Groups underrepresented in medicine, often abbreviated URiM, are racial, ethnic, and other demographic groups whose share of the physician workforce falls well below their share of the general population. The term was formalized in 2003 when the Association of American Medical Colleges shifted from the older label “underrepresented minorities” to “underrepresented in medicine,” tying the definition to population-level proportions rather than a fixed list of groups. The gap is not just a headcount issue. Research consistently links a more representative physician workforce to better preventive care, lower emergency visits, and reduced health spending for minority patients, making the problem both a matter of equity within the profession and a public health concern.
Where the Term Comes From and Who It Covers
Before 2003, medical schools typically used a short list of racial and ethnic categories to track diversity. The AAMC’s redefinition was intentional: rather than naming specific groups, it asked schools to compare the demographics of their students and faculty to the demographics of their surrounding populations. In practice, the groups most consistently identified as URiM in the United States include Black or African American, Hispanic or Latino, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander individuals. But the framework is flexible enough to capture other forms of underrepresentation, including rural background, low socioeconomic status, and first-generation college attendance, depending on local context.1AMA Journal of Ethics. Achieving Ethical Inclusion and Equity in Medical Education
Over time, discussions of underrepresentation have expanded to include students and physicians with disabilities, LGBTQ+ trainees, and women of color who face overlapping barriers. These groups do not always appear in traditional URiM tallies, but the structural challenges they encounter in medical training closely mirror those experienced by racial and ethnic minorities.
Why a Representative Workforce Changes Patient Care
The most concrete argument for diversifying medicine is that patients do better when they can see a physician who shares their background. A study using national survey data found that Black, Asian, and Hispanic patients with a physician of the same race or ethnicity had lower total health care spending, with reductions of roughly 14%, 34%, and 20% respectively compared with patients whose physicians were of a different background. Emergency department visits were also lower among Hispanic patients with race-concordant clinicians.2PubMed. Patient-Physician Racial Concordance Associated with Improved Healthcare Use and Lower Healthcare Expenditures in Minority Populations
The effect extends beyond spending. Research on cardiovascular disease guidelines found that when patients and physicians shared a racial or ethnic background, adherence to evidence-based measures like aspirin use, blood pressure control, and smoking screening improved significantly. The largest improvement appeared in a composite measure capturing management of multiple chronic conditions simultaneously, suggesting concordance matters most for patients navigating complex health issues.3PubMed Central. Patient‐Physician Race/Ethnicity Concordance Improves Adherence to Cardiovascular Disease Guidelines
Where URiM Physicians End Up Practicing
Physicians from underrepresented backgrounds disproportionately serve communities that other doctors avoid. A landmark study in the New England Journal of Medicine found that Black physicians practiced in areas where the percentage of Black residents was nearly five times higher than in areas where other physicians worked, and Hispanic physicians practiced in areas with twice the share of Hispanic residents. Black physicians also cared for more Medicaid patients, and Hispanic physicians for more uninsured patients.4PubMed. The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations
More recent data from California confirms the pattern across specialties. African American, Latino, and Pacific Islander physicians were significantly more likely to work in federally designated medically underserved areas and health professional shortage areas than their white peers, even after adjusting for specialty type. The pattern held for both primary care and non-primary care fields.5PubMed Central. The Association Among Specialty, Race, Ethnicity, and Practice Location Among California Physicians in Diverse Specialties In other words, training more URiM physicians does not just diversify the profession symbolically. It funnels doctors into the exact communities where physician shortages are most acute.
Historical Roots of the Gap
The underrepresentation of Black physicians, in particular, has roots stretching back more than a century. In the early 1900s, seven medical schools served Black students. Abraham Flexner’s influential 1910 report recommended preserving only two of them, and by 1930 five had closed. Historians have debated how much of the blame belongs to Flexner himself versus broader forces: actions by the American Medical Association, restrictive state licensing boards, and severely limited premedical educational opportunities for Black students all contributed to the closures.6Journal of the History of Medicine and Allied Sciences. Revisiting Black Medical School Extinctions in the Flexner Era
The consequences of those closures compounded over decades. A modeling study estimated that had those five schools stayed open and expanded at even a modest rate, they would have collectively trained an additional 28,000 to 35,000 graduates between their closure dates and 2019. By 2019 alone, the number of African American medical graduates might have been roughly 29% higher than it actually was.7JAMA Network Open. Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools That lost pipeline has never been fully replaced.
