Sustaining Minorities in Prehealth Advising Programs: Challenges and Strategies for Success

Saundra Herndon Oyewole

Trinity College, Washington, D.C.

Dramatic racial and ethnic changes in the demographics of the United States make increasing the diversity of the health professions workforce a pragmatic as well as a moral imperative. Yet, despite years of concerted effort, African Americans, Hispanics, and Native Americans continue to be underrepresented in the health professions (CGME, 1998; AADS, 2000; AAMC, 2000a,b). Addressing this persistent problem requires proactive, systemic approaches at all levels of the educational process. Whether the metaphor used is the “pipeline” or Bowen and Bok’s Shape of the River (Bowen & Bok, 1998), the educational system loses many minority students during the undergraduate years. This is especially the case for minority students who enter colleges and universities expressing an interest in the health professions, regardless of their intellectual abilities (Bowen & Bok, 1998; CB, 1999; Gandara, 1999). Attention to the undergraduate years of academic preparation and personal growth is, therefore, essential to achieving the goal of a health professions workforce that reflects the racial and ethnic diversity of this country.

The pervasive inequities in education that leave many underrepresented minority students ill prepared for the rigors of advanced education have been well documented. These inequities severely limit the pool of students entering colleges and universities (NCES, 1998; NSF, 2000). Therefore, it is imperative that undergraduate institutions provide the programmatic and personal support necessary to ensure the persistence of minority students to the baccalaureate. With respect to the health professions, effective undergraduate prehealth advising



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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Sustaining Minorities in Prehealth Advising Programs: Challenges and Strategies for Success Saundra Herndon Oyewole Trinity College, Washington, D.C. Dramatic racial and ethnic changes in the demographics of the United States make increasing the diversity of the health professions workforce a pragmatic as well as a moral imperative. Yet, despite years of concerted effort, African Americans, Hispanics, and Native Americans continue to be underrepresented in the health professions (CGME, 1998; AADS, 2000; AAMC, 2000a,b). Addressing this persistent problem requires proactive, systemic approaches at all levels of the educational process. Whether the metaphor used is the “pipeline” or Bowen and Bok’s Shape of the River (Bowen & Bok, 1998), the educational system loses many minority students during the undergraduate years. This is especially the case for minority students who enter colleges and universities expressing an interest in the health professions, regardless of their intellectual abilities (Bowen & Bok, 1998; CB, 1999; Gandara, 1999). Attention to the undergraduate years of academic preparation and personal growth is, therefore, essential to achieving the goal of a health professions workforce that reflects the racial and ethnic diversity of this country. The pervasive inequities in education that leave many underrepresented minority students ill prepared for the rigors of advanced education have been well documented. These inequities severely limit the pool of students entering colleges and universities (NCES, 1998; NSF, 2000). Therefore, it is imperative that undergraduate institutions provide the programmatic and personal support necessary to ensure the persistence of minority students to the baccalaureate. With respect to the health professions, effective undergraduate prehealth advising

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions programs play a unique and important role in the successful advancement of underrepresented minorities to careers in the health professions. Understanding the root causes of the underrepresentation of minorities in the health professions will facilitate the development of effective strategies for remedying the problem. For example, poor academic performance in science and math courses often impedes the advancement of minority students to health professions schools. Because the factors influencing their performance in rigorous science and mathematics courses are complex, the solutions must be equally creative and multifaceted to have an impact. Several studies on the persistence of minority students to the baccalaureate in all majors, particularly in science and math, illuminate the complexity. These studies move the discourse from anecdote to data, giving direction to those committed to increasing the diversity of the health professions workforce, and contributing persuasive evidence of the need for aggressive action by educational institutions, governmental and private funding agencies, and society at large. The prehealth advising program is a key element in the success of students pursuing careers in the health professions. The quality of prehealth programs is greatly influenced by the level of institutional commitment and external support. The review of successful prehealth advising programs included in this paper is presented in the context of general aspects of the undergraduate experience, with special emphasis on findings related to the performance of underrepresented minorities in science and math. An analysis of health professions advising cannot be uncoupled from an examination of core elements of the undergraduate experience, particularly math and science education. This is important because the majority of minority student applicants and matriculants to health professions schools major in one of the sciences, most often biology (AADS, 1999; NSF, 2000; Van Houten, 2001). Anecdotal evidence suggests that a significant number of minority students have expressed dissatisfaction with the academic and/or prehealth advising they received at their undergraduate institutions. Many have perceived their advisors to be unsupportive. Indeed, there are successful health professionals who give accounts of advisors or faculty members who advised them to give up their goal of a career in a health profession (AADS, 1999). It is difficult to know the number of students who were not able to overcome this discouragement. A survey of minority students attending a Student National Medical Association conference was designed to provide a data-based analysis of student perceptions of the undergraduate prehealth advising programs at their home institutions. An overview of prehealth advising programs and studies on factors affecting the persistence of minority students to the baccalaureate and entrance into health professions schools follows. The paper concludes with recommendations that are a synthesis of the research studies and the recommendations of the participants in the “Sustaining Minorities in Prehealth Advising Programs” workshop at the Symposium on Diversity in the Health Professions in honor of Her-

