Paper Contribution D
Diversity Considerations in Health Professions Education

Jeffrey F. Milem, Eric L. Dey, and Casey B. White,

“Effective participation by members of all racial and ethnic groups in the civic life of our Nation is essential if the dream of one Nation, indivisible, is to be realized.”

—Justice O’Connor in Grutter v. Bollinger

INTRODUCTION

The recent decisions by the U.S. Supreme Court in two cases that challenged the use of affirmative action in undergraduate admissions and in law school admissions at the University of Michigan helped to provide some clarity to an ongoing debate regarding the educational value of diversity, and specifically, racial and ethnic diversity, on our nation’s college campuses. In the opinion that upheld the constitutionality of the admissions process used for selecting law school students at Michigan, Justice O’Connor wrote that a majority of the court agreed that diversity served a compelling interest for institutions of higher education as well as for our society. The University of Michigan successfully demonstrated to the Court that diversity was essential in helping it to achieve its education mission because more diverse colleges and universities provide opportunities for teaching and learning that are not available in institutions that are less diverse. The university was able to make this case, in large part, because of the array of empirical evidence that it and other organizations provided that established how diversity enhanced the learning outcomes for students at Michigan and at colleges and universities across the country.

The primary goal of this paper is to examine the ways in which existing evidence about diversity in higher education and its effects on students, institutions, and society can be used to inform and improve the quality of education received by students in health professions. Published reviews of the literature on undergraduate college students clearly demonstrate that



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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Paper Contribution D Diversity Considerations in Health Professions Education Jeffrey F. Milem, Eric L. Dey, and Casey B. White, “Effective participation by members of all racial and ethnic groups in the civic life of our Nation is essential if the dream of one Nation, indivisible, is to be realized.” —Justice O’Connor in Grutter v. Bollinger INTRODUCTION The recent decisions by the U.S. Supreme Court in two cases that challenged the use of affirmative action in undergraduate admissions and in law school admissions at the University of Michigan helped to provide some clarity to an ongoing debate regarding the educational value of diversity, and specifically, racial and ethnic diversity, on our nation’s college campuses. In the opinion that upheld the constitutionality of the admissions process used for selecting law school students at Michigan, Justice O’Connor wrote that a majority of the court agreed that diversity served a compelling interest for institutions of higher education as well as for our society. The University of Michigan successfully demonstrated to the Court that diversity was essential in helping it to achieve its education mission because more diverse colleges and universities provide opportunities for teaching and learning that are not available in institutions that are less diverse. The university was able to make this case, in large part, because of the array of empirical evidence that it and other organizations provided that established how diversity enhanced the learning outcomes for students at Michigan and at colleges and universities across the country. The primary goal of this paper is to examine the ways in which existing evidence about diversity in higher education and its effects on students, institutions, and society can be used to inform and improve the quality of education received by students in health professions. Published reviews of the literature on undergraduate college students clearly demonstrate that

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce various aspects of racial and ethnic diversity within higher education help promote benefits of assorted kinds (Milem, 2003; Hurtado et al., 2003; Milem and Hakuta, 2000; Gurin, 1999, Appendix A). These reviews indicate that diversity-related benefits are far ranging, spanning from benefits to individual students and the institutions in which they enroll, to private enterprise, the economy, and the broader society. The benefits that accrue to individuals through enhancements to their educational experiences and educational outcomes (including process outcomes that help influence subsequent outcomes of these students; see Milem, 2003; Astin, 1991) are perhaps the most commonly recognized; diversity has been shown to enhance the ability of colleges and universities to achieve their missions—particularly as they relate to the missions of teaching, research, and service. Economic and private-sector benefits are reflected in the ways in which diversity enhances the economy and the functioning of organizations and businesses in the private sector. Societal benefits differ in that they transcend the boundaries of individual organizations and are related to the achievement of democratic ideals, the development of an educated and involved citizenry, and the ways in which underserved groups (e.g., low-income, elderly, those who lack insufficient health care) are able to receive the services they require. Recent original research efforts reinforce this viewpoint in higher education generally (Bowen and Bok, 1998), and specifically in medical education (Whitla et al., 2003). It is important to note that research on the benefits of diversity indicates that these benefits do not automatically accrue to students who attend institutions that are, in terms of student or faculty composition, racially and ethnically diverse. Rather, if the benefits of diversity in higher education are to be realized, close attention must be paid to the institutional context in which that diversity is enacted. In other words, it is not enough to simply bring together a diverse group of students. Although this is an important first step in creating opportunities for students to learn from diversity, it cannot be the only step that is taken. Diverse learning environments provide unique challenges and opportunities that must be considered if we are to maximize the learning opportunities that they present. If we are to change educational environments in ways that allow us to maximize the opportunities and minimize the challenges that are presented by diversity, we must first understand the conditions under which students are able to learn from diversity. In the pages that follow, we summarize the literature that does this. To begin, we review the literature drawn from studies of higher education generally, followed by a focused consideration of issues related specifically to health professions education (with an emphasis on medical education). To begin our discussion of higher education generally, we summarize and extend the key components of a framework for understanding campus diversity issues first developed by Hurtado and

