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The United States is rapidly transforming into one of the most racially and ethnically diverse nations in the world. Groups commonly referred to as minorities including Asian Americans, Pacific Islanders, African Americans, Hispanics, American Indians, and Alaska Natives are the fastest growing segments of the population and emerging as the nation's majority. Despite the rapid growth of racial and ethnic minority groups, their representation among the nation's health professionals has grown only modestly in the past 25 years. This alarming disparity has prompted the recent creation of initiatives to increase diversity in health professions. Healthcare's Compelling Interest considers the benefits of greater racial and ethnic diversity, and identifies institutional and policy-level mechanisms to garner broad support among health professions leaders, community members, and other key stakeholders to implement these strategies. Assessing the potential benefits of greater racial and ethnic diversity among health professionals will improve the access to and quality of healthcare for all Americans.
Ensuring Diversity in the Health-Care Workforce
Copyright © 2004 National Academy of Sciences
All right reserved.
HEALTH CARE'S COMPELLING INTEREST: ENSURING DIVERSITY IN THE HEALTH-CARE WORKFORCE
The United States is rapidly becoming a more diverse nation, as demonstrated by the fact that nonwhite racial and ethnic groups will constitute a majority of the American population later in this century. The representation of many of these groups (e.g., African Americans, Hispanics, and Native Americans) within health professions, however, is far below their representation in the general population. Increasing racial and ethnic diversity among health professionals is important because evidence indicates that diversity is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better educational experiences for health professions students, among many other benefits.
Many groups-including health professions educational institutions (HPEIs), private foundations, and state and federal government agencies-have worked to increase the preparation and motivation of underrepresented minority (URM) students to enter health professions careers. Lessattention, however, has been focused on strategies to reduce institutional- and policy-level barriers to URM participation in health professions training.
HPEIs can improve admissions policies and reduce barriers to URM admission by developing a clear statement of mission that recognizes the value of diversity in health professions education. Admissions policies should be based on a comprehensive review of each applicant, including an assessment of applicants' attributes that best support the mission of the institution (e.g., background, experience, multilingual abilities). Admissions models should balance quantitative data (i.e., prior grades and standardized test scores) with these qualitative characteristics.
The federal Health Resources and Services Administration (HRSA) is a major funder of health professions training that seeks to improve the quality and availability of diverse health professionals through an array of programs. These health professions programs should be evaluated to assess their effectiveness in increasing the numbers of URM students enrolling and graduating from HPEIs, and Congress should provide increased funding for programs shown to be effective in enhancing diversity. State and local entities should increase support for diversity efforts through programs such as loan forgiveness, tuition reimbursement, loan repayment, and other efforts. In addition, private entities should be encouraged to collaborate through business partnerships with HPEIs to support the goal of developing a more diverse health-care workforce.
The U.S. Department of Education should strongly encourage accreditation bodies to be more aggressive in formulating and enforcing standards that result in a critical mass of URMs throughout the health professions. In addition, health professions education accreditation bodies should develop explicit policies articulating the value and importance of diversity among health professionals, and monitor the progress of member institutions toward achieving these goals.
HPEIs should develop and regularly evaluate comprehensive strategies to improve the institutional climate for diversity. As part of this process, HPEIs should proactively and regularly engage and train students, house staff, and faculty regarding institutional diversity-related policies and expectations and the importance of diversity to the long-term institutional mission.
HPEI governing bodies should develop institutional objectives consistent with community benefit principles that support the goal of increasing health-care workforce diversity, including efforts to ease financial and nonfinancial obstacles to URM participation, increase involvement of diverse local stakeholders in key decision-making processes, and undertake initiatives that are responsive to local, regional and societal imperatives. These objectives are best assessed and enforced via the accreditation process.
In a landmark decision that resolved over 5 years of litigation-and an even longer period of contentious national debate-the U.S. Supreme Court ruled in Grutter v. Bollinger et al. that the University of Michigan Law School's consideration of race and ethnicity as one of many factors in the admissions process was lawful, because the practice was "narrowly tailored" and did not violate the constitutional rights of nonminority applicants. Perhaps more importantly, the Court declared that the university's position that achieving a "critical mass" of racial and ethnic diversity in its law school was a compelling interest of the law school and the nation, a rationale that will have far-reaching implications, not just for URM students but also for the nation as a whole.
