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The AMA, Licensing, and African-American Physicians:

The American Medical Association is reportedly going to apologize today for its history of discrimination against African American physicians. I doubt that this apology will include any reference to the fact that the AMA's control of the physician licensing process suppressed the supply of black doctors for decades. Here is a relevant excerpt from my book, Only One Place of Redress: African Americans, Labor Regulations and the Courts from Reconstruction to the New Deal (read reviews here):

Once the AMA took control of licensing procedures, state physician licensing laws began to have marked effects on the number of black doctors. Most important, states ... forced five of the seven existing black medical schools, which educated most black doctors, to close. ... [T]he charitable foundations that supported black medical schools cut off funds to these school, and instead directed their philanthropy to the two black medical schools that survived, Howard and Meharry. Even those two schools were in danger for a time of losing their accreditations.

If licensing officials had taken the interests of the black community to heart, they could have temporarily bent standards in order to allow the other black schools to catch up. Despite [Abraham] Flexner's [author of the influential Flexner Report on medical education] dismissal of these schools as worthless, approximately half of their graduates had been able to pass their states' licensing examinations, and several of their graduates became prominent physicians.

Alternatively, licensing authorities could have pressured the other medical schools to admit black students, or at least create parallel programs for blacks. But the AMA, which controlled the licensing process, was concerned mainly with the interests of its members, who were, by strict rule, all white. Most AMA members were indifferent to the shortage black physicians, and some southern white doctors resented even the minimal competition they received from blacks....

Moreover, there was opposition in the South to allowing blacks to serve as medical personnel at all. Mississippi authorities were reputed to routinely fail black physician and dentist candidates, especially if they were not from the South....

Meanwhile, ever-increasing pre-medical educational requirements made it difficult for students from impoverished backgrounds to achieve the financial wherewithal to attend medical school. Flexner argued that his recommendations for additional pre-medical education would not discourage poor students, because non-profit medical schools, subsidized by foundations and alumni, would be able to offer six years of education for the price that for-profit schools charged for four years of education. Apparently, Flexner ... was not familiar with the concept of opportunity costs....

Not surprisingly, after 1910, the percentage of black doctors, which had been rising, leveled off. Because of the medical establishment's attitude toward blacks, which ranged from indifference to hostility, as late as the 1940s over 80% of black medical students received their education at Howard and Meharry.

Sarcastro (www):
Hey! This sounds like you are arguing that the AMA shoulda performed Affirmative Action! What's a Liberal like you doing in this Conspiracy?
7.10.2008 9:33am
ChrisIowa (mail):

Hey! This sounds like you are arguing that the AMA shoulda performed Affirmative Action! What's a Liberal like you doing in this Conspiracy?


Getting out of the way would have been sufficient.
7.10.2008 9:40am
Sarcastro (www):
"temporarily bent standards"

"pressured the other medical schools to admit black students"


What's next, marrying dogs?
7.10.2008 9:47am
p. rich (mail) (www):
And this is a relevant story today because...? Oh, wait. There's a sorta-black guy running for President. The Guilts. Reparations. Etc. Sorry. Should have been obvious.

Constant reruns of "Guess Who's Coming to Dinner", "Roots" and "The Color Purple" (now resurrected as the Oprah musical) on the way.

Soviet conditioning tactics using the arts and media? Surely just coincidence. Moving along now.
7.10.2008 9:50am
davidbernstein (mail):
Sarcastro, there is a difference between biting wit and willful ignorance disguised as sarcasm. The AMA pressuring medical schools that refuse to admit black students, regardless of their credentials, to admit them, when one must attend one of these medical schools to pass the licensing test dictated by the AMA itself, has only the faintest resemblance to the current controversy over affirmative action.
7.10.2008 9:53am
AnneS:
Let's not forget that the AMA's current med school accreditation process continues to cause a shortage of medical providers. The AMA's concern for the integrity of the profession and the public health have always come in a distant fourth and fifth to it's concern for its own economic interests, specialists' economic interests, and primary care doc's economic interests, in that order. There's a reason that physicians are the best paid profession in the country.
7.10.2008 9:55am
davidbernstein (mail):
Anne, that's why I wouldn't expect the AMA to acknowledge the role of accreditation/licensing in its history of discrimination.

Oddly, we continue to have a shortage of American medical schools while importing foreign physicians whose home institutions are likely on average much worse than whatever would come about if the AMA loosened its stranglehold on medical education.
7.10.2008 9:59am
Sarcastro (www):
Yeah, David, you are right, that was not quality sarcasm, it was just jerking people around. I'll try to be better in the future.
7.10.2008 10:00am
Alan K. Henderson (mail) (www):
Isn't apologizing for something you didn't do an oxymoron? An apology is remorseful acknowledgement of one's own wrongdoing. Let's get the English language right.
7.10.2008 10:38am
Originalism Is Useful (mail):
Alan,

All it takes for evil to prevail is for good men to do nothing.
7.10.2008 10:47am
Happyshooter:
So the AMA should have accepted doctors who failed to meet the standard and were ill-trained because the result was less black doctors?

Let's just drive through detroit throwing out doctor's licenses at random high school dropouts, that will solve any shortfall and make up for the past failure to embrace AA.
7.10.2008 10:52am
guess i'm a racist (mail):
If a person has to choose between a white doctor and a black doctor, it seems to me that it is advisible to choose the white doctor. Why? Because there's always the chance that the black doctor was "helped" along the way, but is not actually as competent or skillful in his profession as a white doctor. If a black doctor is licensed so that the medical profession can pat itself on its back, the impact is actually pernicious.
7.10.2008 12:01pm
albert:
David wrote: Oddly, we continue to have a shortage of American medical schools while importing foreign physicians whose home institutions are likely on average much worse than whatever would come about if the AMA loosened its stranglehold on medical education.

I would be careful before indulging that supposition- Indian immigrant doctors in particular are known for their high quality. The competition to get out of there and to America for the educated classes is so high that the people who come here are usually ridiculously highly qualified. The chief complaint about them in the medical community is not their quality- it is that "those positions could be taken by Americans if the med schools would produce more grads."

Also, your argument is interesting- you are essentially chastising the AMA for not engaging in affirmative action- i.e., lowering standards for black med schools, and making a special point to admit black students at other schools, in order to help out the black community. I thought that you were a critic of such tactics.

In any event I look forward to reading your book, which I'm sure is well-written and thought-provoking like all your other work.
7.10.2008 12:12pm
A. Zarkov (mail):
A long time ago, a black friend of mine enrolled in medical school. He told me that in the summer before classes were to start he would take special course` "anatomy for minorities" (not open to whites). He explained that minorities tended to do poorly in anatomy, so in effect they would take the course twice.
7.10.2008 12:26pm
db (mail):
no. flexner's argument amounted to "blacks are better off with no doctors (remember, southern hospitals were segregated, as was medical care generally) than with doctors who could pass medical liscensing exams but went to schools that didn't meet accreditation standards, some of which were arbitrary. and the ama standards also should not have applied towhites, it just didn't affect them as much.
7.10.2008 12:28pm
Mikeyes (mail):
Has anyone here read the Flexner report?