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce colleagues (1998, 1999). This provides a useful frame for understanding the different dimensions of campus diversity and their importance. Having provided some conceptual definitions of diversity, we turn to research linking diversity and learning, emphasizing in turn cognitive and emotional development issues, contextual issues and learning environments, and pedagogy. The focused discussion of health professions issues follows a similar logic, beginning with a consideration of the importance of diversity in these fields and unique characteristics of these fields of study (including goals, standards, and curricular structure). The status of current curricular approaches that support diversity-related education is discussed as are problems and issues with current approaches. An extension of cognitive and emotional development concerns related to health professions education is presented, followed by a discussion of how educational settings and learning environments can influence learning related to diversity issues, as well as pedagogy that can promote transformative learning. These two strands of work—higher education generally, and health professions specifically—are brought together in a set of recommendations intended to guide the transformation of education in the health professions so that students in these fields realize the educational benefits of diversity, and so that all members of our society will be better served by the professionals who provide them with health care. DEFINING DIVERSITY In considering how we maximize the benefits of diverse learning environments, it is important to define precisely what we mean by diversity. Although other dimensions exist, for the purpose of this paper we will focus on diversity with respect to race and ethnicity. Recent work by Hurtado and colleagues (1998, 1999) provides a useful framework for conceptualizing and understanding the impact of various dimensions of the campus racial climate and documents the importance of an institution’s context in shaping student outcomes. This framework was first introduced in a study of the climate for Latino students (Hurtado, 1994) and further developed in syntheses of research done for policy makers and practitioners (Hurtado et al., 1998, 1999). The campus climate described by Hurtado and colleagues differs from earlier research that defined the climate as reflecting common participant attitudes, perceptions, or observations about the environment (Peterson and Spencer, 1990). These common attitudes and perceptions are identified as malleable and distinguishable from the stable norms and beliefs that may constitute an organizational culture. Although this work has been important in distinguishing the climate from the culture of an organization, it is