Few professional fields will feel the impact of the decision in the Grutter case-and the potential influence of greater levels of racial and ethnic diversity-as profoundly as the health professions. Health professions disciplines are grappling with the impact of major demographic changes in the United States population, including a rapid increase in the proportions of Americans who are nonwhite, who speak primary languages other than English, and who hold a diverse range of cultural values and beliefs regarding health and health care. Efforts to increase the proportions of URMs in health professions fields, however, have met with limited success. To a great extent, efforts to diversify health professions fields have been hampered by gross inequalities in educational opportunity for students of different racial and ethnic groups. Primary and secondary education for URM students is, on average, far below the quality of education for non-URM students. The "supply" of URM students who are well-prepared for higher education and advanced study in health professions fields has therefore suffered.
Equally important, however, are efforts to reduce policy-level barriers to URM participation in health professions training, and to increase the institutional "demand" for URM students. For example, several events-including public referenda (i.e., the California Civil Rights Initiative [Proposition 209] and Initiative 200 in Washington state), judicial decisions (e.g., the Fifth District Court of Appeals finding in Hopwood v. 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 Supreme Court decision in Grutter), and to curtail race- and ethnicity-based financial aid.
Given these problems-an increasing need for URM health professionals, policy challenges to affirmative action, and little progress toward enhancing the numbers of URM students prepared to enter health professions careers-the W.K. Kellogg Foundation requested a study by the Institute of Medicine (IOM) to assess institutional and policy-level strategies for achieving greater diversity among health-care professionals. 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 HPEIs' admissions practices,
o reducing financial barriers to health professions training among minority and lower-income students,
o increasing the emphasis on diversity goals in HPEI program accreditation,
o improving the HPEI campus "climate" for diversity, and
o considering the application of community benefit principles to improve the accountability of nonprofit, tax exempt institutions (e.g., medical schools and teaching hospitals) to the diverse racial and ethnic communities they serve; and
identify mechanisms to garner broad support among health professions leaders, community members, and other key stakeholders to implement these strategies.
This Executive Summary presents a shortened version of the study committee's full report, with summaries of the analysis, findings, and recommendations. The reader is referred to the full report for a more detailed discussion of the committee's findings and recommendations.
Why Is Racial and Ethnic Diversity Important in Health Professions Fields?
A preponderance of scientific evidence supports the importance of increasing racial and ethnic diversity among health professionals. This evidence (some of which is summarized below) 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, better patient-provider communication, and better educational experiences for all students while in training.
Racial and Ethnic Diversity Among Health Professionals and Access to Health Care for Minority Patients
Racial and ethnic minority health care professionals are significantly more likely than their white peers to serve minority and medically under-served communities, thereby helping to improve problems of limited minority access to care. For example, URM physicians are more likely to treat patients of color (Komaromy et al., 1996), indigent patients, and patients that are sicker (Moy and Bartman, 1995; Cantor et al., 1996) than non- URM physicians. Racial and ethnic minority dentists (Solomon et al., 2001) and psychologists (Turner and Turner, 1996) are also more likely than their white peers to practice in racial and ethnic minority communities.
Diversity and Minority Patient Choice and Satisfaction
Minority patients who have a choice are more likely to select healthcare professionals of their own racial or ethnic background (Saha et al., 2000; LaVeist and Nuru-Jeter, 2002). Moreover, racial and ethnic minority patients are generally more satisfied with the care that they receive from minority professionals (Saha et al., 1999; LaVeist and Nuru-Jeter, 2002), and minority patients' ratings of the quality of their health care are generally higher in racially concordant than in racially discordant settings (Cooper-Patrick et al., 1999).
Diversity and Quality of Training for Health Professionals
Diversity in health professions training settings may assist in efforts to improve the cross-cultural training and cultural competencies of all trainees. Interaction among students from diverse backgrounds in training settings may help students to challenge assumptions and broaden perspectives regarding racial, ethnic, and cultural differences (Cohen, 2003; Whitla et al., 2003). In addition, there is growing evidence, primarily from studies of college students' undergraduate experiences, that campus diversity experiences are associated with gains in all students' learning outcomes and community involvement (e.g., Gurin et al., 2002; Antonio et al., in press; Whitla et al., 2003).