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions bert W.Nickens, M.D. Without question, effective prehealth advising is important to the successful advancement of all students to health professions schools. However, it is especially critical to the success of minority students. OVERVIEW OF PREHEALTH ADVISING PROGRAMS Prehealth advising programs vary greatly, reflecting the variety of institutional types in the United States. For example, the prehealth advisor may be a faculty member—often in the sciences—whose primary responsibility is teaching, a member of the academic dean’s office who oversees all academic advising, or a staff member of the institution’s career center who specializes in prehealth advising. Of the respondents to a 2000 survey of the members of the National Association of Advisors for the Health Professions (NAAHP), the percentage of advisors who reside in academic departments versus dean’s offices was 43.8% and 33.7%, respectively (Klein, 2000). The academic department affiliation was most often biology. Only 34.6% of the respondents participated in minority student programs. Although the respondents represented only 58.6% of the NAAHP membership, these data provide some indication of the balance between faculty and administrative affiliations. The student-to-advisor ratio also varies widely among prehealth advising programs, which can have a major impact on the accessibility of the advisor. The most successful advising programs are those that have developed mechanisms for ensuring access regardless of the size of the institution. At large institutions, underrepresented minority students—especially those who are not assertive—are often at the greatest risk of being lost. This is not to suggest that problems do not exist at smaller institutions as well. Often, budget constraints and heavy teaching loads impede the professional development of prehealth advisors at resource-poor institutions. Consequently, the advisor might find it difficult to stay abreast of all the information necessary to be effective. Advisors at smaller institutions often have less difficulty in getting to know their prehealth students. A number of advisors teach one of the prerequisite courses, which is especially advantageous when it comes time to write informed letters of recommendation to health professions schools. Effective advising systems at larger institutions have developed mechanisms for providing informed and personalized evaluations from faculty members who have worked closely with the candidates. The level of institutional support varies among institutions. At smaller institutions, prehealth advisors are not compensated for their work as advisors. Instead, their work as prehealth advisors may be recognized as service to the college. There is often no budget for prehealth advising and a faculty member’s office is the site of prehealth advising. At larger institutions there are usually multiple advisors with support staff. As will be seen later, many successful prehealth advising programs are well funded, from both institutional and external

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions sources. Most institutions probably fall between these extremes of funding and staff support. Technology has played a major role in narrowing the gap between the well-funded institutions and those with less funding. Valuable information about such things as admissions requirements, entrance examinations, the application process, enrollment patterns, and career opportunities is now available on the websites of health professions schools and health professions organizations, as well as prehealth advising programs. A number of prehealth advisors have sophisticated websites with links to all of the relevant sites. Members of NAAHP and its regional affiliates, along with some representatives of health professions schools and organizations, are linked by a Listserv, which has become a major resource for quick feedback on issues related to prehealth advising. A concern is that many disadvantaged students do not have easy access to the Internet (CB, 1999) and will, therefore, not have easy access to information provided through this medium. Effective advisors are student-oriented and committed to assisting students in achieving their goals. They are knowledgeable, supportive individuals whose role is to provide information and guidance as students make academic, personal, and career decisions. Cecilia Fox of Occidental College was the first prehealth advisor honored by the Association of American Medical Colleges (AAMC) Group on Student Affairs-Minority Affairs Section (MAS) with a Herbert W.Nickens, M.D., Special Recognition Award for her outstanding work in advising underrepresented minority students interested in careers in medicine. In honoring Cecilia Fox at the AAMC Annual Meeting in 2000, the MAS acknowledged the importance of prehealth advising to the success of minority students interested in careers in the health professions. Fox exemplifies a prehealth advisor at a small institution who has been especially effective. She tailors her advising to the individual—recognizing that each student’s situation is unique— and advises students in a manner appropriate to their specific needs. Her first contact with prehealth students begins at freshman orientation, if not before. She considers this crucial (personal communication, C.Fox, Occidental College, January 12, 2001). She has helped to create networks on and off campus among students and with admissions officers at health professions schools, especially the University of Southern California School of Medicine and its Health Education Prep Program. This program provides summer enrichment activities for minority students the summer before the freshman year and for two additional summers. The students take science and writing classes, and gain exposure to college juniors and seniors who tutor them as well as to medical school students and faculty. In addition, Occidental prehealth students benefit from special programs organized by the Chicano Medical Student Association and other minority medical student organizations (personal communication, C.Fox, Occidental College, January 12, 2001). Given that prehealth advising is not the primary responsibility of many faculty who serve in that role, professional development opportunities are espe-

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions cially important. Such opportunities are provided by the National Association of Advisors for the Health Professions (NAAHP) and its regional affiliates—the Central, Northeast, Southeastern, and Western Associations of Advisors for the Health Professions (CAAHP, NEAAHP, SAAHP, WAAHP, respectively). NAAHP is the only national organization concerned exclusively with the needs of prehealth professions advisors and their students. NAAHP and its regional affiliates provide professional development opportunities to advisors through national and regional meetings and through electronic and print communication. Collaborative relationships with representatives of health professions schools and their professional organizations have facilitated communication and cooperation among those most important to forming bridges between undergraduate institutions and health professions schools. In response to concerns about the quality of prehealth advising for minority students, the NAAHP Board of Directors recently formed a Committee on Minority Affairs charged with developing programs for enhancing prehealth advising of underrepresented minority students. The committee has identified a range of issues which must be addressed. These issues include: recognizing and encouraging competitive underrepresented minority students; promoting the persistence of minority students through the undergraduate program; advising minority students who experience early academic difficulty; recognizing prospective applicants with potential to succeed in the health professions; clarifying the role of the health professions advisor: gatekeeper vs. advocate; presenting and reporting admissions statistics for students from minority groups; advising rejected students; advising under-prepared students; encouraging advisors to be open to professional development in this area; educating faculty on institutional prehealth advisory committees on issues of affirmative action and minority access to the health professions; developing principles and guidelines for the review and evaluation of underrepresented candidates; addressing constraints, such as limited resources and workload, that impede efforts in this area; increasing membership of advisors from institutions with large African-American, Hispanic/Latino, and Native American populations. The implementation of this agenda will require collaboration among advisors, undergraduate institutions, health professions schools, and funding agencies. Fortunately, a number of important collaborative relationships have already