Remember it was published in 1910 and not a creature of the AMA but funded by the Carnegie Foundation for the Advancement of Teaching. Flexner was an educator, not a physician, and his focus was on how well the schools taught medicine using fairly common sense criteria such as whether or not the students saw patients and took basic science courses. He almost flunked Stanford if that helps.

In the section on "Medical Education of the Negro" he makes the argument that blacks would only be served by black doctors and "poor white ones" and that due to the horrendous (my word) public health problems that blacks were exposed to (as well a poor whites) that fewer well trained physicians and nurses would do a lot more for blacks than "an essentially untrained negro wearing an MD."

He advocated that the money going to the various schools be consolidated and put to use at Meharry and Howard. These schools are still in existence and meeting a stringent standard for medical education even now. I doubt that Flint and the other schools would have been able to keep up in anycase.

When Flexner made his report, there were hundreds of "Joe's Medical Schools", little proprietory schools - often part time and at night - that gave a medical diploma to anyone with enough money. Classes were sparse and often there were no patients to practice on and usually no hospital affiliation. The fact that there were black doctors who were able to pass the board exams only points out that there were black men who were intelligent. The same argument has been proffered many times in the Conspiracy concerning the bar exams. If you can study and have some familiarty with the information you can do well. It says nothing about the ability to practice law or medicine.

The Flexner report did have an effect on state laws regarding medical licensure. The AMA had been pushing for more stringent boards for decades prior to the 1910 Flexner report. They used it to change the laws and one of the unexpected things that may be a result of stricter laws was fewer black physicians. But there were also considerably fewer white physicians to since over half of the medical schools went out of business due to changes in the law and most of them did not accept blacks.

I am not a fan of the AMA by any means, but I don't think that the lack of black physicians can be laid only at their feet. We are talking about the South in 1920 after all and it seems to me that if 20% of black physicians were not trained at the two all-black medical schools in 1940 that this represents quite an advance in both civil rights and medical education. If so, how much did the AMA have to do with that? (Probably not much.)

In 1910 most people died from diseases that can be prevented or cured these days. "Hygiene" was much more important than curing disease since we had very few cures then. Flexner stated that the 5 black medical schools he panned were not even teaching these skills and that blacks would suffer as a result. It was better to serve this population with qualified people and let the remaining schools expand and serve.
7.10.2008 12:38pm
A. Zarkov (mail):
"... flexner's argument amounted to "blacks are better off with no doctors..."

In many cases you are better off with no doctor than an incompetent one. The prime directive in medicine is "first do no harm." In a life-threatening emergency of course you take what's available.

"... but went to schools that didn't meet accreditation standards, some of which were arbitrary."


So how do we decide what's necessary for physician training and what's arbitrary? Let's remember that unlike law schools medical schools really teach their students on-the-job skills.
7.10.2008 12:42pm
Suzy (mail):
"they could have temporarily bent standards in order to allow the other black schools to catch up"

This sounds exactly like affirmative action to me. It also has nothing to do with the AMA pressuring schools to admit well-qualified black students, as was suggested in response to "Sarcastro" above, because it directly refers to the black schools that were being forced out of existence. The justification for this proposal was that "approximately half of their graduates had been able to pass their states' licensing examinations, and several of their graduates became prominent physicians." So, not all of the graduates were qualified, but half were, with some outstanding. Yet the AMA was supposed to temporarily lower standards to allow these schools to catch up. Can anyone explain how that is not "strong" Affirmative Action? What else would it be?
7.10.2008 12:46pm
Sk (mail):
I don't understand: the AMA is going to apologize for enforcing standards?

"If licensing officials had taken the interests of the black community to heart, they could have temporarily bent standards" Yep. AMA is going to apologize for enforcing its standards.

"dismissal of these schools as worthless, approximately half of their graduates had been able to pass their states' licensing examinations"

Thus, they had a pass rate of 50%. How good would a law school be that had a Board pass rate of 50%? Haven't you had this very conversation, here on this site, within the last year, related to affirmative action pushing African Americans into schools for which they weren't qualified (or, into law school when they weren't qualified at all)?

"Alternatively, licensing authorities could have pressured the other medical schools to admit black students".

So, the AMA is now going to apologize for not promoting affirmative action before it existed as a policy? (and, again. Isn't the philosophy of this site anti-affirmative action, at least as applied to law schools?)

"Meanwhile, ever-increasing pre-medical educational requirements made it difficult for students from impoverished backgrounds to achieve the financial wherewithal to attend medical school."

This has always been true. It will always be true. If you have to have 4 years of college, and you have to pay for it, it will cost more than you have to have 2 years of college, and have to pay for it. Was it done to exclude blacks, or was it done to exclude the poor (many of whom were black), or was it done to professionalize medicine (which had the secondary effect of excluding more poor)? If so, was the tradeoff (more professional, yet less poor, or less black, profession) worth it? Perhaps someone will do the necessary research and write a well-documented book some day...

What a weird, exerpt. Nothing in the quoted section has evidence of racist behavior (other than the 'reputed' behavior in Mississippi). This is a perfect example of how a statement ("ever-increasing pre-medical educational requirements made it difficult for students from impoverished backgrounds to achieve the financial wherewithal to attend medical school") could be either wrong or neutral (i.e. racist nor not racist), DEPENDING ON THE BACKGROUND FACTS (were the pre-medical educational requirement established to exclude blacks, or were they established to professionalize the medical establishment? Who knows. Maybe someone will write a book about it and do the necessary research...). But throw enough of these statements back to back("...state physician licensing laws began to have marked effects on the number of black doctors. Most important, states ... forced five of the seven existing black medical schools, which educated most black doctors, to close..." Did they close because the AMA was racist, or did they close because they weren't teaching well?). , illustrate a 'pattern' of behavior X, then assert X. Its easier than researching, or determining, those background facts. You've got yourself tenure in modern-day academia.

Don't feel bad. We here know you're just paying the bills at your school. If they reward sloppy, but politically appropriate writing, and you want tenure, well sloppy but politically appropriate it is. But don't pretend its anything else.

Sk
7.10.2008 12:48pm
R Gould-Saltman (mail):
snark follows:


"Comunique to Secret Soviet Commie Overlords:

Crafty American lackey of imperialism P. Rich has detected our secret Black Nationalist propaganda operatives in the AMA and Harpo Productions. No longer practical to dupe Americans into believing our carefully crafted Big Lie that there was substantial institutionalized racism in US within last century. Foiled again!

Recommend moving to Plan C: propaganda to suggest to Americans that apparently widening wealth disparity between "really filthy friggin' rich" and rest of population might be basis for dissatisfaction with "free market" Republican administration, and that Rush Limbaugh no longer credible spokesperson for interests of working class.

Cloak supply adequate. Send more daggers.

BWAHAHAHAHAH!"
7.10.2008 12:50pm
Mad Max:
Haven't you had this very conversation, here on this site, within the last year, related to affirmative action pushing African Americans into schools for which they weren't qualified (or, into law school when they weren't qualified at all)?

