Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions (1994)

The underrepresentation of minorities in the health and other professions has long cast a shadow over our nation's efforts to develop a more representative and productive society. Many laudable and durable programs have been developed over the past 20 years to enlarge the presence of minorities in health careers, but these efforts have been unable to develop the infrastructure and momentum to produce and sustain an adequate number of minority professionals among the ranks of America's clinicians, researchers, and teachers. While there has been an increase in the numbers of African Americans, Hispanics, and Native Americans enrolled in professional schools during the past decade, this increase remains well below their representation in the population. Minorities in the health professions are more underrepresented today than 15 years ago.

In 1992, underrepresented minorities in medical schools reached 10.3 percent of total enrollment, reflecting a hopeful upward trend after many years of thwarted progress. Nevertheless, these groups, represent over 22 percent of the U.S. population, a percentage that is expected to grow to 25 percent by the year 2000. Underrepresentation is even more disturbing when one looks at the small number of minorities among the nation's health professions faculty and researchers. The percentage of underrepresented medical school minority faculty in 1992 was 3.5 percent; only one-third of U.S. medical schools have 4 percent or more of their faculty who are underrepresented minorities.

These concerns are not new. For more than 25 years, many individuals and institutions have shared a common vision for enhancing the participation of minorities in all aspects of health care, and many resources have been directed toward achieving this goal. Major social forces and strong political leadership helped to bring about the increases in minority enrollment in the health professions that began in 1968. At that time, the climate of the Civil Rights era

and economic prosperity in the United States converged, and the nation seemed poised to commit itself to overcoming the barriers to full participation by minorities in the health professions.

The promise, however, was not fulfilled. Progress in matriculating minorities came to a virtual halt in the mid-1970s, particularly in medicine, which had been at the forefront of earlier efforts to educate minority students.

No one can point to the sole reason for the persistent underrepresentation and stalled progress that began in the late 1970s. Some of the loss of momentum has been attributed to a slower economy, rising deficits, a diminished domestic agenda, and declining interest in providing educational support in the form of scholarships to minority students—in part a response to a broadly publicized study produced in the 1980s, which predicted an oversupply of health care professionals by the year 2000.

Minority students also report an insidious set of less tangible barriers—both academic and social—that stood in the way of educational advancement and the pursuit of a health professions career: denial of access to quality education; teachers who expect too little of students; anti-intellectual peer pressure; and a cultural gap between the world of study and that of their families and neighborhoods. Even significant efforts by government agencies, leading foundations, and a number of committed institutions were not successful in building the institutional and academic infrastructure necessary to eliminate the gap between vision and reality. Past efforts have yielded only marginal gains, occasional snapshots of steps forward that have not developed into a lasting picture of significant and sustained progress.

Today the issue of revitalizing the agenda for broadening the landscape of minority participation in health careers has a new urgency and relevance that go beyond past calls for social equality and justice. 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. Minorities are increasing faster than the rest of the population. By the year 2020, 40 percent of America's youth will be members of minority groups. 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 increasingly diverse ethnic populations.

Mounting social and political pressures in support of major reform of the nation's health care system add yet another dimension of timeliness and urgency to the issue of enhanced minority representation in clinical practice and teaching. Some of the most serious deficiencies in our current health care enterprise are reflected in the growing disparity in health status between minority and majority populations. 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. Data and information do illustrate that minority physicians show a greater tendency to practice in their communities or other underserved areas. Further, minorities practicing medicine, teaching classes, and conducting research with other health professionals can lead to more empathetic communication and health care for minority patients and patients in general. Indeed, the Clinton administration's plan for health care reform calls for the ''creation of a new health workforce" and enhanced investment in "recruiting and supporting the education of health professionals from population groups underrepresented in the field." There is every indication that any reform strategy will provide incentives for enlarging the ranks of primary caregivers, nurses, and allied health professionals who enter community practice, a focus that represents promising career opportunities for minorities.

Within this context of dynamic and exciting change, the committee saw a bright opportunity to assess past programs and policies in order to identify those strategies that can help lead to a more effective and sustained agenda for enhancing the participation of minorities in the health professions. To meet the needs for health care, education, and research in an increasingly diverse society, the committee tried to formulate a strategy that would ensure significant growth and a continuous supply of minority health professionals. 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. The committee approached the study from the perspective of enriching the current and future ethnic mix of health professionals rather than adding to the overall numbers.