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions been established. Developing and implementing strategies that will significantly increase the number of underrepresented minorities entering the health professions will require intentional and sustained effort. In developing advising programs to meet the needs of underrepresented minority students, it is a mistake to ignore their diversity—diversity in race, ethnicity, academic preparation, socioeconomic background, and cultural background. To assume that all minority students have the same needs is to ignore their individuality and, ultimately, to fail them. The ability of advisors to advise minority students effectively can be enhanced by a better understanding of the factors affecting their achievement and persistence to the baccalaureate. Understanding the challenges faced by underrepresented minorities and implementing the strategies demonstrated to lead to a successful transition of minority students to health professions schools are essential to effective advising programs. Advisors at selective institutions must also pay attention to these issues, because there is compelling evidence that minority students with competitive grade point averages (GPAs) and SAT scores do not perform as well as their majority counterparts in these institutions (Bowen & Bok, 1998). Academic ability is not the issue. Because these students are in fact the ones with the greatest potential for success in entering the health professions, we cannot afford to lose them because of a lack of understanding of the factors that affect their performance. A review of factors influencing access, enrollment patterns, retention and graduation, and high achievement of minority students follows. PERSISTENCE TO THE BACCALAUREATE Statistics on the persistence of minority students to the baccalaureate dramatically reflect the high attrition rates of underrepresented minorities (NCES, 1998; NSF, 2000). Simply put, Blacks, Hispanics, and Native Americans are less likely than Whites to graduate from college. Among those who were ages 25–29 in 1998 and who had completed high school, 18% of Blacks, 16% of Hispanics, and 34% of Whites had earned bachelor’s degrees or higher (NCES, 1998). Black and Hispanic students are also less likely to complete a bachelor’s degree within 5 years. While 48% of white students and 47% of Asian students who entered a bachelor’s degree program in 1989 had earned their degree by spring 1994, only 34% of black students and 32% of Hispanic students did so (NCES, 1998). Thirty-seven percent of both black and Hispanic students, compared with 27% of white students and 26% of Asian students, had earned no degree and were no longer enrolled in a bachelor’s program in 1994. As is often the case, there was too small a sample size of Native Americans to allow for a similar analysis during the period studied (NCES, 1998). A number of studies have tried to identify the factors responsible for the higher attrition rates of minority undergraduate students (NCES, 1998; NSF, 2000). Some of the factors identified were age at enrollment, enrollment status

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions (full-time vs. part-time), socioeconomic status, parents’ education, level of first institution (2-year vs. 4-year), and financial resources. Those students entering undergraduate institutions at a younger age, enrolling full-time, beginning at 4-year colleges, and having parents with a 4-year degree or higher, and a higher income were more likely to complete a bachelor’s degree in 5 years (NCES, 1998). Additional factors that influence persistence to the baccalaureate are presented below. RELATIONSHIP OF MATHEMATICS TO BACHELOR’S DEGREE ATTAINMENT Answers in the Tool Box (Adelman, 1999), an analysis of course taking between 1982 and 1993, revealed that mathematics was the most powerful predictor of ultimate completion of bachelor’s degrees. It was determined that of all the components of curriculum intensity and quality, none had a more obvious and powerful relationship to ultimate completion of degrees as the highest level of mathematics studied in high school. This relationship existed for all students, regardless of race/ethnicity, demonstrating that underrepresented minority students can succeed, given high-quality preparation in high school. Unfortunately, minority students are less likely to attend schools that offer advanced math courses that will increase the probability of their earning bachelor’s degrees (Adelman, 1999). Although socioeconomic status is generally one of the most powerful predictors of students’ academic achievement (CB, 1999), the correlation with completion of degrees was stronger with math courses taken than with socioeconomic status. The author of Answers in the Tool Box, Clifford Adelman, was able to develop a “math ladder” correlating the highest math course taken with the percent of high school graduates earning a Bachelor of Arts degree (B.A). The percentages of students earning a B.A. by course taken were: calculus, 79.8%; precalculus, 74.3%; trigonometry, 62.2%; algebra II, 39.5%; and algebra I, 7.9%. Unfortunately, during the period studied, only 23.6% of students entering college in the high school and beyond/sophomore 1982–1993 cohort reached trigonometry or a higher level of math in high school. STATUS OF MINORITIES IN SCIENCE, ENGINEERING, AND TECHNOLOGY An important study commissioned by the U.S. Congress gives greater definition to the magnitude of the problem of underrepresentation of minorities in the majors most often selected by prehealth students. The Commission on the Advancement of Women and Minorities in Science, Engineering, and Technology (CAWMSET, 2000) was mandated to analyze and describe the status of women, underrepresented minorities, and persons with disabilities in the sci-

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions ence, engineering, and technology pipeline. The final report, Land of Plenty: Diversity as America’s Competitive Edge in Science, Engineering, and Technology (CAWMSET, 2000), addresses some of the issues in higher education that have an impact on minorities. Specifically, the report addresses the issue of access, questioning whether the educational system is the “gatekeeper” or “door to the future” for those underrepresented in science, engineering, and technology. The reasons for the higher attrition rates for minorities were found to include financial difficulties, poor pre-college preparation, low expectations from faculty, poor quality of teaching, and an inflexible curriculum (CAWMSET, 2000). This study is relevant to the issue of preparing students for the health professions because of the large percentage of minority prehealth students who choose science as their undergraduate major. The commission concluded that members of underrepresented groups exit in large numbers at different transition points in the mathematics and science pipeline. At the transition from high school to college, a large percentage of highly capable underrepresented minority students is forced out of the pipeline because of a lack of high-quality science and mathematics preparation in high school. The commission identified a need for better articulation between 2-year and 4-year colleges. Rising costs of college tuition and the inadequacy of scholarships and grants available to students have reduced the prospect of a college education, especially for low-income students. The commission recommended that federal and state governments significantly expand financial investment in support of underrepresented groups in science, engineering, and technology higher education through funding to both students and institutions. The commission explicitly recommended that financial support for students should include scholarships, fellowships, and internships, rather than loans. The commission also recommended that expansion of support to institutions include institutional awards, research assistantships, traineeships, and the expansion of proven programs (CAWMSET, 2000). UNDERGRADUATE INSTITUTIONS ATTENDED BY MINORITY STUDENTS For many minority students, persistence to the baccalaureate degree involves transition from a 2-year college to a 4-year college or university. The number of students in this pool is very high, yet formal prehealth advising programs are typically absent from 2-year institutions. Over 40% of African-American students (46% in 1996) and over 50% of Hispanic (54% in 1996) and Native American (52% in 1996) students are enrolled in community colleges (NSF, 2000). Socioeconomic barriers and/or academic deficiencies often influence the decision to enroll in a 2-year institution. Because only a very small percentage of these students continues to the baccalaureate, this is a major untapped pool of minority students. Given that 40–50% of these students take their first

