The workshop continued with a session moderated by Theodore Corbin, M.D., M.P.P. (Drexel University), to examine the opportunities to eliminate students’ debt burden while exploring opportunities and contingencies in science, engineering, and medicine for Black students. Sylvester James Gates Jr., Ph.D. (Brown University), described a major effort within the physics community to increase the number of African Americans with bachelor’s degrees in physics and astronomy. Geoffrey Young, Ph.D. (Association of American Medical Colleges), shared data about students attending medical school and AAMC resources available to current and future medical students. Garth Graham, M.D., Ph.D. (Google), used his own experience as a student with little familiarity with the financial implications of his decisions, as well as his career, to suggest alternate pathways for Black scientists, engineers, and physicians to make a positive impact.
INITIATIVES IN THE PHYSICS COMMUNITY
Dr. Gates shared that his work as a theoretical physicist leads him to ponder large concepts of space and time, while his identity as an African American physicist provides a perspective on his discipline. To frame his presentation, he shared three “voices from the past.” Physicist Albert Einstein said, “Imagination is more important than knowledge. For knowledge is limited to all we now know and understand, while imagination embraces the entire world, and all there will be to know and understand.” Computer scientist Alan Turing said, “Sometimes it is the people no one can imagine anything of who do the things no one can imagine.” Scholar and Holocaust survivor Elie Wiesel said, “The opposite of love is not hate, it is indifference.” To Dr. Gates, these three quotations sum up why diversity is so important in science and engineering and the need to fight
against indifference. Dr. Gates noted Einstein’s relationships with Black leaders including W. E. B. Dubois, and he referred participants to a book about Einstein’s views on race and racism that helps explain why scientists should be involved in issues of diversity, equity, and inclusion (Jerome and Taylor, 2006).
In 2017, the AIP, a consortium of physics organizations, launched an effort that resulted in the report The Time Is Now: Systemic Changes to Increase African Americans with Bachelor’s Degrees in Physics and Astronomy (AIP, 2020). Dr. Gates was a member of the TEAM-UP task force that developed the report. In discussing the removal of barriers, he said, the task force concluded that finance was at the root of the problem, including systemic issues related to the wealth gap between Blacks and whites. Similar homes in mostly Black neighborhoods are valued 23 percent less than in mostly white neighborhoods, Gates reminded the group. Because schools are primarily funded through local property taxes based on home values, housing discrimination affects school funding, which affects education quality.
The report also surveyed physics students. The survey revealed five factors that students consider to be essential, the absence of which can block the pipeline to earning bachelor’s degrees: (1) fostering a sense of belonging for African American student persistence and success; (2) developing a “physics identity,” in which African American students must perceive themselves, and be perceived by others, as future physicists and astronomers; (3) effective teaching and a strength-based approach to academic support; (4) support to offset financial burdens and stress; and (5) leadership and structures that prioritize creating environments, policies, and structures that maximize African American student success (AIP, 2020). An important part of the TEAM-UP report, he added, is the need for change management, noting “a new level of thinking is required to solve a persistent problem.” While the report is broader than finances, he said he would focus on this factor, given the workshop theme.
In talking to students about finances, key findings surfaced, as Dr. Gates related:
The enormous racial wealth gap creates financial stresses for Black students. Working on and off campus can impede academic progress and continuation to degree. Mental health stress related to financial stress was also significant. Student retention was found to improve when students were recognized as individuals with unique and intersecting social identities and experiences such as
first-generation college students or working to support a family. It is important for faculty to provide that support.
A graph in the report shows the needs (see Figure 4-1). When asked about concerns about paying for college, 44 percent of African American students strongly agreed they had this concern, compared with 27 percent of white students and 30 percent of Black/mixed-race students.
The report can serve as a handbook for institutions and organizations affiliated with physics that want to make a difference, Dr. Gates noted in highlighting its recommendations (AIP, 2020). For example, departments should identify campus resources for emergency financial aid, conference travel, and other unmet needs that would help African American students to persist in the discipline. Second, faculty should seek funding for undergraduate students to work in research groups or as learning assistants and find other ways to help students academically advance while earning money. Third, faculty and staff should normalize seeking help by discussing stress and self-care with students and referring them to campus resources.
