1
Introduction

Greater and better use of the diverse human resources of our country is a national imperative. The underrepresentation of minorities in the health professions is but one indicator that we have failed to recognize and develop fully the human resources of our diverse population. Our ability to maintain a position of global leadership depends on our willingness to recognize, stimulate, and develop the capacities of all segments of society and to acknowledge the needs of those segments currently underrepresented in health careers. Policymakers have expressed concern about future productivity across most U.S. industries, including health, unless we can adopt policies that support the development of human resources within our diverse ethnic populations (Quality Education Project, 1990; Gore, 1993).

Past arguments for this kind of national call were based on a moral imperative for social equality and justice, but these arguments have sometimes proved inadequate to sustain the momentum for creating social change in institutions that provide opportunities directly or serve as channels to education and employment. The values of equity and fairness contributed to some positive changes in behavior and attitudes in earlier decades that increased the participation of minorities in the health professions (Simpson and Aronoff, 1988; Petersdorf et al., 1990; Ginzberg and Ostow, 1992). Those values still provide guidance and motivation, but it is now clear there are great benefits to the entire population from a commitment to diversity.

BACKGROUND

Minorities have long been underrepresented in the health professions, but it was not until the Civil Rights movement in the 1960s that particular attention



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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions 1 Introduction Greater and better use of the diverse human resources of our country is a national imperative. The underrepresentation of minorities in the health professions is but one indicator that we have failed to recognize and develop fully the human resources of our diverse population. Our ability to maintain a position of global leadership depends on our willingness to recognize, stimulate, and develop the capacities of all segments of society and to acknowledge the needs of those segments currently underrepresented in health careers. Policymakers have expressed concern about future productivity across most U.S. industries, including health, unless we can adopt policies that support the development of human resources within our diverse ethnic populations (Quality Education Project, 1990; Gore, 1993). Past arguments for this kind of national call were based on a moral imperative for social equality and justice, but these arguments have sometimes proved inadequate to sustain the momentum for creating social change in institutions that provide opportunities directly or serve as channels to education and employment. The values of equity and fairness contributed to some positive changes in behavior and attitudes in earlier decades that increased the participation of minorities in the health professions (Simpson and Aronoff, 1988; Petersdorf et al., 1990; Ginzberg and Ostow, 1992). Those values still provide guidance and motivation, but it is now clear there are great benefits to the entire population from a commitment to diversity. BACKGROUND Minorities have long been underrepresented in the health professions, but it was not until the Civil Rights movement in the 1960s that particular attention

