The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the Health Professions

Brian D.Smedley and Adrienne Y.Stith

Institute of Medicine

Lois Colburn

Association of American Medical Colleges

Clyde H.Evans

Association of Academic Health Centers

INTRODUCTION

Newspaper headlines underscore the challenges that the health professions face in this period of dramatic change in the American health care enterprise: critical shortages of nurses and other health professionals, tight budgets and rising health care costs, increasing public concern about patient safety and medical errors, and rising criticism of the quality of care that Americans receive, to name a few. Indeed, the health professions and health care industry are fighting to retain the public’s confidence that the U.S. health care system can continue to be the world’s best.

Compounding these problems is the future viability of the U.S. health care workforce. The health professions are becoming less appealing to many U.S. high school and college students, as applications for slots in many health professions training programs, such as medical, nursing, and dental schools, have declined over the last decade. Desperate for well-trained nurses and other health professionals, hospitals are recruiting worldwide to fill needed shortages. These trends raise the questions: Will we have the health care workforce we need in the 21st century? Where will future health professionals come from? And what will the U.S. health care workforce look like in the near future?

Demographic trends indicate that future U.S. workers will increasingly be persons of color: by the year 2050, in fact, one of every two U.S. workers will be African American, Hispanic, Asian American, Pacific Islander, or Native American (see Figure 1). In three states and the District of Colombia, these populations already constitute a majority, and in thirteen other states, minorities



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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the Health Professions Brian D.Smedley and Adrienne Y.Stith Institute of Medicine Lois Colburn Association of American Medical Colleges Clyde H.Evans Association of Academic Health Centers INTRODUCTION Newspaper headlines underscore the challenges that the health professions face in this period of dramatic change in the American health care enterprise: critical shortages of nurses and other health professionals, tight budgets and rising health care costs, increasing public concern about patient safety and medical errors, and rising criticism of the quality of care that Americans receive, to name a few. Indeed, the health professions and health care industry are fighting to retain the public’s confidence that the U.S. health care system can continue to be the world’s best. Compounding these problems is the future viability of the U.S. health care workforce. The health professions are becoming less appealing to many U.S. high school and college students, as applications for slots in many health professions training programs, such as medical, nursing, and dental schools, have declined over the last decade. Desperate for well-trained nurses and other health professionals, hospitals are recruiting worldwide to fill needed shortages. These trends raise the questions: Will we have the health care workforce we need in the 21st century? Where will future health professionals come from? And what will the U.S. health care workforce look like in the near future? Demographic trends indicate that future U.S. workers will increasingly be persons of color: by the year 2050, in fact, one of every two U.S. workers will be African American, Hispanic, Asian American, Pacific Islander, or Native American (see Figure 1). In three states and the District of Colombia, these populations already constitute a majority, and in thirteen other states, minorities

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions FIGURE 1 U.S. Population Aged 16–64, Year 2050 (percentages). SOURCE: U.S. Bureau of the Census, Population Projections Program, based on 1990 Census. constitute at least 30% of the populace. In many other locales, current K–12 enrollment suggests that the talent pool for the next generation of professionals is largely composed of children of color. With growing numbers of “baby boomers” and a longer-living population of seniors, today’s youth will be increasingly relied upon to supply the skills and labor needed to maintain a sufficient health care workforce. Many minority groups, however, including African Americans, Hispanics, and Native Americans, are poorly represented in the health professions relative to their proportions in the overall U.S. population. These groups also tend to be less healthy than the U.S. majority, experience greater barriers to accessing health care, and often receive a lower quality and intensity of health care once they reach their doctor’s office. Further, the proportion of these groups within the U.S. population is growing rapidly, increasing the need to respond to their public health and health care needs. This disparity presents a significant challenge to the health professions and to educators, as they must garner all available resources to meet future health care demands. Increasing the diversity of health professionals has been an explicit strategy of the federal government and many private groups to address these needs. Yet the policy context for efforts to increase diversity within the health professions has shifted significantly over the past decade. Several events—including public referenda, judicial decisions, and lawsuits challenging affirmative action policies in 1995, 1996, and 1997 (notably, the Fifth District Court of Appeals finding in Hopwood v. Texas, the California Regents’ decision to ban race or gender-based preferences in admissions, and passage of the California Civil Rights Initiative [Proposition 209] and Initiative 200 in Washington State)—have forced many

