The Right Thing to Do, The Smart Thing to Do Enhancing Diversity in the Health Professions -- Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. (2001) / Chapter Skim
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The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the Health Professions
The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the Health Professions
Pages 1-35
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Desperate for well-trained nurses and other health professionals, hospitals are recruiting worldwide to fill needed shortages. These trends raise the questions: Will we have the health care workforce we need in the 21St century?
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Several events including public referenda, judicial decisions, and lawsuits challenging affirmative action policies in 1995, 1996, and 1997 (notably, the Fifth District Court of Appeals finding in Hopwood v. Texas, the California Regents' decision to ban race or gender-based preferences in admissions, and passage of the California Civil Rights Initiative [Proposition 209]
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Given these problems—an increasing need for minority health professionals, policy challenges to affirmative action, and little progress toward enhancing the numbers of URM students prepared to enter health professions careers three health policy and professional organizations met to consider a major symposium that would explore challenges and strategies to achieving diversity among health professions. Representatives of the Association of American Medical Colleges (AAMC)
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racial and ethnic minorities in health professions, and discuss the strategies that are being developed to respond to underrepresentation; 3. assess the impact of anti-affirmative action legislative and judicial actions on diversity in health professions and health care service delivery to ethnic minority and medically underserved populations; 4.
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. The Smart Thing to Do" Several presenters argued for a re-examination of the rationale for diversity in health professions, and, more specifically, the value of affirmative action as a tool for achieving diversity in health professions training settings.
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Noting that some research and anecdotal evidence supports the argument that a diverse health care workforce helps to improve access to care for minority communities and enhance trust and communication, Smith called for more critical analysis and research. Not all racial and ethnic minority health care providers will "click" with minority patients, he noted; similarly, one should not assume that nonminority providers cannot adequately serve minority patients.
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Supreme Court's ruling in the landmark 1978 Bakke case, which remains the preeminent ruling on affirmative action as of this writing, refutes the notion that race, ethnicity, and color cannot and should not be taken into account in admissions processes. To the contrary, the Bakke decision points out that U.S.
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Like many other schools that have affirmative action policies, Michigan's admissions process considers applicants' academic preparation and achievements in conjunction with other factors- such as their geographic location, leadership, socioeconomic status, athletic abilities, and alumni status to create a diverse student body, said Bollinger. Race and ethnicity are but two of the many factors that must be considered to assemble a class "like a symphony," he said.
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. Kington and colleagues explored the impact of diversity among health professionals via three pathways: the effect of practice choices of minority providers; the quality of communication between minority patients and providers; and the quality of training in health professions training settings as a result of increasing diversity in these settings.
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However, the authors caution, there is little empirical evidence that cultural competence influences patient outcomes, or that increasing the numbers of minority physicians to serve patients of color improves outcomes through culturally appropriate care. In addition, although many speculate that increased diversity in medical training may expose physicians to a wider range of cultural backgrounds and improve their interactions with patients, there is little evidence that diversity within health care training settings (e.g., greater numbers of URM students in medical school)
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They found that minority graduates of these institutions attained levels of academic achievement that were on par with their non-minority peers (e.g., minority and non-minority students attained graduate degrees at approximately equivalent rates)
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Tedesco added that research should be done to assess the contributions of diversity in health professions training, for "it would be an opportunity lost not to study what our students are bringing to us." Finally, Tedesco noted, students trained in diverse health professions education settings are likely to help improve the delivery of health care to minority and medically underserved communities. Observing that mistrust of the medical establishment has been linked to poor patient compliance, lack of participation in clinical trials, and low rates of patient satisfaction, Tedesco argued that diversity experiences can help health care providers and the patients they serve to develop bonds of understanding that will improve trust.