Finally, what Dr. Gates referred to as the “blockbuster” is the report’s recommendation that a consortium of physical science societies should raise a $50 million endowment from foundations and philanthropic sources to support minority students with unmet financial needs in physics and astronomy and to support departments’ implementation of the report’s other recommendations. As an interim step, physics and astronomy societies should raise $1.2 million per year to relieve the debt burden of African American degree students.
SOURCE: Sylvester James Gates Jr., Workshop Presentation, April 19, 2021. Recreated from AIP, 2020, p. 45.
The recommendation of the $50-million endowment constitutes “swinging for the fences,” Dr. Gates acknowledged. “We don’t know if we will be successful, but we know we won’t be successful if we don’t try. The bottom line of the report is let’s go big.” He noted the report was written before the events of 2020, and he is more encouraged about success.
AAMC RESOURCES TO MANAGE THE DEBT BURDEN
Dr. Young shared financial data on family income and debt of medical students and graduates, and he described AAMC resources to help alleviate debt. He also spoke about the recently announced AAMC strategic plan, which includes expanded and enhanced support for underrepresented in medicine (URiM) learners.
Dr. Young drew from U.S. Census data as well as two AAMC student surveys. First, the Matriculating Student Questionnaire (MSQ) is given to first-year medical students and asks, among other items, about household income. Second, the Graduate Student Questionnaire (GSQ) is administered to graduating seniors and asks about student debt levels. Dr. Young pointed out that students can be tracked from the MSQ to the GSQ.
Student Income
Dr. Young explained that the median student debt was about $183,000 in 2015 and about $200,000 in 2020. Adjusted for inflation, the debt level across all graduates has been relatively stable over the past 6 years, while the cost of attendance (for 4 years) has increased from $267,000 to $277,000.
Enrollment in college and medical school is not even across all income levels (see Figure 4-2), Dr. Young pointed out. At the undergraduate level, about 11 percent of students who attend college are from the lowest quintile (i.e., the 20 percent of American households with the lowest incomes), while about 37 percent are from the highest quintile (i.e., the 20 percent of
American households with the highest incomes). Wealthier Americans are disproportionately enrolled in U.S. colleges, according to U.S. Census data.
SOURCES: Geoffrey Young, Workshop Presentation, April 19, 2021, based on U.S. Census data; M. K. Eagan, E. B. Stolzenberg, H. B. Zimmerman, M. C. Aragon, H. Whang Sayson, and C. Rios-Aguilar, 2017, The American Freshman: National Norms Fall 2016, Los Angeles: Higher Education Research Institute, UCLA; and Matriculating Student Questionnaire (MSQ), AAMC.
AAMC data represented in Figure 4-2 show that the disparity is even starker in medical school, Dr. Young continued. About 5 percent of first-year medical students come from the lowest quintile, 8 percent from the second-lowest quintile, and 11 percent from the middle quintile. When reaching the fourth quintile, the percentage rises to 26 percent. Fifty percent of medical students come from the highest quintile, with half that number coming from the highest 5 percent by income. “What this is showing is that as your household income increases, you are more likely to attend college and medical school,” he said. “The key point is that first-year medical students are not evenly distributed by household income.” Expressed another way, Dr. Young said,
For every four matriculants who enter medical school, one will come from the highest 5 percent, one is going to come from the
rest of the highest quintile, one will come from the fourth quintile, and one will come from the three lowest quintiles combined that represent 60 percent of the U.S. population. These data have been consistent since 1987.
Black Medical Students and Debt
Dr. Young summarized findings from a recent AAMC report on the debt burden among Black medical graduates (AAMC, 2020). Black medical students have the highest level of education debt,1 are among the highest percentage with scholarships to support their medical education, have the lowest level of medical education financed by “personal/relatives” funds, and have one of the lowest median parental income levels (see Table 4-1).
Dr. Young referred to the study as a “nuanced narrative.” For example, the type of medical school affects debt level and varies by race, with 50 percent of Black students attending private medical schools. The higher costs of private schools compared with public schools is one driver of debt levels, Dr. Young said. About 91 percent of Black students graduate with debt, the highest of any group, with a median amount of $230,000 in debt. Very few (about 8 percent) have funds from family members to pay expenses.