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions was focused on this issue. When discussion around racial and ethnic distributions takes place, it is generally recognized that white is designated as majority and all other racial and ethnic groups are minority. Using the population parity model, African Americans, Native Americans, Mexican Americans, and mainland Puerto Ricans are underrepresented in the health professions. Within each racial or ethnic subcategory, significant differences can be found.* After more than 20 years of programmatic activity there have been significant increases in minority enrollment. However, the proportion of minorities in all of the health professions schools is still lower than the representation of those groups in the population at large (Bureau of the Health Professions, 1993). During the mid-1970s, the number of persons applying to health professions schools reached a peak, followed by a decline. In the past few years, the numbers have increased again. Thus, when data are examined over a period of time, a notable increase in the numbers of minorities in the health professions is seen, although not in proportion to minority representation in the U.S. population. For example, in 1992, the number of minorities entering medical school was 1,827 (11.2 percent), the highest ever. Overall, 1992 medical school enrollment was 6,787 (10.3 percent), also the highest in many years. That same year the total number of underrepresented minority faculty increased from 2,082 (3.1 percent) in 1991 to 2,489 (3.5 percent) (AAMC [Association of American Medical Colleges], 1993a). In looking at minority participation in the other health professions, medicine had the highest relative enrollment followed by dentistry, podiatry, and nursing. Osteopathy, optometry, and veterinary medicine had the lowest relative minority enrollment. Pharmacy was in the middle of the two extremes (Ready and Nickens, forthcoming). Compelling demographic trends alone speak to the value and wisdom of broadening educational opportunities for minorities to pursue careers in medicine as well as other professional callings that contribute so much to a nation's strength and productivity. In the 1950s, nearly 9 of every 10 Americans were of European descent. Today, 1 of every 4 adults and 1 of every 3 children are of African, Latin American, or Asian origin. Minorities are increasing faster than the rest of the population. Indeed, the Bureau of the Census predicts that by the year 2000, minorities, who today are one-fifth of the national population, will have accounted for 60 percent of the total population growth (Action *   There has been increasing pressure from racial and ethnic groups not presently included as "underrepresented minorities" to achieve recognition. Thus, as a result of the changing racial and ethnic composition of the U.S. population, there are increasing calls to include other groups within this definition of underrepresented, potentially modifying the historically monitored trends.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Council on Minority Education, 1990). Such trends are enough reason to reenergize the agenda for more equitable representation of minorities in health careers. In recent years, however, mounting social and political pressures calling for major reform of the nation's health care system added yet another dimension of timeliness and urgency to the issue of enhanced minority representation in clinical practice and teaching. As part of his health care reform plan, President Clinton has articulated the importance of developing a medical workforce to better reflect the nation's present and future health care needs. As this country embarks on a historical national dialogue for restructuring the health care system, the goal of making health care more appropriate, affordable, and accessible for all our citizens will be receiving priority attention. These new and powerful dynamics stimulated the Institute of Medicine (IOM), with its long interest and commitment to improving the quality and context of our health care system, to appoint a committee that would assess strategies that have focused on helping minority students attain their health career goals. Its findings would assist in developing an action and research agenda responsive to our nation's social and economic needs. The IOM Committee on Increasing Minority Participation in the Health Professions was asked to develop a future-oriented research and strategic action agenda for increasing the participation of minorities in the health professions. Two tasks framed the committee's charge: consider the multiple aspects of professional development, such as education, academic achievement, opportunity, and mentoring, that affect participation of underrepresented minorities in the health professions; and address the field of health professions from a global, broadly defined perspective, with a more targeted focus on minority participation in clinical practice and academic medicine. The committee's deliberations were enhanced through the information it received from three commissioned papers and the informed and spirited deliberations of participants in the workshop it convened. Appendix A provides the authors and titles of the papers and a roster of workshop attendees. The committee discussed a future health professions workforce that looks more like America, where clinicians, researchers, and teachers increasingly reflect the cultural and ethnic diversity that has contributed so much to our nation and holds the key to its future. Although ethnic minorities are expected to continue to grow significantly for the next several decades, they remain vastly underrepresented in clinical practice, teaching, and health sciences research. The committee's concerns are not new. For more than 25 years, many individuals and institutions have shared a common goal of increasing the participation of minorities in all aspects of health care. As Chapters 2 and 3

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions indicate, many resources have been directed toward realizing this goal. Today we appear to be embarking on a new period of concentration and energy to address this issue, spurred by disturbing reports of persistent and, in some cases, growing disparities in access between underrepresented minorities and whites, the reality of America's demographic revolution, and the declining status of the United States in the global economy. In its review of the programmatic interventions discussed in Chapter 3, the committee found that both the public and the private sectors have supported many laudable efforts to enhance the pipeline for minority training in the health professions. Viewed from a national perspective, however, these achievements have not built the institutional and academic infrastructure necessary to eliminate the gap between vision and reality. In an environment of demographic changes and major reforms in health care and in education, the nation cannot afford to fail in generating valid opportunities for minorities to significantly contribute to its social and economic productivity. Minorities, if given the opportunity to participate effectively in the health professions, can contribute to a more equitable and productive society, and help the United States maintain a position of economic and moral leadership in the world. The vision of a more diverse and democratic society is an essential feature of the American dream for the twenty-first century. The committee believes that both the recruitment and the retention of greater numbers of African Americans, Hispanics, and Native Americans represent a critical cog in moving the vision to reality. SIGNIFICANCE OF THE PROBLEM Several national developments point to the importance of having a better understanding of how to improve the recruitment and retention of minorities in the health professions. This problem does not exist in a vacuum. The increasing diversity of the U.S. population is creating new challenges to our democracy. By the year 2000, African Americans, Hispanics, and Native Americans will constitute almost one-fourth of the U.S. population (COGME [Council on Graduate Medical Education], 1992). Some cities even now reflect some of the growing tensions related to demographic change. Urban riots in Los Angeles, Miami, Atlanta, New York, and other cities provide a ''glimpse of the agony and the anger, the struggle and the success of a diverse but still distinct wedge of the population" (Stanfield, 1992). The 1992 Los Angeles eruption, in particular, was but one stark indication that, in spite of some advances, much remains to be done to overcome the problems of poverty, discrimination, and alienation experienced by minority communities. The committee did not try to address these major problems, a task that was beyond its ability and charge, but it considered the background of demographic

