In the Nation's Compelling Interest Ensuring Diversity in the Health-Care Workforce (2004) / Chapter Skim
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1 Introduction
1 Introduction
Pages 23-54
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Groups commonly referred to as minorities -- including Asian Americans, Pacific Islanders, African Americans, Hispanics, American Indians, and Alaska Natives -- are the fastestgrowing segments of the population and are emerging as the nation's majority. Since 2000, for example, Hispanics accounted for 3.5 million -- or over one-half -- of the population increase of 6.9 million individuals in the United States.
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Texas) , and lawsuits challenging affirmative action policies in 1995, 1996, and 1997 -- forced many higher education institutions to abandon the use of race and ethnicity as factors in admissions decisions (in some cases temporarily, in light of the June 2003 Supreme Court decision in Grutter v.
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Institutional and policy-level strategies are defined as specific policies or programs of health professions schools, associations, accreditation bodies, health-care organizations/systems, or state and federal governments, designed to increase access to health professions careers among underrepresented racial and ethnic minority groups, as a means of increasing the likelihood that "pipeline" efforts4 to increase diversity will succeed. Specifically, the IOM was asked to: · assess and describe potential benefits of greater racial and ethnic diversity among health professionals; · assess institutional and policy-level strategies that may increase diversity within the health professions, including: o modifying graduate health professions training programs' admissions practices; o increasing the emphasis in health professions program accreditation on enhancing diversity in training programs and developing crosscultural skills and competencies of health professions trainees; o improving the campus "climate" for diversity, including efforts to recruit and support URM students and faculty and facilitate learning within a context of diversity; o modifying the financing and funding of health professions training in order to reduce financial barriers to health professions training among minority and lower-income students; and 3In a landmark decision that resolved over five years of litigation -- and an even longer period of contentious national debate -- the U.S.
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. · Nearly 2 in 5 Latinos, 27 percent of Asian Americans, 23 percent of African Americans, and 16 percent of whites reported communication problems with their doctor (Collins et al., 1999)
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. Previously, AAMC's definition was limited to historically disadvantaged groups (i.e., African Americans, mainland Puerto
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While the study committee defines URMs broadly, it should be noted that the racial and ethnic groups identified in AAMC's previous definition of URM groups (e.g., African Americans, some Hispanic/Latino groups, American Indians) are historically underrepresented and face long-standing barriers to greater inclusion among health professionals -- including persistent discrimination, educational inequality, and few role models for students of these racial and ethnic groups.
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Racial and Ethnic Diversity Among Health Professionals and Access to Health Care for Minority Patients Racial and ethnic minority health-care clinicians are significantly more likely than their white peers to serve minority and medically underserved communities, thereby helping to improve problems of limited minority access to care. Several studies document this trend across a range of health professions, although the bulk of this research has focused on the practice patterns of physicians.
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Over half of the patients seen by African American and Hispanic physicians, on average, were members of these clinicians' racial or ethnic group. Hispanic and black physicians tended to practice in areas with fewer primary care physicians per capita, but even after adjustment for the proportion of minority residents in the communities studied, African American and Hispanic physicians were more likely to care for African American and Hispanic patients, respectively.
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(1999) , for example, found that African American patients who receive care from physicians of the same race were more likely than African Americans with nonminority clinicians to rate their physicians as excellent in providing health care, in treating them with respect, in explaining their medical problems, in listening to their concerns, and in being accessible.
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Having a race-concordant physician was also associated with higher income for African Americans and not speaking English as a primary language among Hispanics. After adjusting for patients' age, sex, marital status, income, health insurance status, and whether the respondent reported having a choice in physician, African American patients in race-concordant relationships were found to report higher satisfaction than those African Americans in race-discordant relationships.
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. Diversity and Quality of Training for All Health Professionals Racial and ethnic minority patients, when given a choice, tend to choose health-care clinicians from similar backgrounds, as noted above.
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, for example, in a survey of medical school graduates' attitudes regarding diversity in medical education, found that students reported experiencing greater levels of diversity in medical school than in their prior educational experiences, as the percentage of students reporting contact with other groups increased from 50 percent prior to college to 85 percent in medical school. Overwhelmingly, these students viewed diversity among their medical student peers as a positive; 86 percent thought that classroom diversity enhanced discussion and was more likely to foster serious discussions of alternate viewpoints.