Dr. Young next looked at how a doctor’s starting salary might affect a case of $230,000 in education debt, looking at family medicine (median starting salary is $200,000), emergency medicine ($250,000), and cardiology ($300,000). He broke out living expenses into four categories: taxes, loan repayments, housing costs, and other living expenses. Dr. Young explained that the REPAYE (Revised Pay As You Earn) federal repayment plan ties repayment to income rather than debt level.2 With this system, students (including Black and African American students) will be able to repay their education debt, afford their living expenses, and save for retirement, no matter their specialty, barring unique circumstances.
AAMC Resources and Strategic Plan
AAMC data show that the number of students who are URiM, as well as students from low-income families, has remained stagnant over the last
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1 Both medical school debt and premedical, including college, debt.
2 For information on this program, see https://studentaid.gov/manage-loans/repayment/plans/income-driven.
TABLE 4-1 Education Debt Data for 2019 Medical School Graduates by Race and Ethnicity
| Average for percentage of Medical Education to be financed with: | ||||||||
| Race or Ethnicity | With Education Debt | Median Education Debt of Indebted Graduates | Public/Private School | Reported Scholarship Funds | Median Self-Reported Parental Income | “Personal/Parents/ Relatives/ Spouses/ Partners” | Funds “Scholarship with or without a Service Commitment/Work-Study” funds | Loans |
| All | 73% | $200,000 | 61/39 | 62% | $130,000 | 24% | 19% | 56% |
| American Indian and Alaska Native, alone or in combination | 80% | $212,375 | 71/29 | 84% | $90,000 | 14% | 33% | 25% |
| Asian, not Hispanic | 61% | $180,000 | 56/44 | 56% | $120,000 | 33% | 17% | 49% |
| Black, not Hispanic | 91% | $230,000 | 50/50 | 83% | $80,000 | 8% | 34% | 57% |
| Hispanic | 84% | $190,000 | 57/43 | 65% | $70,000 | 13% | 25% | 61% |
| White, not Hispanic | 75% | $200,000 | 65/35 | 61% | $150,000 | 24% | 17% | 58% |
| All others, mostly those reporting multiple combinations of race and ethnicity or “other” | 71% | $200,000 | 59/41 | 64% | $110,000 | 24% | 23% | 53% |
NOTES: Also available from AAMC report Physician Education Debt and the Cost to Attend Medical School: 2020 Update, https://store.aamc.org/physician-education-debtand-the-cost-to-attend-medical-school-2020-update.html. Education debt is the sum of both medical school debt and premedical, including college, debt.
SOURCE: Reproduced from Geoffrey Young, Workshop Presentation, April 19, 2021, from AAMC Medical School Graduation Questionnaire (GQ), 2019, and the corresponding Matriculating Students Questionnaire (MSQ).
15 years, despite larger medical school populations. At its core, he said, this underrepresentation tracks back to systemic racism, structural inequities, and access to education, housing, health care, food security, and criminal justice. These inequities, coupled with exclusionary admissions processes and institutional culture, further impede an already narrow pathway defined by traditional academic medicine. “I propose we have to start upstream, to try to address the inequities, before learners apply to medical school,” he stated.
Dr. Young described a number of AAMC resources. Its Fee Assistance Program provides support for some of the costs associated with medical school applications and examinations. He noted changes in eligibility criteria.3 He also noted an 18 percent increase in overall applicants in 2021 over 2020, including a 31 percent increase in URiM applicants. Among URiM applicants in 2021, 51 percent identified as Black or African American. Women were 68.5 percent of the African American Fee Assistance applicants and men were 31.5 percent. What will be telling is whether this pool of Fee Assistance applicants reflects who matriculates, he added.
Other AAMC resources include financial information, services, and tools (see Box 4-1).
Through the AAMC Strategic Plan, the association is committed to making a difference by working upstream, according to Dr. Young. The plan has 10 actions, including one that he leads that aims to significantly diversify the medical school applicants and matriculants. Achieving this goal requires addressing systemic barriers, he said. Three pillars to achieve it are to leverage data for change; to widen the path to medicine and the health professions by identifying, supporting, and disseminating effective interventions for learners across the educational continuum (including working with partners in the K–12 space); and to address climate and culture in the transition to medical school.4
ALTERNATE CAREER PATHWAYS
Dr. Corbin asked Dr. Graham to talk about his personal experiences and leadership in government and industry. Dr. Graham said he would start
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3 For the full eligibility requirements of the AAMC Fee Assistance Program, see https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program.