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions prehealth-prerequisite science courses at a community college, it is essential that strategies for improving prehealth advising for minority students be disseminated to community colleges as well as 4-year colleges and universities. Asians are more likely than other groups to enroll in Research I institutions—21% of Asian undergraduates versus 7–12% of other racial/ethnic groups. Black and Hispanic undergraduates are enrolled in Research I institutions in the lowest percentages. Higher percentages of black and white undergraduates are enrolled in comprehensive and liberal arts institutions than other racial/ethnic groups. American Indian and Hispanic undergraduates, as indicated earlier, are the most likely of the racial/ethnic groups to enroll in 2-year institutions (NSF, 2000). The AAMC report, Minority Graduates of U.S. Medical Schools: Trends, 1950–1998 (AAMC, 2000a), provides valuable longitudinal data about the undergraduate institutions attended by minority graduates of U.S. medical schools. Although Xavier University of Louisiana has been ranked first among undergraduate institutions sending African Americans to medical school in recent years, Howard University ranked first over the 1950–1998 period, followed by Morehouse, Fisk, Harvard, and Xavier, respectively. The data presented in the report document the effects of desegregation on attendance patterns. Approximately 57% of Blacks attending medical school in the 1950s and 1960s attended historically black colleges and universities (HBCUs) as undergraduates; however, that percentage dropped to just under 22% by the 1980s and 1990s. For the entire 1950–1998 period, however, nearly 29% of all black medical school graduates attended HBCUs as undergraduates. During the 1950–1998 study period, approximately 21% of all minority graduates of U.S. medical schools came from just 10 undergraduate institutions: the University of Puerto Rico-Rio Piedras, the University of California-Berkeley (UC-Berkeley), Howard University, the University of California-Los Angeles (UCLA), Stanford, Harvard, the University of Michigan-Ann Arbor, Northwestern University, the University of California-Irvine, and the University of Texas-Austin. Interestingly, the top five undergraduate institutions varied for different minority groups. For Asians, the top five were UC-Berkeley, UCLA, Stanford, Northwestern, and the University of Michigan-Ann Arbor, respectively. For Hispanics, the top five schools were the University of Puerto Rico-Rio Piedras, the University of Puerto Rico-Mayaguez, the University of Miami, the University of Texas-Austin, and UCLA, respectively. For American Indian/Alaska Natives, the top five were the University of Oklahoma-Norman, Pembroke State University, UC-Berkeley, UC-Davis, and the University of North Dakota-Main Campus, respectively. An assessment of the prehealth advising programs at these and other institutions sending large numbers of underrepresented minorities to health professions schools would provide useful information for developing and disseminating effective strategies for advising minority students. It would be particularly valuable to examine those programs with demonstrated