We could easily have it again! And it will even strike quite close to Bernstein's GMU knuckle:

Not long after the Supreme Court decided Grutter v. Bollinger, the ABA responded to the apparent green light the race-based admission by tightening its diversity standards (a subject for another essay) and by increasing the pressure on law schools that it perceived to be not diverse enough.

The best example of this is George Mason University Law School - an up-and-coming law school in Northern Virginia with a somewhat conservative reputation. GMU's problems began in early 2000, when the American Bar Association visited the law school for its routine reaccreditation inspection. The site evaluation team was unhappy that only 6.5% of entering students were minorities.

Outreach was not the problem; even the site evaluation report (obtained by the Center for Equal Opportunity's FOIA request) conceded that GMU had a "very active effort to recruit minorities." But the school, the report noted, had been "unwilling to engage in any significant preferential affirmative action admissions program." Since most law schools were willing to admit minority students with dramatically lower entering academic credentials, GMU was at a recruitment disadvantage. The site evaluation report noted its "serious concerns" with the school's policy.

Over the next few years, the ABA repeatedly refused to renew GMU's accreditation, citing its lack of a "significant preferential affirmative action program" and supposed lack of diversity. The school stepped up its already-extensive recruitment efforts, but was forced to back away from its opposition to significant preferential treatment. It was thus able to raise the proportion of minorities in its entering class to 10.98% in 2001 and 16.16% in 2002.

The ABA was not satisfied. A few months after the Supreme Court's decision in Grutter v. Bollinger, it summoned the university's president and law school dean to appear before it personally, threatening to revoke the institution's accreditation.

GMU responded by further lowering minority admissions standards. It also increased spending on outreach, appointed an assistant dean to serve as minority coordinator, and established an outside "Minority Recruitment Council." As a result of its efforts to please the ABA, 17.3% of its entering students were minority members in 2003 and 19% in 2004.

The ABA was still not satisfied. "Of the 99 minority students in 2003," the ABA complained, "only 23 were African American; of 111 minority students in 2004, the number of African Americans held at 23." It didn't seem to matter that 63 African Americans had been offered admission, or that many students admitted with lower academic credentials would end up incurring heavy debt but never graduate and pass the bar. What mattered were the numbers. Even a class that was 19% minority was insufficient if only 23 of them were African American.

At no point did the ABA ask about the graduation rate or the bar passage rate of students who were admitted under the lowered admissions standards that they were requiring of GMU. That evidently was not important either.

GMU was finally notified of its re-accreditation in 2006 - just in time to start the seven-year cycle over again. When the ABA again visited in 2007, its site evaluation team again expressed doubts about the school's diversity efforts and it seemed that GMU might be in for a rough time again. This time the GMU dean shot back with the facts. Fully 45% of the African American students that the ABA had pressured GMU to admit experienced academic failure (defined under GMU's academic regulations as a GPA below 2.15) in their first year. In contrast, only 4% of other students did. In a letter to the ABA, the dean complained of the difficulty of complying with the ABA's diversity policy:

"We have an obligation to refrain from victimizing applicants, regardless of race or color, by admitting them to an educational program in which they appear likely to fail. This obligation is recognized in Standard 501(b), but we believe it exists independently of any ABA regulations. Adhering to this principle is the greatest obstacle to our efforts to increase the diversity of the George Mason student body."

GMU's failure rate for affirmative action admittees is hardly unique. Only 45% of African Americans who entered law school in 1992 passed the bar on their first attempt as opposed to over 78% of whites. The rest dropped or failed out of school, decided not to take the bar exam, or failed it. Even after multiple attempts, only 57% of African Americans succeeded. The gap was thus never closed. Many of those who never succeeded were left with huge student loans. Indeed, these days, it is utterly routine for law students to graduate with loans well in excess of $160,000. Some of those students are, of course, minority students.
7.10.2008 1:13pm
Karl Stucky (mail):
What the AMA should apologize for is restricting access to medical school for all qualitified individuals. By restricting supply, the AMA hoped to do what every other guild was doing at the time: raise prices, i.e., raise the incomes of docs at expense of public. Blacks just happened to be the easiest group to cut. The AMA is an evil institution.
7.10.2008 1:17pm
David M. Nieporent (www):
One problem here is that a lot of the commenters don't realize that the Flexner Report did not simply recommend standards for medical schools; the Flexner Report recommended -- independent of quality -- that the number of medical schools be reduced.


And this isn't surprising, because, contrary to the claim that it was "not a creature of the AMA," it actually was; the Carnegie Foundation did run the study, but it was commissioned by the AMA, and the AMA "assisted" Flexner.
7.10.2008 1:18pm
CB55 (mail):
In "Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present", Harriet Washington describes how the corrupt policies of government, science and medicine was used in the advancement of human progress but with tragic results in the Black community. She reports:

"In the mid-19th century, Alabama surgeon James Marion Sims, MD, dedicated his career to the care and cure of women's disorders and opened the nation's first hospital for women in New York City. In 1875, he was elected president of the American Medical Association (AMA). Hospitals still bear his name, including a West African hospital that utilizes the eponymous gynecologic instruments that he first invented for surgical experiments performed on black female slaves in the 1840s. But Sims's laurels were based on abusive involuntary surgeries that he perfected on enslaved women. He acquired black female slaves and gave them morphine until they became addicted in order to perform scores of painful, intimate vaginal surgeries, sans anesthetic, in an attempt to correct a devastating gynecologic condition called vesicovaginal fistula. Slaves did not have to be recruited, persuaded, and cajoled to endure pain and indignity; they could not refuse. Not until he had experimented with surgeries on enslaved women such as "Betsey" and "Anarcha" for four years did Sims venture to cure white women."

And on events on more recent times she reports:

"Misguided research has caused HIV therapy to be
withheld from blacks even as it has heavily ladled guilt for the spread of AIDS upon their shoulders. For example, in the early 1990s, a Johns Hopkins study revealed that HIV-positive whites, but not blacks, were doubling their chances for survival by taking azidothymidine, or AZT. Conventional wisdom has long laid this disparity at the feet of African Americans by insisting that blacks resisted taking AZT (later to be known as zidovudine) because of fear and distrust engendered by the USPHS Syphilis Study at Tuskegee.

But this monomaniac focus on the Tuskegee Syphilis Study as the catalyst for AZT aversion ignores some pertinent research history. In February 1991, soon after azidothymidine was embraced as the first effective drug against HIV infection and AIDS, U.S. Department of Veterans Affairs (VA) researchers informed the U.S. Food and Drug Administration that AZT did not work well for black patients, as it did for whites. The VA researchers also suggested that because AZT's side effects could imperil health, and even life, AZT should be withheld from blacks as an inefficacious and possibly dangerous medication.

Alarmed physicians were loath to prescribe AZT to blacks in the face of such ominous findings. The prohibitions against using AZT to treat blacks quickly became entrenched in the therapeutic canon. However, the VA study had utilized a relatively low number of African American patients and had not been designed to ferret out racial differences. This dramatic racial disparity generated research results that were a fluke, rather than an authentically disparate racial response. Later, rigorous research unmasked salient errors in the study and revealed that AZT was indeed efficacious for blacks. But it was too little, too late: Physicians remained slow to prescribe AZT to their black patients, and these patients were slow to accept it. No government or medical entity undertook the large-scale public relations effort that would have been necessary to repair the damage done to AZT's image.

