Commissioned Papers

Editors’ Note:

The following papers were commissioned by the study committee to provide additional analysis and information regarding several key areas of the study charge. For each paper, nationally known experts were asked to review available literature and draw upon their professional expertise to provide an in-depth analysis of institutional and policy-level strategies to increase diversity in the health professions workforce.

The papers were prepared independently of the IOM study committee’s deliberations and analysis, although some of the commissioned paper authors were asked to present their findings before the study committee in public meetings. The opinions expressed in the papers are solely those of the authors. Several of the papers include findings and recommendations; these should not be confused with the findings and recommendations of the study committee, as indicated in the preceding committee report.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Commissioned Papers Editors’ Note: The following papers were commissioned by the study committee to provide additional analysis and information regarding several key areas of the study charge. For each paper, nationally known experts were asked to review available literature and draw upon their professional expertise to provide an in-depth analysis of institutional and policy-level strategies to increase diversity in the health professions workforce. The papers were prepared independently of the IOM study committee’s deliberations and analysis, although some of the commissioned paper authors were asked to present their findings before the study committee in public meetings. The opinions expressed in the papers are solely those of the authors. Several of the papers include findings and recommendations; these should not be confused with the findings and recommendations of the study committee, as indicated in the preceding committee report.

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce This page intentionally left blank.

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Paper Contribution A Increasing Diversity in the Health Professions: A Look at Best Practices in Admissions Gabriel Garcia, Cathryn L. Nation, and Neil H. Parker In fiscal year 2001–2002, Americans spent more than $1.4 trillion on the cost of health care (CMS, 2003). Despite this staggering investment, an estimated 41.2 million individuals were uninsured and another 92 million lacked adequate access to care (Mills, 2002; KFF, 2002). Not surprisingly, a disproportionate number of these more than 133 million people live in inner cities, rural areas, low-income neighborhoods, and communities with large numbers of minority residents. The diversity of the U.S. population continues to grow, yet the lack of diversity among its health providers is striking by any measure. Recent bans on affirmative action, together with persistent inequities in educational opportunity for many poor and minority students, pose major challenges for schools seeking to diversify their classes. In the face of these realities, a growing sense of urgency has emerged. Evidence regarding race- and ethnicity-based disparities in health status is mounting, and the need to increase diversity in the health workforce as a strategy for improving the nation’s health is both logical and clear. This paper builds on previous work undertaken by the authors as part of the Medical Student Diversity Task Force appointed by University of California President Richard C. Atkinson in October 1999 (UCOP, 2000). The paper uses medicine as a model and starting point for examining admissions practices and institutional strategies for increasing the diversity of health professions classes. It begins with a review of the increasing diversity of the population and the profound disparities in health status among racial and ethnic groups as an imperative for change. A commentary about the responsibilities of U.S. medical schools for training clinicians,

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce researchers, and leaders who will collectively meet the needs of the public follows. The paper briefly reviews the history of affirmative action and recent challenges that affect admissions. The medical school admissions process is described in detail, with a focus on strategies and best practices essential to recruiting and enrolling diverse classes of students. Special commentaries for clinical psychology, nursing, and dentistry are also provided. Across the health professions, however, the authors concur that institutional commitment, strong leadership, support for comprehensive strategies, and thinking “outside the box” have never been needed more urgently. DIVERSITY IN THE HEALTH PROFESSIONS The Demographic Imperative Major advances in science and technology have enabled the quality of medical care to improve for many individuals. Notwithstanding these achievements, significant disparities in health status continue to exist between white people and other racial and ethnic minority groups. In a landmark report issued in 1985 by the U.S. Department of Health and Human Services (DHHS), these disparities were described in terms of excess deaths for six health conditions: cancer, cardiovascular disease and stroke, chemical dependency, diabetes, unintentional injuries, and infant mortality (DHHS, 1985). Fifteen years later in 2000, the Surgeon General reported that minority groups continue to have substantially higher morbidity and mortality associated with the same and other health conditions as their white counterparts. These gaps were so great that a national Race and Health initiative was launched by DHHS in 1998. The project was recently expanded and incorporated as part of Healthy People 2010, a national public health initiative calling for the elimination of these disparities by 2010. For many individuals, race- and ethnicity-based disparities in health status are compounded by reduced access to services, lack of adequate insurance, and inadequate availability of physicians and other health-care professionals. Among the nation’s more than 284 million people (U.S. Census Bureau, 2003), an estimated 133 million lack adequate access to care (Mills, 2002; KFF, 2002). In California alone, more than 4 million residents live in 165 areas designated by the state and federal governments as medically underserved or as health professions shortage areas (Grumbach et al., 1999). Nationally, this number jumps to a stunning 56 million (BHPR, 2003). Although differences exist in the criteria used by state and federal agencies to make such designations, health professions shortage areas, overwhelmingly, are home to poor and minority communi-

