IN THE NATION’S COMPELLING INTEREST

Ensuring Diversity in the Health-Care Workforce

Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce

Board on Health Sciences Policy

Brian D. Smedley, Adrienne Stith Butler, Lonnie R. Bristow, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce IN THE NATION’S COMPELLING INTEREST Ensuring Diversity in the Health-Care Workforce Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce Board on Health Sciences Policy Brian D. Smedley, Adrienne Stith Butler, Lonnie R. Bristow, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. P009518 between the National Academy of Sciences and the W.K. Kellogg Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data In the nation’s compelling interest : ensuring diversity in the health care workforce / Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce, Board on Health Sciences Policy ; Brian D. Smedley, Adrienne Stith Butler, Lonnie R. Bristow, editors. p. ; cm. Includes bibliographical references and index. ISBN 0-309-09125-X (hardcover) 1. Discrimination in medical education—United States—Prevention. 2. Medical colleges—United States—Admission. 3. Minorities in medicine—United States. 4. Minorities—Education (Higher)—United States. 5. Medical personnel—Recruiting—United States. 6. Affirmative action programs—United States. [DNLM: 1. Cultural Diversity—United States. 2. Health Manpower—United States. 3. Accreditation—standards—United States. 4. Education, Medical—economics—United States. 5. Minority Groups—education—United States. 6. Personnel Selection—standards—United States. 7. Public Policy—United States. W 76 I355 2004] I. Smedley, Brian D. II. Butler, Adrienne Stith. III. Bristow, Lonnie R. IV. Institute of Medicine (U.S.). Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce. V. Institute of Medicine (U.S.). Board on Health Sciences Policy. R745.I5 2004 610'.71’173—dc22 2004005891 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce COMMITTEE ON INSTITUTIONAL AND POLICY-LEVEL STRAGEGIES FOR INCREASING THE DIVERSITY OF THE U.S. HEALTH CARE WORKFORCE Lonnie R. Bristow (Chair), Retired physician and former president, American Medical Association, Walnut Creek, CA Colleen Conway-Welch (Vice-Chair), Dean and Professor, School of Nursing, Vanderbilt University, Nashville, TN Brenda E. Armstrong, Associate Dean and Director of Medical School Admissions, Associate Professor of Pediatrics in the Division of Pediatric Cardiology, and Associate Vice Provost, Duke University, Durham, NC Kevin Barnett, Senior Investigator, Public Health Institute, Oakland, CA Joseph Betancourt, Senior Scientist, Institute for Health Policy, Director for Multicultural Education, Multicultural Affairs Office, Massachusetts General Hospital, Partners HealthCare System, and Assistant Professor of Medicine at Harvard Medical School, Boston, MA Michael V. Drake, Vice President, Health Affairs, University of California, Office of the President, and Steven P. Shearing Professor of Ophthalmology, UCSF, Oakland, CA Jay A. Gershen, Executive Vice Chancellor and Professor in the School of Dentistry, University of Colorado Health Sciences Center, Denver, CO Lazar J. Greenfield, Emeritus Executive Vice President for Medical Affairs, Professor of Surgery, University of Michigan, Ann Arbor, MI Robert L. Johnson, Professor and Chair, Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Newark, NJ Bette R. Keltner, Dean, School of Nursing & Health Studies, Georgetown University, Washington, DC (served until September 2003) Ciro V. Sumaya, Dean and Cox Endowed Chair, School of Rural Public Health, Texas A&M University System Health Science Center, Bryan, TX Lisa Tedesco, Vice President and Secretary of the University and Professor of Dentistry, University of Michigan, Ann Arbor, MI Ena Vazquez-Nuttall, Associate Dean and Director, Graduate School, Bouve College of Health Sciences, Northeastern University, Boston, MA Judith A. Winston, Principal and co-founder, Winston Withers & Associates, LLC, Washington, DC Vickie Ybarra, Director, Planning and Development, Yakima Valley Farm Workers Clinic, Yakima, WA