MAJOR FINDINGS AND RECOMMENDATIONS

The committee's major findings and recommendations focus on the need for a more systematic, strategic, and sustained approach to ensure the continuous flow of minority students qualified to choose careers in the health professions. Any substantial improvement in minority health professions school enrollment can occur only if the pipeline is broadened and more minority students are given the opportunity for solid academic preparation in a supportive environment, beginning even before high school.

• A critical aspect of the committee's findings points to the need to place greater emphasis on the "throughput" of the educational process and on

programs that will significantly increase the number of minorities prepared academically to pursue careers in medicine and science.

The goal must be to recruit minority students to science early and to maintain and support them as they pass through the pipeline so that they are better prepared for admission to professional training, thus ensuring that they will graduate and be well established toward a professional career.

A fundamental cause of the underrepresentation of minorities in the health professions is an inadequate number of academically qualified and nearly qualified students interested in health careers. Many past programs and strategies have relied too heavily on supplementary enrichment and recruiting programs for advanced premedical and postgraduate students. They have failed to address the root cause—the need to develop the applicant pool at earlier stages of the educational process. Further, a greater presence of minorities in clinical practice and research will not be achieved by looking at the field of medicine alone. Sustained and concerted strategies to enlarge the pool must include the other health professions as well, including dentistry, optometry, pharmacy, podiatric medicine, veterinary medicine, nursing, and the growing field of allied health.

• The committee calls for the development of intervention programs that emphasize more systematic, integrated strategies to ensure a continuous flow of minority students qualified to choose careers in the health professions.

Only by moving away from ancillary activities aimed at helping students survive the current educational climate to changing the climate in which students are educated, can we significantly affect the participation of minorities in health science careers. Collaboration and linkages among all levels of the institutions and organizations related to the educational process must characterize future efforts to increase minority participation in the health professions. Improvements at each point affect all other points. The weak links among elementary school, high school, college, and graduate school place our students at greatest risk.

• The committee encourages education reform that stresses a strong science and math foundation.

In recent years it has become clear that the quality and quantity of mathematical and science instruction given to students throughout their academic lives determine how prepared they will be for science-based careers. Data show, however, that students of all races filter out of science and math, so that only a fraction of interested high school students go on to earn advanced degrees in these disciplines. The minority pipeline, smaller to begin with, narrows even more sharply than that of the total population. To reverse this trend, effective strategies must focus on making science and mathematics more accessible to all students, especially to minorities and women. Establishing these competencies

early in the educational process will help develop a cadre of minorities qualified to exercise choices about professional health career paths, including those of clinical practice, teaching, and research. The committee also sees the need to create a more inclusive academic environment for math and science training, one that incorporates the understanding and appreciation of diversity as part of the effective teaching of these disciplines. The committee feels strongly that faculty members teaching science must be convinced that recruiting minority students to math and science, not weeding them out, is a major priority.

• The committee urges a shift in perspective to an achievement model for minority education throughout the pipeline. To address current deficits, all educational institutions must set specific goals and implementation plans for inclusion and excellence.

Only when significant value is placed on excellence and achievement, can effective strategies and programs be realized. A growing call for excellence should join with goals of racial diversity and access. As the face of America's population changes, it is no longer appropriate to define quality and excellence in education separate from the need to prepare students for the complex economic, social, educational, and cultural issues they will face in the world of work, family, and community. The importance of encouraging minorities to reach for lofty goals and giving them the confidence to achieve them cannot be overstated.

• The committee advocates that reform agendas and change agents at all levels include an appreciation of cultural diversity, in ways that are guided by genuine respect for students' varying backgrounds, talents, and learning styles.

All programs directed at broadening the educational pipeline must do a better job at reaching out to students, parents, and communities of all racial and ethnic groups. Schools need to mount specific efforts directed at creating and fostering attractive oases of learning and environments more conducive to granting respect—the real heart of multiculturalism and diversity.

• The committee believes that the critical role of mentoring, with its proven track record of helping minorities pursue their aspirations and achieve their career goals, deserves to be more highly valued and to become a structured component of programs dedicated to a larger presence of minorities in the health professions.