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce most important in establishing that the climate is malleable and that the current patterns of beliefs and behaviors are amenable to planned efforts to change or improve the climate. The framework discussed by Hurtado et al. (1998, 1999) builds on this earlier work by expanding our thinking about climate by asserting that the psychological climate (perceptions and attitudes) is linked to a range of social phenomenon that have to do with structure, history, and actual interactions across diverse communities within the environment. Central to their conceptualization of a campus climate for diversity is the notion that students are educated in distinct racial contexts. Both external and internal (institutional) forces shape these contexts in higher education. The external components of climate represent the impact of governmental policy, programs, and initiatives as well as the impact of sociohistorical forces on campus racial climate. The authors indicate that governmental contextual factors that influence the climate for diversity on college campuses include financial aid policies and programs, state and federal policy regarding affirmative action, court decisions related to the desegregation of higher education, and the manner in which states provide for institutional differentiation within their state system of higher education. Hurtado et al. (1998, 1999) describe sociohistoric forces that influence the climate for diversity on campus as events or issues in the larger society that are connected to the ways in which people view racial diversity in society. One recent example of this is the impact that the ongoing debate over affirmative action in college admissions had on the climate for diversity at colleges and universities across the country. Although these forces are usually initiated outside of the context of the institution, they frequently serve as a stimulus for discussion or other activity within the campus context. Because “[n]o policy can be isolated from the social arena in which it is enacted” (Tierney, 1997, p. 177), it is important to note that these two forces mutually influence each other. The institutional context contains multiple dimensions that are a function of educational programs and practices. These include an institution’s historical legacy of inclusion or exclusion of various racial/ethnic groups; its compositional diversity1 in terms of the numerical and proportional 1   Much of the relevant research describes this dimension of climate as structural diversity. However, we prefer the term compositional diversity as it more accurately reflects how this concept has been operationalized in diversity research, without being confused with other aspects of campus structure—such as the curriculum, decision-making practices, reward structures, hiring practices, admissions practices, tenure decisions, and other factors that function as part of the day-to-day “business” on our campuses. Although the term “compositional” is divergent from existing research, we employ it here in hopes of being more direct in describing the concept we are discussing.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce representation of various racial/ethnic groups; the psychological climate, which includes perceptions and attitudes between and among groups; as well as a behavioral climate dimension that is characterized by the nature of intergroup relations on campus. Hurtado et al. (1998, 1999) conceptualize the institutional climate as a product of these dimensions. These dimensions are not discrete; rather, they are connected with each other. For example, a historical vestige of segregation has an impact on an institution’s ability to improve its racial/ethnic student enrollments, and the underrepresentation of specific groups contributes to stereotypical attitudes among individuals within the learning and work environment that affect the psychological and behavioral climate. While some institutions take a “multilayered” approach toward assessing diversity on their campuses and are developing programs to address the climate on campus, most institutions fail to recognize the importance of the dynamics of these interrelated elements of the climate. Historical Legacy of Inclusion or Exclusion Hurtado et al. (1998, 1999) argue that the historical vestiges of segregated schools and colleges continue to affect the climate for racial/ethnic diversity on college campuses. Evidence can be seen in resistance to desegregation in communities and specific campus settings, maintenance of old campus policies at predominantly white institutions (PWIs) that best serve a homogeneous population, and attitudes and behaviors that prevent interaction across race and ethnicity. Duster (1993) argued that many campuses sustain benefits for particular student groups that go largely unrecognized because these institutions are embedded in a culture of a historically segregated environment. While some campuses have a history of admitting and graduating students of color since their founding (i.e., historically black colleges and universities), most PWIs have a history of limited access and exclusion (Thelin, 1985). These institutions have a longer history of segregation and exclusion than they do of inclusion. An institution’s historical legacy of exclusion has a significant impact on the prevailing climate that influences current policies and practices at the institution (Hurtado, 1992; Hurtado et al., 1998, 1999). Institutions that are clear about their history of exclusion and the detrimental impact that this history has had may be able to gain broader support for their efforts to become more diverse through the use of affirmative action and other programs and services designed to improve the climate for diversity. Furthermore, institutions that acknowledge a history of exclusion may be able to demonstrate to people of color that the institution is willing to acknowledge its past transgressions and is working to rid itself of its exclusionary past.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Compositional Diversity Increasing the compositional diversity of an institution is an important initial step toward improving the climate (Hurtado et al., 1998, 1999). The distribution of students in a particular environment shapes the dynamics of social interaction in that environment (Kanter, 1977). For example, Chang (1999) has shown that the likelihood that students will engage with students who are different from them increases as the compositional diversity of the campus increases. Conversely, campuses with high proportions of white students provide limited opportunities for interaction across race/ ethnicity and limit student learning experiences with socially, culturally diverse groups (Hurtado et al., 1994). Moreover, in environments that lack diverse populations, underrepresented groups are frequently viewed as tokens. Tokenism contributes to the heightened visibility of the underrepresented group, overstatement of group differences, and the alteration of images to fit existing stereotypes (Kanter, 1977). In addition, the fact that racial and ethnic students remain minorities in majority white environments contributes to social stigma that can adversely affect their achievement (e.g., see Steele, 1992, 1997, 1998; Steele and Aronson, 1995) and can produce minority status stressors (Prillerman et al., 1989; Smedley et al., 1993). Finally, an institution’s stance on increasing the representation of diverse racial/ethnic groups communicates to external and internal constituencies the importance of maintaining a multicultural environment (Hurtado et al., 1998, 1999). Institutional leaders should not expect that they will substantially improve the campus racial climate merely by increasing the compositional diversity of their institution. As stated earlier, problems may arise if efforts are not made to address and improve other dimensions of the campus climate. However, if increased compositional diversity is accompanied by institutional efforts to become more “student centered” in approaches to teaching and learning (Hurtado, 1992; Hurtado et al., 1998, 1999), and if regular and ongoing opportunities for students to come together to communicate and interact cross-racially are provided (Chang, 1999), increased compositional diversity is likely to be beneficial. Increasing compositional diversity is an important first step in improving the campus climate. The Psychological Climate The psychological dimension of the campus climate includes individuals’ views of group relations and institutional responses to diversity, perceptions of discrimination or racial conflict, and attitudes held toward individuals from different racial/ethnic backgrounds. Increasingly, studies have shown that racially and ethnically diverse administrators, students, and