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These benefits are explored in greater detail in Chapter 5, "Transforming the Institutional Climate for Diversity." Diversity and Research on Racial and Ethnic Minority Health Disparities Diversity among health professionals may improve scientific understanding of the causes and consequences of racial and ethnic health disparities and may help to eliminate these gaps. Minority scientists and researchers bring a wide range of cultural perspectives and experiences to research teams, which increases the likelihood that sociocultural issues influencing health outcomes will be addressed in research design and study questions (Institute of Medicine, 1999)
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Diversity and Health Policy and Health Research Leadership Racial and ethnic diversity in health professions is also critical to enhance the representation of minority groups among the leadership in the health policy and health research enterprises. Racial and ethnic minority health professionals are often able to bring diverse and underrepresented perspectives to both health policy and health systems leadership, which may lead to organizational and programmatic changes that can improve the accessibility and cultural competence of health systems.
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Scientists and clinicians of color have contributed to many medical breakthroughs (e.g., Dr. Daniel Hale Williams, the African American physician credited with performing the first successful surgical repair of a heart wound; Dr.
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workforce vary among racial and ethnic groups. Between 1977 and 1997, the percentage of African Americans among the nursing workforce increased from 2.6 to 4.2 percent, a 62 percent increase, while the representation of Hispanic RNs increased by 1.4 percent to 1.6 percent during the same period (a 17 percent increase; Buerhaus and Auerbach, 1999)
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If trends continue and the problem remains unaddressed, the shortage will grow to 29 percent by 2020. Not unexpectedly -- given their underrepresentation in the current nursing workforce -- the shortage of minority nurses will be particularly difficult to address; an increase of more than 20,000 minority nurses is needed to increase the proportion of minority nurses by just 1 percent (National Advisory Council on Nurse Education and Practice, 2000)
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. Among minorities, African American and those nurses who classified their ethnicity as "other" received the largest percentage of degrees.
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. Data indicate geographic variations in faculty diversity, as the largest percentage of African American nursing faculty are represented among faculty in the south (nearly 10 percent)
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Copyright 2004 by NLN. Physicians URM Representation in the Physician Workforce African Americans, Latinos, and American Indians, and Alaska Natives are underrepresented among United States physicians (Figure 1-5)
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. In recent years, significant progress has been made in increasing the presence of URM faculty at many nonminority medical schools, while at other institutions their presence remains rare.
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Copyright 2004 by AAMC. Asian/Pacific 19.8% Other Minority 2.9% Mainland Puerto Rican 6.4% White Unknown 65.4% Mexican American 22.6% 1.3% Native American 5.9% URM 10.6% Black 65.1% FIGURE 1-7 U.S.
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Approximately 13 percent of dentists are nonwhite (Mertz and O'Neil, 2002) , and African Americans, American Indians, and Hispanics constitute only 6.8 percent of the dental workforce (see Figure 1-9)
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. URM Participation Among Dental School Faculty Trends in the percentage of minority full-time faculty indicate that the number of URM faculty remained low and relatively stable during the 1990s (Figure 1-12)
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25 20 15 Percentage 11.6 10.7 10.3 10.6 10.7 11.2 10 5 1997- 1998- 1999- 2000- 2001- 2002 1998 1999 1900 2001 2002 2003 Year FIGURE 1-11 Underrepresented minority graduates in U.S. dental education programs: Black, Hispanic, Native American.
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Among all tenured professors, 2.5 percent are African American, 2.3 percent Hispanic, and 0.3 percent American Indian. However, URM faculty have slightly higher representation among tenure track professors (5.1 percent black, 4.6 percent Hispanic, and 0.9 percent American Indian)
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SUMMARY African Americans, American Indians and Alaska Natives, and many Hispanic/Latino populations are grossly underrepresented among the nation's physicians, nurses, dentists, and psychologists. These populations also experience generally poorer health status and face greater difficulties in accessing health care.
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Bollinger lawsuit reaffirmed that higher education institutions may consider applicants' race or ethnicity as one of many factors in admissions decisions. But as a result of public referenda, judicial decisions, and lawsuits challenging affirmative action policies in 1995, 1996, and 1997, many higher education institutions abandoned (in some cases, temporarily)
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This evidence demonstrates that greater diversity among health professionals is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better patientclinician communication. Indirectly, this evidence suggests that greater diversity can improve the cultural competence of health professionals and health systems and that such improvements may be associated with better health-care outcomes.
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2001. Trends in underrepresented minority participation in health professions schools.
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2000. A National Agenda for Nursing Workforce Racial/Ethnic Diversity.
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dental schools -- The challenge. Journal of Dental Education 65(6)
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