COLUMBIA — When Dawit Demissie walked across the stage in May to receive his degree from the MU School of Medicine, he was the only African-American in his class of 97.
Next year, three African-American women and one man are expected to graduate.
The numbers illustrate a common dilemma among MU and other medical schools trying — with mixed success — to recruit underrepresented minorities into their programs. That group includes blacks, Native Americans, Hispanics and Latinos but not students from Asia, India and the Middle East.
The prevailing challenge for the nation's 141 medical schools is competition for the same small group of minority candidates who are both interested and adequately prepared.
A backlash against affirmative action quotas has contributed to the troubles schools are having in diversifying their student bodies. Schools also must worry about securing consistent financial support for these students.
Then, once they are recruited and enrolled, the students might encounter hostility, even racism, that prompt some to drop out. That can make it even more difficult to sell the program.
"The history of Missouri and its racism has still left a sour taste in people's mouth when they think of coming here," said Robin Clay, the diversity and inclusion recruitment coordinator for the MU School of Medicine.
In Demissie's case, MU was able to offer significant financial incentives to help pay for his education. He was among the top candidates the year he applied — a graduate of the University of Maryland with degrees in biology and economics and above-average MCAT scores.
“I felt very grateful to do what I had wanted to do all my life,” said Demissie, 25, now a pediatrics resident at Riley Hospital for Children at Indiana University School of Medicine.
"In my experience, I had never felt directly attacked or racism directed at me, thankfully," he said.
"I had heard several serious accounts, which were always in the back of my mind. I was, in a way, waiting for it to happen to me, but I'm fortunate it did not."
The face of medical schools
As the rest of the country diversifies at a rapid rate — nearly 50 percent of the babies born in 2009 belong to a minority group — medical schools, including the one at MU, continue to enroll predominantly white students.
Since enrolling its first black medical student, Robert J. Smith in 1951, the MU School of Medicine has struggled to admit more than just a handful of minority students each year.
In 2007, the situation was especially troubling: The school didn’t have a single black student in its freshman class. The following year, the national accreditation committee for the Association of American Medical Colleges and the American Medical Association told MU officials that it must find a way to diversify its Medical School.
“Despite medical school efforts, including pipeline programs and new scholarships, and university efforts … the number of medical students and faculty from underrepresented groups remains well below desired levels,” the accreditation committee concluded in its 2008 accreditation letter to then-Chancellor Brady Deaton.
The association told the Medical School to develop a strategy to assure that diversifying the student population was a priority, coming up with a plan for recruitment, financial aid, faculty development and community partnerships.
Since then, the school has set up programs aimed at attracting minorities throughout Missouri — local science clubs, simulated Medical School experiences for high school students from St. Louis and Kansas City and Mizzou MedPrep, an academic advising program for nontraditional students.
In the past five years, the School of Medicine has more than doubled its acceptance rate of historically underrepresented minorities, from eight in 2009 to 18 in 2013.
The figures look promising, but various challenges remain. Just seven of the 18 students accepted in 2013 chose to come to MU, according to demographic data from the Association of American Medical Colleges.
“Reflecting a national trend, the numbers of students from historically underrepresented groups who ultimately enrolled in the MU School of Medicine remain lower than we would like,” said Mary Jenkins, spokeswoman for the MU Health System.
The issue, it turns out, is more complex and longstanding than simply demanding that medical schools diversify their student bodies. It is a matter of getting minority students interested in science at an earlier age, supporting them financially through medical school and making them feel at home.
"The most important thing we can do to broaden the participation of minorities in medicine is to double the number of minorities passing algebra by eighth grade," Marc Nivet, chief diversity officer for the Association of American Medical Colleges, said in an email to the Missourian.
According to the U.S. Census Bureau, blacks, Native Americans, Hispanics and Latinos made up 30 percent of the population in 2010, but nationally accounted for about 18 percent of students entering medical school in 2011.
Last fall, MU's first-year Medical School class of 96 included four African-Americans, two Hispanics and one Native American, according to data from the Association of American Medical Colleges.
In 2012, about 5.5 percent, or 22 students, of the school’s 410 came from historically underrepresented populations, according to Jenkins.
Diversity is crucial to improving health care across all demographics in the country, particularly in concentrated urban and rural areas where there is a shortage of medical providers.
Studies show that patients are more apt to follow treatment plans and feel comfortable when they share the same racial or ethnic background as their provider.
Minorities are also more likely than their white counterparts to want to practice medicine in underserved areas. About 55 percent of blacks or African-Americans entering medical school said they planned to practice in an underserved area, compared with about 21 percent of white students, according to 2011 data from the Association of American Medical Colleges.
