The Future of the US Nephrology Workforce following the End of Affirmative Action

Diversity of the nephrology workforce matters. It matters for patient care, for discovery and innovation, and for the development of future leaders of our field. Although understudied in nephrology specifically, some studies document that concordance between a physician and their patient—shared identity such as race or ethnicity—is associated with better outcomes, including greater survival of Black newborns1 and higher life expectancy for Black people living in counties with at least one Black primary care physician.2 In my own clinical practice, I care for a group of patients on in-center hemodialysis who all identify as Black and/or Hispanic. I have found that as a Black person born and raised in the same region of the United States where I currently practice, I relate to my Black patients in ways that my colleagues with other backgrounds do not. I know the current affairs covered by news outlets that are likely to have captivated their attention and concern and can offer them space to debrief about them during my rounds. I am reminded of my own family members when I interact with them and can recognize subtleties in their expressions that indicate times when I need to probe them to learn about how they are really feeling. Our social distance (the distance between individuals or social groups in society) is simply not very "far"; there have been numerous times throughout my career that my patients have expressed, in their own way, that this matters. The importance of enhancing diversity in higher education has long been recognized, and race as a factor in the holistic review of prospective students' applications was first legally sanctioned in 1978 in Regents of the University of California v. Bakke. This decision followed President John F. Kennedy's Executive Order 10,925 in 1961, which established the Committee on Equal Employment Opportunity,3 and this precedent of considering race in the college admissions process was upheld in subsequent cases in 2003 and 2016.4 In medicine, the Liaison Committee on Medical Education assesses medical schools' progress on advancing diversity and inclusion during their accreditation process, and the Association of American Medical Colleges tracks the racial and ethnic representation of students and physicians from several groups who are under-represented in medicine relative to their US general population representation. Progress has been slow with, for 2018–2019, only 6% of US matriculating medical students identified as Hispanic (compared with 18% of the overall population) and 7% identified as Black (compared with 13% of the US population) .5 Socioeconomic diversity is also limited among medical students, with a national survey finding nearly a quarter of matriculating students were drawn from households in the top 5% of annual income for the general US population.6 Diversity among medical faculty is limited but slowly improving, with one study finding that the proportion of internal medicine faculty from under-represented minority groups has doubled from 1980 to 2018 (from 4.1% to 9.7%).7 Among active nephrologists in 2021, only 6% were Black, 6.9% were Hispanic, and 0.1% were American Indian or Alaska Native physicians. 8 On June 29, 2023, the US Supreme Court ruled in favor of Students for Fair Admissions in cases against the University of North Carolina and Harvard College, with a decision that effectively ends the legality of considering race in college admissions. Among other educational sectors, this decision could lead to a significant reversal in progress toward a more diverse medical workforce and could affect health care delivery particularly for populations experiencing health disparities. Justice Ketanji Brown Jackson highlighted such disparities in her dissent, stating, "Gulf-sized race-based gaps exist with respect to the health, wealth, and well-being of American citizens. They were created in the distant past, but have indisputably been passed down to the present day through the generations." In nephrology, where we care for people with CKD and kidney failure who are disproportionately Black, Hispanic, and Native American and who are often from households with low incomes, we cannot afford to lose momentum in our progress toward ensuring our workforce is more inclusive of the very populations we serve. Over the past decade, following the American Society of Nephrology (ASN) Diversity Summit, numerous ASN efforts have led to greater diversity among speakers, committee chairs, award recipients, and councilors. ASN has also launched several programs aimed at attracting medical students and residents from under-represented backgrounds into nephrology, such as through membership recruitment at the Student National Medical Association and Latino Medical Student Association meetings (among the largest organizations serving medical students from under-represented backgrounds) and the ASN Loan Mitigation Pilot Program. However, data from 2022, noting that only 6% of all nephrology fellows (adult and pediatric) identify as Black and 11% identify as Hispanic,9 highlight the need for continued and expanded efforts. In this post-affirmative action era, the nephrology community will need to strengthen old and use new approaches to recruiting and supporting the development of prospective nephrologists from diverse backgrounds. We will continue to face the concurrent challenge of significant workforce shortages; however, the solutions could be synergistic. First, we should take our recruitment and early exposure efforts to settings where we are most likely to find learners from under-represented groups. This would include minority-serving undergraduate institutions (there are over 500 in the United States) that might be near our clinical or academic settings, or within reach through national programs in nephrology. Undergraduate institutions typically have much greater population parity to race, ethnicity, and socioeconomic status than do medical and graduate schools and offer the most opportunity to realize a more diverse medical workforce in the future. Students from these schools may be good candidates for the Kidney Disease Screening and Awareness Program, ASN Tutored Research and Education for Kidney Scholars, or Students and Residents programs, but may lack awareness of their existence. Downstream from undergraduate students are post-baccalaureate scholars, which would be an important group to consider in our efforts. A growing number of college graduates take one or more gap years between undergraduate and medical or graduate school to prepare for standardized tests (e.g., the Medical College Admission Test) and gain clinical and/or research experiences. Some formal post-baccalaureate research programs specifically enroll students from under-represented backgrounds in medicine and science.10 We should enhance exposure to nephrology through such programs or through individual pairings of nephrologists and kidney scientists with post-baccalaureate scholars. Second, we should re-examine our application and interview processes for residency programs and nephrology fellowship. In his closing statement on the Students for Fair Admissions decision, Chief Justice John Roberts noted, "At the same time, nothing prohibits universities from considering an applicant's discussion of how race affected the applicant's life, so long as that discussion is concretely tied to a quality of character or unique ability that the applicant can contribute to the university." This statement seems to invite expanded use of questions during application processes that would allow candidates to share unique aspects of their background that might facilitate a more holistic review of their application. Acknowledging profound kidney health and health care disparities, we might also invite applicants to share not only their own background but what they have done to support diversity, equity, inclusion, and health justice in their academic journey to date. Third, our ability to identify and attract trainees from diverse backgrounds into nephrology largely depends on our capacity to develop and support nephrology leaders from diverse backgrounds. Given the slow progress in increasing representation of Black, Hispanic, Native American, and other under-represented groups among medical students, we should focus our energy on developing and promoting leaders from the current nephrology workforce. Programs, such as ASN's partnership with the Harold Amos Medical Faculty Development Program of the Robert Wood Johnson Foundation, offer such leadership training, but broader efforts are needed to counter the historical exclusion of physicians from under-represented groups from the highest academic ranks and leadership positions and the consequent dearth of role models for contemporary generations. Relatedly, we should identify ways to reward nephrologists who are providing mentorship and sponsorship to trainees from under-represented groups (regardless of the mentors' racial, ethnic, or socioeconomic backgrounds). The scope and effect of such mentorship often goes unrecognized in promotion and tenure processes and, to the well-documented extent to which they provide the bulk of this mentorship, may disproportionately affect the careers of physicians from under-represented groups. With the recent Supreme Court decision, we should proceed with the urgency that addressing inequities in kidney health demands to identify best practices for avoiding major declines in trainees and physicians in our specialty who are from under-represented groups. We will have to find new ways to ensure a diverse nephrology workforce. It simply matters too much and for too many.