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce HEALTH SCIENCES POLICY BOARD LIAISON Sherman James, John P. Kirscht Collegiate Professor of Public Health and Chair, Department of Health Behavior and Education, University of Michigan, Ann Arbor, MI IOM PROJECT STAFF Brian D. Smedley, Study Director Adrienne Stith Butler, Program Officer Thelma L. Cox, Senior Project Assistant IOM BOARD STAFF Andrew M. Pope, Director, Board on Health Sciences Policy Troy Prince, Administrative Assistant Carlos Gabriel, Financial Associate COPY EDITORS James Ryan Laura Penny

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Marilyn Hughes Gaston, National Minority Health Month Kevin Grumbach, University of California, San Francisco George C. Hill, Vanderbilt University Bob Montoya, Sacramento, CA Thomas E. Perez, University of Maryland Joan Y. Reede, Harvard University Lynne D. Richardson, Mount Sinai Hospital Susan C. Scrimshaw, University of Illinois Jeanne C. Sinkford, American Dental Education Association Richard M. Suinn, Colorado State University Charles Terrell, Association of American Medical Colleges William A. Vega, University of Medicine and Dentistry of New Jersey Nancy Woods, University of Washington

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Elaine Larson, Columbia University. Appointed by the National Research Council and Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Acknowledgments Several individuals and organizations made important contributions to the study committee’s process and to this report. The committee wishes to thank these individuals but recognizes that attempts to identify all and acknowledge their contributions would require more space than is available in this brief section. To begin, the committee would like to thank the sponsor of this report. Funds for the committee’s work were provided by the W.K. Kellogg Foundation. The committee thanks Henrie Treadwell, Ph.D., and Bob DeVries, who served as the Project Officers on this grant. The committee found the perspectives of many individuals and organizations to be valuable in understanding institutional and policy-level strategies for increasing the diversity of the health care workforce. Several individuals and organizations provided important information at open workshops of the committee. These include, in order of appearance, L. Natalie Carroll, M.D., President, National Medical Association; David Johnsen, D.D.S., President, American Dental Education Association; Hilda Richards, Ed.D., R.N., President, National Black Nurses Assocation, Inc.; Charles Terrell, Ed.D., Vice President, Division of Community Minority Programs, Association of American Medical Colleges; Barbara Blakeney, MS, APRN, BC, ANP, President, American Nurses Association; Phyllis Kopriva, Director, Women and Minority Services, and Kevin McKinney, M.D., Chair, Minority Affairs Consortium, American Medical Association; Geraldine Bednash, Ph.D., R.N., FAAN, Executive Director, American Association of Colleges of Nursing; Elena Rios, M.D., National Hispanic

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Medical Association; Ben Muneta, M.D., President, Association of American Indian Physicians; Dean Whitla, Ph.D., Director, National Campus Diversity Project, Harvard Graduate School of Education; Ella Cleveland, Ph.D., Association of American Medical Colleges; Gabriel Garcia, M.D., Associate Dean of Medical School Admissions, Stanford University; Joshua Aronson, Ph.D., Assistant Professor, Department of Applied Psychology, New York University; Barbara Grumet, National League for Nursing Accrediting Commission; Charlotte Beason, Ed.D., R.N., C.N.A.A., Commission on Collegiate Nursing Education; Karen Hart, Commission on Dental Accreditation; David Stevens, M.D., Liaison Committee on Medical Education; Susan Zlotlow, Ph.D., American Psychological Association Committee on Accreditation; Kevin Barnett, Dr.PH., M.C.P., Public Health Institute; Paul Hattis, M.D., J.D., M.P.H., Tufts University; JudyAnn Bigby, M.D., Brigham and Women’s Hospital and Harvard Medical School; Bradford Gray, Ph.D., New York Academy of Medicine; William Vega, Ph.D., UMDNJ-Robert Wood Johnson Medical School; Jeffery F. Milem, Ph.D., University of Maryland; Eric L. Dey, Ph.D., University of Michigan; Michael Rainey, Ph.D., Stony Brook University School of Medicine; Daryl G. Smith, Ph.D., Claremont Graduate University; William B. Harvey, Ed.D., American Council on Education; Beauregard Stubblefield-Tave, M.B.A., the Stubblefield-Tave Group; Karen Matherlee, Policy, Inc.; Henry Lopez, Jr., Bureau of Health Professions, Health Resources and Services Administration; and Howard Landesman, D.D.S., M.Ed., School of Dentistry, University of Colorado Health Science Center. The committee also gratefully acknowledges the contributions of the many individuals who assisted the committee in its work, either by providing research support or by assisting in preparation of draft material. Dr. Paul Hattis of Tufts University served as an appointed consultant and assisted the committee in preparation of the chapter, “Community Benefit as a Tool for Institutional Reform.” The committee would also like to thank the many other individuals who provided information pertinent to the committee’s charge, including Linda E. Berlin, Dr.PH., R.N.C., Director of Research and Data Services, American Association of Colleges of Nursing; Melissa Connell, J.D., University of Colorado Health Sciences Center; Lin Jacobson, Ed.D., R.N., C.P.H.Q., Director of Research, National League for Nursing; Marlaine Smith, R.N., Ph.D., Professor & Associate Dean for Academic Affairs, and Pat Moritz, Ph.D., Dean, University of Colorado Health Sciences Center School of Nursing; Donna M. English, M.P.H., R.N., Deputy Director, Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration; Ruth Beer Bletzinger, M.A., Director, Division of Community and Minority Programs, and Lois Colburn, Assistant Vice President, Division of Community and Minority Programs, Association of American Medical Colleges; Denis