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions higher education institutions to abandon the use of race and ethnicity as factors in admissions decisions. To compound this problem, the “pipeline” of elementary, secondary, and higher education that prepares students for careers in health professions continues to rupture with respect to underrepresented minority (URM) students. In particular, the math and science achievement gap between URM and non-URM students persists, and in some cases, has widened, frustrating efforts to increase minority preparation and participation in health professions careers. Given these problems—an increasing need for minority health professionals, policy challenges to affirmative action, and little progress toward enhancing the numbers of URM students prepared to enter health professions careers—three health policy and professional organizations met to consider a major symposium that would explore challenges and strategies to achieving diversity among health professions. Representatives of the Association of American Medical Colleges (AAMC), the Association of Academic Health Centers (AHC), and the Institute of Medicine (IOM) and Division of Behavioral, Social Sciences, and Education (DBASSE) of the National Academy of Sciences met in the early spring of 1999 to consider such a national symposium. Among those in attendance at this meeting was Herbert W.Nickens, M.D., Vice President and Director of Community and Minority Programs at AAMC and a longtime advocate for focused efforts to enhance URM representation in health professions (see text box). Herbert W.Nickens 1947–1999 Until his death on March 22, 1999, Herbert W.Nickens, M.D., M.A., served as the first vice president and director of the Division of Community and Minority Programs at AAMC. AAMC created this division to focus its commitment on an expanded role for minorities in medicine and improving minority health status. Before coming to the AAMC, Dr. Nickens was the first director of the Office of Minority Health, U.S. Department of Health and Human Services. In that role, he was pivotal in crafting the programmatic themes for that office— many of which continue to this day. Prior to that he served on the staff of the landmark Secretary’s Task Force on Black and Minority Health, was director of the Office of Policy, Planning, and Analysis of the National Institute on Aging (NIA), and before that was Deputy Chief, Center on Aging, National Institute of Mental Health (NIMH). Dr. Nickens received his A.B. in 1969 from Harvard College, and a M.D. and M.A. (in Sociology) from the University of Pennsylvania in 1973. He served his residency in psychiatry at Yale and the University of Pennsylvania. At the University of Pennsylvania he was also a Robert Wood Johnson Clinical Scholar, and a member of the faculty of the School of Medicine.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Dr. Nickens’ vision for the symposium was clear and persuasive. Noting that many efforts to enhance minority student preparation and participation in health professions careers had become fragmented, he urged that leading health policymakers, health professions educators, K–12 educators, and higher education policymakers be convened to share strategies and develop a comprehensive plan to address the many political, legal, and educational challenges to greater diversity among health professionals. He also saw such a symposium as an important vehicle to revitalize the case for diversity among health professionals, and as a corollary, to improve public support for and understanding of diversity as a tool to address the nation’s health needs. Tragically, Dr. Nickens passed away before the symposium could be convened. His leadership in promoting diversity and addressing the health needs of communities of color, however, continues to be felt among the many students who have benefited from his efforts to open doors to heath professions careers, and the many faculty and administrators of health professions schools whose work he influenced. To acknowledge his leadership and contributions as a champion of efforts to diversify the health professions, the symposium was named in his honor. These proceedings summarize presentations and discussion during the March 16–17, 2001, “Symposium on Diversity in the Health Professions in Honor of Herbert W.Nickens, M.D.” Consistent with Dr. Nickens’ vision, the symposium was convened to: re-examine and revitalize the rationale for diversity in health professions, particularly in light of the rapid growth of racial and ethnic minority populations in the United States; identify problems in underrepresentation of U.S. racial and ethnic minorities in health professions, and discuss the strategies that are being developed to respond to underrepresentation; assess the impact of anti-affirmative action legislative and judicial actions on diversity in health professions and health care service delivery to ethnic minority and medically underserved populations; identify effective short-term strategies for enhancing racial and ethnic diversity in health professions training programs (e.g., in the admissions process, in pre-matriculation and summer enrichment programs); and identify practices of health professions schools that may assist in improving the preparation of racial and ethnic minority students currently underrepresented in health professions, thereby enhancing the long-term likelihood of greater diversity in health professions. To accomplish these goals, symposium organizers invited nearly two dozen leaders in health policy, higher education, secondary education, education policy, law, health professions education, and minority health to provide presentations at the symposium. Some of these presentations were offered in plenary

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions sessions, while others were delivered in small discussion groups during the second day of the symposium, to encourage dialogue and the development of new alliances and strategies. A list of speakers and paper topics are provided in the appendix of these proceedings. Selected papers from the symposium are published in this volume. THE CASE FOR DIVERSITY IN HEALTH PROFESSIONS “The Right Thing to Do…The Smart Thing to Do” Several presenters argued for a re-examination of the rationale for diversity in health professions, and, more specifically, the value of affirmative action as a tool for achieving diversity in health professions training settings. Mark Smith, president and CEO of the California Health Care Foundation, noted in a keynote address that the two traditional arguments presented in support of affirmative action, fairness and function, must be updated if advocates seek to overcome objections of some policymakers and the prevailing public sentiment. Issues of fairness, Smith stated, have traditionally been at the heart of arguments in support of affirmative action, based on the fact that many racial and ethnic minorities have been traditionally excluded from economic and professional opportunities. Affirmative action policies were therefore established as a mechanism for redress and expanded opportunity. The contemporary challenge, he noted, is to update this understanding of fairness and make the mechanisms of redress more sophisticated to reflect social, economic, and demographic changes that have occurred since affirmative action policies were first implemented. For example, Smith noted that by pointing to minority individuals who have attained success and broken traditional economic and employment barriers, opponents of affirmative action argue that minorities now have equal, if not greater opportunities to succeed. Increasingly, he added, African Americans, Native Americans, and Hispanics have ascended to middle- and upper-class status, creating a perception that affirmative action is no longer needed. Opportunity, however, is still inequitably distributed, according to Smith—a point that will be lost should proponents of affirmative action not acknowledge the economic, political, and educational gains that minorities have made, he added. Proponents of affirmative action must also address the perception that “merit” can be fairly and objectively assessed, according to Smith. This perception is bolstered, he noted, by the heavy reliance among some administrators on test scores in admissions processes. Test scores, Smith stated, create an aura of scientific precision without necessarily predicting the outcomes of interest—such as the kinds of skills necessary to be a good nurse. A silent form of “pseudo precision,” he argued, is conferred when quantitative measures are used without a clear understanding of how and when these data are useful. Such

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions misunderstandings are a “constant threat” to notions of fairness that have been central to efforts to increase diversity, according to Smith. Arguments in support of affirmative action that focus on the functional utility of a diverse workforce must also be updated, according to Smith. Noting that some research and anecdotal evidence supports the argument that a diverse health care workforce helps to improve access to care for minority communities and enhance trust and communication, Smith called for more critical analysis and research. Not all racial and ethnic minority health care providers will “click” with minority patients, he noted; similarly, one should not assume that nonminority providers cannot adequately serve minority patients. Research must better assess the key variables that affect the patient-provider relationship, such as trust, being treated with dignity, and mutual respect, and consider how the race and ethnicity of patients and providers influence these variables, he noted. Smith concluded by drawing an analogy to common myths about the pyramids and other great artifacts of ancient Egypt. He noted that a common misperception about the pyramids is that their construction involved highly technical scientific achievements that were once thought unavailable to the Egyptians. This was not the case, he stated—in fact, much of the construction conformed to basic understandings, and was not “rocket science.” Much the same can be said about efforts to diversify health professions, Smith said, in that basic efforts such as mentoring, developing a critical mass of URM health professions students and faculty, focal and consistent support from leadership, and social and psychological support can all help to enhance diversity. “These are not sophisticated concepts,” he noted. Another myth about the pyramids, Smith stated, is that stone materials used in their construction were brought in from miles away, across desert and waterways. In fact, he noted, the pyramids were built using materials that were readily available. Similarly, we need not look far for sources of future health professionals—tomorrow’s dentists, doctors, nurses, pharmacists, and other health professionals are all around us, he said. Finally, Smith related that the famous Sphinx was not planned, but, rather, was an artifact of another major construction effort that yielded a fortunate discovery. Ancient Egyptians were building a causeway, Smith stated, and came upon a large rock formation that blocked the causeway. Rather than try to remove the rock, the Egyptians carved the Sphinx into its surface. Similarly, proponents of diversity and affirmative action often encounter obstacles and political challenges, but these challenges must be addressed, Smith said. He noted that opponents who cannot be convinced of the need for diversity on political grounds can often be swayed on scientific grounds, heightening the need for creative and well-supported arguments. When “you’ve got lemons, you make lemonade,” he stated, adding that opponents can be swayed that affirmative action is not only “the right thing to do… [but also] the smart thing to do.”