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions change that characterizes this period of our history. The committee approached the study from the perspective of enriching the current and future ethnic mix of health professionals rather than increasing overall numbers. In its call for greater participation, this report reflects several other developments in the United States that are discussed below. Need to Improve Health Services for Minorities Ethnicity is a very important element in determining and evaluating morbidity and mortality. But socioeconomic status is also very significant: How people live, get sick, and die depends not only on their ethnicity, but also on their socioeconomic condition. The quality of health of any individual or any nation is the result of not only having access to adequate health care services, but also having adequate education, income, and housing (Reed et al., 1992; Angell, 1993; Pappas et al., 1993). The increasing diversity of our population has been accompanied by persistent gaps in health status, with certain populations disproportionately affected by some of the most debilitating diseases of our time, including heart disease, cancer, diabetes mellitus, and HIV/AIDS (U.S. Department of Health and Human Services, 1985). Trauma, the fourth most costly disease in the U.S., disproportionately affects underrepresented minorities (Munoz et al., 1992). Over the course of the twentieth century, African Americans have made substantial progress in life expectancy, with the gap between whites and African Americans narrowing from 15 years at the beginning of the century to less than 7 years currently (National Center for Health Statistics, 1992). However, a substantial difference in life expectancy remains, and in recent years, this gap is again widening, due in part to drug use, HIV infection, and homicide, as well as lack of access to adequate health care. While the infant mortality rate has decreased for both the African-American and the white populations, the rate for African Americans is still twice as high as that for whites. Hispanics continue to have a much higher incidence of Type II (adult onset) diabetes, approximately two to three times that of the non-Hispanic population. The literature on access to care provides extensive evidence that Americans of racial and ethnic minorities use fewer health care services than nonminorities, despite having a greater need for care. Even when there is entry into the health care system, minorities receive less aggressive medical care (Whittle et al., 1993). Being of a racial or ethnic minority is highly correlated with underuse and less appropriate use of health care services as well as with worse outcomes. Compared to whites, African Americans and Hispanics have fewer doctors' visits, are more likely to use the hospital emergency department or outpatient clinics as their regular source of care, and have higher rates of morbidity and mortality from preventable diseases (Institute of Medicine, 1988, 1990; Billings