4 For more information, see “A Healthier Future for All: The AAMC Strategic Plan” at https://www.aamc.org/what-we-do/strategic-plan/healthier-future-all-aamc-strategic-plan.
with the context of what Black and Brown communities are facing and the factors that lead to debt burden.
Dr. Graham grew up in Miami where the Robert Wood Johnson Foundation has found a 20-year difference in life expectancy between his community in North Miami compared with more affluent areas in the region. Many Black and Brown medical students, including him, start a life journey that begins with that set of experiences:
By the time we reach medical school, there are experiences that both drive future decisions but also things from the past that we accumulate and bring to the table, both positives and challenges.
The conclusion is that without understanding both the intricacies of financing their education, the social dynamics they bring toward financing that education, and potential opportunities for income, we minimize the potential that Black and Brown students can make in a variety of different contexts.
He recalled that by the time he reached medical school, “I did not really understand the debt papers I was signing, I was just thrilled to be there. If the financial aid office put something in front of me, I signed it as a ticket and opportunity to upward mobility.” He noted he did not understand the concept of debt burden or of future economic dynamics to pass resources on to future generations.
My first takeaway point is that issues around debt burden and financing extend beyond the medical school experience into ways that Black and Brown students are educated about financing in general. We should focus efforts, whether through mentorship or formal efforts, to educate Black and Brown students early in the process about the financing of medical school education.
Data around net worth and income of Black physicians show a disparity, and the capacity to continue upward mobility and pass wealth on to children is a challenge (see also Chapter 2). Black men and boys from higher-income Black families still face challenges to get through educational systems and move ahead. “It’s important to understand generational dynamics,” Dr. Graham said. “We are not necessarily creating wealth even if we make it to medical school.”
Debt burden influenced his career decision-making when he graduated medical school and went on to training, he said. When he went to work at the Department of Health and Human Services, he learned about programs he was not aware of as a student, such as the National Institutes of Health (NIH) loan repayment program,5 Health Resources and Services Administration (HRSA) loan repayment program,6 and others across the federal government. “My point is two-fold. First, make sure students understand
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5 For more information, see the NIH Division of Loan Repayment website at https://www.lrp.nih.gov.
6 For more information, see the HRSA Loan Repayment Program website at https://nhsc.hrsa.gov/loan-repayment/index.html.
these opportunities early on, and second, continue to support these programs as vital to keep the pipeline open,” Dr. Graham said.
He also urged exposing students to nontraditional career paths that allow for mobility. When he left the federal government, he went into academic research, then on to positions in industry. “The tech industry has had a long challenge in recruiting minority professionals from different backgrounds, but the industry has an impact on day-to-day life,” said Dr. Graham. “There is an important need to have Black and Brown voices at those tables, especially in leadership positions.” These opportunities allow Black and Brown students to contribute to communities through nuanced ways, he said. He wants to “open the eyes of our communities to opportunities, to different pathways from medical and health services training and background, and to succeed and manage finances appropriately.” With multiple opportunities for influence and advancement, he urged mentoring students to consider both traditional clinical and nontraditional clinical paths.
He also called for diversifying corporate boards. The lack of Black and Brown members of these major boards is a lost opportunity, he underlined. These companies affect communities’ lives. “I never would have thought of that, but now I see that my experiences are essential to those companies,” he said. He urged the Roundtable on Black Men and Black Women in Science, Engineering, and Medicine to think of “all the different ways we can inspire, educate, and mentor and push through people with different backgrounds like mine to achieve impact,” he stated.
Dr. Graham concluded with three recommendations. First, he called for understanding the context of students from challenging backgrounds and educating them about finances early. Second, he said it is important to understand the impact of federal programs and what they allow students to do. He noted the programs have been under attack and advocacy is necessary. Third, he recommended exposing students to successful nontraditional career paths in high tech and other industries.