Despite the importance of diversity in health professions, African Americans, American Indians and Alaska Natives, many Hispanic/Latino populations, and some Asian American (e.g., Hmong and other Southeast Asians) and Pacific Islander groups (e.g., Native Hawaiians) are grossly underrepresented among the nation's health professionals. A range of institutional and policy-level strategies to increase the presence of URMs in the health professions are discussed below.
Reconceptualizing Admissions Policies and Practices
Although admissions practices vary by institution and discipline, admission into many HPEIs remains a highly competitive process, in which many talented applicants compete for a limited number of slots. For a range of reasons, including efficiency in sorting through a large number of applicants, and to attain a reasonable expectation of how applicants can be expected to perform in HPEIs, many admissions committees rely heavily on quantitative information, such as applicants' prior grades and standardized test scores, in identifying those applicants that will receive serious consideration.
Standardized test scores are generally good predictors of subsequent academic performance but have been used-in some cases inappropriately-as a barometer of applicants' academic "merit," often to the detriment of URM students. Some higher education institutions, as well as many among the general public, cling to the belief that admissions tests measure a "compelling distillation of academic merit" (National Research Council, 1999). Yet standardized admissions tests do not measure the full range of abilities that are needed to succeed in higher education (Sternberg and Williams, 1997), nor were they designed to. In addition, test scores are malleable, and are not indicative of fine distinctions between individual applicants. Admissions tests, whether they measure aptitude or achievement, are therefore best viewed as imprecise estimates of how students might be expected to perform in specific educational contexts, and are best used to sort applicants into broad categories (National Research Council, 1999).
URM students typically score lower than their white or Asian American peers on a range of standardized tests, including the SAT, GRE, and MCAT. This disparity occurs for a variety of reasons, but principally because of poorer educational opportunities afforded to African American, Latino, and American Indian/Alaska Native students. These students are more likely than non-URM students to attend schools that are racially and economically segregated, poorly funded, offer few (if any) advanced placement and college preparatory classes, have fewer credentialed teachers, and suffer from a climate of low expectations (American Sociological Association, 2003; Camara and Schmidt, 1999). Moreover, even among those URM students who are invested in high academic performance, social and psychological factors-such as the pressure to perform above levels suggested by stereotypes of low minority academic ability-may serve to suppress their test performance (Steele, 1997; Steele and Aronson, 1995).
When quantitative variables such as standardized test scores are weighted heavily in the admissions process, URM applicants, because of their generally poorer academic preparation and test performance, are less successful in gaining admission than non-URM applicants. Absent admissions practices that allow applicants' race or ethnicity to be considered along with other personal characteristics of applicants, URM student participation in health professions education is likely to decline sharply. States that have implemented "percent solution" admissions strategies (i.e., where a top percentage of high school graduates are guaranteed admission to the state university system) have found that URM admissions have generally not increased (Tienda et al., 2003; Horn and Flores, 2003; Marin and Lee, 2003). In addition, an analysis by the Association of American Medical Colleges of the likely impact of "race-neutral" admissions policies in medical schools reveals that 70 percent fewer URM students would gain admission under such conditions (Cohen, 2003).
Excerpted from IN THE NATION'S COMPELLING INTEREST Copyright © 2004 by National Academy of Sciences. Excerpted by permission.
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|2||Reconceptualizing admissions policies and practices||55|
|3||Costs and financing of health professions education||88|
|4||Accreditation and diversity in health professions||127|
|5||Transforming the institutional climate to enhance diversity in health professions||143|
|6||Community benefit as a tool for institutional reform||178|
|7||Mechanisms to garner support for institutional and policy-level diversity initiatives||203|
|A||Increasing diversity in the health professions : a look at best practices in admissions||233|
|B||The role of public financing in improving diversity in the health professions||273|
|C||The role of accreditation in increasing racial and ethnic diversity in the health professions||317|
|D||Diversity considerations in health professions education||345|