A 2021 study found that medical schools are admitting proportionally fewer Black and Hispanic men and Native American or Alaska Native men and women than they were 40 years ago, and this is further decreasing their representation with respect to US census data.1 Recent changes in data collection by the American Association of Medical Colleges that allow enrollees to select more than 1 racial and ethnic group have complicated the analysis somewhat. Even so, the overall proportion of Black men in US medical schools fell from 3.1% to 2.9%; Native American or Alaska Native representation dropped to less than 1%. Representation among Native Hawaiians and Pacific Islanders also has plunged since the year 2000 when schools began to tally these groups' enrollment separately from the larger Asian demographic. One of the few areas of progress has been the rising enrollment of women in medical schools; their enrollment has doubled since the late 1970s, and women now represent slightly more than half of all medical students. Most of the gains, however, have come from the increasing enrollment of White and Asian women, says study coauthor Philip A. Gruppuso, MD, professor of pediatrics at Brown University in Providence, Rhode Island. A trend toward gender parity in some specialties also has not translated into an overall parity in the medical workforce, he points out. High-paying specialties such as orthopedic surgery and cardiology, for example, are still dominated by men, and even in specialties where parity has improved, women are underrepresented in senior faculty and leadership positions. The medical profession has only recently begun to focus on diversity with regard to sexual orientation and gender identity, with little baseline data about existing representation in the field and how that might translate to patient care. “We are at risk, I would argue, right now of perhaps missing some major issues for our transgender, nonbinary patients because we simply don't have that representation in our specialty,” says Marissa White, MD, assistant professor of surgical pathology at the Johns Hopkins University School of Medicine in Baltimore, Maryland. Dr. White and her colleagues have documented some troubling demographic trends among pathology residents as well. Although the discipline has made strides in nearing gender parity over the past 25 years, she and her study coauthors conclude, “There was no significant trend in the rate of change per year in Black or American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander resident representation.”2 The disappointing trends have contributed to a rethinking of diversification strategies. One tactic has been pipeline programs from undergraduate institutions, especially those that serve underserved communities. At least so far, however, such programs have not had a big impact on the overall makeup of the American medical student body. In fact, Dr. Gruppuso says, “The handful of historically Black medical schools winds up making a really substantial contribution to the inclusion of African Americans, especially African American men, in the aggregate US medical student body.” Without them, he says, the diversity gap would be even wider. Financial disparities can further perpetuate underrepresentation. Beyond the considerable expense of attending medical school and applying to residency programs, Dr. White says that enrolling in 2- to 4-week “away electives” at institutions where students are considering a residency can compound their financial hardship. “Why does that matter? More students underrepresented in medicine are from socioeconomically disadvantaged backgrounds,” she says. “They are going to have higher levels of education debt.” Financial aid can help to lessen the impact, but the data so far suggest that it has not helped to increase diversity on its own either, Dr. Gruppuso notes. In a more recent trend, some medical schools have begun providing free tuition across the board. The strategy is likely to increase the number of applications, he says, but it is too soon to say whether it may help break down the financial barriers that have often deterred those of lower socioeconomic means. The ongoing political battle over affirmative action has been yet another obstacle to increasing diversity. Medical schools have long talked about using a more holistic admissions process that puts less weight on definable metrics such as Medical College Admission Test scores. “But we've not seen an improvement in the diversity of the student body. So, it may not be that the concept is a problem; it may be that its implementation is a problem,” Dr. Gruppuso says. Among the more positive trends, several physicians have pointed to the launch of DEI committees within medical institutions and professional organizations. Zahra Maleki, MD, an associate professor of pathology and member of the departmental DEI committee at the Johns Hopkins University, says that the committee has sought to attract more diversity to the department and foster a more welcoming and supportive environment for both residents and faculty. In 2012, the DEI committee launched a multipronged campaign to expand the visibility of the Johns Hopkins program and make it easier for underrepresented students to gain “meaningful and early exposure” to pathology, says Dr. White, another committee member. An outreach team makes presentations and meets with students at historically Black colleges and universities; other medical schools, colleges, and community colleges; high schools; and national affinity groups. For each student group, the pathologists explain what they do and showcase the department's elective rotation and residency program. “I would say the journey starts early,” Dr. White says. Reaching student groups that are underrepresented in medicine and that are from socioeconomically disadvantaged backgrounds is not possible if those students never make it out of high school or into a premed program or if they never see pathology as an option. To further increase equity, the pathology department at Johns Hopkins is funding a rotation for underrepresented students. “It lowers the bar appropriately, so that experience is more accessible to those students who normally would not have had that opportunity,” she says. Although obstacles remain, a 2019 article by Dr. White and her colleagues suggested that the efforts at Johns Hopkins have yielded promising results. “The number of rotators increased from 1 in 2013 to 18 in July 2019. Rotators selfidentified as African, African American, Hispanic, and Native American.” Six of those rotators became pathology residents.3 To be successful, she cautions, diversification strategies need robust outreach components and program-wide buy-in. The challenges extend to retaining diversity within medicine, Dr. Maleki says. Because incoming residents may be at different levels of training and experience, some may need more guidance and encouragement than others. In turn, she says, pathology departments should value the willingness of faculty to spend more time nurturing trainees from diverse backgrounds who are eager to improve their skills but may not have had as many prior opportunities to do so. Disparities in career opportunities can also widen through microaggressions and what Dr. Maleki calls “misleading mentorship.” Some early mentors, for instance, openly doubted whether she could survive in such a “brutal” academic environment, whereas others discouraged her from writing books early in her career under the rationale that it was “rehashing old data.” Even steering interested mentees away from administrative responsibilities can make a huge difference; the added responsibilities not only increase a pathologist's salary, she says, but also make them more attractive candidates for other positions if they want to switch institutions. Ultimately, diversifying pathology and other disciplines may take a multi-layered approach that includes earlier outreach, a more holistic application process, broader financial considerations, and a more inclusive environment that encourages and promotes career development opportunities. “The bottom line is that we're evolving—our culture is evolving,” Dr. Maleki says. That may be threatening to some, but as she stresses, “Inclusion doesn't mean the exclusion of others.” Creating a culture of acceptance can require a sustained investment of time and effort. “We will see the results in 20 years,” she says. “But in the end, we will be in a better place.”