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce faculty are likely to view the campus climate differently. Thus, an individual’s position and power within the organization as well as her/his view as “insider” or “outsider” are likely to contribute to different views or standpoints (Collins, 1986). Hurtado et al. (1998, 1999) summarized this phenomenon by asserting that who you are and where you are positioned in an institution affects the way in which you experience and view the institution. These differences in perception of the college experience are significant because perception is both a product of the environment and a potential determinant of future interactions and outcomes (Astin, 1968; Berger and Milem, 1999; Milem and Berger, 1997; Tierney, 1987). Research on the impact of peer groups and other reference groups is helpful in understanding another important aspect of the psychological dimension of climate on campus. Peer groups exert influence over the attitudes and the behavior of students through the norms that they communicate to their members. While faculty play an important role in the educational development of students, most researchers believe that student peer groups are principally responsible for much of the socialization that transpires (Astin, 1993; Chickering, 1969; Dey, 1996, 1997; Feldman and Newcomb, 1969; Milem, 1998). This is not meant to diminish the role that faculty play; rather, it suggests that the normative influence of faculty is likely to be amplified or attenuated by the interactions students have with their peers. Recent research on diverse friendship groups suggests that such dynamics are especially strong in areas where students are in the process of transforming their attitudes related to issues of race and ethnicity as well as those of their peers (Antonio, 2001). The Behavioral Climate The behavioral dimension of the institutional climate consists of general social interaction, interaction between and among individuals from different racial/ethnic backgrounds, as well as the nature of intergroup relations on campus. The prevailing view, particularly in reports forwarded by the popular media, is that campus race relations are poor and that segregation has increased on college campuses among minority groups. However, several research studies present a different picture of students’ actual interactions and relations on campus. For example, while in one study, white students interpreted ethnic group clustering as racial segregation, students of color described this behavior as their attempt to find sources of cultural support within an unsupportive environment (Loo and Rolison, 1986). Another study that examined the nature of cross-racial interaction among college students found that Mexican American, Asian American, and African American students reported widespread and frequent interaction across race/ethnicity in various informal situations (i.e.,