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce ties that lack access to health services and to adequate numbers and types of health-care personnel. The ramifications of these findings for the health of the nation are substantial. By the year 2020, the U.S. population is projected to reach nearly 325 million. Of these, an estimated 117 million will be nonwhite (U.S. Census Bureau, 1999). Research relevant to these changes shows that physicians from groups traditionally underrepresented in medicine are more likely than others to serve those from minority and economically disadvantaged backgrounds, to practice in physician shortage areas, and to serve patients with chronic illness and multiple diagnoses (UCOP, 2000). The Educational Mission of U.S. Medical Schools The mission of U.S. medical schools is to meet the needs of the citizenry by training competent and compassionate physicians. Meeting Public Health Needs Public support and investment in medical education totals more than $10 billion annually through federal Medicare and Medicaid payments alone (MedPAC, 1998). This investment stems from the view that medical schools and teaching hospitals are a “public good” that benefit society by training tomorrow’s practitioners, providing state-of-the-art patient care, and offering promise of new treatments for alleviating human illness and suffering. In fulfilling this trust, medical schools have an obligation to recruit, admit, and train graduates who will collectively meet the health needs of the public. As the public becomes increasingly diverse, the need for medical schools nationwide, and particularly those in racially and ethnically diverse states such as California, Texas, and New York, to diversify student enrollments is clearly evident from the standpoint of educational opportunity, public health, and workforce need. Despite the select successes of some medical schools, diversity efforts on a national scale have had limited overall success. Medical student education in the United States is conducted in 126 allopathic and 19 osteopathic medical schools. Together, these schools admit approximately 20,000 new students each year. Yet among students who started medical school in fall 2002, fewer than 1,970 (or less than 10 percent) are from groups traditionally underrepresented in medicine (AAMC, 2003; AACOM, 2003). Preparing Clinicians, Scientists, and Leaders Although the lack of diversity in medicine is long-standing, U.S. medical schools and teaching hospitals have been subject to increasing aware-

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce ness and criticism by the public, managed care organizations, and policy makers, who argue that medical education is not adapting to meet changing societal needs. In response to this claim, the Hastings Center brought together representatives from 14 countries to develop a consensus view of what society expected of its doctors (Callahan, 1996). The American Association of Medical Colleges (AAMC) began to address the need for changes in medical education and developed several white papers through its Medical School Objectives Projects I–IV (MSOP). The first such report in this series, entitled “Learning Objectives for Medical Education,” focused on “expressed concerns that new doctors were not as well prepared as they should be to meet society’s expectation of them” (AAMC, 1998, p. 1). Four areas were identified in the report as essential characteristics of practicing physicians; these are that doctors be altruistic, knowledgeable, skillful, and dutiful. The AAMC (1998, p. 4) report stated that, “physicians must be compassionate and empathetic in caring for patients and must be trustworthy and truthful in all of their professional dealings…. They must understand the history of medicine, the nature of medicine’s social compact, the ethical precepts of the medical profession, and their obligations under law…. They must seek to understand the meaning of the patients’ stories in the context of the patients’ beliefs and their family and cultural value…. As members of a team addressing individual or population-based health care issues, they must be willing both to provide leadership when appropriate and to defer to the leadership of others when indicated.” At the turn of the past century, doctors tended to the ill in their homes or in public hospitals. Advances in technology and the development of the modern hospital required that students become clinical scientists prepared to care for the sick in hospital settings. Students were selected for their abilities to master a curriculum heavily weighted to the basic and clinical sciences. They were rewarded for being science majors and for achieving high grade point averages (GPAs) and Medical College Admissions Test (MCAT) scores. Although Americans have always had high expectations about the knowledge and skill of their doctors, the growing diversity of the population has created new expectations. Patients today speak many languages and virtually all want doctors who are able to communicate with them in languages and ways they understand. Increasing attention by accreditation bodies and state and national policy makers has similarly focused on the need for medical schools to better address changing societal needs. The Liaison Committee for Medical Education, which accredits allopathic schools, recently added a requirement that medical schools produce graduates who are culturally competent. Discussions at various state and national levels have also begun to consider the value of adding a language requirement as a prerequisite for admission to medical school. These and other initiatives addressing both undergradu-