Minorities who have stayed the educational course often credit someone—a parent, a teacher, or mentor—for helping them to succeed. In assessing past efforts, the committee concluded that two critical components of successful programs are good teaching and mentoring, applied in a systematic way to students of all ages. Long-term mentoring commitments require a solid program infrastructure at the institutional level. In order not to place an undue mentoring

burden on a few individuals within an institution, steps might be considered to develop a mentor-rich environment that will bring minority youths into open, trusting relationships with a variety of role models and supportive professionals.

• The committee believes that educational institutions at all levels must promulgate the principle that "smart isn't something you are, it's something you can become."

A growing body of literature shows that intellectual development is not dependent on special innate gifts, but is more the result of hard work and organized effort. The achievement gap in math and science is unlikely to diminish until, among other things, there are marked changes in the attitudes and beliefs of parents and students about education and the contribution of hard work and effort to academic success.

• The committee advocates that diversity become prized as a resource, one characterized by genuine respect for students' varying backgrounds, talents, and learning styles.

Diversity should be seen as a resource, as a criterion for excellence as our nation moves to a new stage of economic and scientific development. All programs directed at broadening the educational pathway must do better in reaching out to students, parents, and communities of all racial and ethnic groups. Encouraging minorities to pursue more advanced study in the sciences will require improving the climate of the classroom. All students must be made to feel that they are truly valued and that they can achieve academic success. This includes valuing their culture and language, and appreciating their individual talents.

• A national priority must be the collection of better data and tracking systems to measure progress, to identify the most promising and effective interventions, as well as to identify those that are not working.

Major obstacles can be eliminated by expanding or replicating existing successful intervention models. Yet, the committee found that only a few programs have been rigorously assessed or publicly evaluated. Nationwide there are successful programs, but many are overlooked as a result of lack of documentation and publication. There needs to be increasing emphasis on timely dissemination of evaluation findings in a format that can be used by all the various constituencies involved in these efforts.

• The committee suggests that federal funding increasingly reflect the importance of supporting programs that improve the size and quality of the minority applicant pool by focusing on earlier interventions.

A cohesive, strategic framework for broadening the pipeline for minorities in the health professions can make more effective use of existing resources.

Nevertheless, the administration's stated objective of developing a more diverse health professions workforce as a key component of health care reform and broadening access will require additional, well-targeted public resources. Federal funds must continue to be made available to those schools with demonstrated excellence in educating minority students. Incentives and rewards also should be directed at those academic health science centers willing to develop concerted efforts to increase the ranks of minority students and faculty.

• The availability of good student financial assistance must be ensured through public and private sector scholarships.

The high cost of medical education may be a critical factor constraining the size of the minority applicant pool and may make the quicker financial rewards of other career paths more attractive. Outstanding debt for indebted medical school graduates has grown significantly over the past 15 years, the result of major tuition increases and a decline in the availability of scholarships. To the extent that debt is an economic and psychological burden, medical schools may be in the paradoxical position of increasing constraints on the very students they seek to help.

• Resources should be directed at faculty development, curricular revision, and program support for success in achieving greater minority participation at the university level.

Successful strategies on the academic level require faculty time, initiative, innovation, and leadership. They require resources for faculty development, curricular revision, and program support, as well as meaningful incentives for faculty who participate. While universities, as well as other educational institutions, can appeal to the humanitarian impulses of faculty by asking them to be more alert for opportunities to improve the academic climate for minority students and faculty, the committee feels that appeals to altruistic values work best when they are accompanied by rewards and sanctions.

• The committee believes that health care reform should recognize and promote opportunities for greater minority participation in the health professions and for better health service to minority populations.

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. 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 lower 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 or hypertension.

• The committee also sees an urgent need to attract minority physicians to academic medicine and research.

The career pathways of practitioners, researchers, and teachers are essential components; they should not be in competition with each other. Underrepresentation in the health professions is even more disturbing when one looks at the paltry number of minority faculty members in medical schools. The presence of a minority faculty member in a leadership position provides the atmosphere conducive to the recruitment, development, and retention of minority staff and faculty.

Minority students should be exposed to meaningful research experiences early in their academic careers, as early as at the high school level. Such an exposure could broaden the pool of individuals potentially interested in research and teaching positions, as well as contribute to success in the health professions. Minority researchers can contribute significantly to the need for enhanced study of the special conditions that contribute to poor health among minorities.

Through the contributions of the workshop participants, the committee developed six recommendations it feels, if followed, will lead to a strategic action and research agenda for increasing minority participation in the health professions.