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce dining, roommates, dating, socializing), while white students were least likely to report engaging in these activities across race (Hurtado et al., 1994). Moreover, it is clear that the absence of interracial contact influences students’ views toward others, their support for important campus initiatives, and key educational outcomes (Hurtado et al., 1998, 1999). However, students who have the opportunity to engage diverse peers in regular and ongoing structured interaction are more likely to show greater growth on a number of critical educational outcomes. The findings from research on the impact of campus initiatives that bring students from diverse groups together to engage in structured intergroup dialogues indicate that students who participate in these activities are more likely to report growth in their affinity for others. In addition, they are more likely to report enhanced enjoyment in learning about their own background as well as the backgrounds of diverse others. Moreover, these students are likely to report more positive views of conflict and to hold the perception that diversity does not need to be divisive in our society. Gurin (1999) argues that these are essential skills required of all citizens in an increasingly diverse democracy. An important aspect of the behavioral climate involves the extent to which students have the opportunity to engage diverse others as well as diverse information and diverse ideas in their classes. These opportunities are enhanced in classrooms where faculty members use active teaching methods. In these classrooms, students are able to interact with peers from diverse backgrounds through class discussions, collaborative learning methods, and group projects. These activities contribute to a campus climate that is more supportive of diversity and leads to positive outcomes for the students involved (see, for example, Astin, 1993; Gurin, 1999; Hurtado et al., 1998, 1999; Milem, 2003; Milem and Hakuta, 2000; Smith & Associates, 1997). Clearly, there are some disciplines in which it is much easier for students to engage diverse information through course content (e.g., fields such as education, English, humanities, history, political science, psychology, sociology). However, when faculty are conscientious about incorporating active pedagogical methods into the courses they teach, students have frequent opportunities to learn from diverse peers—even in fields that do not appear to readily lend themselves to the incorporation of diverse content and subject matter (e.g., the physical sciences). As we will discuss later in this manuscript, the use of active learning or student-centered pedagogical methods in classes enhances a variety of important learning outcomes for students, including mastery of content in particular disciplines. However, the opportunities that students have to learn from diverse peers in classes that use these active learning methods, even in classes where the content does not deal explicitly with diversity issues, can help students to build bridges across communities of difference.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce The Consequences of Diversity Climate Within the context of an institution’s diversity climate, the effects of diversity play themselves out along a variety of dimensions. The works of Gurin (1999), Chang (1999), Milem (2003), and Milem and Hakuta (2000) argue that, in addition to compositional diversity, there are two additional types of diversity that can have an impact on important educational outcomes. Diversity of interactions is a second type shown to be influential in creating educational benefits and is represented by students’ exchanges with racially and ethnically diverse people and diverse ideas, information, and experiences. People are influenced by their interactions with diverse ideas and information as well as with diverse people. The final type of diversity is characterized by different diversity-related initiatives (i.e., core diversity course requirements, ethnic studies course/programs, diversity enhancement workshops, intergroup dialogue programs, and others) that occur on college and university campuses. While shifts or changes in the compositional diversity of campuses often provide stimulus for the creation and implementation of diversity-related initiatives (Chang, 1999), increasingly more colleges and universities are implementing these initiatives even though their campuses are quite racially and ethnically homogeneous. These types of diversity are not discrete. We are most frequently exposed to diverse information and ideas through the interactions that we have with diverse people. Moreover, while diversity-related initiatives benefit students who are exposed to them—even on campuses that are almost exclusively white—their impact on students is much more powerful on campuses that have greater compositional diversity (Chang, 1999, 2002). Although each type of diversity has the potential to confer significant positive effects on educational outcomes, the impact of each type of diversity is enhanced by the presence of the others (Chang, 1999, 2002; Gurin, 1999; Gurin et al., 2002; Hurtado et al., 1998, 1999; Hurtado et al., 2003; Milem, 2003; Milem and Hakuta, 2000). Conversely, the impact of each type of diversity is diminished in environments where the other types are absent. Chang’s work (1999, 2002) is very helpful in illustrating the three types of diversity we have discussed and the impact they have on students. Chang (1999) found that maximizing cross-racial interaction and encouraging ongoing discussions about race were educational practices that produced positive educational outcomes for students. The findings from Chang’s study revealed that socializing across race and discussing racial/ethnic issues had a positive effect on the likelihood that students would stay enrolled in college, be more satisfied with their college experience, and report higher levels of intellectual and social self-concept (Chang, 1999). However, Chang found that when the effects of higher levels of compositional