As a result, HIV-positive blacks quickly progressed to AIDS, promptly developing the severe opportunistic infections, cancers, neurologic damage, and decimated immune system that heralded the syndrome. Medical researchers and physicians, not fearful black patients traumatized by the Tuskegee Syphilis Study, are responsible for blacks' aversion to AZT."

Harriet Washington has been a fellow in ethics at the Harvard Medical School, a fellow at the Harvard School of Public Health, and a senior research scholar at the National Center for Bioethics at Tuskegee University. As a journalist and editor, she has worked for USA Today and several other publications, and has written for the Harvard Public Health Review and The New England Journal of Medicine.
7.10.2008 1:18pm
db (mail):
requiring two years of college before med school wasas clearly arbitrary. fifty percent of grads pasing the boards belies f's contention that the schools were ""worthless." keeping a black medical school open while it improves because there are no "white" schools in the south where 80 percent of blacks live is a funny deinition of "affirmative action" and the ama licensing prevented black medical schools from focusing on basic hygiene' if that was indeed the problem'. finally' inlike the bar exam, knowing the info on a medical exam may actually be relev ant to practice.
7.10.2008 1:22pm
db (mail):
just to reiterate, blacks were banned from every accredited med school in the south, save howard and meharry. thats nothing like the modern law school 'scenario, but it's also true that the aba firces schools to take students who won'( pass the bar, which is counter productive.
7.10.2008 1:28pm
ScottyD (mail):
To "Guess I'm a..." and all,

You mention, like the Thernstrom's in their work, a preference for a white over black doctor because the inuendo of affirmative action taints a black professional.

One could see it the other way: the young black professional who succeeds in their field is a person of strong character and commitment. Perhaps even a better doctor.

After getting into med school all have to pass the same courses, licensing and board tests. And for a young black student to accomplish these tasks with likely fewer doctors in the family or as role models/support while also being often "the only one" in the class.

Don't underestimate this dynamic -- I went to a (black) family reunion with a friend last weekend and was one of the only white people. Surprisingly, it took extra energy for me to engage with folks while unconsciously aware of that status. Other subtleties exist all the time. A black friend who went to Harvard Law (own merits) is asked all the time around his firm where he went to school. Most people hear "Howard" even though his "Harvard" is said as clearly as a radio host.

As I read Bernstein's work on race is not pro-reparations or about white guilt. It looks to the governmental, union and other "establishment" practices that reinforced the disparities following US slavery. He would like freer and fairer opportunities. Not goverment fiat or other undue burens on markets.
7.10.2008 1:45pm
JoelP:
The number of doctors created every year could not be increased much without severely compromising quality.

If you look at Americans who do not quite get into American medical schools and go on to attend Caribbean medical schools instead: they work very hard, but only half manage to graduate. Few of those can pass the licensing exams, and even fewer are able to make it into practice.

If you look at foreign-trained doctors (such as Indians): we also couldn't take many more of them. Yes, the best Indian doctors are great, and get into top residencies. The foreign graduates that the less-desirable residencies manage to obtain are typically very bright, unable to translate their book knowledge into practice, and overall provide worse care than lower-ranked American graduates.

There is simply not some magic font of great doctors that the AMA has been turning away.
7.10.2008 2:01pm
JoelP:
In fact, if you want to look at artificial manipulation of supply, the government *subsidizes* the educational costs of doctors and nurses, to the tune of about $10 billion a year.
If students had to pay that sum, there'd be a lot fewer medical and nursing students...
7.10.2008 2:15pm
Alan K. Henderson (mail) (www):
All it takes for evil to prevail is for good men to do nothing.
Relevance? How does apologizing for something that happened in the past and that ain't happening now constitute "doing something"?
7.10.2008 2:26pm
Snowdog99 (mail):
An apology? For what? Screening out poor doctors who should never have been admitted to medical school in the first place? While attending a major university in the Midwest during the early 80's, there were several articles in the local papers about the inordinately high failure rate among black students in the university medical school - supposedly due to "discrimination".

One reporter uncharacteristically decided to investigate the matter a little deeper, and found that the medical school had been deliberately lowering the academic requirements for blacks for YEARS in order to increase their numbers (while maintaining high standards for whites and other races). When the failure rates of blacks MEETING the higher standards were compared to those for whites and other minorities, it was discovered that there was NO difference in the number of expulsions. Liberal state politicians however, continued to argue that the medical school make-amends by trying to get more blacks to "succeed" (apparently, by passing them through regardless of performance).

I wonder how many of you would like to go to a physician that had been "passed-through" to meet an arbitrary quota? For that matter, how many blacks would like that opportunity?
7.10.2008 2:43pm
Alan K. Henderson (mail) (www):
Oh, I should add the qualifier that was stated in my original comment: "something that happened in the past that somebody else did and that ain't happening now?

Condemning the past sins of others is another matter. One has to judge on a case-by-case basis when taking that tragical history tour is appropriate. We don't condemn the Pearl Harbor attack every day - just on December 7, and the condemnations aren't as fervent as they were in (say) 1946. For this particular AMA announcement, I think two appropriate times for such a missive would include a) a relevant holiday (in this case, MLK Day), and b) upon announcement of plans to rectify some current misdeed related to the past misdeeds being condemned.
7.10.2008 2:46pm
CB55 (mail):
My second cousin was none other than the late Frank Jordan MD of Dallas, TX. In 1954 St Paul Hospital became the first major Dallas hospital to admit African-American physicians to practice. The five physicians were Drs Frank Jordan, Joseph Williams, William Flowers, and George Shelton. Seated is L.G. Pinkston, founder of Pinkston Clinic, a Dallas medical facility used by African-Americans. The action came the same year the US Supreme Court struck down segregated schools. In 1958 St Paul integrated its facilities for patients and in 1980, Emmett Conrad, MD, became the first African-American chief of staff. My cousin went on to cofound the first medical clinic to treat Blacks with out regards to color.

Their path had been paved by the likes of B.R. Bluitt, MD, who, in 1889, became the first African-American physician in Dallas. He also was the first African-American surgeon in Dallas and in Texas, and perhaps, the South. And Charles Victor Roman, MD, for which the C.V. Roman Medical Society is named, practiced in Dallas from 1890 to 1904.

In June, the 277 DCMS members at the regular meeting voted unanimously to delete the word "white" from the DCMS membership statement, clearing the way for black applicants. The first African-Americans admitted into the Society in December 1955 were Harold H. Culmer, MD; William K. Flowers Jr, MD; and Joseph R. Williams, MD. Four additional applications were pending. There were a total of 18 African-American physicians in Dallas at that time. In 1995, DCMS elected its first black president, James L. Sweatt III, MD.

http://www.dallas-cms.org/ss9/125/afr_am.html
7.10.2008 4:08pm
AnneS:
SK - So pressuring all white schools to end discriminatory policies that barred admission of blacks is now affirmative action? Interesting . . .
7.10.2008 4:10pm
CB55 (mail):
In June of 1955, (my correction to previous post)
7.10.2008 4:12pm
Mikeyes (mail):
I don't have DB's book so I don't know where the cite was for "approximately half of their graduates had been able to pass their states' licensing examinations, and several of their graduates became prominent physicians" but over half of the medical students from all black schools were from the two schools that were spared in the Flexner report. (480 in Meharry and Howard, 354 in the other five)

In addition there is a long section in the report outlining the deficiencies of the various state boards (some of which were not rectified until the 1980's, Florida being a great example) so I am not sure what passing the boards in those days meant.