• The committee recommends that foundations, through a number of demonstration projects, sponsor communities that develop their own comprehensive plan for systematic reform and implement a dynamic, multifaceted community effort directed at minority health professions training, together with a goals statement and implementation plan.

The formal education system alone cannot improve the problem of persistent minority underrepresentation. Future efforts will require a higher level of support among parents and all community-based leaders and organizations that contribute to education, health careers, mentoring, and the promotion of cultural diversity. Each community must become a place where learning can happen, a place that produces children equipped to make a wide array of choices and to succeed in the choices they make.

The committee envisions community efforts that involve institutions of learning from elementary schools through graduate training, churches, business leaders, health care organizations and providers, and other relevant stakeholders. The expectation is that such community-based efforts will raise the quality and

environment for science teaching, attract additional resources, and make the prospect of a health or science career a stimulating, rewarding, and feasible career pathway. A significant component of the community initiative would be a structured grass-roots mentoring program, using the economic, financial, and social leverage of minority and nonminority individuals who have achieved professional standing in their neighborhoods. The committee believes that this kind of coordinated effort can bring about lasting changes in the attitude and behavior of the community.

• The committee recommends that a national information network and clearinghouse be developed that provides timely information on activities relevant to minority health professionals.

The committee believes that such a network would prove invaluable to students, faculty, and administrators. The use of electronic media and interactive communications to disseminate the latest data about educational opportunities, special programs, and financial aid would contribute significantly to broadening the interest and information base in this area. The availability of such a network should be widely advertised. Students, faculty, and mentors should be encouraged not only to use it but also to contribute to ongoing exchange of information.

• The committee recommends that the federal government, the foundation world, and the private sector support an annual workshop and ongoing activities devoted to furthering the state of the art of mentoring in the health professions.

Mentoring has proved to be a critical component of successful voyages through the health professions educational pipeline. Numerous mentoring organizations now exist, many of them engaged in efforts that have met with considerable success. However, more often than not, these kinds of activities are thinly funded. Much could be gained from providing an enrichment opportunity for individuals seriously engaged in mentoring to meet and learn from those who have developed especially effective programs.

• The committee recommends that academic health centers set a higher priority toward enhanced minority participation and maintain a high level of sustained commitment to this goal. The committee encourages academic health centers to forge partnerships with major corporations and other educational entities targeted to building programs to attract and support youths interested in the health professions.

Over the years, many of the nation's academic health centers and the Association of Academic Medical Colleges (AAMC) have made impressive contributions to advancing minorities in the health careers. Despite these worthy efforts, however, little evidence suggests that most medical schools have

developed significant priorities and strategies to increase minority enrollment and faculty development. Many programs have been established as "additions" to ongoing efforts, but they have never become a part of the central, sustained mission of these institutions.

If the leadership of a medical school decides to make minority enrollment and faculty development a top priority, that school is likely to improve its record in this area. Instituting meaningful incentives and sanctions to promote desired outcomes, assigning staff time, and appointing a high-level administrator to address the issue are signs that institutions are serious about enhancing the presence of minorities in the nation's health care enterprise.

• The committee recommends that community service and outreach become a fourth component of an academic health center's mission, in addition to teaching, research, and patient care. Similarly, the committee joins others in recommending formal inclusion of some level of community service among the criteria for academic recognition and advancement, in addition to the time-honored measures of scholarly and clinical achievement.

Academic health centers increasingly need to form community partnerships with local schools and colleges to nurture the interest and to develop the talents of students who may have an interest in health careers. This partnership includes the need to study health and illness in the community setting. Faculty leading and joining such efforts often gain little recognition from the traditional academic reward systems. Implementing the committee recommendations would rapidly bring to academe a new sense of priority for community-based initiatives.

• The committee calls on the corporate sector to develop and support multimedia campaigns to attract youngsters into the health professions. The committee suggests that relevant regulatory organizations within the communications industry be asked to establish a time bank, into which a defined percentage of all radio and TV time periods be deposited. Its objective would be to reserve a portion of America's public voice for social priorities.

The imperative to enhance diversity in the health professions needs a more public voice. The media and their leaders have a key role to play in creating a critical mass of support for turning minority youth "on" to science and careers in medicine. Many educators have observed that children are born scientists, endlessly questioning where things come from and how they work. The media and those who develop advertising campaigns can help educate minority youth about the fun, prestige, challenge, and rewards, both financial and emotional, associated with careers in science and medicine.