BALANCING THE SCALES OF OPPORTUNITY

Ensuring Racial and Ethnic Diversity in the Health Professions

Committee on Increasing Minority Participation in the Health Professions

Marion Ein Lewin and Barbara Rice, Editors

Office of Health Policy Programs and Fellowships

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1994



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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions BALANCING THE SCALES OF OPPORTUNITY Ensuring Racial and Ethnic Diversity in the Health Professions Committee on Increasing Minority Participation in the Health Professions Marion Ein Lewin and Barbara Rice, Editors Office of Health Policy Programs and Fellowships INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1994

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C.20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by The Josiah Macy, Jr., Foundation (Grant No. S9171 1), The Robert Wood Johnson Foundation (Grant No. 18530), The Pew Charitable Trusts (Grant No. 91-01994-000), and the Office of Special Populations, National Institute of Mental Health, U.S. Department of Health and Human Services (Grant No. 92MF34075601 D). Library of Congress Catalog Card No.94-66070 International Standard Book No.0-309-05078-2 Additional copies of this book are available from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). B333 Copyright 1994 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions COMMITTEE TO INCREASE MINORITY PARTICIPATION IN THE HEALTH PROFESSIONS M. ALFRED HAYNES,*Chair, Formerly of Drew University of Medicine and Science, Los Angeles, California JOAN BARATZ-SNOWDEN, National Board for Professional Teaching Standards, Washington, D.C. THOMAS L. DELBANCO, Harvard Medical School and Beth Israel Hospital, Boston, Massachusetts JUANITA W. FLEMING,* Academic Affairs, University of Kentucky, Lexington, Kentucky JAMES R. GAVIN III, Howard Hughes Medical Institute, Bethesda, Maryland GERALD HILL, Center of American Indian and Minority Health, University of Minnesota School of Medicine, Duluth, Minnesota JAMES JENNINGS, William Monroe Trotter Institute, University of Massachusetts, Boston, Massachusetts LEON JOHNSON, JR., National Medical Fellowships, Inc., New York, New York DEIDRE DUMAS LABAT, College of Arts and Sciences, Xavier University, New Orleans, Louisiana TANYA PAGAN RAGGIO, Healthy Start, Inc., Pittsburgh, Pennsylvania DAVID J. SANCHEZ, JR., Academic Affairs/Academic Programs, University of California at San Francisco, San Francisco, California EDWARD J. STEMMLER,* Association of American Medical Colleges, Washington, D.C. STUDY STAFF Office of Health Policy Programs and Fellowships MARION EIN LEWIN, Study Director JO HARRIS-WEHLING, Program Officer VALERIE TATE, Program Assistant COIMBRA SIRICA, Writer BARBARA RICE, Editor *   Institute of Medicine Member

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Preface The report Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions, was initiated in response to numerous requests from the membership of the Institute of Medicine (IOM), including several members serving on the Institute's Council and Program Committee, to reassess underrepresentation of minorities in the health professions in light of impending health care reform and its implications for the nation's future workforce. The leadership of the Association of Academic Minority Physicians and the National Cancer Institute of the National Institutes of Health also encouraged the Institute to undertake this kind of effort. While recently published data indicate a significant upturn in the number of minorities entering medical school, an enrollment goal of 12 percent set by the Association of American Medical Colleges in the mid-1970s still remains elusive. Minorities enrolled in medical schools reached only 10.3 percent in 1992, although these groups represent 22.1 percent of the U.S. population. Underrepresentation in the health professions is even more disturbing when one looks at the paltry number of minority faculty. In 1992, they made up only 3.5 percent of faculty members in medical schools. Interest in the study came amidst an increasing sense of crisis about the U.S. health care system, particularly the widening gap in health status between majority and minority populations. These pressing concerns were being viewed within the broader context of a changing demographic landscape and the importance of giving greater attention to the health and social needs of America's fastest growing population groups: African Americans, Hispanics, and Native Americans. Underlying these trends was the growing realization that our nation would not be able to thrive in the twenty-first century without a willingness to recognize, stimulate, and develop the capacities of all segments

