Diversity Evolution

The United States is becoming more diverse. Is the medical education system adapting quickly enough?

The need for increased diversity in the medical profession is not breaking news. In 2004, the Institute of Medicine (IOM) called for a more diverse health-care workforce for the good of the nation. In its report, "In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce," IOM argued that "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 profession students, among many other benefits."¹

The report suggests that, while the U.S. health-care system would clearly benefit from the increased participation of underrepresented minority students, too little attention is paid to methods of reducing the institutional- and policy-level factors that impede such participation.

Yet, more than a decade later, the consideration of race in the academic admissions process was again a topic of debate, when the Supreme Court upheld an affirmative action program in Fisher v. University of Texas (see SIDEBAR).²

Commenting on the Fisher decision, Association of American Medical Colleges (AAMC) President and Chief Executive Officer Darrell G. Kirch, MD, wrote: "In light of this decision, U.S. medical schools may continue their institution-specific efforts to ensure that graduating physicians are prepared to practice medicine in an increasingly diverse society, and to address the disparities that exist in today's health-care system."³

President Donald Trump's recent executive order temporarily banning citizens from seven Muslim-majority countries from entering the United States – and its potential negative implications for medical research – have thrust this topic into the spotlight again. "The benefits of scientific collaborations are amplified by our diversity," the American Society of Hematology (ASH) wrote in a joint statement with the American Association for Cancer Research, the Association of American Cancer Institutes, the American Society for Radiation Oncology, the American Society of Pediatric Hematology/Oncology, and the LUNGevity Foundation. "For [scientific] progress to continue, it is going to require an even greater commitment to collaborations among international organizations, governments, public and private institutions, and individuals dedicated to this cause."⁴

ASH Clinical News spoke with representatives from AAMC and other experts to learn more about efforts to boost the number of underrepresented minority students and faculty in the U.S. medical education system, as well as what is being done to foster diversity and inclusiveness in medical education.

Defining Diversity

Data from the 2015 U.S. census show that nearly 40 percent of Americans identify as "non-white," a 2 percent increase from the 2010 U.S. census.⁵ In medical education, though, white students continue to represent the majority of graduates, according to 2012 AAMC data.⁶ The same is true for medical school faculty: A 2013 study published in JAMA found that the percentage of underrepresented minorities (including African-Americans, Hispanics or Latinos, American Indians or Alaska Natives, and Native Hawaiians and other Pacific Islanders) in full-time faculty positions has seen only a slight increase – from 6.8 percent in 2000 to 8 percent in 2010.⁷ Additionally, the authors reported that a faculty development program targeting underrepresented minority faculty did not succeed in increasing representation, recruitment, or promotion of these groups at U.S. medical schools.

"If you look nationwide at diversity in medical schools, it is shocking that fewer than 10 percent of all medical school faculty are from underrepresented minority groups," Belinda R. Avalos, MD, chair of the ASH Committee on Promoting Diversity and vice chair of hematologic oncology and blood disorders at the Levine Cancer Institute in Charlotte, North Carolina, told ASH Clinical News.

Of course, the issue of diversity extends beyond that of just race and ethnicity. The National Institutes of Health (NIH) defines diversity as "the range of human differences, including but not limited to race, ethnicity, gender, sexual orientation, age, social class, physical ability or attributes, religious or ethical value system, national origin, and political beliefs."⁸

“We are trying to create more opportunities for underrepresented minority trainees to pursue a career in hematology.”

Belinda R. Avalos, MD, chair of the ASH Committee on Promoting Diversity

This definition has evolved greatly in the past 30 years, according to André L. Churchwell, MD, chief diversity officer at Vanderbilt University Medical Center in Nashville, Tennessee. "We have begun to recognize that there are other groups that are often left out of the equation," said Dr. Churchwell. "We are talking about members of the lesbian, gay, bisexual, and transgender (LGBT) community, women, veterans, people with disabilities, and others. We have to be more open in our mindset, and our tent of inclusion should be broadened."

As the definition of diversity has evolved, so have the efforts to increase it. Many initiatives now link the idea of diversity with that of inclusion, or "involvement and empowerment, where the inherent worth and dignity of all people is recognized."⁸

"There are arguments for diversity related to proportionality; in other words, the idea that if African-Americans comprise 13 to 15 percent of the general population, the percentage of African-Americans among our nursing and physician staff should reflect that percentage," explained Marcella Nunez-Smith, MD, MHS, director of the Equity Research and Innovation Center at Yale School of Medicine in New Haven, Connecticut. "Inclusion language represents the idea that diversity is more robust – and more difficult – than reaching a ‘quota' of minority staff members."

