Changing Missions of Medical Schools and Trends in Medical Student Diversity

The Association of American Medical Colleges (AAMC) and many medical schools have voiced their commitment to improving physician workforce diversity. ^{1, 2} Nevertheless, growth in the numbers of medical students from underrepresented in medicine (URM) backgrounds (including African American or Black, Latinx, and Native American) has been slow and has not reached parity with the US population. ^{3, 4}

Setting a school-wide mission statement to address the lack of diversity in medicine can help direct attention, resources, and support toward initiatives to increase the number of URM matriculants, ^5-9 and schools that have done so have greater representation of URM physicians among their graduates. ⁸, ¹⁰ Currently, this proposition is based on cross-sectional comparisons; outcomes of actual changes in school mission statements have not yet been examined. In this study, we analyzed changes in medical school mission statements between 2013 and 2021 and correlated changes in mission statements with trends in URM student representation. We hypothesized that the proportion of enrolled URM students increased faster among medical schools that added diversity or equity content to their mission statements.

We selected schools for analysis that had been included in a previous study wherein mission statements from 136 US MD-granting medical schools were rated on social mission content (SMC) by a panel of 37 raters. ¹⁰ In April 2021, we reviewed and classified those schools’ current mission statements into three mutually exclusive categories: (1) schools that changed their mission statement, adding diversity or equity language; (2) schools that changed their mission statement, but did not add diversity and equity language; and (3) schools that had no change or no substantive change to their mission statement (eg, the only change was the name of the school; Table 1). Disagreements were resolved through discussion with a third author. Schools for which a current mission statement could not be located were excluded from the analysis. We then obtained data from AAMC on the percentage of enrolled medical students identifying as URM in each academic year from 2013 to 2021.

For each school category, we summarized URM student representation using medians with interquartile ranges and compared them using Kruskal-Wallis tests. We used mixed-effects regression to estimate the trend in URM student representation (ie, the change with each additional year), differences in URM student representation by category of mission statement change, and interaction of these two terms (to determine how the trend in URM student representation was associated with changes in each school’s mission statement over the study period). In this model, we controlled for each school’s baseline SMC rating and baseline (2013) enrollment. We used school-level random intercepts and cluster-robust standard errors to account for nonindependence of repeated observations of the same school.

We used matching to further isolate how adding diversity and equity content to each school’s mission statement was associated with the trend in URM student representation. Specifically, for each school that added diversity or equity content, we identified the most similar school in the “no change” group based on the 2013 SMC rating, using 1:1 nearest-neighbor matching without replacement. In the matched sample, we modeled the proportion of URM students in each academic year using pair fixed effects regression, which included a calendar year covariate and an interaction between that covariate and whether the school added diversity and equity content to its mission statement. We completed data analysis in Stata/SE 16.1 (StataCorp, LP), and considered P<.05 statistically significant.

This study was deemed exempt from approval by the Institutional Review Board at East Carolina University.

Bivariate analysis of medical schools classified by a change in mission statement revealed no differences in URM student representation from the 2013 to 2021 academic years (Table 2). Multivariable analysis of the entire sample found that at schools that added diversity and equity content to their mission statement, URM student representation increased by 0.4% per year. No such trend was observed among schools that did not change their mission statement or changed their mission statement without adding diversity and equity content (Table 3). After using 2013 SMC scores to match each of the 30 schools that added diversity and equity content to its mission statement with a similar school that made no changes to its mission statement, we used fixed-effects regression to confirm that representation of URM students increased among schools that added diversity and equity content to their mission statement (at a rate of 0.4%/year, 95% confidence interval [CI]: +0.1%, +0.6%; P=.010), but did not increase among the matched control schools that did not change their mission statement (-0.1%/year; 95% CI: -0.4%, +0.2%; P=.506).

Given the link between diversity-minded mission statements and representation of URM students, ⁸ changes in the mission statements of academic medical centers made to reflect priorities of diversity, equity, and inclusion should undergo further study to determine how they can be used to impact the experiences and recruitment of URM students. ⁶ Examining trends in URM student representation, we found a pattern of increase among schools that added diversity and equity content to their mission statements but not among schools making other changes (or those making no changes). Based on our study, changing mission statements to reflect priorities of diversity, equity, and inclusion may be associated with a small impact on trends of URM student representation. One possibility is that schools that were more concerned with increasing diversity, equity, and inclusion increased the URM enrollment as well as changed their mission statements.These results underscore the need for ongoing work to increase numbers of URM learners in medical school; changing mission statements may be of only limited help.

Our study is not without limitations. First, we used a selected group of medical schools determined from previous work. ¹⁰ We did not explore why missions were changed or what specific elements of diversity, equity, and inclusion were addressed in the new mission statements. Because our study looked only at mission statements from 2013 to 2021 and at whether diversity content was added, we did not determine how long a changed mission statement had been in effect and what that may have meant for trends in URM representation. Differences in duration of a changed statement may have led to different outcomes in our study. Another important limitation and impact on our data could be the events of our nation during the time of our study period. We did not consider the political environment, effects of the coronavirus pandemic, or murders of Black men by police (the most notable being the murder of George Floyd in May of 2020) that happened during our study period. All of these elements could have potentially impacted the results of our study and served as confounders. In addition, schools may have had written and unwritten policies and procedures that attracted URM students.

While more research is needed to further characterize the impact of mission statements on the presence of URM learners in academic medicine, diversifying the health care workforce remains a prominent and urgent goal as long as the proportion of URM students enrolled in medical schools remains inconsistent with the population proportion of these groups. ¹¹ Mission statements should undergo further study to determine their usefulness in increasing numbers of URM students in academic medicine.