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce ate and graduate medical education are driven by growing recognition of the need to improve access to care, reduce disparities in health status, and respond more effectively to the changing needs of the public. The need for diversity in the scientific and research community is equally compelling. Graduates of medical schools frequently do more than just practice medicine. Many are directly and indirectly involved in research at the basic science and clinical levels. All medical students and physicians should be trained to understand research design and its applications and limitations to various patient populations. Research and provider communities should understand that the number of research and clinical trials involving individuals from all races and ethnicities is inadequate, and that this insufficiency limits the application of some research findings. To improve health outcomes, clinicians and researchers will require increased understanding of the disparities in health status that exist between racial and ethnic groups. Improving health outcomes will also require that health-care providers make efforts to improve their own cultural competency and to enhance their awareness of the diversity of belief systems and behavioral determinants that are characteristic of the patient populations they serve. PAST AND PRESENT CHALLENGES TO DIVERSITY Public health needs in America have changed, but efforts to diversify the health professions workforce are by no means new concepts or goals. Just as the achievements of individual schools have varied over time, so have the obstacles to their progress been influenced by changing law, public policy, and societal values. Past challenges remain and new ones have emerged. Critical to the success of some institutions is the use of affirmative action policies that encourage and allow consideration of race/ethnicity as one among many factors considered in the admissions process. Recent bans on affirmative action, however, have created new obstacles for a number of public institutions seeking to diversify their student bodies. A brief review of the history of affirmative action and recent major state initiatives and legal challenges in this area provides useful context for those charged with developing effective institutional policies in the future. Historical Ramifications of Segregation For the first two-thirds of the twentieth century, U.S. medical schools were de facto segregated. The Flexner Report of 1910, which shaped medical education in the subsequent century, encouraged the support of medical education at the historically black colleges and universities to provide a physician workforce that would serve black Americans, yet its recommen-

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce dations resulted in the closure of five of the seven majority medical schools that trained African American physicians (Shea and Fullilove, 1985). As recently as 1964, 93 percent of all medical students in the United States were men and 97 percent were non-Hispanic whites. Of the remaining 3 percent, all but a few were enrolled in the nation’s (then) two predominantly black medical schools, Howard University in Washington, DC, and Meharry Medical College in Nashville, Tennessee. At that time, less than 0.2 percent of all medical students were Mexican American, Puerto Rican, American Indian, or Alaskan Native. Prevailing societal values and practices within the profession were reflected in restricted opportunities for minority medical school graduates to participate in specialty training, medical society membership, hospital staff membership, and other professional activities. Affirmative Action as a Remedy Beginning in the late 1960s, a handful of other medical schools changed their admissions policies and favored a more integrated student body through affirmative action. An example at the time was the University of California Davis campus, where the medical school guaranteed 16 percent of the seats in each incoming class to African American and Mexican American applicants. By 1970, the AAMC adopted a recommendation to medical schools that strongly encouraged vigorous expansion of efforts to recruit and enroll minority students. The AAMC’s stated goal was “to achieve equality of opportunity by relieving or eliminating inequitable barriers and constraints to access to the medical profession” (AAMC, 1970). The widely recognized underrepresentation of minorities in medicine during the middle of this century was one of the driving forces behind the passage of the Federal Comprehensive Health Manpower Training Act of 1971 and its articulation of a new national policy intended to produce a physician workforce that would draw on the knowledge and skills of people from all segments of society. These efforts yielded promising early results. In the 6-year period between 1968 and 1974, enrollment of minority students increased from 3 percent of all entering students to approximately 8 percent nationwide (AAMC, 2000). No significant changes in minority enrollment in medical schools occurred until 1990, when the AAMC established Project 3000 by 2000. This initiative called on U.S. medical schools to increase the number of minority students to 3,000 entering students by the year 2000. It recognized that medical schools have the means and the responsibility to improve educational opportunities for young people and their communities, but that they cannot solve the problem of minority underrepresentation alone. The initiative established both enrichment programs for college students and educa-

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce tional exercises for medical school admissions committee members, which led to a slow but steady rise in minority enrollment until peak levels of 2,014 students (12.4 percent) were reached in 1994. The Bakke Decision In the mid-1970s, and the years that followed, previous gains leveled off. Among the prime causes was a 1974 reverse discrimination lawsuit heard by the U.S. Supreme Court and brought by Allan Bakke against the University of California (UC). Bakke was a 33-year-old white man who applied to the UC-Davis School of Medicine during the time when positions in the entering class were “reserved” for qualified minority students. When Bakke was denied admission, he argued that the admissions process at UC-Davis was discriminatory because only minority students could compete for those seats. The complexity of the Supreme Court’s 1978 decision was reflected in the more than 150 pages and nine opinions necessary to express its result. Six justices wrote separate opinions, with no more than four agreeing fully in their reasoning. Justice Powell cast the deciding vote. In his written opinion, Powell stated, “the State has a substantial interest that legitimately may be served by a properly devised admissions program involving the competitive consideration of race and ethnic origin.” He also quoted the president of Princeton University regarding the benefits of diversity on the learning process, stating that, “it occurs through interactions among students of both sexes; of different races, religions and backgrounds … who are able, directly or indirectly, to learn from their differences and to stimulate one another to examine even their most deeply held assumptions about themselves and their world” (Powell, 1978). As a result of the Court’s decision, Bakke was admitted to medical school at UC-Davis and the school’s special admissions program was invalidated insofar as it reserved seats for minority applicants. More significantly, however, the Court’s decision affirmed the use of race as one among many factors that could be considered as part of the medical school admissions process. Throughout the 1980s and early 1990s, the Supreme Court’s decision set the standard for U.S. medical schools—and for many higher educational institutions nationwide—that sought to increase the diversity of their student bodies. Recent Anti-Affirmative Action Initiatives In the mid-1990s, several high-profile changes in public higher education challenged the use of affirmative action in admissions. The first occurred in July 1995, when the University of California Board of Regents

