Dismantling racism in medicine begins long before medical school & residency. The path to representative numbers of currently underrepresented minorities will not be solved with performative activism. Foundational changes, all the way back to K-14 education are needed. Thread 1/

While many are pushing for representative percentages of matriculants to the regions where each medical school is located, this is not sufficient. Schools, rightly, push back that underrepresented minority students do not apply at the same rates. 2/

Additionally, the geography of medical schools is not representative of the country as a whole, using local percentages as the sole standard could unintentionally limit Latinx and Indigenous applicants as their populations are larger in the west where there are fewer schools 3/

But to the point about having non-representative portions of applicants - this is not an excuse to accept the status quo, but rather to address pipeline issues effecting K-14 students & non-traditional students as well - barriers that are actively preventing URMs from applying 4/

First and foremost we must address school funding. As public school funds are largely based on local property taxes racist #redlining practices have left a legacy of underfunded schools in minority dominant neighborhoods. Additional supports beyond property tax are needed 5/

Without adequate funding these students lack the same access to high quality STEM education, AP & dual-enrollments courses as their peers from wealthier districts. The same is also true for students in rural areas (which include many native populations & immigrant farm workers)6/

In rural areas the cause is less to do with redlining and more to do with the overall lack of dense residential and commercial property to tax in the first place. Less people, less property, less school funding. 7/

(Personal aside: I graduated from a rural HS in a class of 60. We did not have any AP or dual-enrollment STEM courses at my school. This contributed to my sense that I would not be a competitive applicant to a STEM major for college. Even though I wanted to major in biochem...8/

since I was 11 yrs old. I ended up giving up on my dream and going to school as a performing arts major instead. I am a non-traditional student now, in large part because I did not have the tools to be a traditional student back then). 9/

These schools need additional funding beyond property tax so that their students may compete on a level playing field with their peers in better funded school systems. 10/

Now if a student from a low-socioeconomic status background and/or one whose grades were not especially competitive wishes to pursue college, many will start out in the community college system. 11/

With evening classes and more affordable tuition this is also a popular choice for students working while pursuing their educations, including non-traditional students like myself. Yet some medical schools do not even accept community college coursework. 12/

Among med schools that do accept CC courses, these credits are often dinged as being of lower quality and even high marks at CC are treated as if the applicant has a lower GPA than they actually do.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245373/
13/

(Personal aside: On the back of student loans I attended a private 4 yr university, did a semester abroad in the University of London system and went to a private Uni again for my masters. I have also done community college courses as dual-enrollment, J-terms & for prereqs...14/

The community college courses as have taken have been every bit as rigorous as any course I have taken at internationally recognized universities. But they were much more affordable, such that I could pay out of pocket and not have to take on yet more student debt. 15/

The availability of evening and online courses has also meant that I could continue to work full time while pursuing my pre-requisites towards medical school. Since I work in public service this is helping me pay off my existing loans & qualify for PSLF. 16/

I would likely not have been able to pursue this dream any further were it not for community college. To do so would have been a financial risk I could not afford, especially when I'm also taking care of my widowed mom.) ... 17/

If a student is able to get funding to continue their education, graduate with a baccalaureate degree and not decide to go into a field with a lower barrier to entry... Minority applicants still face the barriers that go along with the application process itself. 18/

The first big hurdle is the MCAT. This is huge as ample recent events have shown. @khanacademy will no longer be supporting the free #MCAT #NCLEX and Health Science curricula on their site. @AAMC_MCAT could easily fund ongoing access as a sponsor, but has so far failed to. 19/

Likely they would much rather make money off of selling access to more MCAT prep resources, or only include free access to those who qualify for FAP. The FAP itself is a deeply flawed application process. Rather than being based on FAFSA information, FAP requires even... 20/

independent students to include the income of their parents. It does not account for cost of living when deciding funding need (as FAFSA does), nor does it account for existing student loan debts. 21/