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions The Necessity of Sustained Efforts Lee Bollinger, president of the University of Michigan, delivered a theme similar to that of Smith in a keynote address that focused on Michigan’s efforts to defend its affirmative action policies against two lawsuits that questioned the constitutionality of affirmative action. Bollinger, a constitutional law scholar, argued that the U.S. Supreme Court’s ruling in the landmark 1978 Bakke case, which remains the preeminent ruling on affirmative action as of this writing, refutes the notion that race, ethnicity, and color cannot and should not be taken into account in admissions processes. To the contrary, the Bakke decision points out that U.S. society is not “color-blind,” as opponents have argued, borrowing civil rights-era language, according to Bollinger. Combating such arguments has been challenging, he said, in the wake of an increasingly conservative Supreme Court, nationwide efforts to bring suit against universities that have affirmative action policies, state referenda (e.g., Proposition 209), and public attitudes that indicate dwindling support for affirmative action. Bollinger noted that affirmative action proponents are often urged to “move on,” or to find some other way to accomplish diversity without explicitly considering race or ethnicity in admissions processes. Under his leadership, however, the University of Michigan won the lawsuit challenging its undergraduate admissions processes, and is appealing a ruling against the school’s law school admissions policies. In the process, Bollinger stated, he has learned that: 1) higher education, when organized and ready to address challenges, is “hard to beat;” 2) it is important not to accept the attitudes of the times (e.g., that affirmative action has been beaten, and that other alternatives should be explored); and 3) one must never underestimate the necessity of sustained efforts in dealing with diversity issues. Michigan’s success in defending its affirmative action policies can be linked to two broad-based strategies, said Bollinger. The first was a legal strategy to provide support for the rationale in the Bakke decision, which assumes that a racially diverse student body leads to better educational outcomes for all students and serves compelling government interests. Michigan’s defense drew from several sources, including social science research indicating that educational and civic outcomes were better for college students educated in more diverse environments. The second strategy, according to Bollinger, was a public education campaign that sought to “make the case, with complete openness and candor,” to inform the public about admissions processes and the benefits of diversity. Bollinger and his colleagues actively sought opportunities to present Michigan’s rationale for diversity, while continuing to build allies among other higher education leaders, as well as businesses and corporations, such as General Motors. In the process, Bollinger stated, Michigan was able to identify and debunk several misperceptions about affirmative action:

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Race is no longer a factor in American life, and therefore should not be a factor in admissions processes. Bollinger responded to this charge by noting that the vast majority of Michigan students, both minority and non-minority, came from starkly segregated high schools. This suggests that college represents the first opportunity for many of these students to work and live with people from other backgrounds, in effect training them for participation in the working world. Admissions processes should be based on applicants’ credentials, not race. Like many other schools that have affirmative action policies, Michigan’s admissions process considers applicants’ academic preparation and achievements in conjunction with other factors—such as their geographic location, leadership, socioeconomic status, athletic abilities, and alumni status—to create a diverse student body, said Bollinger. Race and ethnicity are but two of the many factors that must be considered to assemble a class “like a symphony,” he said. Noting that the term “affirmative action” is not commonly used when universities consider applicants’ “legacy” status (i.e., children of alumni), Bollinger said that people mistakenly believe that applicants’ race or ethnicity is somehow given greater emphasis than other attributes when admissions committees attempt to assemble a diverse student body. Diversity is not central to the educational mission, but rather an add-on. Bollinger refuted this argument, stating that diversity is critical to efforts that help students to “get outside of their own perceptions and viewpoints and encounter other perspectives. “This why we study history, law…and literature,” he said, noting that undergraduate curricula typically requires study outside of students’ major field, to ensure breadth. Similarly, he argued, students should be exposed to other cultures, viewpoints, and perspectives. Diversity does not work because students self-segregate on campus, nullifying its benefits. Bollinger acknowledged that students of different racial and ethnic backgrounds do segregate themselves, but believes such segregation is less prevalent than commonly believed. In part, this may reflect what students are most comfortable with, given that they arrive on campus with generally limited exposure to other racial and ethnic groups, he said. Further, he argued, such self-segregation occurs in society, but should not be an excuse for failing to encourage students to learn from each other. College and university admissions committees can achieve diversity by striving for a socioeconomic mix, or by automatically admitting a percentage of the top high school graduates. Bollinger also refuted this argument. Using socioeconomic status alone as a key factor in admissions will not ensure racial and ethnic diversity, he argued, as most poor individuals are white. In addition, automatically admitting a percentage of the top high school graduates removes the discretion and autonomy of universities to choose the type of student body that they feel would create the best learning environment.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Can Diversity Among Health Professionals Decrease Health Disparities? African Americans and Native Americans, and to a lesser extent Hispanics, experience rates of mortality and disability from disease and illness that are significantly higher than rates for white Americans. The excess burden of illness in these populations is due to many complex factors, including socioeconomic inequality, environmental and occupational exposures, direct and indirect consequences of discrimination, health risk factors such as overweight, cultural and psychosocial factors such as health-seeking behavior, biological differences, and less access to health insurance and health care. Because many racial and ethnic minority communities have a shortage of physicians, increasing the numbers of health professionals—and in particular, providers who are themselves racial and ethnic minorities—to serve in these communities has been proposed as one means of addressing the excess burden of illness among minorities. Raynard Kington, Diana Tisnado, and David Carlisle explored this hypothesis in a symposium presentation, noting that the question of training minority health providers to serve in minority communities extends back at least to the 1910 Flexner report, which advocated that “Negro” doctors be trained exclusively to serve the African-American population (see Kington, Tisnado, and Carlisle, this volume). Kington and colleagues explored the impact of diversity among health professionals via three pathways: the effect of practice choices of minority providers; the quality of communication between minority patients and providers; and the quality of training in health professions training settings as a result of increasing diversity in these settings. Kington et al. addressed these questions using data for physicians, because these data are generally more available and reliable than data for other health professionals. Kington and colleagues noted that African-American and Hispanic patients are less likely than whites to have a regular physician, to have health insurance, to have routine visits with a physician, and to receive some preventive and screening services. After gaining access to health care, however, minorities still do not fare as well as their white counterparts; African Americans, and to a lesser extent Hispanics, receive fewer diagnostic and therapeutic procedures than whites, even after controlling for clinical, co-morbid, and sociodemographic factors. Not surprisingly, Kington and his colleagues note, physician supply is inversely related to the concentration of African Americans and Hispanics in health service areas, even after adjusting for community income levels. A consistent body of research, however, indicates that African-American and Hispanic physicians are more likely to provide services in minority and underserved communities, and are more likely to treat poor (e.g., Medicaid-eligible) and sicker patients. Some studies, according to Kington and his co-authors, indicate that on average, minority physicians treat four to five times the numbers of minority patients than