As for the qualifications of black medical students, the MCAT has all the statistics in plain view on their web site. If you are interested, you can see that information by googling MCAT.

Medicine has always been asymmetrically represented by various ethnic groups. When I was in medical school my class was at least 50% Jewish and I was at a school in the South. Now Asians are over represented, but as my terminally prejudiced grandmother use to say, " I want a Jewish doctor" even though she refused to speak to her Jewish neighbors.

Another aspect of the Flexner report was that it encouraged medical schools to start accepting only college students. If you look at the list of medical schools pre-1910, many prominent schools accepted HS graduates (the way most European schools do) but a large number had no criteria (Leonard in NC, Knoxville Medical College, University of West Tennessee, Louisville National Medical College, Flint Medical School - all the black schools that were cut - for example) for entrance. This changed after the legislatures of the various states started demanding that their state medical schools admit HS graduates at least. (As an aside, Wisconsin and other states still have such a program, a six year college and med school program.)

I'm not sure that there were enough black men in college from 1910 to 1940 to populate medical schools in large numbers. I think that the percentage of people who were college graduates in general in that period was very small and overwhelmingly not black. It may seem unfair to demand college credentials, but is it really? College helps parse out persons with the ability to work hard (a pre-requisite for medical school) and gives a hint about intellectual ability. While it left out a lot of my relatives (well, all of them) and decreased the number of Irish-American doctors, it is a legitimate way to winnow down the numbers of persons unsuitable for medical school.

Professor Bernstein, could you point me to that cite? (I am asking because I am interested, not to be snarky.)
7.10.2008 4:12pm
CB55 (mail):
Can any one make a case for AA for White people? Yes, we and most White do despite the fact that Asians have a higher academic success rate as to test scores, grades and graduation rates. It is widely reported that if there was no such thing as AA for White people, most of our colleges would have a higher head count of Asians than is reported and that more qualified Asians are turned away in favor of less qualified Whites.

It has been reported by the San Jose Mercury New that the Silicon Valley work force is over 40% foreign born and most are from China and Indo India. So if Whites must whine about who is eating their lunch, they better start worrying about who is taking their jobs and who is giving it to them and why (most White do not study hard science or applied science)
7.10.2008 4:23pm
AnneS:
Joel, the major reason that accreditation standards contribute to a doctor shortage is completely unrelated to the quality of education or the qualifications of applicants. The AMA bases the number of slots it will accredit on the number of doctors it projects the public will need. The AMA has consistently and systematically underestimated this number. There is likely a finite number of people qualified to be physicians, but the number who are qualified is much larger than the number of slots in med schools.

The AMA and its state counterparts have also consistently fought against policy initiatives that would increase access to and decrease the cost of medical care by utilizing competent, non-physician providers such as nurse practitioners. Further back, the AMA (unsuccessfully) spearheaded a movement to restrict hospital admitting privileges to specialists (effectively getting rid of the GPs who are so vital to providing care to most of the population)- that is part of what drove the creation of a "Family Practice" specialty. The AMA's judgment on matters related to the public health needs of the population and the requirements of competent medical providers is, shall we say, suspect.
7.10.2008 4:27pm
davidbernstein (mail):
The failure of commenters here to be able to distinguish between modern AA programs, and the possibility that the AMA should not have been so quick in a segregated society to close down 5 of the the only medical schools willing to admit ANY blacks under ANY circumstances in the South suggests why proponents of AA often doubt the good will of their antagonists.
7.10.2008 4:31pm
albert:
The failure of commenters here to be able to distinguish between modern AA programs, and the possibility that the AMA should not have been so quick in a segregated society to close down 5 of the the only medical schools willing to admit ANY blacks under ANY circumstances in the South suggests why proponents of AA often doubt the good will of their antagonists.

I think the parallels between what you advocate in the book excerpt, and what you criticize in other contexts, deserve something more than this semi-rude response. Beyond the relaxation of accreditation standards, you suggested that med schools should have admitted black students less qualified than others ("licensing authorities could have pressured the other medical schools to admit black students, or at least create parallel programs for blacks").
7.10.2008 5:06pm
AnneS:
Of course, albert, it's possible that Professor Bernstein was writing what he meant, rather than in some super secret pro-affirmative action code. The medical schools being referred to didn't just happen not to admit blacks - they did not accept black applicants. The AMA could have pressured those schools to end their discriminatory and immoral policies or, failing that, to create separate programs for blacks. The horror.
7.10.2008 5:11pm
CB55 (mail):
Alan K. Henderson does not get the point. The tragic actions of the AMA is not ancient history or simply events of the remote past. It resonates today because many of those events are with in living memory if not White people the events impact Blacks on a real and present manner each day as to their quality of life. There's a significant gap in mortality rates between black Americans and white Americans, a gap that accounts for 80,000-plus excess deaths annually among African-Americans. We do know that being Black is a health hazard no matter the class, status or income, or education - Blacks die too soon.
7.10.2008 5:27pm
Dilan Esper (mail) (www):
The other side of this debate is that if you eliminate AMA accreditation, you may end up with more Charles Drew Universities, i.e., medical schools that are inadequate and "serve" the black community in a particularly appalling manner, which is what we saw at King-Drew Hospital in South L.A. for many years.

This is a very difficult issue.
7.10.2008 5:42pm
davidbernstein (mail):
Beyond the relaxation of accreditation standards, you suggested that med schools should have admitted black students less qualified than others ("licensing authorities could have pressured the other medical schools to admit black students, or at least create parallel programs for blacks").
How exactly is pressuring medical schools who refuse to admit blacks, or at least create a segregated program for them, "affirmative action?" It's actually just a step toward equality of treatment. I just don't get what part of "all the medical schools in the South save Meharry and Howard refused to admit any blacks under any circumstances" is so unclear.
7.10.2008 5:44pm
davidbernstein (mail):
Okay, perhaps I was being too harsh, because I see that one of the messages I sent through my phone came out a bit garbled. I should have written that there were no "white" medical schools in the South, where 80% of blacks lived, that would admit black students under any circumstances. Now that we all understand that, I think it's pretty obvious that it's problematic for the AMA to be in charge of accreditation standards, close down five of the seven black medical schools, and do nothing to encourage the "white" medical schools to provide any opportunities for blacks.
7.10.2008 5:53pm
davidbernstein (mail):
Okay, perhaps I was being too harsh, because I see that one of the messages I sent through my phone came out a bit garbled. I should have written that there were no "white" medical schools in the South, where 80% of blacks lived, that would admit black students under any circumstances. Now that we all understand that, I think it's pretty obvious that it's problematic for the AMA to be in charge of accreditation standards, close down five of the seven black medical schools, and do nothing to encourage the "white" medical schools to provide any opportunities for blacks.
7.10.2008 5:53pm
CB55 (mail):
What the good people of this board that oppose AA do not get is that AA is not only about Black people, but also White women who happen to be a protected class under law according to AA. The biggest gainers according to labor and census reports are White women - for they are in the majority CEOs and executives when one does a head count with regards to AA.
7.10.2008 5:53pm
davidbernstein (mail):
The 50% figure is I think from either Herbert M. Morais, The History of the Afro-American in Medicine 90 (rev. ed. 1976), or Todd Savitt, The Education of Black Physicians at Shaw University, 1882-1918, in Black Americans in North Carolina and the South 160, 181-85 (Jeffrey J. Crow &Flora J. Hatley eds. 1984).