UCLA found that students who attended a racially diverse medical school felt both better prepared to care for patients from a different racial or ethnic group and more likely to view health care as a societal right rather than a privilege.
Clay cited an enhanced academic experience and healthier patients as the main benefits of diversity.
"The biggest thing that (diversity) improves is patient care," Clay said.
“Creating and supporting opportunities for medical students to combine their differing backgrounds, perspectives and skills … will enhance their ability to work with diverse peers and patients as they enter the workforce,” the Association of American Medical Colleges wrote in its 2012 facts and figures report.
But respecting differences and creating a collegial environment do not always accompany the push to be inclusive.
“Not all physicians are culturally competent, and that includes some of our faculty and staff,” Clay said.
So, the Medical School has staff in place to address the conflicts that might arise. He said it's about "really committing to training our faculty members and making sure that they are culturally aware and, if not, that they are able to openly, respectfully ask those questions and address those issues if they are not comfortable.”
Uncomfortable realities such as institutionalized racism, economic disparities and wariness of reverse racism are holding back many schools, including MU, said Traci Wilson-Kleekamp, the former director for diversity at MU's Medical School.
Additionally, the school finds it difficult to talk about race, privilege and oppression, she said.
"They are not prepared to come outside their bubble, so to speak, and risk, if you will, having that kind of conversation," Wilson-Kleekamp said. "It's unfortunate because those are the conversations you really need to have."
During her time at MU, she said minority students described incidents of racial insensitivity. They came to study medicine, not teach their classmates how to be respectful, she said.
Wilson-Kleekamp said "micro-aggressive" comments — patronizing statements intended to be compliments — as well as more overt aggression hurt both students and staff. A micro-aggressive comment would be an indication of surprise, for example, that someone could speak or dress well.
"I think the climate of inclusion was pretty poor overall," said Kristal Matlock, an African-American graduate of the School of Medicine in 2012. "It seemed people weren’t interested in making people of color feel welcome – mostly administrators, but students as well."
While a student at the MU School of Medicine in 2010, she was taking a break with other students when one of them used the "n-word" while describing a comedy routine.
The incident rattled Matlock, who is now a resident at a hospital in Ohio. Instead of focusing on her exams, she couldn't stop thinking about the slur.
It was neither the first nor last time Matlock said she witnessed racial insensitivity at the Medical School. Between 2008 and 2012, she said she observed insensitivity among some students and faculty toward blacks, Asians and Indians.
"It made me feel like I was less important than other students, especially when an administrator is sitting right there and makes no effort to correct that person," Matlock said. "It makes me angry, but also nervous, because I don’t want to show that anger.”
Nivet said in an email that "the biggest challenge to diversification is the nation's poor performing K-12 school systems across the country, particularly in urban and rural environments."
The Association of American Medical Colleges is pushing, even requiring, schools to target underrepresented minorities — defined as African-Americans, Hispanics, Latinos and Native Americans. The end goal of diversity is creating a physician workforce that is reflective of the society it serves, Nivet said.
"Finding and harnessing all talent from different socio-economic or racial and ethnic and gender backgrounds is critical to ensuring we have a workforce that is willing to work in specialties and in geographic areas of high need," he said.
Experts such as Nivet agree that diversifying medical schools starts early — even in elementary school. A few of MU’s pipeline programs are aimed at underrepresented minority high school students from St. Louis and Kansas City.
Ellis Ingram, a pathologist, the senior associate dean for diversity and inclusion at MU and an associate professor, also runs science clubs with minority students in Columbia in collaboration with the medical school.
Nationally, black students on average score 7 points lower on the MCAT than their white and Asian counterparts. Latinos fare better with scores 4 points lower than whites and Asians. The MCAT, a national screening exam for prospective medical students, is often viewed as the key indicator of success in medical school.
The data suggests the preparation and training of students from minority backgrounds is not as strong as it needs to be.
"We have too many students, especially minority males, either dropping out of high school or are in under-performing school districts that don't prepare them for the rigors of upper level science and math," Nivet said.
"In other words, we need to go much further down the pipeline to develop talent so that we can increase the likelihood we will have a robust and growing number of minority students prepared for all STEM careers, including the health professions," Nivet said.
Route to physician
Demissie knew he wanted to be a pediatrician when he was 6. Once he moved past the astronaut/firefighter phase at age 4 or 5, he started telling his own pediatrician in Salisbury, Md., that he wanted to be just like him when he grew up.
He chose MU because the school offered financial assistance but also because Columbia is where his parents met. Ejigou Demissie, 62, and Nohora Rivero, 56, met while he was teaching economics at Lincoln University in Jefferson City and Rivero was visiting her sister Martha in Columbia.
They kept in touch after his mother returned home to her native country, Colombia, and the two married in 1986 — just seven months after they met — and moved to Maryland to start a family.