Financial Barriers Before, During, and After Medical School
The cost of becoming a physician falls unevenly. A study of medical students found that about 77% of Black students anticipated graduating with more than $150,000 in educational debt, compared with roughly 65% of white students and 50% of Asian students. Even after accounting for family income and other factors, Black students were nearly three times as likely as Asian students to expect debt above that threshold.8PubMed Central. The Color of Debt: Racial Disparities in Anticipated Medical Student Debt in the United States
These disparities persist into residency. Analyzing national data from 2014 through 2019, researchers found that 96% of Black trainees carried some form of debt, compared with 83% overall. Black trainees were also far more likely to carry premedical education loans and consumer debt. While overall debt prevalence decreased somewhat during the study period, the decline for Black trainees was minimal and remained stable across specialties, suggesting the gap is structural rather than tied to any particular career path.9PubMed Central. Differences In Debt Among Postgraduate Medical Residents By Self-Designated Race And Ethnicity, 2014-19 Debt levels influence specialty choice, practice location, and whether a graduate pursues academic medicine, all of which shape the pipeline for future diversity.
How Admissions Policies Shape the Pipeline
Medical school admissions have become one of the most visible policy levers for addressing underrepresentation. Holistic review, which weighs applicant experiences, attributes, and community background alongside test scores and grades, has measurable effects. Research shows that holistic screening significantly increases the proportion of URiM, first-generation, and self-identified disadvantaged applicants invited for interviews compared with academic-metrics-only screening.10PubMed. Impact of holistic review on student interview pool diversity When the AAMC offered holistic review workshops to medical schools, participating institutions saw sustained increases in the diversity of both accepted applicants and matriculants.11Academic Medicine. The Association Between a Holistic Review in Admissions Workshop and the Diversity of Accepted Applicants and Students Matriculating to Medical School
Affirmative action bans push sharply in the opposite direction. A study of state-level bans on race-conscious admissions found that the share of URiM students in affected public medical schools dropped by about five percentage points within five years of implementation, while comparable schools in states without bans saw a slight increase.12PubMed. Affirmative Action Bans and Enrollment of Students From Underrepresented Racial and Ethnic Groups in U.S. Public Medical Schools Separate research estimated the decline at around 17% in first-time URiM matriculation across ban states.13PubMed Central. Racial Diversity in the Medical Profession: The Impact of Affirmative Action Bans on Underrepresented Student of Color Matriculation in Medical Schools
The most recent national data, following the Supreme Court’s 2023 decision ending race-conscious admissions at all U.S. colleges, shows the effects playing out in real time. Between the entering classes of 2023 and 2024, Black matriculants to MD programs fell by roughly 12% and Hispanic matriculants by about 11%, even though the proportions of applicants from those groups held steady. American Indian or Alaska Native matriculation dropped by about 22%, though the small numbers made that change statistically nonsignificant.14JAMA Network Open. Affirmative Action Repeal and Racial and Ethnic Diversity in US Medical School Admissions
Microaggressions and the Learning Environment
Getting into medical school is only the first obstacle. Once there, URiM students frequently encounter a climate that undermines their learning. In a validation study of medical students across the U.S., 55% of URiM respondents reported experiencing race-related microaggressions during training, compared with 31% of non-URiM students. Among those who experienced microaggressions, 62% of URiM students said these contributed to feelings of burnout, and 64% said they compromised their learning.15PubMed. Evaluation of Racial Microaggressions Experienced During Medical School Training and the Effect on Medical Student Education and Burnout: A Validation Study
Qualitative research has fleshed out what these experiences look like. Students described feeling devalued by peers, faculty, and preceptors. Microaggressions came not only from interpersonal interactions but from the structure of the curriculum itself. Students reported strong emotional responses, including stress, frustration, and anger, and believed the experiences harmed their academic performance and well-being.16Academic Medicine. Seeking Inclusion Excellence: Understanding Racial Microaggressions as Experienced by Underrepresented Medical and Nursing Students A parallel study from UK medical schools found strikingly similar patterns: students from racial minority backgrounds described feeling invisible on clinical placements, being denied learning opportunities given to white peers, and maintaining a posture of apprehension at the start of every new rotation.17BMJ Open. ‘Where are you really from?’: a qualitative study of racial microaggressions and the impact on medical students in the UK
Bias in Clinical Grading
The hostile climate is not just a matter of interpersonal slights. It appears to show up in evaluations. A review covering more than 100,000 students across up to 113 schools found that racial minority students received significantly fewer Honors grades in core clerkships than white students. Three additional studies examining nearly 95,000 written evaluations found significant disparities in the language used to describe students, with evaluators using different wording based on race or ethnicity.18PubMed. Racial and Ethnic Bias in Medical School Clinical Grading: A Review Because clerkship grades and evaluation language feed directly into residency applications, these disparities have consequences that extend well beyond medical school.