Imagine an aspiring black doctor in North Carolina in 1918. Can I go to Shaw University? No, it's being closed down by the state, supported by the AMA. Okay, how about another medical school somewhere in the Carolinas? Sorry, none of them accept blacks. How about the entire rest of the South? You can try Howard or Meharry.
7.10.2008 5:57pm
CB55 (mail):
See Sweat vs Painter.

Facts of the Case

In 1946, Herman Marion Sweatt, a black man, applied for admission to the University of Texas Law School. State law restricted access to the university to whites, and Sweatt's application was automatically rejected because of his race. When Sweatt asked the state courts to order his admission, the university attempted to provide separate but equal facilities for black law students.

Question

Did the Texas admissions scheme violate the Equal Protection Clause of the Fourteenth Amendment?

Conclusion

In a unanimous decision, the Court held that the Equal Protection Clause required that Sweatt be admitted to the university. The Court found that the "law school for Negroes," which was to have opened in 1947, would have been grossly unequal to the University of Texas Law School. The Court argued that the separate school would be inferior in a number of areas, including faculty, course variety, library facilities, legal writing opportunities, and overall prestige. The Court also found that the mere separation from the majority of law students harmed students' abilities to compete in the legal arena.

Spin Off: After Sweat vs Painter The state of Texas created Texas Southern University for Black law students
7.10.2008 5:58pm
CB55 (mail):
When Sweat took his seat in class the university placed a petition around his desk seat so as not to be seen but heard by other students.
7.10.2008 6:01pm
CB55 (mail):
I attended UT Austin with Heman Sweat - the nephew of Herman Sweat.
7.10.2008 6:05pm
Dr. T (mail) (www):
The closing of black medical schools a century ago by the AMA was not a racist act. This occurred in the context of the first true enforcement of medical education standards. Most 'medical' schools in the 1800s were diploma mills or quackery shops. Many medical schools in the 1800s did not even require that their graduates be literate.

In the U.S., science (other than basic anatomy) did not become part of any medical school's curriculum until the late 1800s. Johns Hopkins became the focal point for the transformation of U.S. medical schools into schools that taught the science of medicine (rather than medicine as a simple trade). Flexner was an influential faculty member at Hopkins who spearheaded the push for better standards.

The AMA had fought against curriculum changes in the past but finally agreed to base its accreditation standards on the Johns Hopkins model. When these standards went into effect, many medical schools lost accreditation, not just 'black' medical schools. There were proportionately more closures among the 'black' medical schools because they had minimal or no standards for acceptance, poorly educated instructors, and essentially no science in their programs. If these schools had been left alone, there would have been a much longer period with two widely disparate standards of medical care based on race.
7.10.2008 8:11pm
Suzy (mail):
Two proposals were being made above: 1) the AMA could bend its standards temporarily to respond to the needs of the black community, and 2) the AMA could pressure white schools to admit black students. I agree that (2) is a great idea and that it is not AA, but simply an end to discrimination. I am talking about proposal (1), which is precisely what strong AA is all about: temporarily changing standards in response to historical discrimination and the need for a rapid correction mechanism. So the somewhat testy response that ignored (1) and mentioned only (2) was not to the point.

The answer to real discrimination should not have been for the AMA to bend any quality standards. The response should have been to stop discriminating! Start granting licenses to qualified applicants, for example, or apply pressure to make that happen in various locations. Judge the medical schools fairly, since it's not obvious that was happening either if they were producing many qualified graduates (were the rates really so much better at many "all-white" institutions?).

I'm simply asking for consistency. If we accept lowered standards in one case and not another, and if the justification for the philosophical difference is simply that one case is more dire than another, I think the pro-AA side has won the argument. After all, AA supporters (like O'Connor in Grutter) refer to the changing historical context, and suggest that AA will eventually be outmoded when circumstances are less dire. Today we see disproportionately few black law students, after a long history of discrimination, and the community would benefit if more black students entered the legal profession. Is that good enough to justify bending some standards?

Meanwhile, we've got people here saying they'd prefer not to have a black doctor because they're less likely to be qualified due to AA, which is utterly ridiculous. Does anyone with that attitude sit on a licensing board, one wonders?
7.10.2008 8:19pm
response to CB55 (mail):
CB55, why, you're just a great and virtuous man!

What the good people of this board that oppose AA do not get is that AA is not only about Black people, but also White women who happen to be a protected class under law according to AA. The biggest gainers according to labor and census reports are White women - for they are in the majority CEOs and executives when one does a head count with regards to AA.

How do you know that we don't "get" that fact? Maybe it's immaterial to the topic at hand, so we didn't bother addressing it. But since you bring it up, if white women are "in the majority CEOs and executives when one does a head count with regards to AA," that begs the following questions: Were they qualified, apart from gender? How were their actual performances?

Returning to the topic of black doctors, does anyone remember the Bakke affirmative action decision, and Dr. Patrick Chavis?
7.10.2008 8:30pm
davidbernstein (mail):
The Flexner standards were not simply about scientific education (and medical education still lacks a bit in training students regarding the scientific method), but also about making medicine a gentlemen's profession, free of (a) physicians who went to for-profit schools; (b) physicians who didn't have a college education; and (c) capitalistic competition. Hendce, the war on for-profit schools, the requirement of pre-medical school education, and an arbitrary limit on the number of medical schools. Blacks certainly didn't fit the standard idea of gentlemen at the time, so the fact that they would especially harmed by the relevant rules was, if anything, not a bug but a feature.
7.10.2008 8:53pm
davidbernstein (mail):
Bending the standards temporarily would not be an example of AA for the following reason: in general, after Flexner, there would be enough medical schools with enough graduates to serve whites. There would not be nearly enough to serve blacks, given segregation. Medical schools like Shaw did graduate some competent physicians, and were willing to work to meet the new standards. It strikes me that the cost-benefit analysis was clearly in favor of giving these schools some leeway to improve themselves, rather than to encourage foundations to cut off their funding and close them down. Taking into account the relevant social and legal context in the world of Jim Crow hardly strikes me as "affirmative action."
7.10.2008 9:02pm
Harry Eagar (mail):
Well, Professor Bernstein, you can be as snarky as you like about letting SOMEBODY regulate the practice of medicine, but then you have to deal with Judge Manion's decision on chiropractors.

