At Med Schools, a New Degree of Diversity
Classes Reflect A Foreign Flavor

By David Brown
Washington Post Staff Writer
Friday, June 1, 2007

The six members of Medical Team 4 have a lot in common. Each wears a white coat, has a stethoscope for a necklace and has stayed up late this week. They can all start an IV and work up a solitary lung nodule.

They share something less obvious, too. With one exception, none has a grandparent born in the United States.

Med 4 at the Veterans Affairs Medical Center in Northwest Washington is the new face of American medicine. Its members happen to come from Georgetown and George Washington universities, but the team is indistinguishable from similar groups of young doctors and doctors-to-be at many of the country's 125 medical schools.

In the past 15 years, U.S. medicine has seen a huge influx of first- and second-generation immigrants. It follows and augments a different demographic trend that began 30 years ago with the acceptance of increasing numbers of women into medical schools. As a result of that earlier revolutionary change, half of new practitioners today are women.

The Norman Rockwell-Marcus Welby image of the American doctor -- an avuncular white man, often in a bow tie -- is rapidly disappearing.

From 1980 to 2004, the fraction of medical school graduates describing themselves as white fell from 85 percent to 64 percent. Over that same period, the percentage of Asians increased from 3 percent to 20 percent, with Indians and Chinese the two biggest ethnic groups.

Counted in the "white" category, moreover, are a moderate number of ethnic Persians whose families fled the 1979 Iranian revolution, and a smaller number of more recent arrivals from Eastern Europe and the former Soviet Union. In the "black" category is an unknown number of graduates whose families recently arrived from Africa, predominantly Nigerians and Ghanaians.

"We are seeing more and more kids of foreign-born parents, especially in the last eight to 10 years. I don't think there is any doubt about it," said Milford M. Foxwell, a physician and dean of admissions at the University of Maryland School of Medicine. In his 18 years on the job, he has reviewed about 75,000 applications.

Many forces are sketching this changing portrait of the American medical student. They include a general increase in immigration, a large influx of foreigners trained in scientific and technical professions, and a culture of educational achievement in communities of newly arrived immigrants that prepares their children for the competition and rigors of medical school.

How -- or whether -- this trend will change the practice of medicine in this country is uncertain.

There is a small amount of evidence that a diverse student body may be more attuned to disparities in medical care than a homogeneous one. A study published in 2004 found that black, Hispanic and Asian medical students (in descending order) are more likely than white ones to think that U.S. medicine often "treats people unfairly" based on race, ethnicity, insurance status, income or ability to speak English.

In general, though, few are eager to touch on the implications of the new ethnic mix in medical schools. Officials at institutions as different as the University of Vermont and Howard University declined multiple requests to discuss, even anecdotally, the evolution of their student makeup.

In the case of Med 4, its roots stretch to India (two students), Bangladesh (one), Austria (one) and Russia (one). The sole team member without a family narrative of recent arrival is African American.

The door to the team's office at the VA hospital humorously telegraphs an awareness that the people inside the windowless warren of cubicles, computers, backpacks and water bottles are not quite a random sample of America. Someone has taped on it a page from the supermarket tabloid Weekly World News.

"Your doctor could be an alien! They're working undercover!" shouts the headline. Under it is a photo of four masked-and-gowned physicians -- one with dark space-creature eyes -- gathered around a supine patient.

Team 4's international coloration includes even its senior physician, Divya Shroff, an assistant professor of medicine at GW.

Her father immigrated from India to study chemical engineering in graduate school, returned to India to marry, then came back to the United States with his bride. Shroff and her younger brother and sister grew up in the Chicago suburbs but spent three years in New Delhi in the 1980s. Her brother is also a physician, her sister an investment banker.

"We were never forced into medicine," she said recently in her office at the VA hospital. "But in the Indian community in Chicago, everyone was a professional. Everyone was a doctor or an engineer."

