IN THE NATION’S COMPELLING INTEREST
Ensuring Diversity in the Health-Care Workforce
Brian D. Smedley, Adrienne Stith Butler, Lonnie R. Bristow, Editors
THE NATIONAL ACADEMIES PRESS
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, NW Washington, DC 20001
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 study was supported by Contract No. P009518 between the National Academy of Sciences and the W.K. Kellogg Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
In the nation’s compelling interest : ensuring diversity in the health care workforce / Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce, Board on Health Sciences Policy ; Brian D. Smedley, Adrienne Stith Butler, Lonnie R. Bristow, editors.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-09125-X (hardcover)
1. Discrimination in medical education—United States—Prevention. 2. Medical colleges—United States—Admission. 3. Minorities in medicine—United States. 4. Minorities—Education (Higher)—United States. 5. Medical personnel—Recruiting—United States. 6. Affirmative action programs—United States.
[DNLM: 1. Cultural Diversity—United States. 2. Health Manpower—United States. 3. Accreditation—standards—United States. 4. Education, Medical—economics—United States. 5. Minority Groups—education—United States. 6. Personnel Selection—standards—United States. 7. Public Policy—United States. W 76 I355 2004] I. Smedley, Brian D. II. Butler, Adrienne Stith. III. Bristow, Lonnie R. IV. Institute of Medicine (U.S.). Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce. V. Institute of Medicine (U.S.). Board on Health Sciences Policy.
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COMMITTEE ON INSTITUTIONAL AND POLICY-LEVEL STRAGEGIES FOR INCREASING THE DIVERSITY OF THE U.S. HEALTH CARE WORKFORCE
Lonnie R. Bristow (Chair), Retired physician and former president,
American Medical Association, Walnut Creek, CA
Colleen Conway-Welch (Vice-Chair), Dean and Professor,
School of Nursing, Vanderbilt University, Nashville, TN
Brenda E. Armstrong, Associate Dean and Director of Medical School Admissions, Associate Professor of Pediatrics in the Division of Pediatric Cardiology, and Associate Vice Provost,
Duke University, Durham, NC
Kevin Barnett, Senior Investigator,
Public Health Institute, Oakland, CA
Joseph Betancourt, Senior Scientist,
Institute for Health Policy,
for Multicultural Education, Multicultural Affairs Office, Massachusetts General Hospital, Partners HealthCare System, and
Assistant Professor of Medicine
at Harvard Medical School, Boston, MA
Michael V. Drake, Vice President,
Health Affairs, University of California,
Office of the President, and Steven P. Shearing Professor of Ophthalmology,
UCSF, Oakland, CA
Jay A. Gershen, Executive Vice Chancellor and Professor in the School of Dentistry,
University of Colorado Health Sciences Center, Denver, CO
Lazar J. Greenfield, Emeritus Executive Vice President for Medical Affairs, Professor of Surgery,
University of Michigan, Ann Arbor, MI
Robert L. Johnson, Professor and Chair,
Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Newark, NJ
Bette R. Keltner, Dean,
School of Nursing & Health Studies, Georgetown University, Washington, DC (served until September 2003)
Ciro V. Sumaya, Dean and Cox Endowed Chair,
School of Rural Public Health, Texas A&M University System Health Science Center, Bryan, TX
Lisa Tedesco, Vice President and Secretary of the University and Professor of Dentistry,
University of Michigan, Ann Arbor, MI
Ena Vazquez-Nuttall, Associate Dean and Director,
Graduate School, Bouve College of Health Sciences, Northeastern University, Boston, MA
Judith A. Winston, Principal and co-founder,
Winston Withers & Associates, LLC, Washington, DC
Vickie Ybarra, Director,
Planning and Development, Yakima Valley Farm Workers Clinic, Yakima, WA
HEALTH SCIENCES POLICY BOARD LIAISON
Sherman James, John P. Kirscht Collegiate Professor of Public Health and Chair, Department of Health Behavior and Education,
University of Michigan, Ann Arbor, MI
IOM PROJECT STAFF
Brian D. Smedley, Study Director
Adrienne Stith Butler, Program Officer
Thelma L. Cox, Senior Project Assistant
IOM BOARD STAFF
Andrew M. Pope, Director,
Board on Health Sciences Policy
Troy Prince, Administrative Assistant
Carlos Gabriel, Financial Associate
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Marilyn Hughes Gaston, National Minority Health Month
Kevin Grumbach, University of California, San Francisco
George C. Hill, Vanderbilt University
Bob Montoya, Sacramento, CA
Thomas E. Perez, University of Maryland
Joan Y. Reede, Harvard University
Lynne D. Richardson, Mount Sinai Hospital
Susan C. Scrimshaw, University of Illinois
Jeanne C. Sinkford, American Dental Education Association
Richard M. Suinn, Colorado State University
Charles Terrell, Association of American Medical Colleges
William A. Vega, University of Medicine and Dentistry of New Jersey
Nancy Woods, University of Washington
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Elaine Larson, Columbia University. Appointed by the National Research Council and Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Several individuals and organizations made important contributions to the study committee’s process and to this report. The committee wishes to thank these individuals but recognizes that attempts to identify all and acknowledge their contributions would require more space than is available in this brief section.