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions and Teicholz, 1990). Efforts to understand the reasons for these disparities have been hampered by data limitations. The Council on Ethical and Judicial Affairs of the American Medical Association (AMA) has concluded that persistent, and sometimes substantial, differences continue to exist between the health status of African Americans and their white counterparts. The council emphasizes the need for greater access to health care for African Americans and for greater awareness among physicians of existing and potential disparities in treatment (AMA Council on Ethical and Judicial Affairs, 1990). Similar findings were reported by the AMA's Council on Scientific Affairs in its 1991 report on Hispanic health in the United States. In an issue of the Journal of the American Medical Association devoted to this topic, the council points out that Hispanics are the fastest growing minority group in the United States; Hispanic subgroups need to be considered separately; and poverty, lack of insurance, and level of acculturation are the greatest impediments to health care for this population (AMA Council on Scientific Affairs, 1991). While a host of factors—socioeconomic, genetic, cultural, and institutional—determine an individual's health status and use of health care services, a starting point to improving minority access may be to increase the supply of minority physicians. Although the link between improved access and the number of minority health providers is weak, the literature suggests that interactions between provider and patient race, ethnicity, and gender affect access to and use of health care services (COGME, 1992). Data and information do illustrate that minority physicians show a greater tendency to practice in their communities or other underserved areas. In 1988, 48.9 percent of minority medical school graduates said they planned to practice in socioeconomically deprived areas, while only 13.6 percent of their nonminority peers reported such plans. In 1993, figures for both groups dropped, with 36 percent of minority students still preparing to serve in deprived areas while the percentage for all graduates fell to 8 percent (AAMC, 1993a). Further, some evidence links the quality of health care with accessibility to and use of primary care physicians. Minority physicians, either by choice or by necessity, tend to practice as primary care physicians (COGME, 1992; Hopkins, 1992; Fox, 1993). After extensive discussions as well as reviews of commissioned papers on various aspects of this topic, the committee believes that an increase in the participation of minorities in the structures and processes used to determine research priorities, research protocols, and health services delivery will provide new opportunities to broaden our understanding of the science and art of effective health care, not only for minorities but for the public in general.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Professional Development for All Personnel Minorities practicing medicine, teaching classes, and conducting research in a joint endeavor with other health professionals can lead to more empathetic communication and health care for minority patients and patients in general. According to recent statistics from the National Science Foundation, about 11,500 African-American, Hispanic, Asian, and Native American researchers work in the life sciences, compared with 104,300 whites. In addition: African Americans constitute 10.1 percent of the workforce, but only 3.7 percent of the nation's physicians, only 2.1 percent of the nation's dentists, and only 2.4 percent of the nation's natural scientists. Hispanics make up 6.9 percent of the total workforce, yet only 5.5 percent of the nation's physicians, 3.3 percent of the nation's dentists, and 2.7 percent of the nation's natural scientists. Of the 4,779 doctorates awarded in the life sciences in this country in 1990, only eight went to Native Americans (Healy, 1992). While there are important roles to be played by other professionals and disciplines in the movement toward a more inclusive and comprehensive agenda for health, this study targets those institutions and professionals most directly responsible for developing the strategies and programs for training the future health workforce. Recent research findings suggest that sectors other than the health care sector must contribute to reducing the disparities of health status in minorities. But it is principally the responsibility of the health care professional to translate relevant social, fiscal, and scientific developments and apply them to effective health care (Ginzberg and Ostow, 1991; Dougherty, 1992). Loss in Economic Productivity The net loss to the U.S. economy resulting from the disproportionately poor health status of minority populations is difficult to measure accurately. Nevertheless, most analysts would argue that a healthy workforce is more productive than one that is less healthy. Minority health care providers are more likely to be culturally sensitive to their populations and to organize the delivery system in ways that better suit their health care needs (COGME, 1992). Increased diversity of health professionals has the potential for leading to better and more efficient patient care for minorities. Timely access and strong patient-provider relationships may diminish health care costs through improving patient compliance, decreasing emergency room episodes, and reinforcing behavioral and lifestyle changes that reduce or eliminate risk factors, such as smoking (Edwards, forthcoming).

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Influencing and Improving Public Policy The issue of greater representation for minorities goes beyond increased access and better health care. Many of the researchers, analysts, and other leaders who frame health policies, develop priorities for allocating resources, and identify new interventions are drawn largely from the faculties of health professions schools. Minorities are severely underrepresented among these faculties and the consequences are considerable. In 1992, they made up only 3.5 percent of the faculty members in medical schools. If one removes traditional minority medical schools—Howard, Meharry, Morehouse, and the University of Puerto Rico—from these calculations, the minority faculty representation in the remaining 122 medical schools falls to approximately 2.6 percent (AAMC, 1993a). Unfortunately, internal medicine, the specialty that produces the majority of academicians in medicine, lags behind the overall percentage for minority faculty at medical schools at 2.9 percent. There also appears to be an especially disturbing lack of minorities in senior faculty positions particularly at the level of deans and senior academic officers in our health science institutions. Professional associations such as the Association of Academic Minority Physicians articulate these concerns at the national level. Implicit in the paucity of representation is the message that faculty status and influence are not readily achievable goals or realistic professional options for minority students in medicine. The situation is similar for the other health professions as well (National Research Council, 1989). Thus, the absence of immediate access to educators who have shared their experiences can often constitute a significant void in the course of training for students who are struggling with questions about career choices and the odds of and obstacles to success. Facilitating Institutional Change An institution's commitment to increasing its opportunities for minorities is often influenced by the strong support of minority faculty, whose advocacy may range from subtle consciousness-raising to aggressive promotion of change. The need for more minority representation on admission and evaluation committees has been long apparent. This need has perhaps less to do with the lack of fairness in the process than with the acknowledgment of the importance of diversity among those who select and evaluate future professionals to serve the broad and heterogeneous needs of the population. Diversity at these levels ensures that the institution's intentions and commitment will be communicated to those persons it wishes to persuade toward careers such as medicine and health services research (Cregler et al., 1993; Ready and Nickens, 1993).