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce diversity were considered without involvement in activities that provided students with opportunities to interact in meaningful ways cross-racially, students of color were likely to report less overall satisfaction with their college experience (Chang, 1999). In other words, increasing only the compositional diversity of an institution without considering the influence that these changes will have on other dimensions of the campus racial climate is likely to produce problems for students at these institutions. This finding is consistent with scholarship on race relations, which indicates that as organizations become more racially diverse, the likelihood of conflict increases (Blalock, 1967). Chang’s work also shows that students who attended more compositionally diverse institutions had more frequent opportunities to engage students from different racial/ethnic backgrounds. In other words, as compositional diversity increases, so does the likelihood that students will engage with students who are different from them. This work establishes that compositional diversity (represented by the enrollment of students of color at an institution) is an essential ingredient in providing opportunities for this interaction to occur. LINKING DIVERSITY AND LEARNING It is important to have a framework that helps us to understand the ways in which diversity can be connected to student learning. The most current and relevant framework for understanding the link between diversity and learning can be found in the material developed and tested as part of the Michigan legal cases (Gurin, 1999; Gurin et al., 2002, 2003) and is drawn largely from social psychological theories and research. As part of the Michigan legal cases, Gurin (1999) argued persuasively that higher education institutions are uniquely positioned to enhance the cognitive and psychosocial development of students. Building on previous research and conceptual frameworks, she argued that students are at a critical stage in their human growth and development in which diversity, broadly defined, can facilitate greater awareness of the learning process, better critical thinking skills, and better preparation for the complex challenges they face as involved citizens in a democratic, multiracial society. Conceptions of Development Erikson’s work (1946, 1956, cited in Gurin, 1999) regarding psychosocial development indicated that individuals’ social and personal identity is formed during late adolescence and early adulthood—the time when many students attend college and graduate/professional school. Institutions of higher education can facilitate the development of individual identity. For