To begin, the committee would like to thank the sponsor of this report. Funds for the committee’s work were provided by the W.K. Kellogg Foundation. The committee thanks Henrie Treadwell, Ph.D., and Bob DeVries, who served as the Project Officers on this grant.
The committee found the perspectives of many individuals and organizations to be valuable in understanding institutional and policy-level strategies for increasing the diversity of the health care workforce. Several individuals and organizations provided important information at open workshops of the committee. These include, in order of appearance, L. Natalie Carroll, M.D., President, National Medical Association; David Johnsen, D.D.S., President, American Dental Education Association; Hilda Richards, Ed.D., R.N., President, National Black Nurses Assocation, Inc.; Charles Terrell, Ed.D., Vice President, Division of Community Minority Programs, Association of American Medical Colleges; Barbara Blakeney, MS, APRN, BC, ANP, President, American Nurses Association; Phyllis Kopriva, Director, Women and Minority Services, and Kevin McKinney, M.D., Chair, Minority Affairs Consortium, American Medical Association; Geraldine Bednash, Ph.D., R.N., FAAN, Executive Director, American Association of Colleges of Nursing; Elena Rios, M.D., National Hispanic
Medical Association; Ben Muneta, M.D., President, Association of American Indian Physicians; Dean Whitla, Ph.D., Director, National Campus Diversity Project, Harvard Graduate School of Education; Ella Cleveland, Ph.D., Association of American Medical Colleges; Gabriel Garcia, M.D., Associate Dean of Medical School Admissions, Stanford University; Joshua Aronson, Ph.D., Assistant Professor, Department of Applied Psychology, New York University; Barbara Grumet, National League for Nursing Accrediting Commission; Charlotte Beason, Ed.D., R.N., C.N.A.A., Commission on Collegiate Nursing Education; Karen Hart, Commission on Dental Accreditation; David Stevens, M.D., Liaison Committee on Medical Education; Susan Zlotlow, Ph.D., American Psychological Association Committee on Accreditation; Kevin Barnett, Dr.PH., M.C.P., Public Health Institute; Paul Hattis, M.D., J.D., M.P.H., Tufts University; JudyAnn Bigby, M.D., Brigham and Women’s Hospital and Harvard Medical School; Bradford Gray, Ph.D., New York Academy of Medicine; William Vega, Ph.D., UMDNJ-Robert Wood Johnson Medical School; Jeffery F. Milem, Ph.D., University of Maryland; Eric L. Dey, Ph.D., University of Michigan; Michael Rainey, Ph.D., Stony Brook University School of Medicine; Daryl G. Smith, Ph.D., Claremont Graduate University; William B. Harvey, Ed.D., American Council on Education; Beauregard Stubblefield-Tave, M.B.A., the Stubblefield-Tave Group; Karen Matherlee, Policy, Inc.; Henry Lopez, Jr., Bureau of Health Professions, Health Resources and Services Administration; and Howard Landesman, D.D.S., M.Ed., School of Dentistry, University of Colorado Health Science Center.
The committee also gratefully acknowledges the contributions of the many individuals who assisted the committee in its work, either by providing research support or by assisting in preparation of draft material. Dr. Paul Hattis of Tufts University served as an appointed consultant and assisted the committee in preparation of the chapter, “Community Benefit as a Tool for Institutional Reform.” The committee would also like to thank the many other individuals who provided information pertinent to the committee’s charge, including Linda E. Berlin, Dr.PH., R.N.C., Director of Research and Data Services, American Association of Colleges of Nursing; Melissa Connell, J.D., University of Colorado Health Sciences Center; Lin Jacobson, Ed.D., R.N., C.P.H.Q., Director of Research, National League for Nursing; Marlaine Smith, R.N., Ph.D., Professor & Associate Dean for Academic Affairs, and Pat Moritz, Ph.D., Dean, University of Colorado Health Sciences Center School of Nursing; Donna M. English, M.P.H., R.N., Deputy Director, Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration; Ruth Beer Bletzinger, M.A., Director, Division of Community and Minority Programs, and Lois Colburn, Assistant Vice President, Division of Community and Minority Programs, Association of American Medical Colleges; Denis
Nissim-Sabat, Ph.D., Senior Policy Analyst, Public Policy Office, American Psychological Association (APA); Jessica Kohout, Ph.D., Director, Research Office, APA, and staff of the APA Research Office; and Kim Nickerson, Ph.D., Assistant Director, Minority Fellowship Program, APA.
Finally, the committee would also like to thank the authors whose papers contributed to the evidence base that the committee examined. These include Jeffery F. Milem, Ph.D., University of Maryland; Eric L. Dey, Ph.D., and Casey E. White, University of Michigan; Cathryn L. Nation, M.D., University of California; Gabriel Garcia, M.D., Stanford University; Neil Parker, M.D., University of California, Los Angeles; Karen Matherlee, Policy, Inc.; Norma E. Wagoner, Ph.D.; Leon Johnson, D.Ed., M.B.A.; and Harry S. Jonas, M.D.