Faculty Promotion Gaps and the Minority Tax
For those who enter academic medicine, career advancement is slower. A national cohort study followed medical school faculty over more than a decade and found that by 1997, 46% of white assistant professors had been promoted, compared with 30% of URiM assistant professors. After adjusting for sex, tenure status, degree type, department, school type, and NIH funding, URiM faculty were still about 32% less likely to be promoted.19JAMA. Racial and Ethnic Disparities in Faculty Promotion in Academic Medicine More recent data shows that the gap has narrowed slightly but persists: URiM faculty had a promotion rate of 31%, compared with 40% for white faculty.20Academic Medicine. Recent Trends in Faculty Promotion in U.S. Medical Schools: Implications for Recruitment, Retention, and Diversity and Inclusion
Part of the explanation is what researchers call the “minority tax,” the extra, often uncompensated burden placed on URiM faculty to serve as diversity representatives, mentors to minority students, and community liaisons. These faculty members are disproportionately asked to sit on diversity-related committees, sometimes to fulfill a perceived “check box,” and to do so more often than non-URiM colleagues.21PubMed Central. Are committee experiences of minoritized family medicine faculty part of the minority tax? a qualitative study The irony is that this work, while institutionally valued in rhetoric, is often devalued in promotion decisions, leaving URiM faculty with less time for the research and publications that actually advance their careers.22PubMed Central. Addressing disparities in academic medicine: what of the minority tax?
The Leadership Ceiling
The promotion gap narrows somewhat at senior ranks but never disappears, and it is starkest at the top of the institutional hierarchy. A 12-year review of U.S. teaching institutions found that white physicians accounted for roughly 85% of professors, 88% of department chairs, and 91% of medical school deans. Black physicians held about 1% of professorships and 5% of deanships; Hispanic physicians held about 3% of each.23PubMed. Minorities struggle to advance in academic medicine: A 12-y review of diversity at the highest levels of America’s teaching institutions By 2019, only about 11% of medical school deans were from underrepresented minority backgrounds, a figure still far below national demographics.24PubMed. Stalled Progress: Medical School Dean Demographics Dean-level representation matters because deans control admissions policies, faculty hiring, curriculum design, and institutional culture.
Specialty Patterns
A common assumption is that URiM physicians cluster in primary care and are absent from surgical or competitive fields. The truth is slightly more nuanced. Data on residency positions from 2013 to 2019 found that URiM residents made up about 16% of both surgical and nonsurgical specialties. The gap appeared not between surgery and non-surgery, but between competitive and noncompetitive programs: URiM trainees made up roughly 12% of competitive specialties and 18% of noncompetitive ones. The three specialties with the highest share of URiM residents were all primary care fields.25PubMed. Underrepresented in medicine resident physician distribution by race, gender, and specialty trends from 2013-2019 Application data from 2010 to 2018 showed that surgical specialties actually attracted a slightly higher percentage of URiM applicants than nonsurgical ones, suggesting that interest is not the bottleneck.26JAMA Network Open. Trends in Race/Ethnicity Among Applicants and Matriculants to US Surgical Specialties, 2010-2018
American Indian and Alaska Native Students
No group faces a wider pipeline gap than American Indian and Alaska Native (AI/AN) individuals. Compared with white peers, AI/AN individuals had 63% lower odds of even applying to medical school. Once they did apply, their chances of acceptance, matriculation, and graduation were statistically similar to those of white applicants, suggesting the barrier is overwhelmingly pre-application: limited access to premedical resources, geographic isolation, and financial constraints. However, AI/AN residents had about 48% lower odds of becoming faculty, pointing to a second bottleneck at the academic career stage.27JAMA Network Open. Representation of American Indian and Alaska Native Individuals in Academic Medical Training AI/AN students were also more likely to report being first-generation college students, coming from low-income households, and experiencing imposter syndrome during training.28PubMed. Understanding the Experiences of American Indian and Alaska Native Students Enrolled in Allopathic and Osteopathic Medical Degree Programs Those AI/AN residents who do complete training showed 54% higher odds of working in specialties designated as health priorities for Indigenous communities, reinforcing the workforce argument for diversifying the pipeline.
