Letter to the GME Community from Thomas J. Nasca, MD, MACP, President and Chief Executive Officer of the ACGME: Why Workforce Diversity Matters to Health Care and Graduate Medical Education

Dear Colleagues in the Graduate Medical Education Community, 

The United States Supreme Court is soon to issue decisions in actions brought by Students for Fair Admissions, Inc. against Harvard College and the University of North Carolina. Although these cases address consideration of race in undergraduate admissions (covered under Title VI of the Civil Rights Act of 1964), the decision may have implications for undergraduate medical education and possibly for accreditation of graduate medical education (GME). When these decisions are issued and after review and consideration of them, the ACGME will release a statement addressing the accreditation impact of these decisions. 

As you are aware, the Mission of the ACGME is to “improve health care and population health by assessing and enhancing the quality of resident and fellow physicians' education through advancements in accreditation and education.”¹ The ACGME views disparities in health care as opportunities for quality improvement for our educational programs and our teaching institutions, and a foundational element of our Clinical Learning Environment Review (CLER) Program effort in service of our Mission.² In this manner, we aim to improve quality and eliminate health care disparities and inequities in clinical outcomes, both today and into the future. Collectively, the GME community is a powerful lever for good, and each of us in this loosely knit system plays an important role in achievement of this Mission. 

Despite awareness of racial and ethnic health inequities made clear more than 20 years ago in Unequal Treatment (and other sources),^3,4 reduction in these disparities has remained mostly unchanged.⁵ A recommendation of this report was to increase racial and ethnic diversity of the health care workforce. Multiple studies, before and since the report’s publication, have suggested that a racially concordant and ethnically diverse workforce offers an effective means to accelerate access to physicians who are most likely to care for minoritized patients and work in underserved communities. Many of you have worked diligently to accomplish these aims. 

In furtherance of our Mission to improve health care for individuals and communities through the accreditation process and educational efforts, the ACGME requires each program and institution to work to enhance the diversity of its workforce. Medicine has historically excluded minoritized individuals and women. While progress has been made in gender equality in medical school acceptance, individuals from many minoritized communities are not represented in numbers proportionate to that in the population. These individuals are essential to meet the health care needs of populations experiencing lack of access to care, and disparities in care delivery. Currently, regulations related to Title VII of the Civil Rights Act of 1964⁶ offer remedies to allow hiring practices to eliminate manifest racial imbalances in traditionally segregated job categories. 

As confirmed by a body of scientific research compiled over decades and embraced in our own ACGME Mission and Vision, medical care by a racially diverse care team, or by physicians who benefitted from exposure to diverse professional or educational environments, greatly increases the likelihood of positive medical outcomes for all patients, and particularly for minoritized patients.⁷ Indeed, reducing and eliminating health care disparities and inequities in clinical outcomes is a pivotal element in achieving the ACGME’s Vision.⁸ 

Consistent with this Vision, the ACGME Institutional Requirements state that the “Sponsoring Institution, in partnership with each of its programs, must engage in practices that focus on ongoing, mission-driven, systematic recruitment and retention of a diverse and inclusive workforce of residents/fellows, faculty members, senior administrative staff members, and other relevant members of its GME community.” (Institutional Requirement III.B.8.)⁹ There is an imperative for physician identity formation in the GME phase to occur in an environment that is sensitive and responsive to the changing needs and preferences of all members of an increasingly diverse patient population, while focused on providing equitable, patient-centered care, and optimizing clinical outcomes for all. ACGME accreditation requirements are designed to assist programs and institutions in achieving these results. Nothing in the ACGME’s standards is intended to require programs or institutions to violate the law. 

In the United States, diversity, equity, and inclusion activities and programs have been challenged by the current political and social environment. Nevertheless, the ACGME remains committed to its Mission, Vision, and Values, which support its accreditation requirement for “respect and responsiveness to diverse patient populations, including but not limited to diversity in gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation.” (Common Program Requirement IV.B.1.a).(1).(e))¹⁰ In addition, Sponsoring Institutions and programs “must provide a professional, equitable, respectful, and civil environment that is free from discrimination, sexual and other forms of harassment, mistreatment, abuse, or coercion of students, residents [fellows], faculty members, and staff members.” (Common Program Requirement VI.B.6.) 

While political and legal decisions may create uncertainty regarding the "how" we accomplish our responsibility, there is no doubt about the “why.” The ACGME remains firm in its social contract-based commitment to educating and developing physicians who will care for every member of our society, including those in minoritized or marginalized groups, in a manner that engages them in their care, and results in the best possible clinical outcomes. The ACGME continues to encourage the work in GME necessary to develop and execute pathways that increase diversity in medical education and create a sufficient number of physicians who will provide the care required by minoritized patients and communities, giving them access with the goal of eliminating health care disparities and inequities in clinical outcomes in care. In this manner, we seek to achieve optimal care for all members of our society. 

Sincerely, 

Thomas J. Nasca, MD, MACP 
President and Chief Executive Officer 
ACGME 

1. ACGME. “Mission, Vision, and Values.” Accessed June 3, 2023. https://www.acgme.org/about/overview/Mission-Vision-and-Values. 

2. Koh, Nancy J., Robin Wagner, Robin C. Newton, Catherine M. Kuhn, John Patrick T. Co, and Kevin B. Weiss, on behalf of the CLER Evaluation Committee and the CLER Program. 2021. CLER National Report of Findings 2021. Chicago: ACGME. doi: 10.35425/ACGME.0008. https://www.acgme.org/globalassets/pdfs/cler/2021clernationalreportoffindings.pdf. 

3. Nelson, Alan. 2002. “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” Journal of the National Medical Association 94 (8): 666. 

4. Williams, D.R. and T.D. Rucker. 2000. “Understanding and Addressing Racial Disparities in Health Care.” Health Care Financing Review 21 (4): 75-90. PMID: 11481746; PMCID: PMC4194634. 

5. Ndugga, Nambi and Samantha Artiga. 2023. “Disparities in Health and Health Care.” Kaiser Family Foundation. Accessed June 3, 2023. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/. 

6. US Equal Employment Opportunity Commission. 1964. “Title VII of the Civil Rights Act of 1964.” Accessed June 3, 2023. https://www.eeoc.gov/statutes/title-vii-civil-rights-act-1964. 

7. Saha, Somnath, Gretchen Guiton, Paul F. Wimmer, and LuAnn Wilkerson. 2008. “Student Body Racial and Ethnic Composition and Diversity-Related Outcomes in US Medical Schools.” JAMA 300: 1135–45. https://doi.org/10.1001/jama.300.10.1135. 

8. ACGME. “ACGME Vision Statement.” Accessed June 3, 2023. https://www.acgme.org/about/overview/mission-vision-and-values/. 

9. ACGME. “ACGME Institutional Requirements.” Accessed June 3, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/800_institutionalrequirements2022.pdf. 

10. ACGME. “ACGME Common Program Requirements (Residency).” Accessed June 3, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf.