be a deterrent for someone from more humble beginnings. Even though the Black community in America has numerous families that are well off, a significant discrepancy still exists between White and Black wealth overall. For example, a recent Boston Globe investigation found the median net worth of White households in Boston was $247,500, while that of African American households was only $8. Although this discrepancy in Boston may be one of the worst in the country, in most cities in America, Black families are more likely to be working class compared to White families. And in many working class families, it is not uncommon to find multiple family members pitching in to make ends meet. It then makes sense that those who grew up in such environments and eventually attain a higher education often prefer to minimize their time without an income so that they continue to provide for their family as soon as possible. Therefore, a field such as medicine that demands an individual to forgo at least eight years of earning potential poses even more of a burden.

“Nowadays, there are fewer legal barriers preventing Black people in this country from pursuing higher education. However, it is important to reflect on how much progress has actually been made given the crippling socio-economic and political barriers that are preventing poor Black children from receiving a proper education.”

Before acceptance to medical school, one’s finances can already limit the odds of acceptance. Classes that teach students how to get higher scores on the MCAT (the medical school equivalent of the SAT/ACT) are costly. In addition to this, the actual application process is prohibitively expensive when the cost to apply to schools and fly around the country to interview is taken into consideration. According to the UC Berkeley Career Center, the average cost of this whole process is approximately $7520, assuming that a student takes an MCAT course and applies to an average of 25 schools to optimize their chances of admission.

From the UC Berkeley Career Center Website

Even after one is admitted to medical school, the wallet continues to be drained. For instance, the accreditation process requires one to take several expensive exams along the way. Hence, one ends up paying a few thousand dollars to take even more exams that require one to sit and stare at a computer screen for hours upon hours until one begins to weep either due to dry eyes, test taking-induced exhaustion, or the thought of how much money was spent on these exams. And once again, at the end of medical school, one must pay large sums of money to apply to residency, and drop a few thousand dollars to interview around the country for various residency positions. This entire process is extremely expensive, and for someone already at a socioeconomic disadvantage in this education system, this could be another major hurdle to overcome.

Although one starts generating an income during residency, the salaries are small. Residents on average make approximately $50K a year. When considering the sheer number of hours one is working, both in and out of the hospital, the pay per hour is estimated to being as low as $13 per hour. Moreover, when factoring the hundreds of thousands of dollars in debt that most medical students accrue during college and medical school, one has to account for multiple years of loan repayment during and after residency before one is actually considered to be debt-free.

“Even though there are no longer any legal barriers to prevent someone from pursuing a profession based on race, there are a multitude of other ways to discourage or prevent a group from pursuing a field.”

If the major hindrance to Black men pursuing a career as a doctor is the time and the financial constraints, perhaps there are other fields within medicine where they are more represented? I searched for the racial breakdown of physician assistants who are able to do many of the same tasks as physicians, but who don’t have to be in school for nearly as long. However, the numbers here were even more abysmal with Blacks (men and women combined) only representing 4% of all PAs in 2016. Moreover, given there is a 68% predominance of females in the field, one can surmise how underrepresented Black men are within this field as well.

From the 2016 Statistical Profile of Certified Physicians Assistants

Even though comparing the raw numbers of Black men between 1978 and 2014 already illustrates the stark lack of representation, a further look into the demographics of these two groups leads to more questions. In the 1970s, it was likely that the majority of the Black men enrolling into medical school were of African American descent. Today, this demographic has likely changed considerably. Although no comprehensive studies have been published on this topic, my personal experience as well as the collective observations of several colleagues in medicine suggest that many, if not the majority, of Black men in medical school currently are either first or second generation of African or Caribbean immigrants. To be clear, I reject any suggestion that this change represents a difference in inherent abilities between immigrants and African Americans. Instead, I believe that this emphasizes the immigrant paradox and relative privilege that some immigrant kids enjoy when it comes to pursuing higher education in the US — whether this comes in the form of parental education level, parental financial stability, or family and community encouragement to pursue higher education. Sadly, this means that Black kids who do not have these privileges have even fewer opportunities now than they might have had in the past. Yet, if Afro-Caribbean immigration is increasing the number of Black people in the US and consequently the numbers applying to medical school, shouldn’t the overall number of Black men and women in medical school also increase as well to accommodate for this change in population demographics?

In “The Autobiography of Malcolm X” by Alex Haley, after Malcolm revealed to his 8th grade teacher that he was interested in becoming a lawyer, he was infamously told “Malcolm, one of life’s first needs is for us to be realistic… A lawyer — that’s no realistic goal for a nigger… Everyone admires your carpentry shop work. Why don’t you plan on carpentry?” Malcolm X described how defeating such a statement was to his passion for learning at the time, and how this discouragement eventually led to him dropping out of school. Even though there are no longer any legal barriers to prevent someone from pursuing a profession based on race, there are a multitude of other ways to discourage or prevent a group from pursuing a field.

However, to change the representation of Black men in medicine, it is imperative to focus on improving the factors that can be changed for every Black boy that may be interested in pursuing medicine. For example, teachers from K-12 can help encourage students and families to pursue summer enrichment programs geared towards catching kids up that may be behind and keeping them interested in the sciences. College guidance and pre-medical counselors can direct their interested students early on to the multiple pre-med minority enrichment programs that are focused on increasing the number of minorities in medicine, and often provide a stipend for interested college students to attend. Finally, medical schools that are not historically Black institutions should also make a dedicated effort to not only increase the number of Black medical students in their classes, but should also work to recruit more Black faculty members as well.

With all the barriers to entry present within the field of medicine, one can easily rationalize how the numbers of Black men has been decreasing over the past few decades. Currently, there are more Black people attending two and four year universities than ever before, which demonstrates that progress has and can be made when it comes to giving Black youth the opportunities to succeed. However, to further improve the numbers of Black men in medicine, there is a lot more work to be done. Since it is unlikely that neither the length nor the cost of medical training will decrease anytime soon, it is imperative that we focus on other areas of improvement from exposure and media representation, to education and scholarships. Similar to the ways in which the groundwork was laid for years in order to improve the numbers of Black students attending universities, I’m confident that it is also possible to lay down a similar foundation in order to see more Black men in white coats.

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AK Agunbiade is an Emergency Medicine Resident Physician and a comedian who lives in Chicago. More information about previous work can be found at www.akagunbiade.com