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions success in preparing Native Americans for the health professions, because statistically valid data from national databases are limited by the small sample size of Native Americans in the pools studied. PREMEDICAL EDUCATION AT HISTORICALLY BLACK COLLEGES AND UNIVERSITIES There are little empirical data to illuminate the factors that influence the persistence of underrepresented minority students through the undergraduate years to admission to health professions schools. However, some insight can be gained from data collected by various organizations. Of particular interest is a study that focused on nine HBCUs with respect to the number of their graduates entering medical school (Atkinson et al., 1994). Completed in 1991 by the Division of Disadvantaged Assistance, Bureau of Health Professions, Health Resources and Services Administration within the Public Health Service, the study was motivated by the decline in the number of black applicants and matriculants to medical school from HBCUs. During the mid-1980s, nearly 30% of all black applicants to medical schools received their degrees from HBCUs (AAMC, 2000a). The nine schools studied were divided into two groups based on medical school acceptance rates, one group higher-ranked and the other group lower-ranked. The medical school acceptance rates for participating HBCUs ranged from about 14% to 58%. Interestingly, all of the higher-ranked and two of the lower-ranked institutions had Health Careers Opportunity Programs (HCOP), programs designed to increase the pool of underrepresented minorities and other disadvantaged students successfully entering and completing health professions training programs. Comparisons of data on the schools from the two cohorts revealed factors that might be related to the difference in acceptance rates. An assessment of the curricula of both cohorts revealed little difference between the types of courses required for premedical students at the HBCUs in each group. Although the courses were the same, there was a difference in the pattern of course taking and curriculum design. Institutions with higher acceptance rates reduced course loads in the freshman and sophomore years. At two of the institutions with lower acceptance rates, students took biology, chemistry, and mathematics in the freshman year. There was also a notable difference in course content. Science faculty at four of the five institutions with higher acceptance rates did not tailor their courses specifically for premedical students; however, faculty at the lower acceptance rate institutions tended to tailor their curricula to the needs of premedical students, with some gearing their courses to the Medical College Admission Test (MCAT). With respect to teaching, introductory biology and chemistry courses at institutions with lower acceptance rates were more likely to belong to a single faculty member. At the institutions with higher acceptance rates, a team-teaching departmental approach was common.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Interestingly, MCAT scores or grade point averages could not explain the difference in acceptance rates between the two cohorts. However, medical school admissions officers considered the premedical programs at some of the institutions with higher acceptance rates to be very strong, based on their experience with graduates and premedical advisors of those institutions, and not necessarily on knowledge of the curriculum or programs at the schools. This points to the importance of the relationships that are established between prehealth advisors and admissions officers and to the effect that performance of admitted students has on the success of future applicants from the same undergraduate institution. Not surprisingly, the more successful institutions were found to have more resources, including larger faculties. In addition the more successful institutions had larger numbers of students interested in medicine and other health professions, even though the total student enrollment was small. There were more biology majors (12–27%) at the institutions with higher acceptance rates, with an average of only 5% at the institutions with lower acceptance rates. These findings reflect the recurring theme that resources enhance the quality of prehealth advising programs and also suggest that students benefit from having a community of students with common interests. The two factors might be linked in that the distribution of financial resources, both internal and external, is often linked to enrollment. Among the factors thought to contribute to the success of the higher-achieving programs were positive relationships with medical schools, summer internship and work programs, clinical and research experiences, visits to hospitals, and interactions between medical school and undergraduate faculty members. All of the institutions had academic enrichment programs, but the higher-achieving schools had more. In addition, the institutions with higher acceptance rates had more externally sponsored enrichment programs, such as NIH-funded Minority Biomedical Research Support Programs, Minority Access to Research Careers Honors Undergraduate Research Training Programs, and Howard Hughes Medical Institute Undergraduate Biological Sciences Education Initiative Grants. Although all nine of the participating institutions believed premedical advising to be a strength of their program, three of the five institutions with lower acceptance rates had no funds for an institutional or departmental premedical component. These institutions did not provide support for the premedical advisor. Given these findings, it is not surprising that the advisors from the institutions with higher acceptance rates were more likely to belong to the National Association of Advisors for the Health Professions (NAAHP) or the National Association of Medical Minority Educators (NAMME) and their regional affiliates. Advisors from the institutions with higher acceptance rates were also more likely to participate in other professional organizations and attend professional meetings. Only one of the four institutions with lower acceptance rates had an advisor who was active in these organizations.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions wen and Derek Bok, and Priming the Pump: Strategies for Increasing the Achievement of Underrepresented Minority Undergraduates (1999) by Patricia Gandara. Bowen and Bok’s study focused on the academic, employment, and personal histories of more than 45,000 students of all races who attended a set of academically selective colleges and universities. Their study provides an empirical base for evaluating the impact of race-sensitive admissions policies on students of different races, particularly on Whites and African Americans. The Gandara study, commissioned by the College Board’s National Task Force on Minority High Achievement, focused on 20 programs seen as exemplars of effective efforts toward increasing the number of high-achieving underrepresented minority students eligible for graduate and professional study. The study focused on programs with students with a wide range of abilities, but excluded programs that were remedial in nature. The majority of the programs studied focused on the physical and biological sciences, engineering, and technology. Five major components of successful programs were identified in Priming the Pump: 1) mentoring, 2) financial support, 3) academic support, 4) psychosocial support, and 5) professional opportunities. Financial support was found to be the least common feature, although inadequate financial resources have been shown to contribute to higher minority attrition rates (CB, 1999). The programs and students studied by Gandara and Bowen and Bok have relevance for all prehealth advisors, but particularly those at selective majority institutions. Underrepresented minority students at majority colleges and universities generally do not earn grades that are as high as the grades of white and Asian students with similar high school GPAs and SAT scores (Steele, 1997; Bowen & Bok, 1998; CB, 1999). Bowen and Bok provided extensive confirmation of this pattern. In their study, African-American students at 28 selective colleges and universities graduated with significantly lower GPAs, on average, than their white counterparts with similar SAT I scores. Among these African Americans were many students who were well prepared academically for selective institutions and who were from middle and high socioeconomic status families. The Hispanic students in the study also had lower GPAs than white students with similar scores. There is compelling empirical evidence that the underperformance of black students may be caused by the fear of confirming the stereotype that they are intellectually inferior, in spite of their competitive SAT scores and high school grades upon entry. This phenomenon has been referred to as “stereotype threat” (Steele, 1997). Fear of confirming negative stereotypes also prevents some minority students from taking advantage of academic support systems, which means that health professions advisors must be proactive in encouraging minority students to understand that all students can benefit from using academic support services. Gandara points out that close supervision of students’ academic progress and decision making is necessary because many minority students lack the “cultural capital” that provides familiarity with strategies for navigating suc-

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions cessfully through college and career decisions. Many of the successful programs have socialized students to a set of high expectations that the students internalized (Gandara, 1999). The programs that have been successful are concerned with both the academic and social development of participating students. In summary, programs with demonstrated success in improving academic performance of underrepresented minority students were found to: stress scholastic excellence; encourage each student to do his or her best; emphasize helping students succeed in freshman year; focus on mastery in foundation courses; help students build strong academically-oriented peer groups; build strong student/faculty relationships; focus on providing good ongoing academic advising services; encourage participation in research; provide strong support beyond the freshman year; and provide students with sufficient financial aid to concentrate fully on their studies. In addition, the following broader categories have been found to be strongly associated with student educational outcomes: 1) economic circumstances; 2) level of parents’ education; 3) racial and ethnic prejudice and discrimination; 4) cultural attributes of the home, community, and school; and 5) quality, amount and uses of school resources (CB, 1999). To be effective, prehealth advisors must also consider these factors when designing programs to assist minority students in preparing for health profession schools. SURVEY OF STUDENT OPINION Understanding student perceptions of their prehealth advising programs must be a part of the effort to improve prehealth advising programs. In the fall of 2001, a survey developed by the author to assess student perceptions of their prehealth/premed advising programs was administered at the Student National Medical Association (SNMA), Region IX Symposium “Critical Choices: Overcoming the Medical Pipeline Challenges.” The conference was organized by SNMA members and members of the Minority Association of Pre-Health Students (MAPS). SNMA is the nation’s oldest and largest organization focused on the needs and concerns of medical students of color. Its membership includes medical students, premedical students, residents, and physicians. MAPS is targeted towards undergraduate pre-medical students and aims to increase the matriculation of underrepresented students into health professions-related programs through partnerships with local SNMA chapters. The partnership primarily serves as an academic support system by providing information on how under-