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Nissim-Sabat, Ph.D., Senior Policy Analyst, Public Policy Office, American Psychological Association (APA); Jessica Kohout, Ph.D., Director, Research Office, APA, and staff of the APA Research Office; and Kim Nickerson, Ph.D., Assistant Director, Minority Fellowship Program, APA. Finally, the committee would also like to thank the authors whose papers contributed to the evidence base that the committee examined. These include Jeffery F. Milem, Ph.D., University of Maryland; Eric L. Dey, Ph.D., and Casey E. White, University of Michigan; Cathryn L. Nation, M.D., University of California; Gabriel Garcia, M.D., Stanford University; Neil Parker, M.D., University of California, Los Angeles; Karen Matherlee, Policy, Inc.; Norma E. Wagoner, Ph.D.; Leon Johnson, D.Ed., M.B.A.; and Harry S. Jonas, M.D.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Preface For almost a decade, several state referenda and federal court decisions have limited the ability of many universities to consider race and ethnicity in admissions processes. With that background, in a real sense, this committee’s assignment has been to examine the question of whether we, as a nation, are properly utilizing the pool of applicants to training in the health professions that we already have (or will have in the future). The need and desire of the American people for competent, compassionate health professionals who have the necessary communication skills for an increasingly diverse society already exists and will only rapidly increase. Are we getting all of the qualified students and faculty that we should from the available applicant pool? From its inception, the committee also recognized there is a need to answer the very important, but usually unspoken, question of how does the broader society benefit by having increased diversity among health care professionals, aside from the gratification of doing what is morally right? Stated more narrowly and precisely, the IOM was asked for a study assessing the potential for institutional and policy-level strategies to increase under-represented minority participation in the health professions. In other words, do these two particular strata offer any unique potential to increase diversity? Our exploration therefore required the committee to assess (a) whether our current institutional processes and policy-level factors are, at times unintentionally creating barriers to providing the nation with the culturally competent caregivers it needs, and (b) if so, how can they be improved? Can