(Another personal aside: As previously mentioned, I help support my widowed mom. She lives with me rent free as her job as a case worker does not pay enough for her to afford her own place because the cost of living where I am, esp for housing, is quite high. 22/

when her income was included with mine I did not qualify for FAP when I applied this year. I might have qualified under the expanded qualifications for this yr due to COVID, but unfortunately do not have pay stubs that can prove my loss of income from my freelance writing). 23/

The cost of MCAT prep materials and test fees can quickly approach $1000+ even among those taking advantage of free resources like @khanacademy, their public or school libraries, and YouTube channels like @TheCrashCourse 24/

And this is in a usual year. As I am focusing on persistent systemic pipeline barriers to medical education for BIPOC/URM students, I won't even go into the (pardon my language) clusterfuck that this year's MCAT takers have had to go through. 25/

Check out @miaowlex @memesMD or just search #MCAT or the replies to any @AAMC_MCAT post for more information on that whole mess. 26/

Another portion of the medical school application process is the expectation that students will have shadowing or clinical experiences coming in. Since URM students are, by definition, underrepresented, they lack social networks of physicians to ask about such opportunities. 27/

While paid clinical experience is available, underpaid CNA, MA and scribe positions may not be accessible to students who need to work to pay tuition and support families. Medical schools & residency programs should actively seek opportunities for URM shadowing. 28/

If students ask, say yes! Better yet, don't wait for students to ask. Reach out to local schools (including community colleges) and let advisors know that you welcome shadowing from pre-med students. 29/

If a student manages to surmount the barriers of underfunded K-12 schooling, attaining an baccalaureate degree (even if starting out at community college), gets great grades, great MCAT and clinical experiences they still face the final hurdle of the application & interview. 30/

The primary application is straight forward enough, and if the applicant was able to qualify for FAP and AACOMAS financial aid, despite their flaws, it even approaches affordable, depending on the number of schools the student is applying to. 31/

But many schools send out secondaries to all or nearly all applicants, as a means to fleece students of secondary fees and pad their own bottom lines. This can be $50-$100 per school and are not usually covered by financial assistance. 32/

It should be noted & praised though, that there are also some schools that waive secondary fees for FAP recipients and/or do not send secondaries to applicants they do not genuinely wish to learn more about and probably interview. 33/

Still, both within medicine and the larger working world, there is still bias against "ethnic-sounding" names and natural hair styles. Such implicit bias contributes to URM, esp Black & Afro-Latinx applicants being seen as "less professional". 34/ https://www.forbes.com/sites/janicegassam/2020/02/20/are-job-candidates-still-being-penalized-for-having-ghetto-names/#78577c9f50ed

So what can be done? I've mentioned a few of these along the way in this thread but for all the #TLDR folks, here are the highlights:
1) Reform public school funding so that all students have access to quality STEM courses, including AP and dual-enrollment
35/

2) Welcome course credit from accredited community colleges and online credit from accredited schools. Do not ding such coursework as "less than".
3) @AAMC_MCAT should work to continue funding FREE MCAT prep resources like those from @khanacademy
36/

4) Reform the FAP application process to better reflect the actual financial needs of students and minimize paperwork barriers.
5) #MedEd should welcome shadowing, even invite students to shadow by reaching out to academic/premed advisors in their states (incl. CC)
37/

6) Waive secondary fees for FAP recipients and do not send out secondaries without a preliminary screening. Don't take $$ from applicants you have no interest in matriculating.
7) Work to reduce implicit bias and consider blinding applicant names during screening.
38/

I welcome any additional insights others may have, especially other URM/BIPOC students. As we share about the barriers we have faced I hope that @AAMCtoday and leaders in #MedEd will listen & learn so that we can be part of the process to improve healthcare in this country.
end/

If you agree would you amplify? @medicalschoolhq @LMSA_National @LatinasInMed @SNMA @MinoritySTEM @AAPolicyForum @NAACP @AAMCtoday @AIPInstitute
Again, I definitely encourage more input from other URM/BIPOC applicants. We need your voices!

https://twitter.com/justshaily/status/1278378237505175552?s=21 Great info straight from the research that echoes my first hand experience. https://twitter.com/justshaily/status/1278378237505175552