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Community Leadership and Advocacy Still another reason for the focus on increasing the participation of minorities relates to community leadership and advocacy. Health professionals, particularly physicians, represent not only respected professions, but also important sources of leadership for their local communities (Nickens, 1992; Cregler et al., 1993). They serve on boards and commissions and in other essential community leadership roles. As minority and majority health professionals work together as partners with community leaders, the community develops pride in its diversity. Through membership in and support of minority professional societies, such as the National Medical Association, National Black Nurses Association, or the National Dental Association, minorities can more effectively accomplish what they could not do individually. These societies can provide leadership in community efforts to enhance health and can improve educational opportunities for others who are aspiring to the professions. Relevance to Health Care Reform Developing a new research and action agenda for enhancing minority participation in the health professions is closely related to some of the most desired goals of health care reform: equity, justice, and greater economic productivity. The degree to which these goals are not now being achieved is apparent through the continued, striking differences between certain minority and majority groups for all of the key health status indicators. An increasing acknowledgment of the primary care physician's importance in health care is emerging, and it is reflected in Medicare's new resource-based, relative value scale payment structure and in the pivotal role given to primary care in all of the major health care reform proposals. Higher percentages of young African-American and Hispanic physicians choose primary care specialties than either white or other young physicians (Cohen et al., 1990; Ginzberg et al., 1993). It is too early to tell what health care reform will mean to minorities in the health care professions, but every indication is that stronger incentives will be placed on developing a health professions workforce more responsive to the nation's changing demographic profile and its different health care needs (American Health Security Act, 1993; Gore, 1993). Members of our society widely believe that a basic level of medical care should be available to all citizens. Little consensus exists, however, on how to finance universal access and what package of benefits should be assured. Nevertheless, as the debates on how to assure universal access to appropriate and necessary health care become more intense, it is important to ensure that the guardians of this public good mirror the country's cultural diversity.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Relevance to Reform in Public Education A growing body of literature indicates that universal access to health care may do little to improve health status if public education and other essential social support systems are underdeveloped (Starfield, 1991; Pappas et al., 1993). The education of health professionals is strongly influenced by the quality of public education, which is in a period of great change. If the United States wants to compete as a first-class economy, it is imperative that it develop its human resources to much higher levels of skill and competence. Especially important will be developing the talents of minorities, who along with white women and immigrants, will constitute almost 90 percent of the new growth of our workforce for the rest of this century (Action Council on Minority Education, 1990). Unlike the reform movement of the post-Sputnik era, which sought to increase the numbers of highly trained young people who were talented in science and engineering, the current focus is on "Science for Every American" (Ebert, 1993). Higher-quality schooling for everyone will make a difference in preparing more students for entry into professional and technical training. To avoid widening the existing gap, every effort is being made to broaden the base of competence in science and mathematics education in an inclusive manner. This approach could create more opportunities for minorities and eliminate some of the existing barriers to professional development. Science and mathematics are important core subjects in preparing for the health professions, but the committee did not limit its attention to them. Its deliberations pointed to the belief that learning cannot take place effectively outside a context of racial diversity. Effective learning for today's social, economic, and intellectual challenges can take place only in environments that allow for understanding the total human experience. Quality education must now mean promoting interaction that allows people to see each other from their own cultural vantage points (Jennings, 1989). These interactive settings may result in the questioning and challenging of traditional economic, cultural, and political arrangements. Before change can happen, the underlying issues and facts must be understood. The next chapter looks at what happens to students throughout their educational years and how it eventually affects minority participation in health professions.