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce approved a new policy prohibiting the use of “race, religion, sex, color, ethnicity, or national origin as criteria for either admission to the University or to any program of study.” Within 18 months of the regents’ action, two other challenges to affirmative action occurred. In March 1996, the U.S. Supreme Court refused to review the Fifth District Court of Appeals decision in Hopwood v. Texas, which found that the civil rights of four white applicants had been violated by the minority admissions process of the University of Texas School of Law. The Court ruled that the school could not use race as a factor in its admissions process. Although not binding for the rest of the nation, this ruling prohibits the consideration of race in the admissions process among all public higher educational institutions in Texas, Louisiana, and Mississippi. In the November 1996 state general election, California voters passed Proposition 209, thereby adding state constitutional backing to the anti-affirmative action effect of the (then) new regents policy. Proposition 209 provided that the state, including the University of California, “shall not discriminate against, or grant preferential treatment to, any individual or group on the basis of race, sex, color, ethnicity, or national origin in the operation of public employment, public education, or public contracting.” Although the regents rescinded the policy in May 2001, the effects of Proposition 209 nevertheless prohibit the consideration of race in the admissions process. The state of Washington subsequently passed a similar initiative and other states have considered measures intended to achieve the same goal. These state mandates have had significant effects on the rates of admission of underrepresented minority students to medical schools in these states. In fact, reductions in minority student enrollments in these states have been a major cause of the nearly 12 percent decline in the matriculation of underrepresented students at U.S. medical schools between 1995 and 2001 (Cohen, 2003) (Table PCA-1). The Supreme Court Ruling in the University of Michigan Lawsuits The U.S. Supreme Court recently heard two admissions cases, Grutter v. Bollinger and Gratz v. Bollinger, involving the University of Michigan and the constitutionality of using race-conscious decisions as part of its admissions process. Although neither case directly involved medical school or other health profession admissions, the Court’s ruling was widely recognized as one that would have profound bearing on the future of affirmative action in public higher education nationwide. In June 2003, the Court ruled on these separate but parallel cases. In Grutter v. Bollinger, the justices voted 5-4 to uphold the University of Michigan’s law school affirmative action policy. Writing the majority opinion, Justice O’Connor wrote that diversity served a compelling interest in

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce TABLE PCA-1 Underrepresented Minority Matriculants to U.S. Medical Schools, 1995–2001 State 1995 2001 Change % Change California 179 126 –53 –29.6 Louisiana 46 35 –11 –23.9 Mississippi 14 5 –9 –64.3 Texas 218 181 –37 –17.0 Washington 14 6 –8 –57.1 All other states 1,554 1,433 –121 –7.8 Total 2,025 1,786 –239 –11.8   SOURCE: Cohen, 2003. higher education, thereby enabling the school to continue taking race and ethnicity into account. Avoiding the use of quotas, the Court ruled that the school may take steps to “narrowly tailor” its admissions program. In Gratz v. Bollinger, the Court’s 6-3 vote struck down the affirmative action policy for undergraduate admissions, which awarded points related to ethnic background on an admissions rating scale. With these rulings, the Supreme Court recognized the value of diversity in higher education and preserved the ability to consider race as a factor in admissions decisions. Although the Supreme Court’s ruling is a victory for those committed to success in this area, it does not change the fact that affirmative action is now prohibited in some of the most populous states in the nation. It also does not change the fact that bans already in effect for several large and prominent public higher education systems have contributed substantially to the decline in the enrollment of minority students in U.S. medical schools. Further challenges to affirmative action appear likely; if enacted, these can be expected to have similar effects. Ramifications and Implications of Affirmative Action Bans It has been estimated that if affirmative action is prohibited nationally, the number of minority medical students will decrease from 10 percent to fewer than 3 percent (Cohen, 2003). Should this occur, the effect would be less diverse student populations and diminished ability for students to learn in an environment that increases cultural competence and promotes understanding and tolerance of individuals with different backgrounds and opinions. This change would decrease the diversity of future faculty, thereby decreasing the minority representation among those involved in research, teaching, and future leadership of health sciences schools, physician groups, and clinics and medical centers. The applicant pools for these professions will again shrink as prohibitions against race-conscious admissions impact