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions white physicians do. These practice patterns appear to be by choice, according to the authors; studies of new minority medical graduates, for example, indicate a greater preference to serve in minority and underserved communities. Kington and his colleagues also reviewed several studies that examine the quality of patient-provider communication across and within racial and ethnic groups. These studies indicate that for some minority patients, having a minority physician may result in better communication, greater patient satisfaction with care, and greater use of preventive services. However, the authors caution, there is little empirical evidence that cultural competence influences patient outcomes, or that increasing the numbers of minority physicians to serve patients of color improves outcomes through culturally appropriate care. In addition, although many speculate that increased diversity in medical training may expose physicians to a wider range of cultural backgrounds and improve their interactions with patients, there is little evidence that diversity within health care training settings (e.g., greater numbers of URM students in medical school) improves training for all medical students, according to Kington et al. The authors noted, however, that this question has not been subject to consistent, rigorous study. Kington and colleagues concluded that increased diversity among physicians appears to be valuable for increasing access to care in minority communities. Minority providers, they argue, are more likely to seek to serve individuals of their own racial and ethnic backgrounds, and tend to positively influence minority patients’ satisfaction with clinical encounters. Further, these providers are more likely to provide preventive and primary care services that are most needed among less healthy populations. Kington and his co-authors caution, however, that while the evidence supports increasing the numbers of minority physicians to meet health needs of minority communities, we must guard against the notion that minority providers should be trained primarily to serve racial and ethnic minorities, or that white physicians cannot adequately serve minority patients. Given the disproportionately low representation of minorities among the ranks of health professions, such simplistic assumptions are likely to widen the gap in access and quality of care for minority patients. The Impact of Diversity in Health Professions Education As Kington and colleagues noted, a potentially important aspect of the case for diversity in health professions is the impact of diversity within health professions education settings. Lisa Tedesco, Vice President and Secretary of the University of Michigan, explored the theoretical and empirical evidence for this argument. Tedesco cited a growing number of studies indicating that diversity in higher education settings is associated with positive academic and social outcomes for students, and argued that such benefits extend to health professions training, as well.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions One such landmark study, said Tedesco, was described in The Shape of the River, a book by William Bowen and Derek Bok (1998). Bowen and Bok studied educational and career outcomes for two cohorts of white and minority students who attended 28 selective colleges and universities in the 1970s and 1980s. They found that minority graduates of these institutions attained levels of academic achievement that were on par with their non-minority peers (e.g., minority and non-minority students attained graduate degrees at approximately equivalent rates). Further, minority graduates of these schools obtained professional degrees in fields such as law, medicine, and business at rates far higher than national averages for all students. African-American students from selected schools in the 1976 cohort, for example, were seven times more likely to receive degrees in law and five times more likely to receive degrees in medicine compared with the general college population, according to Tedesco. Similarly, African-American students in the 1989 cohort of students in this study were only slightly less likely to earn doctorates than were white students. Significantly, Tedesco noted, civic engagement and community activity was higher among minorities from the selected schools than their white counterparts. Similar findings were obtained by Patricia Gurin, said Tedesco. Gurin, a professor of psychology at the University of Michigan, studied academic and civic outcomes of college students who attended racially and ethnically diverse colleges, and those who attended less diverse institutions. Gurin found that students at diverse institutions were more likely to be involved in community and civic activities, and were “better able to participate in an increasingly heterogeneous and complex democracy,” according to Tedesco. These students, she added, were better able to understand and consider multiple perspectives, deal with the conflicts that different perspectives sometimes create, and “appreciate the common values and integrated forces that harness differences in pursuit of the common good.” Gurin concluded that students can best develop the capacity to understand the ideas and feelings of others in an environment characterized by a diverse study body, equality among peers, and discussion of the rules of civil discourse. “These factors are present on a campus with a racially diverse student body,” Tedesco stated. “Encountering students from different racial and ethnic groups enables students to get to know one another and appreciate both similarities and differences.” Significantly, Tedesco noted, diversity was also associated with a range of better cognitive and intellectual outcomes. Gurin found, according to Tedesco, that “interactions with peers from diverse racial backgrounds, both in the classroom and informally, is cognitively associated with a host of what are called learn- “Students who experience the most racial and ethnic diversity in classroom settings and in informal interactions with peers show the greatest engagement in active thinking processes, growth in intellectual engagement and motivation and growth in intellectual and academic skills.” Lisa Tedesco