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce example, among the conditions in college that facilitate the development of identity is the opportunity to be exposed to people, experiences, and ideas that differ from one’s past milieu (Gurin, 1999). Moreover, as mentioned earlier, the learning environment in higher education is likely to accentuate the normative influence of peer groups. Diversity and complexity in the college environment “encourage intellectual experimentation and recognition of varied future possibilities” (Gurin, 1999, p. 103). These conditions are critical to the successful development of identity. Gurin (1999) used the work of Piaget (1971, 1975/1985) as a conceptual and theoretical rationale for how diversity facilitates students’ cognitive development. Piaget argued that cognitive growth is facilitated by disequilibrium, or periods of incongruity and dissonance. For adolescents to develop the ability to understand and appreciate the perspectives and feelings of others, they must interact with diverse individuals in roughly equal status situations. These conditions foster a process of “perspective taking” and allow students to progress in intellectual and moral development. For “perspective taking” to occur, both diversity and equality must be present in the learning environment (Gurin, 1999). While Piaget’s work was done primarily with children and adolescents, the applicability of this work to the development processes of college-age students was well documented in the work of William Perry. Perry’s (1970) work with college students laid a foundation for understanding development that occurs in the college environment. At Harvard, over a 15-year period in the 1950s and 1960s, Perry and his colleagues conducted a series of interviews with a population of men at the end of each year of college. From these interviews Perry and his team constructed a schema of cognitive and personal development involving a progression from viewing knowledge as right or wrong (dualism), to beginning to understand a dimension of uncertainty related to knowledge (multiplicity), to accepting knowledge as contingent and contextual (relativism; i.e., not only are there alternate views, but some may be better than others). In the final position, students make a commitment to living in a world with many answers, some good and some bad, and they reinforce this commitment by constructing their own values and opinions. Perry’s model used an explicitly Piagetian perspective in tracing the development of students’ thinking about the nature of knowledge, truth, values, and the meaning of life and responsibilities (King, 1978). Specifically, Perry’s theory examined students’ intellect (how they understand the world and the nature of knowledge) and their identity (how they find meaning for their place in the world) (King, 1978). Key to the successful progression of students through the developmental stages in this theory is the ability to recognize the existence of multiple viewpoints and “‘the indeterminacies’ of ‘Truth’” (Pascarella and Terenzini, 1991, p. 29). The pro-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce vironments where all have an equal opportunity to participate and be heard—the process of perspective taking, which stimulates development, is fostered. However, there is a strong correlation between the ethnic/racial composition of the student body and the educational benefits to be gained from such diversity-related initiatives. For example, Chang (1999) provided evidence about the diminished benefits of diversity-related pedagogy and approaches when they are adopted with little or no change in student body composition. Currently, the number and percentage of medical school matriculants in the United States remains predominantly white, with little change in underrepresented minorities over the past 10 years. Given this, efforts to engage medical students from diverse backgrounds in educational initiatives to achieve goals for cultural competence will have diminished impact if student diversity is not increased. Although our manuscript does not focus on admissions practices in medical school or health professions programs, deans and admissions directors should consider the connections that we have shown exist between a diverse student body and educational initiatives that help students achieve cultural competence as they reflect on the criteria they use for admissions to their programs. This is an important consideration to make in pondering ways to achieve greater diversity in these programs. Bowen and Bok (1998) wrote about society’s increasing dependence on the character of the individuals who serve society in professional roles. Levin (1996) said, “Academic excellence must remain the most important single criterion for admission … but we should continue to look for something more—for those elusive qualities of character that give young men and women the potential to have an impact on the world, to make contributions to the larger society through their scholarly, artistic, and professional achievements, and to work and to encourage others to work for the betterment of the human condition.” Recent reports detailing health-care disparities (e.g., Institute of Medicine, 2003) underscore the need to address more directly “the betterment of the human condition” by ensuring access to health care to certain populations in the United States. By achieving greater nonwhite diversity among their students, medical schools can play a key role in the longer-term solutions to these disparities. Studies conducted by Komaromy and colleagues (1996, reported in Bowen and Bok, 1998) and Keith and colleagues (1985, reported in Bowen and Bok, 1998) provide important evidence that black and Hispanic physicians are much more likely to treat patients in minority communities that include poor people and that minority physicians are twice as likely to treat patients in locations where there are health-care shortages (as identified by the federal government). Medical schools may want to consider documented outcomes like this or evidence about the