Unless the actual ability of the "doctors" to cure is irrelevant.
7.10.2008 9:34pm
Mikeyes (mail):
Professor Bernstein,

I think you probably have a case when it comes to Leonard (Shaw) Medical School as Flexner thought that it had some good points, mainly the didactic years. He did object to the fact that almost all the money raised went to the clinical staff and that there were no patients to practice on. (The hospital had three patients when he visited.)

It appears that they had at least $30,000 to spend on buildings, etc, but they did not apply that money in spite of the fact that they had no library or dispensary. Flexner stated that in spite of a fairly good philanthropic endowment, they had failed to spend the money on anything other than paying teachers unlike Meharry or Howard both of which had invested money in clinical spaces and labs. He saw this as a failure of the administration in developing the school.

Leonard had an attendance of 125 students, about half of either Meharry or Howard, and probably graduated 35 students a year. The contribution to the black community would have been significant, but if only half of their graduates passed the medical boards, then it would not have meant that many doctors in practice. Your observation that it was a borderline call on the part of Flexner does have some weight, however but if you use Johns Hopkins as the ideal (which Flexner did) you have to concede that there was some "bending of the standards" in this case.
7.10.2008 10:10pm
CB55 (mail):
"Were they qualified, apart from gender? How were their actual performances? "

I am sorry to say I was not aware there there is some objective measure and method for job qualification and performance. Perhaps you will share the science with me.


"How do you know that we don't "get" that fact? Maybe it's immaterial to the topic at hand, so we didn't bother addressing it"

It is immaterial to you because you are not aware and will not bother to learn the history of our national civil rights laws and that includes Affirmative Action laws and regulations. When you debate such instances of law it is grounded not in the points of law or even history but personal opinion that can not always be projected on law or the facts of history.
7.10.2008 11:32pm
Happyshooter:
I sometimes have a drink with an older man who during the 70s was an adjunct at a large university. He will not go to a black doctor and he will tell people why.

Prior to the 70s a black medical school grad was well qualifed and trained, at least as good as his classmates. In the 70s the school started admitting blacks who were less qualifed in large numbers. When they started to fail out they chained themselves to the main door of the school for a day.

The medical school announced they would no longer fail out black students, and they went back to class. The adjunct will not see a black doctor. He has convinced me, as well.
7.11.2008 8:50am
Mikeyes (mail):
I have to disagree about your statement that "The Flexner standards were not simply about scientific education (and medical education still lacks a bit in training students regarding the scientific method), but also about making medicine a gentlemen's profession, free of (a) physicians who went to for-profit schools; (b) physicians who didn't have a college education" in that Flexner has a section on what pre-med requirements should be and also talks about it in the state by state section. While he obviously favored college as a preparation, he recognized that in 1909 there were few college graduates. Instead he forcefully suggested that entrants into medical schools have a high school education and met a standard such as the Regents exam in New York state. His thesis was that high schools were everywhere and that completing high school was a pre-requisite. Most of the proprietary schools did not adhere to that standard and even some of the university related programs failed to do so.

His model was Johns Hopkins which had the highest standards of all the schools in the country. But he also thought highly of a number of other schools that admitted high school graduates, especially those schools in New York state. This model (med school after high school) is still the standard in most of the rest of the world. I don't doubt that the AMA may have wanted to limit who had a license to practice medicine, but even if there are economic reasons to support such a licensing scheme, there is also a strong public safety issue present that can't be denied.

As for physicians lacking scientific education, I assume you are focusing on the statistical aspect of research. Bayesian logic is not a strong point of any physician I know, but most of the that knowledge refers to large numbers in a sample and not to individuals. Medicine is not a scientific pursuit (although there are scientists in medicine), it is an applied science that takes a case at a time. Scientific analysis is basically a guideline since research findings reveal trends in groups and to be statistically relevant you have to study large numbers. Not every patient will conform to these findings and research tries to eliminate all but a few variables while a patient come to the physician loaded with variables, many of which are not known by either the patient or the doctor.

Since the AMA is apologizing for what may have been an unintended consequence of eliminating deficient medical schools, has the ABA ever considered apologizing for just the opposite - promulgating policies that allow anyone who persists to get into law schools that have minimal requirements with the result that these students, many minorities, pay all that money only to find that they cannot pass the various bar exams or get a job as a lawyer?
7.11.2008 11:32am
Alan K. Henderson (mail) (www):
Alan K. Henderson does not get the point. The tragic actions of the AMA is not ancient history or simply events of the remote past. It resonates today because many of those events are with in living memory if not White people the events impact Blacks on a real and present manner each day as to their quality of life.
You do not get the point. Only the person who did a particular wrongdoing can apologize for it. Only those individuals who were personally involved in those wrongful AMA policies can apologize for them. Anybody can rightfully condemn those practices - but please, please, please do not treat "apology" and "condemnation" as synonyms.
7.11.2008 12:19pm
JoelP:
Anne: This "cartel" idea is frequently asserted, but it makes no sense.
1. Few members of the AMA are looking for more work; most are looking for less.
2. Doctors salaries continue to fall.
3. The difference in quality between US grads and Caribbean grads (i.e. those people who would be US grads if more slots opened) is too large.
The fact is, we do need standards for doctors. It's not clear that we can get many more doctors without significantly lowering those standards.
7.11.2008 12:52pm
AnneS:
First, I never said the AMA was perfectly effective or smart about everything it does (see the AMA's opposition to Medicare vs. its actual effect on physician salaries), nor that it perfectly represented its members interests. Nevertheless, it has clearly had a long policy and practice of protecting its own and its members economic interests (not necessarily the same thing, BTW) by artificially limiting the number of doctors and fighting the use of other kinds of health care professionals (i.e. nurse practitioners). What other reason could there possibly be for them to continue to artificially limit the number of med school slots based on consistently wrong projections of the population's need? Controlling the number of slots has nothing to do with quality - it's pure trade protectionism.

As for the success of Carribean med students, I have a few observations. First, most people who are rejected from med school don't go to Carribean med schools - they find other careers and move on with their lives. Second, the relatively high failure rate of Carribean med school graduates is only partially attributable to the lower quality of the applicants - it is also related to the quality of instruction and the lack of available residency slots. Finally, no one is saying that most rejected applicants are possible doctors. But, based on their numbers (test scores and GPAs), a significant percentage of them are capable of becoming doctors - they're barred from medical education not because they're not smart or hardworking enough, but because there just aren't enough slots.

Finally, I'm a doctor's daughter and work with doctors every day, but if there is one thing I have no sympathy for it is doctors who whine constantly about their "falling" salaries. Doctors are not only still the best paid occupation in the country, but they are also virtually guaranteed employment in their chosen profession. Doctors' stagnant reimbursement over the past decade or so may be evidence that the AMA is not as all powerful as its more strident detractors think it is, but it certainly isn't evidence that the AMA's efforts to protect doctors' economic interests have been ineffective.
7.11.2008 2:32pm
Harry Eagar (mail):
Unless you rhink physicians should work for love, falling salaries do mean something.

I live in a county with high housing prices. It has become almost impossible to recruit young doctors here because even an income of $150,000-$200,000 (which is more than most can aspire to) would not support the doctor, the doctor's mortgage and the doctor's student loans.