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions plicants by the early 1990s, but this trend, the authors noted, began to reverse in 1995. As a result, the growth in the proportion of URM students entering allopathic medical schools seen in the early 1990s was reversed by the late 1990s. In fact, since 1999, non-URM applicants have experienced a growing likelihood of acceptance while URM applicants face a declining likelihood of acceptance. Grumbach and his colleagues’ analysis also indicated that allopathic medical schools in California and Texas experienced more substantial decreases in URM matriculants than schools in other states in the late 1990s. In Texas, URM matriculants declined from 21% of entering allopathic medical school classes in 1996 to 15.6% in 2000, while California schools observed a similar decline. The authors concluded that “much of the overall decline in URM matriculation in medical schools in the United States is accounted for by the decreases in California and Texas.” This is not surprising, Grumbach et al. noted, as these states, because of their large African-American and Hispanic populations, have traditionally enrolled a disproportionately large share of minorities in health professions training programs. Osteopathic medicine has traditionally been less successful than allopathic medicine in attracting URM students, as the proportion of URM students entering these schools is approximately half that of URM participation in allopathic medical schools. Overall, applications to osteopathic medical schools increased by 168% between 1990 and 1999, but URM applications increased less dramatically. While data on acceptance rates were not available, Grumbach and colleagues found that URM matriculation rates lagged behind that of non-URM students in the early 1990s, then exceeded that of non-URM students in 1995 and 1996, only to decline nearly 6% below that of non-URM students by 1998. In that year, the last year for which matriculation data are available, URM matriculants represented 8% of all osteopathic medical school students, a decline of 20% from 1995. Similarly, data for dentistry are limited to numbers of applicants and matriculants, but these data indicate patterns similar to those seen for osteopathic medicine. Matriculation rates for URM dental students fell below that of non-URM dental students in 1997, declining to the point where URM students represented slightly less than 10% of all dental students by 1999. In California and Texas, the percentage of URM students matriculating in dental schools declined precipitously over the decade of the 1990s, with California URM dental school matriculation rates falling to 3.6% by 1999. This percentage, Grumbach et al. noted, is 10 times below that of the population of African Americans, Hispanics, and Native Americans in the state. Pharmacy, public health, and nursing programs enjoyed greater success than other health professions in the 1990s in attracting and enrolling URM students, according to the authors. URM participation in pharmacy programs (including both B.S. and Pharm.D.) increased 19% between 1990 and 1999, to the point where 13.8% of pharmacy matriculants were URM students. Nursing programs, which offer the greatest diversity of entry points into the profession via two-

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions year, four-year, and graduate degree programs, saw the greatest sustained growth in URM student participation. Grumbach et al.’s analysis of nursing programs, which was limited to baccalaureate degree programs, revealed that URM participation increased 48% between 1991 and 1999. By 1999, URM students represented 16% of matriculants in baccalaureate nursing programs. Public health programs have the highest proportion of URM enrollees of any of the health professions analyzed by Grumbach and his colleagues; as with nursing and pharmacy programs, public health saw a steady increase in URM student participation during the 1990s, increasing from 15.3% of all matriculants in 1990 to 19.5% in 1999. Noting that a decreasing proportion of URM students are enrolling in medical schools in California and Texas, Grumbach and his colleagues concluded that “recent legislative and judicial decisions limiting the consideration of race and ethnicity in health professions’ schools admissions decisions may be contributing to diverging trends for URM and non-URM acceptance rates.” For other health professions such as public health, nursing, and pharmacy, they noted, trends in URM matriculation rates in California and Texas are consistent with the rest of the nation. Grumbach et al. speculated that in part, these schools may be able to maintain or increase levels of URM participation because they are under less public scrutiny than fields such as medicine, or may be less affected by policy changes in admissions processes. Improving Access to Quality Education and Health Careers for Minority Students Addressing Educational Inequality in the United States Efforts to enhance the pipeline of URM students prepared to enter health professions careers must address the structural and economic problems of schools that educate these students, stated Linda Darling-Hammond, who discussed the implications of inequities in funding of public schools on the quality of education for racial and ethnic minority students (Darling-Hammond, this volume). Inequities in the quality of teaching and schooling in the United States, she noted, are striking. While European and Asian nations fund schools centrally and equally, in the United States, the wealthiest ten percent of school districts spend almost 10 times more than the poorest 10 percent. Poor and minority students attend the least well-funded schools, which have fewer resources than schools serving mostly white students. The consequences of these inequities are tragic for students of color, according to Darling-Hammond: as an example, she noted that in 1993 African-American dropouts had only a 25% chance of being employed, compared with a 50% chance for white dropouts. Darling-Hammond argued that educational inequality is fueled by the increasing segregation of minority students. Almost two-thirds of minority students

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions attend predominantly minority schools, and one-third of African-American students attend intensely segregated schools (90% or more minority enrollment), most of which are located in central cities. These schools have difficulty competing for the most qualified teachers, which is a major contributor to the achievement gap, according to Darling-Hammond. As an example, she cited a study of 900 school districts in Texas, which found that, after controlling for students ‘socioeconomic background, the wide variability in teachers’ qualifications accounted for almost all of the variation in black and white students’ test scores. Darling-Hammond also contended that school funding systems and tax policies result in fewer resources allocated to urban districts compared with suburban districts. In general, she noted, urban schools suffer from lower expenditures of state and local dollars per pupil, higher student-teacher ratios and student-staff ratios, larger class sizes, lower teacher experience, and poorer teacher qualifications. These inequities have prompted legal action in some areas. In New York State, for example, the supreme court ruled that the funding system was unconstitutional because it denied students in high-need and low-spending districts the opportunities to learn material required by state standards, and failed to provide well-qualified teachers and curriculum supports. Three factors, according to Darling-Hammond, are important in determining the quality of teaching for low-income and minority students—access to good teaching, the distribution of teachers, and access to high-quality curriculum. Problems in access to teaching, Darling-Hammond stated, include the fact that policymakers are frequently willing to lower standards in order to fill teaching vacancies. Poorly prepared teachers, however, are less skilled at implementing instruction, are less able to anticipate students’ potential difficulties, and are more likely to blame students if their teaching is not successful, she stated. Most importantly, their students learn at lower levels. In terms of the distribution of teachers, unqualified and underprepared teachers are found disproportionately in schools servicing greater numbers of low-income or minority students. This is due in part, she said, to real shortages, but also to hiring practices in urban districts that are highly bureaucratic and poorly managed. The quality of curriculum is another critical variable in teaching, according to Darling-Hammond. Schools that serve primarily low-income and minority students offer few advanced and more remedial courses, and have smaller academic tracks and larger vocational programs. Darling-Hammond cited as an example a study in New Jersey finding that 20% of 11th and 12th grade students in a wealthy suburb participated in Advanced Placement courses, while none were offered in nearby poor and predominantly African-American communities. In addition, the practice of tracking students within schools rations challenging curricula to a very small proportion of students, she said. Darling-Hammond suggested three policy initiatives to equalize educational opportunities for minority and low-income students: resource equalization, changes in curriculum and testing, and increasing the supply of highly qualified