She went from high school into a program at the University of Missouri where students got both a bachelor's degree and a medical degree in six years. Of the 10 people in her group, "maybe one was Caucasian," she recalled. The majority were Indians.

The culture of high expectation holds true for another South Asian on the team, resident Moneera Haque, who grew up in Bethesda with parents who immigrated from Bangladesh.

Haque, 30, has a doctorate in social work along with her medical degree. She recently presented a paper on "racial differences in utilization of cardiac rehabilitation" at a scientific meeting in New Orleans and another paper at a conference in Amsterdam. Her brother is a neurosurgeon.

In her household, the notion that education came first "was simply the way things were," Haque said while sipping a drink in a break room. "For me, that didn't seem like pressure." But she admitted she wasn't studying just for herself: "We have a sense of obligation to our parents to help them fulfill their dreams as well."

Alexandra Langer, a third-year medical student at GW, traced a distinctly different path.

Langer, 30, grew up in Yekaterinburg, in central Russia. Her father managed a pension fund, and her mother was a police officer. As a high school student, she aspired to become a doctor, but her parents talked her out of it.

"In Russia, doctors are much lower status than here," she said. "And they are very low-paid."

So at 18 she left home and moved to Prague, where she studied Czech, English and international relations, but she never really gave up her original idea. She married an American, moved to the United States, graduated from college in North Carolina and got into medical school.

"It seems like a very, very long time," she said. "But it's worth it."

Although the Association of American Medical Colleges asks all medical school applicants and matriculants to describe their race and ethnicity in general terms, there is little published information about national background and none about family history. Anecdotes, however, suggest that immigrants' children are more likely to attend schools on both coasts.

S. Balasubramaniam, a surgeon at Charles R. Drew University of Medicine and Science in Los Angeles who emigrated from India in 1971, recently queried 50 medical schools and calculated that 12 percent of the class that entered in 2006 is of Indian heritage. The highest percentages are in California, Texas, New York, New Jersey and New England.

Na Shen, 25, a second-year medical student at Maryland who was born in Shanghai, calculated that 12 percent of her school's students are from China, Taiwan, Korea and Japan, and 1 percent from Southeast Asia. When South Asians are included, the Asian portion of the school rises to 21 percent.

In contrast, University of Kansas medical school students since 1996 have consistently run about 10 percent "either born overseas or of parents who were born overseas," said Glendon Cox, the vice dean.

The most recent arrivals -- Africans -- are the hardest to quantify.

Morehouse School of Medicine, in Atlanta, has 12 students born in Africa out of about 210 in the M.D. program. Meharry Medical College, another historically black institution, in the past eight years has had an average of two foreigners per year in its incoming classes of about 60. It has no data, however, on students with recent ties to Africa who are U.S. citizens or permanent residents. Howard, the third historically black medical school, did not provide information when asked.

A half-dozen people at the Student National Medical Association -- the main U.S. organization of black medical students -- did not respond to inquiries.

Lauree Thomas, an African American physician who is associate dean for admissions at the University of Texas Medical Branch in Galveston, estimated that "20 to 30 percent of the black applicant pool" at her school is students who were born in Nigeria, or of Nigerian parents. Foxwell, the Maryland dean, estimates that close to half the black students there have recent ties to Africa.

This is a touchy subject in the black medical community.

Albert Morris Jr., a diagnostic radiologist in Memphis who is president of the predominantly black National Medical Association, said he recently talked to black students at Pennsylvania State University's medical school in Hershey. Afterward, several took him aside and quietly complained about the rising number of Africans.

"It was a big topic -- that people were coming in and getting slots that they thought should be going to African Americans," he recalled.

Blacks constitute about 13 percent of the U.S. population, but only 4 percent of U.S. doctors. There has been much effort in the last two decades to remedy this imbalance. Morris, a graduate of Howard, said he understands the students' sensitivities.

"We are happy to see doctors who are ready to treat minority populations, no matter their nationality," said Morris, 56. "But we want to make sure that those of us who have helped open the doors [to medical school for blacks] get to share in the bounty."