For almost a decade, several state referenda and federal court decisions have limited the ability of many universities to consider race and ethnicity in admissions processes. With that background, in a real sense, this committee’s assignment has been to examine the question of whether we, as a nation, are properly utilizing the pool of applicants to training in the health professions that we already have (or will have in the future). The need and desire of the American people for competent, compassionate health professionals who have the necessary communication skills for an increasingly diverse society already exists and will only rapidly increase. Are we getting all of the qualified students and faculty that we should from the available applicant pool? From its inception, the committee also recognized there is a need to answer the very important, but usually unspoken, question of how does the broader society benefit by having increased diversity among health care professionals, aside from the gratification of doing what is morally right?
Stated more narrowly and precisely, the IOM was asked for a study assessing the potential for institutional and policy-level strategies to increase under-represented minority participation in the health professions. In other words, do these two particular strata offer any unique potential to increase diversity?
Our exploration therefore required the committee to assess (a) whether our current institutional processes and policy-level factors are, at times unintentionally creating barriers to providing the nation with the culturally competent caregivers it needs, and (b) if so, how can they be improved? Can
some of the assumptions we have made for a great many decades be fairly challenged, as to exactly what is “the best and the brightest?” Our committee believes they can be so challenged and, in fact, improved upon in light of the twenty-first century needs of America.
Much of that “unspoken question” about value to the broader society was addressed by the June 23, 2003, decision by the Supreme Court on the Grutter v. Bollinger et al. case, when the majority opinion found there is substantial evidence that the quality of the educational experience in a university that has achieved a “critical mass” of diversity is significantly greater than what is experienced without said diversity. It was necessary for our committee to carefully examine that evidence, and go beyond, to draw our own conclusions.
The Supreme Court further found that the need of the American society for such better-educated future leaders, who are also better accustomed to interacting with a diverse world community, as well as a more diverse American society, is indeed a “compelling governmental interest.”
Logic would suggest the different problem-solving skills found amongst those of diverse ethnic and cultural backgrounds should lead to more creative thinking about clinical, research, patient satisfaction, and/or cost problems, which are the bottom lines for health care. Every student and every patient will be advantaged from the achievement of a critical mass of diversity in all health profession education, not just the minority students and minority patients.
The methodology employed by this committee involved researching the pertinent literature, inviting much valued input from all key interested parties in a series of six workshops, and, in particular, studying the existing models of success in this activity. We have tried to identify and spotlight those characteristics that seem to be essential to that success and to codify them in a series of recommendations. These recommendations should be seen as being generic, and applicable to each of the healing professions, not simply to only one or the other of Dentistry, Medicine, Nursing, and Psychology. We have also attempted to make due note when unique and innovative programs were encountered that merit continued interest because of their “thinking outside the box.”
Identifying needed modifications, however, is not enough. One should not design a sailboat without identifying a realistic source of wind to make it move. Similarly, with the objective of increasing diversity, there must be such a credible source of wind to fill the sail. We believe that can best be done in any professional endeavor through the standards which are set by that profession. Accordingly, we invite the attention of the reader to the standard-setting process (and how it might be improved or stimulated to accept this task), of each of the components in health profession education.
Without coalescence around standards set by the professions themselves, little movement will occur.
Of significant importance, however, is the need to remember that, in the background remains the grim visage of the law. Justice O’Connor articulated the majority opinion in Grutter v. Bollinger et al. that, while the government’s compelling interest currently justifies this continued exception to an unflinching application of the Equal Protection Amendment, it is not intended to be a permanent exception to that Amendment. She writes, “We see no reason to exempt race-conscious admissions programs from the requirement that all governmental use of race must have a logical end point. … We expect that 25 years from now, the use of racial preferences will no longer be necessary to further the interest approved today.”
The lesson is not subtle. The challenge to American society is clear. In the view of the Court, 25 years (or one generation) from now, we as a nation should have reached a place where there is no longer a compelling need for an exception to the 14th Constitutional Amendment. This IOM committee’s report offers important tools for that achievement, but keep in mind that the clock is ticking.
The committee benefited from excellent staff support, under the leadership of Study Director Brian D. Smedley, Ph.D., assisted by Adrienne Stith Butler, Ph.D., and Thelma L. Cox, all of whom rose to every challenge, including a tight time frame for the study. Our sponsor, the Kellogg Foundation, was clear in their stated objective and unflagging in their interest and support.
Our hope is that those who read this will find light for their paths and then take action accordingly. Et facta est lux (“light is made”).
Lonnie R. Bristow, M.D.
Walnut Creek, CA
Increasing Diversity in the Health Professions: A Look at Best Practices in Admissions
The Role of Accreditation in Increasing Racial and Ethnic Diversity in the Health Professions
Diversity Considerations in Health Professions Education