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions teachers. Resources, she stated, should be equalized between states, among districts, among schools within districts, and among students within schools. Many of the problems with schools attended by low-income and minority students begin with district and state policies and practices that provide inadequate funding and “incompetent” staff, and require inordinate attention to arcane administrative requirements, Darling-Hammond stated. Initiatives should improve the core practices of schooling, she added, rather than layering additional programs onto an already faulty base. Another important goal, Darling Hammond added, is to equalize the hiring of high-quality teachers across urban and suburban areas. Changes in curriculum and testing, Darling-Hammond maintained, should include the development of “opportunity to learn” standards that would define a floor of core resources and provide incentives for schools to work toward professional standards of practice. Curriculum, she noted, should move away from a focus on lower-order rote skills and move toward independent analysis and problem solving, research and writing, use of technology, and accessing and using resources in new situations, or “thinking curriculum.” Similarly, the types and uses of achievement tests should be steered toward more performance-oriented (e.g., analysis, writing) objectives, and should not be used to punish students and schools, but as a tool for identifying strengths and needs. Tests should improve teaching and learning, and should not, as Darling-Hammond stated, “serve to reinforce tendencies to sort and select those who will get high quality education from those who will not.” Finally, according to Darling-Hammond, quality teaching can be achieved through providing all teachers with a greater knowledge base and ensuring mastery of this knowledge in areas that include how children learn and develop, how curricular and instructional strategies can help them, and how changes in classroom and school practices can support achievement. This, she says, will help eliminate the practice of allowing poorly trained personnel to teach in underserved schools in disproportionate numbers and will raise the knowledge base for the occupation. Darling-Hammond called on the federal government to serve as a leader in providing an adequate supply of qualified teachers, citing similar action on behalf of physicians with the passage of the 1963 Health Professions Education Assistance Act. This provision supported and improved the caliber of medical training and teaching hospitals, provided scholarships and loans for medical students, and created incentives for physicians to train in certain specialties and practice in underserved areas. Darling-Hammond also stated that federal initiatives should be implemented that would help to recruit new teachers, strengthen and improve teachers’ preparation, and improve teacher retention and effectiveness. “Tests should improve teaching and learning, and should not, “serve to reinforce tendencies to sort and select those who will get high quality education from those who will not.” Linda Darling-Hammond

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Rethinking Admissions Processes With recent challenges to affirmative action policies, increasing numbers of institutions of higher learning are re-examining the processes by which they identify and select underrepresented and disadvantaged applicants. The challenge has been difficult for many, forcing the reevaluation of standards of merit and concepts of fairness, according to Filo Maldonado, Assistant Dean for Admissions at Texas A&M College of Medicine (Maldonado, this volume). Maldonado discussed the importance of diversity in health professions and examined the issues involved in race-neutral admissions in Texas, which has been barred from considering applicants’ race or ethnicity in admissions as a result of the Hopwood decision. Maldonado contended that a lack of adequate access to health care—particularly for those who live in inner cities and rural areas—and the erosion of trust between patients and doctors are significant problems that health professions schools must address. He argued that because physicians from underrepresented minority groups are more likely to practice in minority and poor communities, diversity among health professionals will help to ensure that the needs of these communities are met. “Enrolling more qualified underrepresented and disadvantaged applicants to medical schools,” Maldonado stated, “not only promotes better access to health care—and in all probability, improved health—but helps fulfill in large part medicine’s social obligation to serve society’s needs.” Maldonado argued for the importance of using both cognitive and noncognitive criteria in selecting applicants. Most medical schools, he stated, do, in fact, value non-cognitive traits (e.g., motivation, knowledge of profession through experience, leadership skills, resilience) when making admissions decisions. He also indicated that there is evidence of a significant relationship between both cognitive and non-cognitive variables and performance in medical school. Some schools, he said, have begun to track the performance of students who possess strong non-cognitive traits and less strong GPAs and MCAT scores. According to Maldonado, there is some evidence that successful at-risk students are more focused on academics and less likely to scatter their attention in school. While some of these studies have limitations, findings indicate that MCAT scores were predictive of success for at-risk white students but not for at-risk African-American students. In addition, he cited evidence that using MCAT scores along with other pre-admission data improved prediction of clerkship grades over the use of MCATs alone. This was particularly true for African Americans and Hispanics. As an illustration of the importance of both cognitive and non-cognitive factors, Maldonado cited the AAMC’s Predictive Validity Research Study, which indicated that 34% of the variation in students’ medical school GPAs can be explained by undergraduate GPA, and that 41% of students’ medical school GPAs can be explained by MCAT scores (58% variance explained by both).