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions of society and to acknowledge the needs of those groups currently underrepresented in health careers. These new and powerful dynamics stimulated the IOM, with its long interest and commitment to improving the quality and context of our health care system, to appoint a committee that would help to develop a future-oriented action and research agenda for enhancing minority participation in the health professions. The 12 members chosen for the committee represented a range of views on medical and science education, health professions training, minority recruitment, retention, outreach programs, and medical education financing. Funding for the study came from three foundations and one government organization well-recognized for their interest and commitment to this issue: The Macy Foundation; The Robert Wood Johnson Foundation; The Pew Charitable Trusts; and the Office of Special Populations, the National Institute of Mental Health. The committee was charged with three tasks: to develop a future-oriented research and strategic action agenda, responsive to the realities of the 1990s; to focus on multiple aspects of professional development that affect participation of underrepresented minorities in the health professions, such as education, academic achievement, opportunity, and mentoring; and to address the "health professions" (in as much as resources allow) from a global, broadly defined perspective, with a more targeted focus on minority participation in clinical practice and academic medicine. The undertaking of original data analysis was beyond the scope of the committee. However, an extensive literature search of data findings, past activities, evaluations, and related information was conducted. As the centerpiece of its study effort, the committee convened an invitational workshop to discuss ways in which the country can enhance the presence of minority participation in the health professions. Twenty-four participants from across the nation were invited, representing a wide range of backgrounds and experiences in this arena. Participants were invited on the basis of their noted contributions to the field of minority education and advancement, as health professionals, educators, community leaders, and researchers. The group was challenged to think broadly and creatively about developing strategic future directions for helping more minority Americans realize their capacities in professional health careers. During a day and a half of interactive dialogue and small group discussion, workshop participants identified obstacles and the promising strategies and approaches for ensuring the greater participation of minorities in the health professions. The workshop discussions were informed and guided in part by

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions several formal papers commissioned by the committee. These papers included the following: "Inventory and Analysis of the Effectiveness of Strategies and Programs for Increasing Minority Participation in Medicine" by Timothy Ready and Herbert Nickens. "Educational and Career Obstacles and Opportunities in Academic Medicine and Clinical Practice for Priorities: Is Progress Occurring?" by Louis Cregler, Luther Clark, and Edgar Jackson. "Increasing Minority Participation in the Health Professions—The Problem of underrepresentation and an Inventory and Analysis of Effective Strategies and Programs" by A. Cherrie Epps, Mary Cureton-Russell, and Helen Kitzman. During the workshop deliberations the committee used several terms requiring definition: African American, participation, minority, and health professions. Although the term "African American" can be used to refer to only one sector in the broader black community, the committee made a deliberate decision to include all groups of African descent; thus, the term is meant to include West Indians and Africans, as well as those black groups who have lived in the United States since its founding. While there are recognized differences among subgroups of all the ethnic minorities discussed in this report, the committee preferred not to subdivide the groups, and especially not to make a distinction on the basis of country of origin. By "participation" the committee covered all areas of the health professions: clinical service, teaching, or research within any health profession. Furthermore, full participation means that minorities will have equal opportunities to fulfill their potential without barriers based on race or ethnicity. The committee was aware of different ways of defining "minorities" and of increasing pressure from racial and ethnic groups not presently included as "underrepresented minorities." For this reason the committee chose definitions specifically for the purposes of this study. By "minorities" the committee means African Americans, Hispanics, and Native Americans. These groups are the focus of this study not only because they are markedly underrepresented in the health professions, but also because they are a statistical minority that has a documented group history of deprivation in U.S. society. Large numbers of these groups have historically and systematically been excluded from admission to educational institutions or from professional employment opportunities because of their "racial" identity or because they were ill prepared, when the lack of preparation was in large measure due to being a member of a minority group. The committee explored the reasons for the underrepresentation and considered strategies that have made or could make a real difference in outcomes.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions By "health professions" the committee intended to include the major healing professions such as medicine, dentistry, and nursing. However, more data are available on medicine than on the other professions. To the extent problems are similar, it is possible to draw broader conclusions based on the more adequate data on physicians. Although all three ethnic groups are the focus of attention, the report provides more data on African Americans simply because more data are available on this group. Data routinely collected by the Association of American Medical Colleges (AAMC) include information about African Americans, Native Americans, Mexican Americans, and mainland Puerto Ricans. Other health professions do not have a similar database, although Hispanic and Native American scholars could assist in developing a more useful database if resources were available. Data on Hispanics represent a special challenge due to differences in definitions that make it impossible to reconcile data from different sources (IOM, 1993). For the purpose of this study, the AAMC's categorization is used. The committee's report contains an Executive Summary, with key observations and recommendations; four chapters; and two appendixes. Chapter 1 describes the rationale for the study and the significance of the problem. Chapter 2 presents data that help to define the problem of underrepresentation and identifies underlying factors that contribute to the failure to achieve desired societal goals. Chapter 3 provides information on programs that illustrate various attempts to solve the problems identified in Chapter 2. In Chapter 4, the committee proposes a number of strategies developed at the workshop. These strategies are intended to grasp the opportunities inherent in the current climate of change and to ensure a greatly increased and continuous flow of qualified minority health professionals prepared to meet the challenges of the future. Finally, Appendix A contains the lists of participants and commissioned papers for the workshop, and Appendix B provides the names of additional organizations and publications that focus on the committee's concerns. M. Alfred Haynes, M.D. Chair