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necessity" argument, which links the state's interest c,.l,Ten' ~thce~On in facilitating the health care of its citizens via a ra- ~~ i;~.s~ape ins heed Ifcially and ethnically diverse health care workforce, c~on~sq~i~e~;se~:~l~ Perez stated. This argument, he noted, has met with ~~ -- ~-~-~-~,,-~-~ success in some legal challenges to affirmative action - - - Y; ~ ~ ~ ~ -I ~ ~~ ~~ ~~-~ ~~-~-~ ~~ ~ ~~ ~ ~~ ~~ ~~ ~~ ~ ~~ ~ ~ Teas- P~ -- ~~ ~~in the context of police and corrections hiring.
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REDEFINING EDUCATIONAL MERIT Standardized Testing and Educational Opportunity Noting that "tests and assessments are the most powerful levers of opportunity to higher status education and employment," Michael Nettles and Catherine Millett analyzed trends in the performance of African-American and Hispanic students on standardized tests, and discussed the implications of group differences in test performance for the participation of URM students in higher education (Nettles and Millet, this volume)
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Several factors correlate with minority student performance on standardized tests, according to Nettles and Millett. Not surprisingly, they noted, the concentration of minority students in schools is inversely associated with students' test performance.
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When founding the National School of Public Health, Herman stated, two fundamental principles had to be addressed. The first was equity, a term Herman prefers to affirmative action.
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MEDUNSA also helps to upgrade the skills of high school science and math teachers with refresher courses and university "open days." The end result of these outreach efforts, Herman stated, is that MEDI3NSA has been able to make strides toward addressing South Africa's need for a diverse health care workforce. While many students of color choose to attend majority white schools because they have more resources, he stated, MEDI)
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Today, however, computer-based technology and intellectual labor drive the economy, and minority children must be prepared to participate. "The new technology has brought with it a new requirement for literacy for citizenship," Moses stated.
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We need a discussion about the floor. What's the floor out here for everyone to stand on, so that if we provide this floor and they get on it then they have a real opportunity to be citizens." TRENDS IN ADMISSION, ENROLLMENT, AND RETENTION OF URM STUDENTS IN THE HEALTH PROFESSIONS EDUCATION PIPELINE Lost Opportunities: The Journey to Higher Education for URM Students Noting large disparities in educational outcomes between underrepresented minority (URM)
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Middle school, Gandara noted, presents another stage at which URM students face educational risks, as this is a stage when curriculum tracking begins. Children who are held back in basic math courses, she stated, will have difficulty catching up and may not be able to complete college preparatory courses in high school.
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population, URM students attained only 14% of bachelor's degrees conferred in 1997, according to Gandara. Further, URM students are less likely to be enrolled in biological/life sciences or health professions, further diminishing the supply of potential health professionals.
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Rather, URM matriculation in these states generally has declined, a trend that is even more disturbing considering the large increases of URM students among the school-age population in these states. Tienda analyzed undergraduate enrollment in the two states' flagship institutions (the University of California at Berkeley and the University of California at Los Angeles in California, and University of Texas at Austin and Texas A&M University in Texas)
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Tienda attributed this decline to significant differences between the two institutions in their response to Hopwood; at UT Austin, university officials conducted significant outreach efforts to encourage URM students to apply to the university, and increased scholarship support to ensure that admitted URM students would be able to clear financial barriers and matriculate. California, in contrast to Texas, did not immediately implement an alternative policy to address its prohibition on the use of race and ethnicity in admissions decisions, according to Tienda.
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"If swelling numbers of Hispanic college-age youth are not accompanied by commensurate increases in college attendance and graduation," Tienda noted, "education inequality will rise dramatically in the foreseeable future." Trends in URM Participation in Health Professions Kevin Grumbach and his colleagues (Grumbach, Coffman, Rosenoff, and Munoz, this volume) assessed trends in the participation rates of URM students in a variety of health professions training programs (i.e., allopathic and osteopathic medicine, nursing, public health, dentistry, pharmacy, and veterinary medicine)
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Osteopathic medicine has traditionally been less successful than allopathic medicine in attracting URM students, as the proportion of URM students entering these schools is approximately half that of URM participation in allopathic medical schools. Overall, applications to osteopathic medical schools increased by 168% between 1990 and 1999, but URM applications increased less dramatically.