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Although the factor(s) considered most important by an individual student may differ, most students consistently identify the following as among the most important: academic reputation of the school, anticipated costs of attendance, financial aid offered, location of the school (e.g., urban versus suburban or rural settings), and diversity of the student body, faculty, and surrounding community. Recruitment efforts for students already admitted involve simultaneously putting the school’s “best face” forward and providing an honest assessment of the learning climate and institutional culture on campus. At some schools, this is likely to occur during the interview process itself, with seasoned interviewers recognizing the opportunity to begin recruiting their applicants as soon as they have identified them as highly desirable. Often, this project involves the faculty, students, and staff of the school, all of whom are stakeholders in creating an ideal learning climate that is both excellent and diverse. Different approaches are used, but typical strategies include pairing current students with an accepted applicant to maintain communications and answer questions and inviting accepted applicants to a preview weekend when the school can optimally display its learning climate and diverse community. It is important to note, however, that most applicants will assess the school’s commitment to diversity by looking at the numbers of minority students and faculty and the quality of enrichment and support programs in place and by considering the mission and goals of the institution. Recommendation: Develop educational programs that allow disadvantaged and minority students to succeed. Successful in this regard are early matriculation programs that allow students who have had little exposure to research to establish a relationship with a research mentor, develop skills for research endeavors, and learn leadership skills. One of these programs (the Stanford Early Matriculation Program) has been shown to enhance the likelihood that a minority medical student will have a competitive research grant funded (from 42 percent to 65 percent), that a minority student will publish a manuscript in a peer-reviewed journal (from 16 percent to 22 percent), and that a minority student will graduate from medical school (from 90 percent to 98 percent). Students who enter medical schools with limited prior educational opportunities may have had limited didactic preparation in upper level science courses. These students benefit greatly from schools that provide an environment in which learning skills are assessed and taught, the option to take required courses ahead of schedule is available, and the flexibility to decelerate their coursework is permissible to allow mastery of the curriculum at their own pace. It is important for all medical schools to allow all students

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce to succeed, and this requires the need to accommodate varying levels of achievement and different learning styles. Medical schools should enhance the ability of their students to choose from all careers in medicine to determine those that best fit their skills and interests. Research-intensive medical schools should create an educational environment that encourages participation in scholarly activities, ensures mentorship by faculty, stimulates interest in academic medicine, and enables the student to develop the skills necessary for a career as an educator and researcher. Public-service-oriented schools should teach students how to translate new medical knowledge into effective medical care to all citizens in the community. Faculty should be encouraged to lead by example in teaching students to deliver culturally respectful and competent care to all patients and to work toward reducing the disparities in health status that exist. Recommendation: Establish and maintain outreach programs to increase student interest in the health professions and their eligibility for admission. Many schools have programs that span the educational pipeline, beginning in elementary school and continuing through high school, into college, and beyond. Successful programs should include efforts to provide information to prospective applicants and be tailored appropriately to various educational levels. Medical, dental, and other health professions schools should send representatives to other campuses and undergraduate institutions as well as to community forums and fairs that hold informational sessions for prospective applicants, making special efforts to reach disadvantaged and underrepresented students. These efforts will help to ensure that students identify a health professions career as an option and that they have access to reliable information when preparing for and applying to medical school. For students who apply, but are not initially accepted, many medical schools and some dental schools offer postbaccalaureate programs to help students prepare and reapply. These programs are available to students who seek to improve their application; some are available to those making a career change. These programs typically offer programs that can be adjusted to meet the needs of individual students; most, however, offer MCAT (or other standardized test) preparation, additional science coursework, and support with the application process for disadvantaged students who are reapplying. Many postbaccalaureate programs have had highly successful records in helping promising young students gain admission. Health professions schools that do not offer a postbaccalaureate program should consider creating a program or partnering with a school that has an existing program with a record of success.