Beyond Race and Ethnicity
The URiM framework increasingly acknowledges that underrepresentation is not exclusively a racial or ethnic phenomenon. Students with disabilities, for example, remain severely underrepresented and face barriers at every stage. A scoping review of the literature found that disability in medical education is often framed as a deficiency rather than a dimension of diversity, and it is habitually omitted from inclusion conversations altogether.29Academic Medicine. Disability in Undergraduate Medical Education in the United States: A Scoping Review Disabled students reported persistent stigma, difficult-to-navigate accommodation systems, and restrictive technical standards that sometimes functioned as de facto exclusion criteria.30Academic Medicine. “We Need a Seismic Shift”: Disabled Student Perspectives on Disability Inclusion in U.S. Medical Education In surgical fields, the evidence base is almost nonexistent: one scoping review found only five published studies on trainees with motor or sensory disabilities in surgical specialties, covering just four medical students and one resident in total.31PubMed. A Scoping Review of Trainees With Motor and Sensory Disabilities in Surgical Specialties: Barriers, Representation, and Inclusive Solutions
LGBTQ+ trainees face a distinct set of obstacles. Research highlights external factors influencing career decisions, a near-absence of LGBTQ+ health topics in the curriculum, discriminatory social interactions, limited same-identity mentorship, and a higher mental health burden. LGBTQ+ trainees may also weigh institutional inclusiveness heavily when choosing medical schools and residency programs, which concentrates them in certain regions and leaves less welcoming institutions with even less representation.32PubMed Central. The sexual and gender minority (LGBTQ+) medical trainee: the journey through medical education
For women from racial and ethnic minority backgrounds, race-based barriers tend to be more salient than gender-based ones, even though both are present. Research on the “double jeopardy” of being Black and female in medicine found that racially minoritized women described race-based inequities more frequently than gender-based ones, and that existing diversity initiatives often failed to address the intersection of the two.33PubMed Central. Double jeopardy: black and female in medicine
What Seems to Help
Pipeline programs that target pre-college and pre-medical URiM students show promising results, though the evidence base is still largely built on self-reported outcomes. One summer program for underrepresented students measured improvements in participants’ confidence in challenging science courses, sense of belonging in the medical profession, and connection to mentors, all of which roughly doubled from the program’s start to its end.34Advances in Medical Education and Practice. A New Way of Evaluating Effectiveness of URM Summer Pipeline Programs
Mentorship programs also appear effective, particularly for URiM faculty. A systematic review of mentorship programs designed for underrepresented physicians and trainees found that evaluations consistently reported high satisfaction, and some tracked objective outcomes like publications, retention, and promotion rates.35PubMed Central. Mentorship of Underrepresented Physicians and Trainees in Academic Medicine: a Systematic Review A URiM-specific mentorship program in family medicine found significant improvements in participants’ ability to identify career resources and their confidence in pursuing advancement.36Family Medicine. Underrepresented in Medicine Mentorship Program: Perceived Benefits and Lessons Learned Virtual formats have expanded access: a pilot program pairing URiM medical students interested in surgery with surgeon mentors found the model feasible and effective even across geographic distances.37PubMed. Outcomes of a pilot virtual mentorship program for medical students interested in surgery
What none of these interventions can do on their own is fix a problem that operates at every stage of the training continuum. Pipeline programs help students get to the application. Holistic admissions help applicants get through the door. Climate interventions and anti-bias training address what happens inside the walls. Mentorship and promotion reform tackle faculty retention. The evidence makes clear that there is no single bottleneck. The pipeline leaks at every joint, and patching one section while ignoring the rest just moves the attrition downstream.