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce some of the assumptions we have made for a great many decades be fairly challenged, as to exactly what is “the best and the brightest?” Our committee believes they can be so challenged and, in fact, improved upon in light of the twenty-first century needs of America. Much of that “unspoken question” about value to the broader society was addressed by the June 23, 2003, decision by the Supreme Court on the Grutter v. Bollinger et al. case, when the majority opinion found there is substantial evidence that the quality of the educational experience in a university that has achieved a “critical mass” of diversity is significantly greater than what is experienced without said diversity. It was necessary for our committee to carefully examine that evidence, and go beyond, to draw our own conclusions. The Supreme Court further found that the need of the American society for such better-educated future leaders, who are also better accustomed to interacting with a diverse world community, as well as a more diverse American society, is indeed a “compelling governmental interest.” Logic would suggest the different problem-solving skills found amongst those of diverse ethnic and cultural backgrounds should lead to more creative thinking about clinical, research, patient satisfaction, and/or cost problems, which are the bottom lines for health care. Every student and every patient will be advantaged from the achievement of a critical mass of diversity in all health profession education, not just the minority students and minority patients. The methodology employed by this committee involved researching the pertinent literature, inviting much valued input from all key interested parties in a series of six workshops, and, in particular, studying the existing models of success in this activity. We have tried to identify and spotlight those characteristics that seem to be essential to that success and to codify them in a series of recommendations. These recommendations should be seen as being generic, and applicable to each of the healing professions, not simply to only one or the other of Dentistry, Medicine, Nursing, and Psychology. We have also attempted to make due note when unique and innovative programs were encountered that merit continued interest because of their “thinking outside the box.” Identifying needed modifications, however, is not enough. One should not design a sailboat without identifying a realistic source of wind to make it move. Similarly, with the objective of increasing diversity, there must be such a credible source of wind to fill the sail. We believe that can best be done in any professional endeavor through the standards which are set by that profession. Accordingly, we invite the attention of the reader to the standard-setting process (and how it might be improved or stimulated to accept this task), of each of the components in health profession education.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Without coalescence around standards set by the professions themselves, little movement will occur. Of significant importance, however, is the need to remember that, in the background remains the grim visage of the law. Justice O’Connor articulated the majority opinion in Grutter v. Bollinger et al. that, while the government’s compelling interest currently justifies this continued exception to an unflinching application of the Equal Protection Amendment, it is not intended to be a permanent exception to that Amendment. She writes, “We see no reason to exempt race-conscious admissions programs from the requirement that all governmental use of race must have a logical end point. … We expect that 25 years from now, the use of racial preferences will no longer be necessary to further the interest approved today.” The lesson is not subtle. The challenge to American society is clear. In the view of the Court, 25 years (or one generation) from now, we as a nation should have reached a place where there is no longer a compelling need for an exception to the 14th Constitutional Amendment. This IOM committee’s report offers important tools for that achievement, but keep in mind that the clock is ticking. The committee benefited from excellent staff support, under the leadership of Study Director Brian D. Smedley, Ph.D., assisted by Adrienne Stith Butler, Ph.D., and Thelma L. Cox, all of whom rose to every challenge, including a tight time frame for the study. Our sponsor, the Kellogg Foundation, was clear in their stated objective and unflagging in their interest and support. Our hope is that those who read this will find light for their paths and then take action accordingly. Et facta est lux (“light is made”). Lonnie R. Bristow, M.D. Walnut Creek, CA September 2003

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Contents     Executive Summary   1 1   Introduction   23 2   Reconceptualizing Admissions Policies and Practices   55 3   Costs and Financing of Health Professions Education   88 4   Accreditation and Diversity in Health Professions   127 5   Transforming the Institutional Climate to Enhance Diversity In Health Professions   143 6   Community Benefit as a Tool for Institutional Reform   178 7   Mechanisms to Garner Support for Institutional and Policy-level Diversity Initiatives   203

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce     Appendixes     A   Data Sources and Methods   213 B   Committee and Staff Biographies   220     Commissioned Papers     A   Increasing Diversity in the Health Professions: A Look at Best Practices in Admissions Gabriel Garcia, Cathryn L. Nation, and Neil H. Parker   233 B   The Role of Public Financing in Improving Diversity in the Health Professions Karen Matherlee   273 C   The Role of Accreditation in Increasing Racial and Ethnic Diversity in the Health Professions Norma E. Wagoner, Leon Johnson, and Harry S. Jonas   317 D   Diversity Considerations in Health Professions Education Jeffrey F. Milem, Eric L. Dey, and Casey B. White   345     INDEX   391

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce IN THE NATION’S COMPELLING INTEREST

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