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Recommendation: Improve and maintain active partnerships with undergraduate health sciences advisors. The academic and personal advising that many students receive in high school and college plays an influential role in building confidence and in determining whether many students will go on to apply to medical or health professions programs. For those experiencing academic difficulties at an early stage, tutoring and advising by knowledgeable teachers or advisors often make the critical difference in developing the skills and confidence needed for success. Many students believe that science grades are the exclusive or primary factor considered in the admissions process. As a result, poor grades or difficulty with an introductory undergraduate course such as inorganic chemistry or physics may deter an otherwise promising undergraduate from giving further consideration to the health sciences as an educational option. For students with relatively poor high school preparation, such as those entering college with few opportunities to have taken advanced placement courses, these perceptions can play a powerful role at an early stage in their decision making relative to a future career in medicine. REFERENCES AACN (American Association of Colleges of Nursing). 2001. Effective Strategies for Increasing Diversity in Nursing Programs. [Online]. Available: http://www.aacn.nche.edu/Publications/issues/dec01.htm [accessed August 26, 2003]. AACOM (American Association of Colleges of Osteopathic Medicine). 2003. AACOMAS Update. [Online]. Available: http://www.aacom.org/data/advisorupdate/ [accessed August 21, 2003]. AAMC (Association of American Medical Colleges). 1970. Report of the Association of American Medical Colleges Task Force to the Inter-Association Committee on Expanding Educational Opportunities in Medicine for Blacks and Other Minority Students, April 22, 1970. Washington, DC: AAMC. AAMC. 1998. Report I. Learning Objectives for Medical Education: Guidelines for Medical Schools. Washington, DC: Medical School Objectives Project. AAMC. 2000. Minority Graduates of U.S. Medical Schools: Trends, 1950–1998. Washington, DC: Association of American Medical Colleges. AAMC. 2003. Medical School Profile System. [Online]. Available: http://services.aamc.org/msps/report.cfm [accessed August 21, 2003]. APA (American Psychological Association). 2000. Model Strategies for Ethnic Minority Recruitment, Retention and Training in Higher Education. Washington, DC: APA Office of Ethnic Minority Affairs. APA. 2003a. 2004 Graduate Study in Psychology, Research Office, APA. Washington, DC: American Psychological Association. APA. 2003b. Summary Report: Doctorate Recipients from United States Universities (selected years). Washington, DC: APA Research Office. Basco WT Jr., Way DP, Gilbert GE, Hudson A. 2002. Undergraduate institutional MCAT scores as predictors of USMLE Step 1 performance. Academic Medicine 77:S13–S16.

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce BHPR (Bureau of Health Professions). 2003. Health Professional Shortage Areas: Shortage Designation. Health Resources and Services Administration. [Online]. Available: http://bhpr.hrsa.gov/shortage/index.htm [accessed August 21, 2003]. Callahan D. 1996. The goals of medicine: Setting new priorities. The Hastings Center Report 26:S1-S27. CMS (Centers for Medicare & Medicaid Services). 2003. Highlights—National Health Expenditures, 2001. [Online]. Available: http://cms.hhs.gov/statistics/nhe/ [accessed August 20, 2003]. Cohen JJ. 2003. The consequences of premature abandonment of affirmative action in medical school admissions. Journal of the American Medical Association 289:1143–1149. Davidson RC, Montoya R. 1987. The distribution of medical services to the underserved: A comparison of majority and minority medical graduates in California. Western Journal of Medicine 146:114–117. DHHS (Department of Health and Human Services). 1985. Health, United States, 1983 and Prevention Profile. Publication number (PHS) 84-1232. Pp. 1–256. [Online]. Available: http://www.cdc.gov/nchs/data/hus/hus83acc.pdf [accessed July 13, 2003]. DHHS (Department of Health and Human Services). 2000. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. Pp. 1–332. Grumbach K, Coffman J, Liu R, Mertz E. 1999. Strategies for Increasing Physician Supply in Medically Underserved Communities in California. San Francisco: University of California, California Policy Research Center. Haden NK, Catalanotto FA, Alexander CJ et al. 2003. Improving the Oral Health Status of All Americans: Roles and Responsibilities of Academic Dental Institutions. The Report of the ADEA President’s Commission. Washington, DC: American Dental Education Association. Pp. 1–22. Hennessey J. 2003. Statement on Affirmative Action. Meeting of the Stanford University Faculty Senate, Stanford, CA, January 23, 2003. Holliday BG et al. 1997. Visions and Transformations: The Final Report. American Psychological Association, Washington, DC, January 1997. [Online]. Available: http://www.apa.org/pi/oema/visions/resolution.html [accessed December 16, 2003]. HRSA (Health Resources and Services Administration). 2002a. The Registered Nurse Population: March 2000. Findings from the National Sample Survey of Registered Nurses. Washington, DC: Bureau of Health Professions, Division of Nursing. Pp. 1–125. HRSA (Health Resources and Services Administration). 2002b. Shortage Designation Branch, Bureau of Health Professions. [Online]. Available: http://bphc.hrsa.gov/databases/newhpsa/newhpsa.cfm [accessed November 26, 2002]. Huff KL, Fang D. 1999. When are students most at risk of encountering academic difficulty? A study of 1992 matriculants to U.S. medical schools. Academic Medicine 74:454–460. IPEDS. 1999. 1997 Fall Enrollment. Barron’s Profiles of American Colleges. Julian E. 2000. The predictive ability of the Medical College Admissions Test. Contemporary Issues in Medical Education 3(2):1–2. Keith SN, Bell RN, Swanson AG, Williams AP. 1985. Effects of affirmative action in medical schools: A study of the class of 1975. New England Journal of Medicine 313:1519–1525. KFF (Kaiser Family Foundation). 2002. Underinsured in America: Is Health Coverage Adequate? Menlo Park, CA: Kaiser Commission on Medicaid and the Uninsured. Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, Bindman AB. 1996. The role of black and Hispanic physicians in providing health care for underserved populations. New England Journal of Medicine 334:1305–1310.

