What Does the Supreme Court’s Rejection of Affirmative Action Mean for Narrative Competence in Clinical Practice? - Annals of Internal Medicine: Fresh Look Blog


Wednesday, August 16, 2023

What Does the Supreme Court’s Rejection of Affirmative Action Mean for Narrative Competence in Clinical Practice?

Picture this: A 6-foot-tall Black or Brown professional feels excruciating abdominal pain and has to present to the emergency department. Somewhere at the back of his mind, he cannot shake off the nagging feeling that he might be profiled as a drug addict because of his looks or hair, so he tries to dress “respectably.” Still, chances are he will be profiled negatively regardless of his educational background or career achievements. The color of his skin has put a target on his back.

Many patients who identify as members of Black, Hispanic, or other minority populations are wary of the health care system and have felt the sting of marginalization when accessing health care. In fact, many members of this populace are so scared for their lives that they’d rather steer clear of the hospital environment, with the odds of reporting medical mistrust being 73% and 49% greater for non-Hispanic Black and Hispanic adults, respectively, than for non-Hispanic White adults (1). With poorer clinical outcomes across all spectrums recorded among such patients, there is a dire need to address this issue.

One way of addressing the issue of minority marginalization is to improve the narrative competence of health care providers. What exactly is narrative competence as it relates to evidence-based medical care? It is the critical ability to understand and be touched by patients’ stories, requiring physicians to understand that every encounter with each patient can become a crucial part of their story. The challenge in attaining this level of competence, however, is that it’s quite hard to feel the pain of someone whose reality is far removed from yours. In a recent Annals publication, Vijayan and colleagues explained the significant impact of racial disparities on medical education, with individuals from groups underrepresented in medicine grappling with socioeconomic challenges that aren’t fully captured in residency and fellowship applications (2). In the interest of improving health equity, we need Black and Brown physicians, as well as other health care workers in the room, to advocate for patients who look like them and whose realities closely mirror theirs. Nonetheless, diversity and medical meritocracy (3) are not mutually exclusive, with minority physicians often needing to overcome significantly more adversity to succeed, whilst exerting incredible effort to match up with their more privileged colleagues.

With the Supreme Court’s rejection of race-conscious affirmative action (4), the concepts of cultural cohesion, cultural humility (5), and health care equity stand on the brink of erosion. Ultimately, this has the ripple effect of reduced narrative competence for minority patients who feel lost in the maze of a complicated health care system. The gatekeeping that is bound to follow this enactment will further lead to the disenfranchisement of intending minority physicians. With a crucial portion of this demographic being already disadvantaged, they will likely lose access to these spaces that they otherwise would not have the resources to get into. On the other side of this decision are the millions of Black and Brown people who will fall on the sad spectrum of receiving poor health care to dying directly as a result of lack of advocacy and narrative competence. Narrative competence and health equity are not just buzzwords, they save lives. In the absence of race-conscious affirmative action, we can sadly expect to see an erosion of the gains made over the years in the health equity space. Unfortunately, minority patients lose out the most, and what is a better justification for the continuation of affirmative action than the metric of “more lives saved”?


  1. Bazargan M, Cobb S, Assari S. Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. Ann Fam Med. 2021;19:4-15. [PMID: 33431385] doi:10.1370/afm.2632
  2. Vijayan T, Graber CJ, Harris CE, et al. Achieving equity in residency and fellowship applications with a partial blindfold: a call for measuring the distance traveled [Editorial]. Ann Intern Med. 2023;176:985-986. [PMID: 37364262] doi:10.7326/M23-0334
  3. Razack S, Risør T, Hodges B, et al. Beyond the cultural myth of medical meritocracy. Med Educ. 2020;54:46-53. [PMID: 31464349] doi:10.1111/medu.13871
  4. Sangal A, Vogt A, Kashiwagi S, et al. June 29, 2023 Supreme Court affirmative action decision. CNN. 29 June 2023. Accessed at www.cnn.com/politics/live-news/supreme-court-decisions/index.html on 11 August 2023.
  5. Solchanyk D, Ekeh O, Saffran L, et al. Integrating cultural humility into the medical education curriculum: strategies for educators. Teach Learn Med. 2021;33:554-560. [PMID: 33573412] doi:10.1080/10401334.2021.1877711

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