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions However, 42% of the variance was not explained by these factors. These other factors, he posits, may include educational achievements or experiences, major, additional degrees, community services activities, or character and motivation. The Texas A&M College of Medicine and other Texas medical and dental schools have begun to develop a race-neutral admissions process in the aftermath of Hopwood, said Maldonado, that administrators hope will help to achieve the goal of diversity. According to Maldonado, the new admissions plan calls for: 1) a mindfulness of the vision and mission of the institution in assessing and selecting students; 2) a more inclusive approach in assessing cognitive abilities; 3) a broad-minded scrutiny of applicants’ non-cognitive characteristics at the pre-interview and interview phase of the evaluation; 4) enhanced interview techniques; 5) improved protocol for admissions committee deliberations; and 6) frequent self-monitoring. As an initial step, MCAT and GPA scores are weighted, and applicants sorted. This is completed in a manner that will jeopardize neither the integrity of academic criteria nor the breadth of qualified applicants, according to Maldonado. The admissions committee then screens between 900 and 1,000 applicants for interviews. In addition to consideration of academic scores, a screening form has been created to “widen the field of vision.” Items on the screening instrument fall into four categories including: 1) academic performance and intellectual capacity, 2) humanism, dedication to service, and capacity for effective interactions, 3) special life experiences, and 4) other compelling factors (including supportive letters of evaluation, areas of interest within medicine, area where applicant lives, and awareness of and knowledge about the impact of cultural factors on heath care). While the implementation of this new admissions process at Texas A&M has improved the number of underrepresented minority students being interviewed and offered acceptances following the Hopwood decision, the number of these students enrolling is still low (3% in 2000, compared to 15.6% in 1996 before Hopwood). Changing the perspective of a medical institution, Maldonado said, from an insular and narrow one to one that examines unique qualities of students is difficult work that may often prove frustrating and produce discouraging results. In order to increase diversity, however, schools must critically assess themselves and commit to redesigning their admissions processes, he stated. Retaining URM Students in Health Professions Programs While the most popular strategy to increase the number of underrepresented minorities in health professions has been to increase admissions to health professions schools, minorities are more likely than non-minority students to experience academic problems that result in a change in their academic status and delayed graduation, according to Michael Rainey, Acting Associate Dean for Academic Affairs at SUNY-Stony Brook School of Medicine (Rainey, this volume). He indicated that URM students in medical schools are dismissed six

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions times more frequently than white students, withdraw three times more frequently, and are three times more likely to still be enrolled in medical school in the sixth year. Rainey discussed five reasons for difficulties in retaining underrepresented minorities in the health professions—admissions policies, faculty, curriculum, support services, and remedial strategies used by schools. He cited several problems related to admissions. Although some medical schools’ deans have provided vital leadership in the effort to attain a diverse student body, recent turnover in the medical education leadership makes it difficult to maintain strong and consistent support for increasing admissions and retention of URM students. However, Rainey noted that some schools are increasingly interested in considering non-cognitive factors (e.g., students’ knowledge of their ways of learning, openness to seek out help, time management skills, family support) during the admissions process in order to better predict what types of students are likely to succeed in future years. The curricula of many health professions training programs pose another challenge to the retention of URM students. Rainey argued that there is a heavy reliance on content delivery (e.g., lecture format) rather than focusing on student learning, particularly in the first year. He cited one study suggesting that URM students may prefer a more interactive style of teaching, compared to white students, who in general prefer a lecture format. In addition to issues of content, Rainey stated that the standard curriculum is fast-paced, with little time to ask questions, and that there is a “boot camp” atmosphere in schools. “The word ‘survival’ is common when students talk about the first semester,” he stated. Because of these factors, he said, it is the least-prepared students who will have the most difficulty. URM students are at greater risk for attrition than nonminority students given their generally poorer academic preparation and lack of familiarity with the culture and fast-paced environment of medical school, according to Rainey. Faculty, Rainey maintained, are under increased pressure to engage in research and generate income through clinical practice. Teaching is not valued or rewarded in tenure and salary increase decisions. In addition, Rainey stated, the shortage of URM faculty in health professions “marginalizes” underrepresented minority students because they have little contact with faculty with whom they can identify. As an example, Rainey cited results from the 2000 AAMC Medical School Graduation Questionnaire, in which 20% of students indicated they were mistreated during medical school. Of this group, 12% said they were denied opportunities for training or rewards because of their race/ethnicity one or more times during their schooling, and 16% indicated they had been subjected to racially/ethnically offensive remarks directed towards them. The source of this mistreatment was typically faculty in clinical settings and interns/residents. The lack of support services for underrepresented minorities also presents a significant obstacle to the retention of URM students, according to Rainey. For