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Leahy M, Cullen W, Bury G. 2003. “What makes a good doctor?” A cross sectional survey of public opinion. Irish Medical Journal 96(2):38–41. MedPAC (Medicare Payment Advisory Commission). 1998. Rethinking Medicare’s Payment Policies for Graduate Medical Education and Teaching Hospitals. Report to the Congress. Washington, DC: Medicare Payment Advisory Commission. Pp. 1–19. Mills R. 2002, September 30. Health insurance coverage: 2001. Current Population Reports. Washington, DC: U.S. Census Bureau, U.S. Department of Commerce, Economics and Statistic Administration. Pp. 1–24. Moy E, Bartman BA, Weir MR. 1995. Access to hypertensive care. Archives of Internal Medicine 155:1497–1502. Powell L. 1978. Bakke, 438 U.S. at 312–13 n.48. Shea S, Fullilove M. 1985. Entry of blacks and other medical students into U.S. medical schools: Historical perspective and recent trends. New England Journal of Medicine 313:933–940. Silver B, Hodgson CS. 1997. Evaluating GPAs and MCAT scores as predictors of NBME I and clerkship performances based on students’ data from one undergraduate institution. Academic Medicine 72:394–396. Steele CM, Aronson J. 1995. Stereotype threat and the intellectual test performance of African Americans. Journal of Personality and Social Psychology 69:797–811. UCOP (University of California Office of the President). 2000. Special Report on Medical Student Diversity. Medical Student Diversity Task Force, Office of Health Affairs, University of California. Oakland, CA: UCOP. Pp. 1–75. University of Michigan. 2003. University Record. [Online]. Available: http:/www.umich.edu/~urecord/0203/June16_03/19_mahoney.shtml [accessed June 23, 2003]. U.S. Census Bureau. 1999. U.S. Population by Race: 1980, 2000, and 2020. U.S. Population Trends. [Online]. Available: http://www.census.gov/mso/www/pres_lib/poptrnd/sld023.htm [accessed August 21, 2003]. U.S. Census Bureau. 2003. Population Briefing: National Population Estimates for July 21, 2002. [Online]. Available: http://eire.census.gov/popest/data/national/popbriefing.php [accessed August 21, 2003]. U.S. Department of Education. 2000. National Center for Education Statistics. [Online]. Available: http://nces.ed.gov/ [accessed August 21, 2003]. Valachovic RW, Weaver RG, Sinkford JC, Haden NK. 2001. Trends in dentistry and dental education. Journal of Dental Education 65(6):539–563. Weaver RG. 2003. Priming the Pipeline II: Recruiting Dental Professionals for the Future. Presentation to the National Dental Association’s 2003 Minority Faculty and Administrators’ Forum. New Orleans, August 1, 2003. Weaver RG, Haden NK, Valachovic RW. 2000. U.S. dental school applicants and enrollees: A ten-year perspective. Journal of Dental Education 64:867–868.

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce APPENDIX TO COMMISSIONED PAPER A DISADVANTAGED STATUS EVALUATION FORM This form is included in the folders of applicants who consider themselves disadvantaged according to the following American Medical College Application Service (AMCAS) question: “Do you wish to be considered a disadvantaged applicant by any of your designated medical schools which may consider such factors (social, economic, or educational)?” APPLICANT’S NAME: ___________________________________ Average parental education (See AMCAS “Parent Information” Section—Pg. 2): Elementary school or less High school Some college, no degree (Q: fix vertical alignment) College, advance degree (Q: advanced?) Parental occupation (Please fill in): Geographic location where applicant was raised (See AMCAS “Bio. Info.” Section—Pg. 2): Inner City Rural Suburban or City Hours per week applicant worked for self-support during school year (See AMCAS “Experience” Section—Various Hrs.): 20 or more 15–20 <15 English is applicant’s second language (See AMCAS “Bio. Info.” Section—Pg. 2): Yes No

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Additional factors indicated (e.g., physical handicap, immigrant, experience with prejudice, special family situation/responsibilities, cultural differences)? (See AMCAS “Bio.” Section for Hardships & Family Income) Please list:____________________________________________________ Please circle which best describes your assessment of this applicant as Disadvantaged: 1 2 3 4 Very Disadvantaged Somewhat Disadvantaged Little Evidence of Disadvantaged Status No Evidence of Disadvantaged Status