DISCUSSION
In answer to a question about whether the TEAM-UP project found different outcomes based on institution type (specifically Historically Black Colleges and Universities [HBCUs] compared with Predominately White Institutions, or PWIs), Dr. Gates said the answer depends on the outcome looked at. If the outcome is completion of undergraduate degree, HBCUs
perform better. If the outcome is a long-term career in research, the data get more complicated, he said.7
During a discussion about medical school admission rates, Dr. Young said one way to narrow the disparity is for multiple communities to educate and work with admissions officers and committees who serve as the gatekeepers. It is important to emphasize holistic admissions that will enrich the learning environment in line with the mission of the medical school, he noted. Schools make decisions about the type of physicians they want to train. To the point about students’ lack of financial literacy, he agreed schools do not always do a good job in explaining what is involved and possible resources. AAMC programs can help, but students should start learning in high school and college about medical school costs. Once students are in school, it is important to think how they will thrive, he added. “I have seen too many students, especially Black men, go to a top medical school and experience difficulty because it is not a good place for them. The social environment affects students’ ability to thrive,” he said. He stressed the need for support from leadership.
Dr. Louis Sullivan (Sullivan Alliance) asked Dr. Gates about the goal for the AIP-proposed $50 million endowment fund in terms of the number of Black physicists. Dr. Gates noted that from 1999 to 2017, about 5 percent of physics degree recipients were Black, and the goal of an extended effort would be to double the number. Dr. Daley asked about trends in physics degrees. Dr. Gates said the number of Americans getting degrees in physics has roughly doubled in recent years, but the level has stagnated among African Americans. A decrease in the overall number of undergraduate physics degrees in the 1990s led to an earlier AIP report, called SPIN-UP, that was very effective (AIP, 2003). He continued, “I think COVID-19 will give all the STEM (science, technology, engineering, and mathematics) fields a burst. This is a second Sputnik moment.”
Related to increasing the number of Black medical students, Dr. Young said AAMC anticipates a physician shortage by the early 2030s. Thirty new medical schools have been opened in the past 20 years, but diversity within those schools has not increased. AAMC is calling for strengthening pipeline programs and mechanisms to identify effective practices. He noted the AAMC strategic plan looks across the continuum of medical education. For example, he said, “Resources are needed to support young learners so they
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7 Further discussion can be found at https://www.aip.org/diversity-initiatives/team-up-task-force or in AIP, 2020.
are ready and prepared to be competitive. Once in school, potential barriers must be addressed. There is a cap on the number of residency programs, and those numbers need to increase. All these efforts must be undertaken in a sustained way with long-term commitments.”
Dr. Sullivan observed that in the 1950s and 1960s, members of Congress were often effective in obtaining funding for the medical centers in their districts. More broadly, said Dr. Sullivan, “We have lost faith in ourselves as a nation.” He called for bold commitments and leadership, similar to the Marshall Plan after World War II and the Great Society in the 1960s. “The nation does not recognize the benefits from these prior investments. My hope is that COVID-19 will open the eyes of what the medical system can provide and what it should do in the future, but we need the people and systems to make that happen,” Dr. Sullivan said. Dr. Gates agreed that a loss of confidence is at the core of many difficulties in the country. On a positive note, he pointed out the business community seems to be more involved than previously. “We have to work in partnership with Corporate America,” Dr. Gates said. “There is evidence that business understands we cannot go backwards to have leadership.”
Dr. Corbin asked Dr. Graham to weigh in on the opportunities for partnerships with the private sector on diversity, equity, and inclusion initiatives. Dr. Graham said the private sector can play an important role, but support has to be consistent and sustained year over year, not just done to achieve visibility. In addition to funding, businesses can provide ways for youths to get involved. He noted the private sector can also influence public discourse and have political impact.
REFERENCES
AAMC (Association of American Medical Colleges). 2020. Physician Education Debt and the Cost to Attend Medical School. https://www.aamc.org/data-reports/students-residents/report/physician-education-debt-and-cost-attend-medical-school.
AIP (American Institute of Physics). 2003. National Task Force on Undergraduate Physics. Strategic Programs for Innovations in Undergraduate Physics. College Park, MD: American Association of Physics Teachers.
AIP. 2020. National Task Force to Elevate African American Representation in Undergraduate Physics & Astronomy (TEAM-UP). The Time Is Now: Systemic Changes to Increase African Americans with Bachelor’s Degrees in Physics and Astronomy.https://www.aip.org/sites/default/files/aipcorp/files/teamup-full-report.pdf.
Jerome, F., and R. Taylor. 2006. Einstein on Race and Racism. Piscataway, NJ: Rutgers University Press.