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Acknowledgments I want to take this opportunity to thank my colleagues on the committee for their dedication and extremely hard work. As a committee we wish to acknowledge the individuals who led and participated in the workshop and who gave so generously of their time to help enrich our study (see Appendix A). In addition, the committee wants to express special appreciation to the primary authors of the commissioned papers: Louis Cregler, A. Cherrie Epps, Herbert Nickens, and Timothy Ready. The thoughtful and informative background papers enhanced our understanding of the many dimensions of this complex issue. The committee wishes to recognize the substantial help that it received from various individuals at the American Association for the Advancement of Science, the National Science Foundation, the Association of American Medical Colleges, Education West, and the Health Careers Opportunity Program of the Department of Health and Human Services. We owe a debt of gratitude to National Medical Fellowships, Inc. for its inspiration for the report's title. The committee wants to give special thanks to the dedicated and hardworking professional staff at the Institute of Medicine: study director Marion Ein Lewin; program officer Jo Harris-Wehling; program assistant Valerie Tate; and program associate Karen Orlando. Coimbra Sirica had the difficult task of assuming some major writing responsibilities midstream. Barbara Rice deserves many thanks for her excellent editing, managing to integrate a variety of ideas and writing styles. We are especially grateful to them.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   11     Background   11     Significance of the Problem   14 2   FACTORS THAT DEFINE THE PIPELINE   21     Where the Leak Begins   26     Factors Associated with Minority Underrepresentation   38     Conclusion   45 3   LESSONS FROM SUCCESSFUL PROGRAMS   46     Medical School Level   46     Postbaccalaureate Programs   48     College Programs   49     University Outreach   52     High School Program   54     Comprehensive Programs   54     Summary   56 4   SHARING VISIONS AND WORKING TOWARD THE FUTURE   58     Building the Vision   61     Moving the Vision Forward   71     Summary   74     REFERENCES   76 APPENDIX A:   LISTING OF WORKSHOP PARTICIPANTS AND COMMISSIONED PAPERS   82 APPENDIX B:   FURTHER SOURCES OF INFORMATION   85

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