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 2002–2003 ADMISSIONS SEASON – MD FILE REVIEW FORM Please circle your scores for each category. HIGH LOW RESEARCH OR OTHER SCHOLARLY PROJECTS 1 2 3 4 In-depth experience with significant productivity (e.g., publication). Evidence of critical independence and outstanding scholarship. In-depth (>1 year) experience in a single area. Letters suggest above average scholarship and potential as an independent investigator. Some experience (<1 year), usually in nonindependent or technical capacity. Or, may have short experiences (e.g., in summers) in different fields. May be seen as “industrious, learns techniques quickly,” etc., but no suggestion of scholarly independence. Little (3 months or less) or no experience. LEADERSHIP 1 2 3 4 Outstanding in all areas. Demonstrated clear evidence of innovative thinking, left a legacy of her/his work. Held a leadership position of consequence, elected or appointed. Sustained commitment to activities. Felt to be a strong team player and/or congenial and mature. Showed up for activities as a member but added little value to them beyond his/her participation (or less). ORIGINALITY, CREATIVITY 1 2 3 4 Everyone comments on it—unusual accomplishment in science, fine arts, etc. Comments by more than one person—may have substantial musical, artistic, literary, organizational, etc., talents. One person comments (usually a research advisor)—no, or little, other evidence for it. No mention in letters; no evidence in research or otherwise (music, art, organizational talents, etc).

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce NONACADEMIC ACCOMPLISHMENTS (includes working) 1 2 3 4 Outstanding accomplishments (national recognition in sports, artistic endeavors, established business or program, etc.). Above-average skill/achievement in an extracurricular area (e.g., varsity sports, arts, editor of yearbook, etc.) plus participation in other areas. Heavy work load (>15 hrs/wk) during academic year required for self-support. Participation in routine extracurricular activities (intramurals, premed club, etc.), routine jobs. Few, if any, extracurricular activities—routine jobs, few hours. We interview to confirm that an applicant is outstanding, not just to gain more info. not evident in the Supplemental Application. 1 INTERVIEW (Most impressive type of candidate) 2 PROBABLY INTERVIEW (Interview if there are not 500 candid. in Group 1) 3 PROBABLY DO NOT INTERVIEW (Very good but not outstand.) 4 DO NOT INTERVIEW (Fine person but not competitive with others) Please circle one. Why YOU DO or DO NOT favor an interview? Please explain below. Indicate specific aspects of the application that an interviewer should clarify during the interview. INTERVIEW FORM Name of Candidate:_____________________ Date of Interview: _______ Undergraduate University:________________ Time of Interview: _______ Interviewer:_____________________________ Place of Interview: _______ Note: The interview report should provide the Admissions Committee with more information about the candidate’s apparent strengths and weaknesses and should supply information that is not evident from the file. It is most important that you give evidence (i.e., SPECIFIC DETAILS OF YOUR

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce CONVERSATION) rather than mere impressions. We request that you address at least the following issues in your interview: Does your interaction with the candidate conform to expectations derived from reading the application? If not, what are the discrepancies, re: major commitments, scholarly interests, and long-range goals? In the candidate’s research, are you able to determine the motivation, persistence, level of independence—i.e., range from talented technician, to independent execution of a research protocol established by others, or to responsibility for developing an original research proposal and execution thereof? What role did the candidate play in interpretation and reporting of results? Does the candidate have an appreciation of how the results of the research project(s) fit into a larger field of knowledge? What are the candidate’s plans for research in the future? Do you think the letters of support fairly represent the candidate? Does the candidate have a lively interest in the world outside of academics and an interest in the welfare of others? Does the candidate have any significant knowledge of our school and how it would benefit him/her in pursuit of stated goals? Has the candidate volunteered any consideration for exploring a career in academic medicine? Do you consider that a career in academic medicine will be likely for this candidate? Do you think the candidate has a reasonable understanding of the positive and the negative aspects of a career in medicine? Please evaluate the educational context of this applicant with respect to high school education; parental income, education, and occupation; hours per week of work during college; geographic location where applicant grew up; prior experiences with prejudice; cultural and language barriers or other special family circumstances. Have you explored answers to questions raised by file reviewers? Do you detect any characteristics that cause you to question the candidate’s suitability for a career in medicine or the ability to think logically and critically?

OCR for page 231
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Are there specific concerns the candidate may have about our school? Is follow-up necessary by the Admissions Office or Committee? Yes___ No___ (If yes, please specify: e.g., “Solicit further information from Dr. X on candidate’s research role,” etc.) Summary Statement: We will only interview the most compelling 8–10 percent of our applicant pool. We will only make an initial offer of acceptance to one-third (1/3) of applicants interviewed. Please rank this applicant with an “X” anywhere along this scale based on your review of the file and your interview. If you interview a random pool of applicants, you should only score 1/3 of your interviewees in the top group. 1 2 3 A must-have candidate, with evidence of independent thinking and creativity, potential for an academic medicine career or leadership role, outstanding depth of education and community service activities, and a contribution to the learning environment and diversity of the school. An excellent candidate who may have an outstanding track record in one or more areas of interest to us but lacks the special qualities of our top applicants. Capable of the intellectual demands of medical school but whose accomplishments and potential for success in scholarly, educational, or service activities are not exceptional. Briefly state the most significant item in this application that resulted in this ranking.