Retiring physicians with thriving practices cannot give them away.
7.11.2008 2:44pm
LM (mail):
davidbernstein:

The failure of commenters here to be able to distinguish between modern AA programs, and the possibility that the AMA should not have been so quick in a segregated society to close down 5 of the the only medical schools willing to admit ANY blacks under ANY circumstances in the South suggests why proponents of AA often doubt the good will of their antagonists.

As an AA proponent, I don't doubt the good will of most AA opponents. There are perfectly legitimate reasons to oppose AA. But I do hate when social policy discourse gets dragged down, as above, by the habit of ideologues (on both sides) to react to certain buzz words like bulls seeing red, rather than make the small effort to reason their way to a conclusion as if they didn't already know the only possible answer.
7.11.2008 5:19pm
AnneS:
I don't know where you live, Harry, but the average salary nationally for family physicians is over $150K. The average first year starting salary is in the neighborhood of $125K. There are very few, if any, areas of the country where salaries in that range are insufficient to support a doctor and his loans comfortably. Moreover, many employers in high need areas offer loan repayment assistance to attract young docs. The fact that your county has difficulty filling positions is probably less a function of "low" salaries than the overall doctor shortage - there are more well paying jobs nationally than doctors willing to take them, the geographic variation in starting salaries is relatively low, and doctors are therefore free to pick based on other factors.

Then, of course, there's the problem of how the heck your area attracts anyone to work there if things are so bad that salaries between $150K and $200K are insufficient to support doctors and their loans. Student loans are expensive, but they're not so expensive that a doc making $125K is more unable to survive than a young lawyer trying to pay back his loans and live on a mere $80K (or - gasp! - less). Forget about the nurses, teachers, pharmacists . . .
7.11.2008 7:15pm
JoelP:
"Second, the relatively high failure rate of Carribean med school graduates is only partially attributable to the lower quality of the applicants - it is also related to the quality of instruction"

This is an important point. Carribean schools cost a lot. The only reason American schools can provide a top quality education for a mere $50k/year is the billions of educational subsidies that the US government provides. If you want to educate more people, you'll need to increase those subsidies more than proportionally.
Why more than proportionally?
1. The lower graduation rate for lower quality incoming students (assuming you maintain the standards for graduation).
2. The places that can most cheaply/efficiently educate students are already doing so; the next tier requires higher subsidies to make effective.

Obviously the federal government could spend another ~10 billion a year educating doctors, but it's not an obvious choice or a decision to take lightly.
7.12.2008 3:51pm
CB55 (mail):
Alan K. Henderson, the AMA did benefit from racism just as the Swiss, American, and German corporate machine gain from the enslavement and death of the Jews in Nazi Germany. Is it not the case that American commerce and industry did benefit from Jim Crow laws and slavery?
7.12.2008 5:44pm
Alan K. Henderson (mail) (www):
CB55,

Have you not even read my comments? I have addressed one specific topic: the proper definition of "apology." I have not made any claims regarding the AMA's history of discrimination, and I have not implied that there should be no talk about past abuses within the AMA. My sole argument is that the English language must not be misused.

Perhaps I need to add one necessary detail (in itals) to the definition of apology: an individual's confession of personal guilt. Organizations aren't individuals - they are formal networks by which individuals gather to seek common goals. If some individuals use the network to do wrong, those people are at fault, not the network itself and not those members who did not participate in those wrongs.

If the AMA feels the need to address past discrimination, fine. Just don't call it an apology, unless it's being offered by the people who actually participated in that past discrimination, and that they are placing the blame on themselves and not on the AMA as a whole. If not, then the proper term in the English language is "condemnation," not "apology." It is very important to get the language right.

Is it not the case that American commerce and industry did benefit from Jim Crow laws and slavery?
Off-topic, but since you brought it up...I can't see how the case can be made. The South was poor during slavery and Jim Crow. American prosperity was where those institutions weren't. Prosperity came to the South after the Jim Crow era went.

One might ask: "If slavery and Jim Crow were so bad economically, then why did the South have 'em?" Slavery benefited powerful special interests who controlled the political machinery. As for Jim Crow - hey, human history is replete with dominant populations discriminating against minorities without recognizing or considering the economic consequences.
7.12.2008 11:00pm
CB55 (mail):
I'm sorry Mister Henderson but I thought we both believed in the classical theory of justice with regards to "collective guilt". I think we are not on the same page or even in the same book with regards to moral philosophy. I think you would agree that the United States was wrong for giving Japanese Americans one dime or making any apology, but I here by defer with you as to my moral position. You do not think that the United States of America both North and South benefit from slavery and Jim Crow laws in a tangible measurable way, but the public and personal records shows that America did make real and measurable gains from slavery and Jim Crow.
7.13.2008 1:03am
CB55 (mail):
Henderson, do you have any problem with Muhammad Ali as to his position in his refusal to fight in the Vietnam War? Yes, the question and the answer are off topic but it is connected. If the state has no moral or legal obligation to Ali for past and present injustice, did Ali have a duty to protect and defend such a system (In 1966 Jim Crow law was alive and well in much of the United States).
7.13.2008 2:09am
Alan K. Henderson (mail) (www):
Vietnam: the war wasn't fought to preserve America's injustices; it was fought to contain the expansion of Communism, at that time the world's greatest tyranny.

Jim Crow: the idea that discrimination can boost an economy flies in the face of the Econ 101 lessons on comparative advantage. Global wealth is maximized when nations focus on their innately most efficient industries. By the same logic, a nation's wealth is maximized when individuals focus on their best talents. Discrimination hampers the ability of the discriminated to seek their comparative advantage. Historically, the societies with the most inter-factional cooperation are the most prosperous.

Slavery: I know from American history that America and especially the South were more prosperous after slavery than during - you're going to have to explain how the opposite was true. Slavery is an extreme form of suppressing comparative advantage, it is less productive than voluntary labor, and it breeds more strife than free markets do, and strife eventually costs. Its biggest non-economic legacy was artificially inflating the South's population, and thus its Congressional delegation in Washington. This benefited the elite who ran the Southern government, not the poor whites who had little actual voice, nor the blacks who had none.

Collective guilt: The concept is not a legitimate one, as I have explained earlier. We are not Borg. We do not share a hive mind. We are individuals. When I join an organization, I do not assimilate the guilt of all actions that have been performed officlaly and unofficially in its name.

Japanese-American reparations: My first thought is that whatever legal recourse for illegal imprisonment there is should apply here.

Secondly, internment also involved illegal property seizure, so we have here two separate issues of guilt for the theft and financial debt. The guilt for the theft is held by the individuals who did the stealing; the $$$ debt is held by the entity whose books received the stolen property (which in this case would be the US Treasury.) As Wikipedia states, the known quantity was rectified via the "American Japanese Claims Act" of 1948.

Arbitrary reparations means that the victims will either be underpayed or overpayed - determining which is the lesser evil is a judgment call.

This page has an image of Bush 41's officiam memo on the Civil Rights Act of 1988 reparations measure. The memo implies an understanding of my point that you can't apologize for what others did (he offers no apology for the internment) but you can certainly condemn it.
7.14.2008 3:45pm