Because his mother is from Colombia and his father is Ethiopian, Dawit Demissie calls himself "Colopian."
He and his two younger brothers, Yoseph and Paulo, grew up with predominantly white peers and attended a small private Catholic school from kindergarten through the eighth grade.
His parents taught their three sons to embrace their dual, even triple, identities as people with roots in the U.S., Colombia and Ethiopia.
“Being different wasn’t a bad thing growing up,” Demissie said. “You get to share your differences with other people.”
When he arrived at MU four years ago, he wasn’t terribly surprised to find he was the only black student in his class.
“I was so incredibly happy to be in medical school, I didn’t care about anything else at that time,” he said.
As he progressed through school, he took advantage of opportunities to talk about race, diversity and the importance of being culturally competent.
Demissie served on the MU Health System Diversity Advisory Council for about 2 1/2 years. “I was by far the youngest person there,” he said. “But you keep making comments, you’re helping the conversation. That was really empowering.”
He found mentors in Ingram; Aneesh Tosh, a physician in adolescent medicine; and Michael Cooperstock, a pediatric infectious disease physician and professor emeritus and division director at the Medical School.
Ingram said he always appreciated Demissie’s passion for medicine: “He has incredible skills and is going to be an outstanding doctor.”
Ontario "Terry" Lacey, who is also African-American and a medical student at MU, has a back story and an experience at the School of Medicine that has been quite different from Demissie's.
Lacey is a 39-year-old nontraditional student, one of four African-Americans in his class but the only black man. He is about to enter his fourth year of medical school.
His mother and father met and married in high school, and Lacey was born in 1974 when his mother was 18. For the first few years of his life, he moved around Birmingham, Ala., with his mom and younger siblings. He said his family had little money, and his early years were unstable.
When he was 6, he went to stay with his maternal grandmother at a housing project in Birmingham. He describes it as a tough area where gang violence, drug dealing and neighborhood fighting were prevalent.
“I know what it’s like to come from farther down,” Lacey said of his childhood.
His grandmother worked as a “domestic” for Gail Cassell, one of the nation’s leading infectious disease specialists and a professor at the University of Alabama at Birmingham for many years.
His grandmother encouraged him to pursue academics, and during high school, he worked on and off in Cassell's research lab. Cassell solidified his desire to attend medical school, he said, rather than pursue a doctorate.
Lacey enrolled at the University of Rochester in New York, but he said he wasn't ready to focus on school and dropped out after one year. He met his wife, Lakeitha, when he was 19. The couple married in 1996 and have a daughter, Simone, who is 9.
Before starting Medical School in 2011, Lacey spent 15 years with the Navy. He was stationed in New Orleans for four years and then at the Point Magu Naval Base near Malibu, Calif., for another 11. He will become a lieutenant once he graduates and plans to work in a Navy hospital.
Lacey said he was accepted into other prestigious programs that offered him a year-long preparation course before medical school. He opted for MU because it was the first school to accept him and because he didn’t want to extend his time in school for another year at his age.
After three years in the School of Medicine, Lacey said he doesn’t believe white America is quite ready to have black men as physicians.
He said he has heard hostile comments about his appearance, clothing and the way he carries himself. He’s been called arrogant, confident, easy-going and unprofessional.
“They perceive me one way, and that’s totally different than what I do,” he said.
The problem is that people find him intimidating, he said. In his view, it's his body language and the way he communicates.
"They will argue that we should all communicate the same, but that’s not true,” he said.
Part of the answer could be better preparation for minority students, who may not have had access to strong primary and secondary education or preparation programs. But it's also important to build a culture of inclusivity, both Demissie and Clay said.
MU does not offer an extensive pre-enrollment preparation program for underrepresented minorities. But the school has undertaken a number of initiatives, such as the formation of the diversity council, inclusiveness training, diversity goals and a campaign to raise scholarship money for minority students.
The school uses the same definition of underrepresented minority as the Association of American Medical Colleges, with one addition: MU targets students from rural areas because these communities are experiencing physician shortages nationwide.
In addition to rural pipeline programs, the school also offers nontraditional students assistance with the application process and supports them once they are accepted.
Tomorrow's work force
Demissie and Lacey are both optimistic about the future and hope to see changes in the makeup of the medical student population.
It's not just about diversifying the Medical School's student body, Demissie said. It’s also about bringing all types of diversity from the top down.
“Mizzou has an opportunity, I think here in the next few months and years, to bring in a lot of diverse thought as well as culture," Demissie said.
"Doing a little more to recruit people from other parts of the country and other parts of the world, is going to be really important not only for the students, but more importantly, for the patients they are being trained to serve."
Richard Webner contributed to this report.
Supervising editor is Jeanne Abbott.