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions graduates may establish themselves as competitive candidates for medical school early in their undergraduate careers. The students attending the conference were from undergraduate institutions in the Northeast/Mid-Atlantic region, and some of them were accompanied by prehealth advisors and parents. The purpose of the survey was to reconcile the analysis of prehealth advising programs with the perceptions of minority undergraduate prehealth/premedical students. It is a small step toward providing more than anecdotal evidence about the quality of prehealth advising for minority students. Assessment of prehealth programs must be influenced by both student perceptions and outcomes. Survey Design Students identified their institutions by the following descriptors: 1) community college, 4-year college, university; 2) private, public; 3) student enrollment; 4) HBCU, minority-serving (more than 50% minority), majority. Students were asked to describe their prehealth advisors as: 1) a single faculty member (scientist or non-scientist); 2) committee of faculty; 3) committee of faculty and non-faculty; 4) non-faculty; 5) team of non-faculty advisors. Questions were also asked about the time of first contact with the prehealth advisor and the frequency of contact. Students were then asked to evaluate their advisors’ attitudes toward them. Using a scale of 1–5 (1-Poor, 2-Fair, 3-Good, 4-Very Good, 5-Excellent) and not applicable (N/A), the students rated their premedical advising program, the personal support received, and the quality of programs tailored to the needs of minority students. There were opportunities for additional open-ended responses to each of these questions. The students were then asked to rate the quality of information provided on the following topics: summer programs for minority students, academic support services, premedical requirements, allopathic medical schools, osteopathic medical schools, other health professions programs, internships, post-baccalaureate programs, exams (MCAT, DAT, VAT), the admissions process, and profiles of competitive minority students. These were aggregated into a category called “information provided.” Finally, students were given an opportunity through an open-ended question to share additional thoughts on factors that influenced their persistence toward their goal of becoming a doctor. The surveys were analyzed using SPSS. All correlations were significant at the 0.05 level (2–tailed). Results and Discussion Seventy-one students completed the survey. Of the 71 students, three were medical students and all but one were undergraduates from 4-year colleges or universities with enrollments that ranged from under 2,000 students to over 10,000. One percent attended a community college, 37% attended a 4-year col-

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions lege, and 54% attended a university. Thirteen percent reported attending an HBCU, 10% reported attending a minority-serving institution, and 20% reported attending a majority institution. Fifty-seven percent of the students did not respond to this question. This was possibly due, in part, to their difficulty in distinguishing between a minority-serving institution and a majority institution. Regarding the structure of the prehealth advising program, 41% had a single faculty member, 38% had a committee of faculty, 10% had a committee of faculty and non-faculty members, and 10% had a team of non-faculty advisors. The results showed that students at the SNMA symposium had mixed opinions about their prehealth advising programs. Twenty-seven percent of the students gave their programs a “good” rating, 24% gave their programs a “very good” rating, and 6% gave their programs an “excellent” rating. Although this means over half of the students were pleased with their advising programs, a significant proportion of the students considered their programs fair (20%) or poor (20%). Four percent responded “not applicable” when asked to rate the quality of their prehealth advising program. Unfortunately, we cannot be sure, nor can we assume, that N/A means that no such programs exist at the institutions attended by these respondents. The students expressed a similar range of opinions when asked about the quality of the personal support they received from their institutions. Twenty-six percent rated the support they received as good, 22% very good, and 12% excellent. But again, a significant proportion of the students gave ratings below good: 15% fair, 18% poor, and 7% N/A. The increase in excellent ratings between this question and the question about advising programs may be an indication that students found specific advising programs or activities lacking, but found personal attention from advisors more beneficial. Another item on the survey asked students to rate specific programs tailored to the needs of minority students. In response, 19% indicated their programs were good, 16% indicated they were very good, and 13% of the students thought the programs that met minority needs were excellent. In contrast to the previous questions, this left more than half of the students who rated their programs as less than good. Fourteen percent rated minority programs fair, 19% rated them poor, and 19% responded N/A. Due to the large difference between the N/A responses for the two questions about general prehealth advising programs and the N/A responses for a question about programs specifically for minorities, we can speculate that minority programs are absent from some of the institutions the students attend. Such speculation is also based on some open-ended responses in which students stated a lack of minority programs at their institutions. In order to get a sense of how early advising begins for underrepresented minorities, the students were asked to indicate when they first met their prehealth advisors. Fourteen percent of the students first met their advisors before matriculation, 16% during freshman orientation, and 19% during the freshman year. The remaining 51% percent of the students did not meet their advisors

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions until their sophomore year or later: 30% in sophomore year, 16% in junior year, and 4% in senior year. It may seem that a large proportion of students met their advisor when they were well into their undergraduate education; however, this may be a function of when some students decide to pursue a career in a health profession. Some may not decide until after their sophomore year. Nevertheless, this may limit the impact of prehealth advising, as there is evidence supporting the importance of early identification and support in ensuring high academic achievement by minority students (Gandara, 1999). Further analysis of the survey results examined the relationships between different items. For example, a negative relationship was found between the size of the institution the students attended and the students’ ratings of minority needs programs and personal support received. That is, students at larger institutions were more likely to have lower ratings of minority programs and personal support. They also gave lower ratings to the quality of information provided on various programs, types of medical schools, and medical school admissions procedures. Students who responded with higher overall ratings of advising programs were more likely to give higher ratings of the personal support they received, the quality of minority needs programs, and the quality of information their advising programs offered. One might expect that students who met with their advisors more frequently would have higher ratings of the support they received. However, students who met their advisors more often were more likely to have lower ratings of the personal support their institutions provided. This is an interesting observation that requires further exploration. There was one community college student among the respondents. She made a plea that programs such as the one organized by SNMA be offered at community colleges. She made the point that there are many minority students at her community college. Data presented earlier strongly support the importance of addressing the needs of minority students interested in the health professions who begin their undergraduate education at community colleges. In summary, it is evident that the students’ perceptions of their prehealth advising programs were mixed. While it is encouraging that many of these students found their programs to be good to excellent, a significant number rated the programs at their home institutions as poor or fair. Conversations with individual students suggested that the survey approach should be supplemented with student interviews to obtain more detailed information about which aspects of advising programs should be strengthened. Certainly all prehealth advising programs would benefit from periodic assessment with the goal of continued improvement. Understanding and being responsive to the reasons for student perceptions, both positive and negative, will strengthen advising programs.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Challenges and Strategies for Success Without question, minority students face many challenges as they prepare for careers in the health professions. To be effective, prehealth advisors must be aware of and sensitive to these challenges. Increasing the number of minority students advancing to health professions schools requires special attention on the part of advisors. Fortunately, there are many advisors who are doing an excellent job; however, inadequate guidance and information specific to the academic, experiential, and personal development of minority students is a barrier to success. It is essential that all prehealth advisors be well informed about the admissions profiles of competitive minority matriculants to all health professions schools. Often advisors are fearful that poor grades in the freshman year are a forecast of failure, and believe that they are acting in the student’s best interest when they counsel them out of prehealth advising programs in their freshman year. With the appropriate academic, financial, and/or personal support, many of those students can overcome the deficit in their academic record. Fortunately, some of these students later enroll in postbaccalaureate programs, once they have regained their confidence (CGME, 1998). Advisors are an important component of the evaluation process for admission to health professions schools, and they therefore influence the number of minority students applying to health professions schools. Striking the balance between advocate and evaluator can be challenging. More comprehensive information from the health professions schools on profiles of competitive minority applicants would facilitate a more appropriate assessment of minority students. Many advisors are advising based on published average test scores and GPAs of all students admitted to various health professions schools without an appreciation for the range of scores of admitted students. It is important that advisors’ letters of recommendation for applicants to health professions schools be culturally sensitive and free of cultural stereotypes. The letters must also give insights into the personal characteristics and life experiences of individual students that complement test scores and GPAs. Personal attributes, sometimes referred to as “non-cognitive skills,” certainly factor into the admissions process, but they are not easily quantified. Many have argued that the focus on numbers is a major disadvantage for minority students who have the skills to become successful health professionals, but lack competitive numbers. Breaking the hold of the meritocracy of numbers will continue to be a challenge, especially as opponents of affirmative action continue to use numbers to justify their position. There is a need for longitudinal studies documenting the success of minority health professionals whose numbers alone would not have gained them admission to medical school. In the absence of such a research base, the emphasis on numbers will continue. Features of effective prehealth advising programs have been shown to include most, if not all, of the following features:

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions early identification of students interested in the health professions; pre-matriculation activities; proactive academic support; early identification of academic problems; academic skills development; study skills workshops; time management workshops; formation of study groups; four-year advising plan specific to preparation for health professions schools; peer mentoring; special interest student groups; and advice on summer enrichment programs and research opportunities. Many of these strategies contribute to the recruitment, retention, and high achievement of underrepresented minority students. Academic support services and other student services, such as financial aid, are essential elements for success. What follows is an elaboration on some of these strategies, which includes a synthesis of the discussion at the “Sustaining Minorities in Health Professions Programs” workshop at the Symposium on Diversity in the Health Professions in honor of Herbert W.Nickens, M.D. One important recommendation from the workshop is that minority high school students interested in careers in the health professions should consider the quality of the prehealth advising program for minority students when selecting a college or university. Early Intervention Early interventions with proactive academic and personal support have been shown to be effective strategies. During the first semester of the freshman year, many underrepresented minority students experience their first academic difficulty. Therefore, assessing the readiness of students for a rigorous academic program is very important. Frequent feedback, especially positive and encouraging feedback, in spite of deficiencies, is essential. This does not mean that deficiencies should not be addressed honestly. Strategies for early intervention are: 1) tutoring by a faculty member, learning center staff member, or a peer; 2) reducing the number of science courses taken in one semester; and/or 3) aligning course schedules with academic preparation, for example, additional math and English courses might be needed before taking biology. Many minority students require assistance in becoming acclimated to the academic culture. In some cases, it is simply that very intelligent students have not been challenged in their high schools and have underestimated the effort required to earn the As that came with little effort in high school. The issue of lower grades may not be related to intellectual ability, but may reflect poor time-management skills and poor study skills.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Access to undergraduate education without support often leads to failure. Although many prehealth advisors are members of the science faculty, many others are members of an advising staff, with limited influence as to what goes on in the classroom. It is imperative that faculty members teaching the “gateway courses” understand the importance of early and consistent intervention to ensure high achievement among minority students in their classes. Academic support must go beyond remediation and include the support necessary to enhance the performance of high-achieving minority students. Identifying best practices will be of little value if those practices are not disseminated widely and implemented. Their implementation will require both human and financial resources. In addition, professional development opportunities for those professionals involved in the preparation of undergraduate students for entry into health professions schools must be provided. Chilly Climate and Stereotyping As stated earlier, it is absolutely essential that the individuality of each minority student be recognized, and that stereotyping not interfere with appropriate and competent individualized advising. Many minorities, regardless of their socioeconomic background or level of academic preparation, are plagued by ongoing racial and ethnic stereotyping. There must be an institutional commitment to creating a welcoming climate. Prehealth advising programs can assist by offering appropriate co-curricular programming, promoting the formation of student groups focused on the health professions, and providing opportunities for students to work one-on-one with faculty. Building a Critical Mass Finding ways to build a critical mass of minority prehealth students may involve establishing partnerships among small colleges and encouraging students to form student organizations that focus on minority students interested in the health professions. Such strategies can help to minimize isolation. Advisors at small institutions often feel it is an imposition to invite admissions officers to their campuses to meet a small number of students. Forming local and regional networks is an effective solution to this problem. Financial Support Providing students with sufficient financial aid to allow them to concentrate fully on their studies is important. Minority students from disadvantaged socioeconomic backgrounds often have parents who have difficulty with financial aid forms, and they may therefore need assistance from financial aid officers at the undergraduate institution. Prehealth advisors can help by directing students to the appropriate resources.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Too many students end their undergraduate years with both educational and consumer debt. It is important that students understand the importance of a good credit rating to ensure eligibility for the loans necessary to pay for a medical education. Students must also be made aware of the possibility of fee waivers for those who qualify and how to plan for all the expenses associated with the application process, including the cost of traveling to interviews. It is also essential that financial support be provided for prehealth programs designed to ensure high academic achievement by minority students. Committed individuals can do great things with limited resources; however, institutional support is essential to sustaining programs. Many of the programs recognized for their documented success have benefited from external funding. Mentoring Mentoring has been demonstrated to be an important component of effective advising programs. Successful mentoring programs use a variety of formats and components to meet the differing needs of individual students. Programs that provide a continuous structure and offer ongoing reinforcement, encouragement, and support are most helpful. Upper-level undergraduate and graduate students can be effective mentors for students. Effective mentoring programs reduce isolation and facilitate acclimation to the undergraduate institution. Summer Enrichment Programs and Post-Baccalaureate Programs Summer enrichment programs have been shown to significantly benefit minority students interested in the health professions (AAMC, 1999). One of the most successful is the Minority Medical Education Program (MMEP) of the Robert Wood Johnson Foundation and the Association of American Medical Colleges. MMEP programs are located at 11 medical schools around the country. For a number of students, these programs provide academic advising specific to the needs of underrepresented minority students. Postbaccalaureate programs are especially valuable for students who choose to pursue a degree in the health professions after completing a bachelor’s degree. There are a number of programs designed for underrepresented minority students. These programs may consist of upper-level science courses. Others offer master’s degrees in physiology and biophysics. These programs are typically 1-year programs. The Application Process Effective prehealth advising programs give students very specific guidelines on a 4-year time line for preparing for admission to health professions schools. According to a number of admissions officers, many minority students do not

