Legislation, wizardry, and standing up for med ed

ACP and other organizations oppose legislation introduced in the U.S. House of Representatives that would bar medical schools engaged in diversity, equity, and inclusion activities from receiving federal funding.

Although I am not much of a Harry Potter fan, I have been reflecting a lot lately on a line from the first movie, where a character, school headmaster Albus Dumbledore, tells his students that "it takes a great deal of bravery to stand up to our enemies, but a great deal more to stand up to your friends." This applies to advocacy as well.

While elected officials, and their offices and staff, are neither our enemies nor friends, there are lawmakers and offices with whom we have good working relationships, and who are supportive of a number of College policy priorities. There are also those who are rarely in alignment with College policies and with whom collaboration is more limited. Allowing for these nuanced differences, the challenge remains the same: how to tell a friend or supporter, especially someone whose partnership may be needed to advance other important issues, that we disagree with them and think they are wrong.

This is where ACP and other organizations found ourselves this spring 2024. In mid-March, legislation was introduced in the U.S. House of Representatives that would bar medical schools engaged in diversity, equity, and inclusion (DEI) activities from receiving federal funding. Within a week, the bill had more than 40 cosponsors. A Senate version of the bill was introduced in April.

Among those supporting this legislation are more than a half-dozen members of the House Doctors Caucus (including the lead sponsor) and several other members of Congress who have been leaders on legislation benefiting internal medicine physicians and their patients. Many of these sponsors have galvanized efforts to improve and stabilize physician payment, reduce administrative burden, reform step therapy protocols, and provide student debt relief for physicians. This is not an uncommon scenario, as organizations often have elected officials whom they work with on some issues but are on opposing sides from for others.

ACP has a history of working with members of Congress from across the political spectrum to cultivate support from and collaboration with lawmakers to increase graduate medical education (GME) funding, improve Medicare payment, reduce administrative burden, and advance a range of other policy solutions benefiting physicians and patients. At the same time, some of the same members of Congress who have supported or even championed these issues have been on the opposing side of other College priorities, such as protecting access to reproductive health care or making comprehensive health insurance more affordable.

Legislation is introduced every year that may conflict with ACP policy or is potentially detrimental to internal medicine physicians and patient care. The anti-DEI legislation introduced earlier this year has drawn scrutiny, not just because of the flawed policies it would enact, but also for how it grossly distorts the educational programs and resources that are foundationally in place at medical schools.

For example, as a condition of federal funding, this legislation would prohibit medical schools from directing faculty or students to affirm that "any sex, race, ethnicity, religion, color, or national origin makes an individual a member of oppressed or oppressor categories" and that "individuals should be adversely treated on the basis of their sex, race, ethnicity, religion, color, or national origin." Recognizing the myriad ways in which gender, race, religion, and culture may influence patient behavior, experiences, and perspectives, one would expect that opposition to these actions is both a universal and noncontroversial component of medical education. Inclusion of these and other similar items in this legislation implies that inappropriate practices are occurring at medical schools and that the items are included to delegitimize and justify banning appropriate educational practices, as well as unrelated DEI programming and resource allocations to improve workforce diversity and culture.

DEI efforts in medical schools cover an array of programs, resources, and services. Collectively, they are intended to produce a more competent health care workforce, mitigate well-documented systemic shortcomings in care provided to a broad array of diverse communities and populations, and, yes, support the development and growth of a diverse physician workforce. Medical school DEI programs range from mentoring and other services to support the unique needs of medical students who are the first in their families to attend college, to unconscious bias training for faculty and students, and to building cultural competence to address diverse needs of patients.

Unfortunately, the recently introduced federal legislation is not unique. Over the last few years, at least a dozen states have enacted laws restricting DEI activities and initiatives in higher education. These laws risk exacerbating existing health disparities. In response to the federal legislation, ACP led an organizational sign-on letter and circulated a grassroots alert to facilitate individual messages to members of Congress in opposition to the bill.

Our public policy advocacy remains consistent with other policy positions ACP has undertaken over the past several years. Similar to the wizards at Hogwarts, we have an obligation to acknowledge and learn from past mistakes as we develop policies and programs to mitigate those errors.

In September 2020, ACP announced its commitment to being an antiracist, diverse, equitable, and inclusive organization and acknowledged aspects of our history that now seem unthinkable. In the first half of the 20th century, College membership was limited to English-language speakers in North America. There was not a Black ACP member until after 1947, and the first record of any formal ACP activity to study and develop recommendations on diversity wasn't until 1971.

Today, the College recognizes that providing high-quality health care for everyone requires understanding and addressing the unique circumstances influencing individuals and populations because of their gender, race, ethnicity, religion, and cultural characteristics and identities. From a workforce perspective, studies show that patients with racially concordant physicians experienced improvements in outcomes and rates of preventive services, demonstrating the importance of recruitment and retention of physicians from underrepresented backgrounds.

In addition, physicians from underrepresented backgrounds are more likely to care for patients from underserved racial and ethnic communities and economically underserved populations. To address these needs, ACP research has shown that to nurture and grow a diverse physician pathway, medical schools must undertake efforts to eliminate barriers preventing underrepresented students from attending and completing medical school.

We must take action to support evidence-based policy solutions that improve care and strengthen the physician workforce. We also have a responsibility to call out legislation and other policy proposals that undermine, delegitimize, or distort these efforts or their intended purposes. With the understanding that diversity is an inherent part of medicine, DEI programs in medical education help address a broad array of issues to advance equity in health care, improve health outcomes and understanding among clinicians and patients, and facilitate quality care through an inclusive physician workforce.