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions example, he reported that of the 120 predominately white medical schools in the United States, 57% indicate having a minority affairs officer. Only one in four of these is an M.D. or Ph.D. with senior rank, which means that they are less likely to be a voting member of admissions, promotions, or curriculum committees. In addition, he noted that underrepresented minority students are more reliant on loans and scholarships than non-minority students (these students receive 6% of their education costs from families, as compared with 20% for nonminority students). Financial aid officers therefore need to be an active and involved member of the support team for URM students, according to Rainey, but this is often not the case. Lastly, Rainey contended that some remedial strategies employed by health professions schools may be inappropriate for many URM students. For instance, some schools identify at-risk students and intervene shortly after classes start. However, many minority students resist this and feel stigmatized. Alternatively, many students with academic difficulty are simply given more time to learn material, which may be a mistake for underrepresented minority students, according to Rainey. Rather than additional time, he stated, more focus may be needed on learning techniques. In some cases students having academic difficulty are granted a leave of absence. However, this removes them from sources of support, their classmates, and learning assistance. It is important, he added, to keep students in an academic environment whenever possible. In conclusion, Rainey offered 34 recommendations for institutions to increase the admission and retention of underrepresented minority students, in the areas of admissions, curriculum, faculty, and support services. In admissions, for example, Rainey suggested that the word “diversity” be part of the mission statement of every medical school accredited by LCME, and that institutions should deploy senior URM faculty, residents, and students to serve on admissions committees as recruiters, interviewers, and voting committee members. With regard to curriculum, Rainey advised that orientation be at least two weeks long and should include an orientation to the curriculum, learning styles, testing strategies, and small group work as well as an introduction to the medical school and the community. In addition, an extended orientation program should be instituted, during which some classes should cover prerequisite material. Material should be tested in the same way the first semester courses are tested. Feedback should be provided to students that identifies areas of strength and weakness. Rainey also advocated exploring ways to help URM faculty earn tenure and promotion at the same rate as non-minority faculty, and address the issues of clinical faculty and resident/intern discrimination and harassment directed at URM students in school. Finally, as an example of strategies to help improve support services, he recommended that the institutions’ office of minority affairs be staffed with high-ranking, visible, and available staff and have resources to provide support services to URM students.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions DISCUSSION AMONG SYMPOSIUM PARTICIPANTS As noted earlier, a major goal of the symposium was to foster discussion among individuals representing a range of disciplines and perspectives, including primary and secondary school educators and policymakers, health professions educators, professional associations, and others. To further this goal, several small discussion sections were convened during the second day of the symposium to allow participants to react to paper presentations summarized above. These small discussion sections were asked to generate recommendations regarding strategies to improve minority student preparation and achievement in primary and secondary schools, to enhance the representation of URM students in higher education, to improve health professions’ schools admissions processes to achieve greater diversity in these settings, and to better retain URM students in health professions. These recommendations are summarized below. Improving URM Student Achievement in Primary and Secondary Schools Two small discussion groups reacted to presentations focused on improving the achievement of URM students in K–12 education. Rapporteurs for these groups stated that health professions must “de-isolate” themselves from communities, particularly minority communities that may serve as the source of future health professionals. Health professions organizations should advocate to improve the quality of teaching, one stated, by urging additional funding to help better prepare teachers, particularly in math and science. This rapporteur also noted that health professions should seek roles in assisting school reform, such as converting large urban schools into smaller segments (e.g., “schools within schools”) to develop more supportive relationships with students. Support for teaching should also include advocacy to ensure that all students have access to high-quality curriculum. Health professions should take a lead role, another rapporteur noted, in assisting teachers and providing them with effective resources, such as tools to improve students’ analytical reasoning and literacy skills. These interventions should not be focused solely at one or a handful of schools, the rapporteur stated, but rather toward coalitions or regional alliances of schools. Another discussion group considered the impact of high-stakes standardized testing on URM student achievement in K–12 settings. The rapporteur for this group urged that the health professions education and policy communities should carefully consider the messages that are conveyed in their use of test data, such as MCAT scores. The community should consider what these tests measure and how they are used in admissions processes, as educational leaders will be influenced by how health professions view and use such tests. Health professions should also highlight important issues in high-stakes testing, such as differences in teaching, curricula, and educational resources across schools that can have an impact on student performance.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Recruiting, Admitting, and Retaining URM Students in Health Professions Education Three discussion groups explored strategies to recruit, admit, and retain URM students in health professions education programs. Sustaining URM students in undergraduate pre-medical and pre-health career tracks, one rapporteur noted, can be accomplished with a variety of academic, peer, and economic supports. Health professions organizations should invest in education and professional development for health careers advisors, and reward faculty for serving as advisors and mentors for pre-health career URM students. This can be accomplished by providing financial and logistical support to faculty advisors, considering such work in tenure decisions, and developing networks for advisors to share strategies and provide junior advising staff with resources and supports, the rapporteur stated. Additional financial supports should be provided to prehealth students so that they can be less reliant on outside jobs; in addition, economic barriers to applying to health professions schools (e.g., costs of MCAT and other tests, application fees, travel) should be addressed. Finally, health professions should tap pools of URM students who are “nontraditional” or mature students. These students may require remediation, child care, and/or economic support, and could benefit from post-baccalaureate programs or other initiatives that consider their special circumstances. New admissions strategies can be successfully developed that address the need for racial and ethnic diversity in health professions training settings while acknowledging the shifting policy contexts regarding affirmative action, another rapporteur noted. Drawing on Maldonado’s example of new admissions strategies and criteria used at the Texas A&M College of Medicine, the rapporteur urged that all health professions schools adopt admissions criteria that give greater consideration to applicants’ non-cognitive attributes, such as life experiences and commitment to serving poor and minority communities. Changing admissions criteria, however, will require integration of these changes into institutions’ mission and goals. Faculty, administrators, and staff must “buy in” to new admissions processes and the consequences of such changes, such as the fact that new students may be admitted who flourish under different learning conditions and different teaching styles. Finally, the rapporteur noted that because admissions efforts are limited by the quality of the pool of applicants, greater outreach efforts are needed to “beat the drums a little more loudly to get people to start thinking about health professions careers” earlier than college. Similarly, retaining URM students in health professions training settings will require a re-examination of the institution’s goals and priorities, according to another rapporteur. Institutions must conduct honest assessments to determine how the climate of the institution affects progress and learning for both URM and non-URM students. Research is also needed to better understand the reasons why students withdraw from health professions schools. Some research has fo-

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions cused on the difficulties that medical students face in the first year, for example, but little is known about the third and fourth year, when evaluation is more subjective. The rapporteur suggested that greater support be provided for mentoring, particularly where URM faculty currently offers informal mentoring. These roles could be more formalized and institutional support provided so that minority faculty are not disproportionately burdened. Finally, the rapporteur urged that health professions educators revisit the way that students are trained. The style of teaching and grading typically used in these settings may disproportionately affect URM students, as Rainey noted above, and should be re-evaluated to improve learning for all students. A closing panel discussion on the first day of the symposium featured reactions and commentary from several leaders in health, public health, and education. One of the panel members, Vanessa Northington Gamble, Vice President of the Division of Community and Minority Programs at AAMC, noted that efforts to enhance diversity in health professions must be expanded to address educational inequities beginning at primary school levels. These effects will be enhanced by building coalitions and educating the public about the importance of diversity in all levels of education and in the health professions. “We have to really raise the expectations of our children, and also raise expectations of other people for children and of our communities,” she stated, noting, “This is not a minority issue—this is an American issue.” “This is not a minority issue—this is an American issue.” Vanessa Northington Gamble CONCLUSION The Symposium on Diversity in the Health Professions in Honor of Herbert W.Nickens, M.D., was convened to provide a forum for health policymakers, health professions educators, education policymakers, researchers, and others to address three significant, and at times, contradictory challenges: the continued underrepresentation of African Americans, Hispanics, and Native Americans in health professions; the growth of these populations in the United States and subsequent pressure to address their health care needs; and the recent policy, legislative, and legal challenges to affirmative action that may limit access among URM students to health professions training. The symposium summary and collection of papers from the symposium presented here are intended to help stimulate further discussion and action toward addressing these challenges.