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions submit applications by the deadline or believe that merely making the deadline is sufficient. Students must be made aware of the implications of the rolling admission process. Given that many minority students are first-generation college students and that most are first-generation health professions students, they may not have a family network of academic support and advice. The advice must come from the prehealth advising program or from the academic advisor. Professional Development for Prehealth Advisors Evidence presented earlier supports the value of participation in professional organizations focused on developing advising skills. Many prehealth advisors work in isolation and have few opportunities for professional development. Organizations such as the National Association of Advisors for the Health Professions (NAAHP) and the National Association of Medical Minority Educators (NAMME) can play a major role in providing such professional training. The goals of the newly established NAAHP Committee on Minority Affairs were described earlier. Collaboration between key partners in the recruitment, retention, and acceptance of underrepresented minorities into undergraduate prehealth programs and health professions schools is essential. Short meeting sessions are helpful, but not sufficient to provide the in-depth training needed. Resources will be necessary to support this effort. On many campuses, prehealth advising is not a priority. Therefore, efforts must be made to impress upon administrators at undergraduate institutions the importance of strong institutional support for prehealth advising programs. Most successful programs benefit from such support. Finally, attention to the undergraduate prehealth experience must be a major part of the portfolio of strategies designed to increase the number of underrepresented minorities entering the health professions. The strategies for success presented here must be implemented nationwide to have a significant impact. The dynamic and evolving nature of the health professions requires continued expansion and modification of the programs that prepare future health professionals. The success of the effort will depend on the development of strong partnerships and programs that are student-centered. Minority students must not be denied the personal and professional rewards of careers in the health professions. Furthermore, this nation cannot afford to waste their considerable talents and promise as contributing members of the nation’s health professions workforce. REFERENCES American Association of Dental Schools. (1999). Opportunities for minority students in United States dental schools: 2000–2002, 3rd Edition. Washington, DC: AADS. Association of American Medical Colleges (AAMC). (1999). Special theme issue: Educational programs to strengthen the medical school pipeline. Academic Medicine 74 (4):305–460.

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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions AAMC. (2000a). Minority graduates of U.S. medical schools: Trends, 1950–1998. Washington, DC: AAMC. AAMC. (2000b). Minority student opportunities in United States medical schools 2000. Washington, DC: AAMC. Adelman C., (1999). Answers in the toolbox: Academic intensity, attendance patterns, and Bachelor’s degree attainment. Jessup, MD: U.S. Department of Education, Education Publications Center. Atkinson, D.D., Spratley, E., & Simpson, C.E. (1994). Increasing the pool of qualified minority medical school applicants: Premedical training at historically black colleges and universities. Public Health Report 109(1):77–85. Bowen, W. & Bok, D., (1998). The shape of the river: Long-term consequences of considering race in college and university admissions. Princeton, NJ: Princeton University Press. Carmichael, J.W., Jr., Bauer, J., Hunter, J., Labat, D., & Sevenair, J. (1988). An assessment of a premedical program in terms of its ability to serve black Americans. Journal of the National Medical Association 80(10):1094–1104. Carmichael, J.W., Jr., Labat, D., Hunter, J., Preivett, J., & Sevenair J. (1993). Minorities in the biological sciences—The Xavier success story and some implications. Bioscience 43(8):564–569. College Board. (1999). Reaching the top. New York: National Task Force on Minority High Achievement/College Board. Commission on the Advancement of Women and Minorities in Science Engineering and Technology Development. (2000). Land of plenty: Diversity as America’s competitive edge in science, engineering and technology. [Online]. Available: http://www.nsf.gov/od/cawmset/report [accessed May 17, 2001]. Council on Graduate Medical Education. (1998). Twelfth Report. Rockville, MD: U.S. Department of Health and Human Services. Gandara, P. (1999). Priming the pump: Strategies for increasing the achievement of underrepresented minority undergraduates. New York: National Task Force on Minority High Achievement/College Board. Klein, J. (2000). Results from the Advisor Survey 2000. The Advisor 20(4):50–66. National Center for Education Statistics. 1998. The Condition of Education 1998, NCES 98–013, by Wirt, J., Snyder, T., Sable, J., Choy, S.P., Bae, Y., Stennett, J., Gruner, A., and Perie, M. Washington, DC: U.S. Government Printing Office. National Science Foundation. (2000). Women, minorities, and persons with disabilities in science and engineering: 2000. Arlington, VA: National Science Foundation. Nickens, H.W., Ready, T.P., & Petersdorf, R.G. (1994). Project 3000 by 2000: Racial and ethnic diversity in U.S. medical schools. New England Journal of Medicine 331(7):472–476. Steele, C.M. (1997). A threat in the air: How stereotypes shape intellectual identity and performance. American Psychologist 52(6):613–629. Van Houten, P. (2001). A retrospective look at premedical students’ majors. The Advisor 21(2):31–33.