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speculated that in part, these schools may be able to maintain or increase levels of URM participation because they are under less public scrutiny than fields such as medicine, or may be less affected by policy changes in admissions processes. Improving Access to Quality Education and Health Careers for Minority Students Addressing Educational Inequality in the United States Efforts to enhance the pipeline of URM students prepared to enter health professions careers must address the structural and economic problems of schools that educate these students, stated Linda Darling-Hammond, who discussed the implications of inequities in funding of public schools on the quality of education for racial and ethnic minority students (Darling-Hammond, this volume)
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The quality of curriculum is another critical variable in teaching, according to Darling-Hammond. Schools that serve primarily low-income and minority students offer few advanced and more remedial courses, and have smaller academic tracks and larger vocational programs.
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Many of the problems with schools attended by low-income and minority students begin with district and state policies and practices that provide inadequate funding and "incompetent" staff, and require inordinate attention to arcane administrative requirements, Darling-Hammond stated. Initiatives should improve the core practices of schooling, she added, rather than layering additional programs onto an already faulty base.
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Maldonado contended that a lack of adequate access to health care- particularly for those who live in inner cities and rural areas- and the erosion of trust between patients and doctors are significant problems that health professions schools must address. He argued that because physicians from underrepresented minority groups are more likely to practice in minority and poor communities, diversity among health professionals will help to ensure that the needs of these communities are met.
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Retaining URM Students in Health Professions Programs While the most popular strategy to increase the number of underrepresented minorities in health professions has been to increase admissions to health professions schools, minorities are more likely than non-minority students to experience academic problems that result in a change in their academic status and delayed graduation, according to Michael Rainey, Acting Associate Dean for Academic Affairs at SUNY-Stony Brook School of Medicine (Rainey, this volume)
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Because of these factors, he said, it is the least-prepared students who will have the most difficulty. URM students are at greater risk for attrition than nonminority students given their generally poorer academic preparation and lack of familiarity with the culture and fast-paced environment of medical school, according to Rainey.
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Rainey also advocated exploring ways to help URM faculty earn tenure and promotion at the same rate as non-minority faculty, and address the issues of clinical faculty and resident/intern discrimination and harassment directed at URM students in school. Finally, as an example of strategies to help improve support services, he recommended that the institutions' office of minority affairs be staffed with high-ranking, visible, and available staff and have resources to provide support services to URM students.
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These small discussion sections were asked to generate recommendations regarding strategies to improve minority student preparation and achievement in primary and secondary schools, to enhance the representation of URM students in higher education, to improve health professions' schools admissions processes to achieve greater diversity in these settings, and to better retain URM students in health professions. These recommendations are summarized below.
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Finally, the rapporteur noted that because admissions efforts are limited by the quality of the pool of applicants, greater outreach efforts are needed to "beat the drums a little more loudly to get people to start ~inldng about health professions careers" earlier than college. Similarly, retaining URM students in health professions training settings will require a re-examination of the institution's goals and priorities, according to another rapporteur.
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"We have to really raise the expectations of our children, and also raise expectations of other people for children and of our communities," she stated, noting, "This is not a minority issue—this is an American issue." CONCLUSION The Symposium on Diversity in the Health Professions in Honor of Herbert W Nickens, M.D., was convened to provide a forum for health policymakers, health professions educators, education policymakers, researchers, and others to address three significant, and at times, contradictory challenges: the continued underrepresentation of African Americans, Hispanics, and Native Americans in health professions; the growth of these populations in the United States and subsequent pressure to address their health care needs; and the recent policy, legislative, and legal challenges to affirmative action that may limit access among URM students to health professions training.
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