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce predictive value of admissions criteria as they contemplate increasing diversity in the medical student population. For example, a recent analysis of predictors of medical school performance (White et al., unpublished) showed that for underrepresented minority students at one medical school, academic performance (i.e., the undergraduate grade point average) is a better predictor of academic performance in medical school (measured at three time points, progressively) than standardized test scores (i.e., the Medical College Admissions Test, or MCAT), which reliably predicted only scores on future standardized tests (i.e., USMLE Step 1 examination). Extending the Transformation into the Clinical Years We ask medical educators to consider how studies reported in the higher education and psychology literatures (and to a lesser degree in the medical education literature), many of which are presented here, can be used to develop approaches that ensure medical student achievement of cultural competence. The methods and pedagogies discussed in this paper can potentially help medical students transform their perspectives about diversity and at the same time progress toward achievement of self-author-ship, which provides a foundation for understanding the perspectives of those from other cultures and backgrounds. However, in considering a comprehensive educational approach within the medical education context, the “negative reinforcement” issues also must be addressed. When students begin clinical training, they leave behind the sheltered environment of the classrooms and clinical skills laboratories, and the day-to-day influence of the faculty members who have taught them in the first 2 years. As they enter the clinics, hospitals, and operating rooms, the “hidden curriculum” (Hafferty, 1998) and “hidden culture” (Taylor, 2003) largely dictate the cultural norms students will need to survive or even thrive. As noted by Hafferty (1998), the values underlying these informal curricula might be in direct conflict with the values underlying the goals of the formal curriculum. The challenge for medical educators is how to extend learning into a very influential milieu over which they have limited control and which in fact may serve to undermine or undo learning that has occurred. In this paper we have encouraged medical educators to contemplate connections between attributes associated with specific developmental levels and those associated with educational standards and goals for cultural competence. As noted, language in the standards describing desired attributes of physicians closely mirrors language that Perry (1970), Kegan (1994) and others use to describe a high (or in some cases the highest) level of cognitive and interpersonal development—one in which individuals be-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce come the creators of their own lives, with their own sets of values and convictions to guide them, along with the abilities to self-reflect, self-assess, and self-direct. It might be reasonable to anticipate that students who have achieved self-authorship prior to being sent into the realm of the informal curriculum have in essence been “armed” with the capability to create and rely on their own value structures, thus possibly diminishing (at least in the short term, until they gain more professional autonomy) the undermining influence of the informal curriculum. Comprehensive assessments already in place in most medical schools can be used to monitor the longitudinal effectiveness of newly adopted pedagogies and approaches by measuring mastery of specific learning outcomes into and after one or both of the intensive clinical years. It is also not impossible to imagine a health-care world where educational values correlate more closely with conflicting cultural values. Standards developed by the Joint Commission on Accreditation of Healthcare Organizations (2003) include quality of patient care, which many institutions are assessing through surveys of patient satisfaction. This process provides a direct evaluation link between health-care organizations and the individuals they serve and underlies efforts that can be made to modify and influence behavior of those who are providing health care. Whether such efforts can influence the “moral underbelly” (Hafferty, 1998) of health care organizations remains to be seen, but with regard to influence over student values related to cultural competence, they are a move in the right direction. CONCLUDING THOUGHTS In this paper we have presented an evidence-based argument to support the importance and benefits of diversity in higher and health professions education. To understand specifically what we mean by “diversity in higher education,” we began with a description of the factors within college/university campus climates that impact educational diversity: historical legacy (resistance to desegregation and unrecognized, embedded advantages for dominant cultures), psychological climate (perceptions of discrimination and attitudes toward individuals from different cultures), behavioral climate (social and educational interactions among students and faculty), and compositional diversity (racial/ethnic composition of the student body). In a discussion about linking diversity with learning, we presented information about college student cognitive and emotional development; approaches to learning that are active and student-centered and provide the discontinuity and discrepancy that stimulate development within a cognitive framework; and specific learning methodologies that encourage cooperation, deepen understanding, and enhance self-esteem.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Finally, we presented information on the increased benefits of combining student composition with educational initiatives, impediments to institutionalizing diversity-based programs, and principles that might guide thinking and action related to integrating diversity-based initiatives into college and university life. We then linked this body of evidence to health professions education, in a specific medical education context, where the argument supporting the educational value of diversity is even more compelling given the goals and standards related to the competent care of patients in an increasingly diverse U.S. population. Specifically, we presented a brief history and described the structure of medical education programs, and described external goals and standards that guide medical educators in developing specific institutional goals and learning outcomes. We explained current educational initiatives in the medical education literature designed to achieve cultural competence and suggested a potential “disconnect” between current approaches and educational goals and standards. We linked student development to potentially effective pedagogies, building on the higher education research on transformative learning and adding information about social justice educational principles and pedagogies from the higher education and medical education literatures. Although not a primary concern of this paper because of the evidence that cautions educators about important connections between the racial and ethnic composition of student bodies and diversity-based initiatives to achieve educational outcomes, we briefly discussed the current composition of students in U.S. medical schools. Finally, we recognized that changes in curriculum and composition alone will not address the negative reinforcements that can undermine educational goals and standards. We asked readers of this paper to think about how pedagogy and experience to help medical students achieve self-authorship not only yields benefits related to learning and autonomy, but might also serve to at least diminish the influence of negative reinforcements that can weaken efforts to achieve clinical competence. To achieve these benefits and maximize the opportunities for teaching and learning that diverse learning environments provide, it is important to give careful consideration to the context in which the diversity is enacted. Merely bringing diverse people together in an institution or an educational program does not ensure that the benefits of diversity will be achieved. Although it is an important first step, it cannot be the only step that this taken. In reviewing the relevant literatures, we have attempted to identify some general principles that can guide efforts to enhance the goals of diversity in health professions education.

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