Why Diversify?

Inclusion is what animates diversity, according to Laura Castillo-Page, PhD, acting chief diversity and inclusion officer at the AAMC. "You may have diversity within your institution, but if you don't leverage that diversity, you don't get the benefits," she explained.

Research has shown that the benefits of diversity in health care are innumerable – for patients and physicians. African-American and Latino patients are more likely to seek medical care from physicians of their own race based on personal preference and language, and when patients see a physician of their own race, they are more likely to rate the physician's decision-making style as participatory, compared with patients seeing a physician of a different race.^9,10

Patients who have experienced more than one discriminatory experience may delay seeking medical care and may have poor adherence to health recommendations.¹¹

These attitudes extend to medical students: A survey found that white students at the most diverse medical schools (ranking in the highest quintile for racial and ethnic diversity in the student body) were more likely to rate themselves as highly prepared to care for minority populations than students who attended the least diverse medical schools.¹²

"Another rationale for gaining diversity is that diverse teams are simply more successful," said Dr. Nunez-Smith. "Whatever the goal is, teams do it better, faster, more efficiently, and more effectively when they include a diverse perspective."

All-Out Efforts to Promote Diversity

Medical associations like ASH and AAMC, medical institutions, and the U.S. government have all launched a variety of initiatives to increase diversity in medical education and training.

In 2003, ASH was one of the first professional societies to launch its own effort to increase the number of underrepresented minorities in hematology-related fields and the number of minority hematologists with academic and research appointments: the ASH Minority Recruitment Initiative. This group of programs includes the Minority Medical Student Award Program, which offers an introductory, mentored, biomedical research experience to medical school students, and the new Minority Resident Hematology Award Program, which supports minority resident physicians as they conduct hematology-focused research. (For more about these initiatives, see the SIDEBAR.)

"We are trying to create more opportunities for underrepresented minority trainees to pursue a career in hematology," said Dr. Avalos. "By creating longitudinal pathways, we hope to maintain student and resident interest in hematology and to develop a networking community where they can stay in touch with each other and their mentors along the way."

According to Dr. Castillo-Page, AAMC is actively exploring holistic admission, which "involves working with admissions committees to think more broadly about admissions criteria, or moving beyond test scores to include the student, the student experience, and what they bring to the table," said Dr. Castillo-Page.

“Every patient has an identity. Everybody has a culture and a lived experience that is informing their health."

Marcella Nunez-Smith, MD, MHS

Once they're in the door, AAMC also is working to provide mentoring and academic support to all medical students, regardless of race, to ensure that they have the support they need to succeed. "We don't want to just enroll more minority students; we want to make sure that they get in and graduate successfully," she said.

Many medical institutions also are intensifying their efforts to foster more inclusive environments on their campuses. At Vanderbilt University, the newly created Inclusion Initiatives and Cultural Competence Office hosts professional development and training events to help students develop skills to promote social justice and to have constructive conversations, Dr. Churchwell explained.

Vanderbilt University was recently chosen by the NIH to be the Data and Research Support Center for the Precision Medicine Initiative Cohort Program, designed to study genetic, environmental, and lifestyle factors affecting health. "Part of the grant will go toward putting together processes, concepts, and tools to ensure that research projects include people of underrepresented status," said Dr. Churchwell. "We are going to take our precision medicine work and look at how social determinants of health in underrepresented populations influence genomics and clinical expression of disease."

Diversity among the health-care workforce has also become a federal concern, with the government implementing a series of programs intended to promote diversity and inclusion in health care, such as the Health Careers Opportunity Program and the Programs to Increase Diversity Among Individuals Engaged in Health-Related Research.

The Work That Remains

Despite the growing number of programs available to promote diversity and inclusion, more work remains, according to Dr. Nunez-Smith. "When the idea of cultural competency training first came about, it forced people to have conversations about diversity," she said. "A couple decades later, though, I think it is time to reevaluate."

Cultural competency training involves educating people to understand or relate to a patient's diverse values, beliefs, and behaviors, and to adjust treatment based on those factors. However, Dr. Nunez-Smith said that cultural competency training often gets boiled down to three-hour workshops that do not translate into necessary long-term behavior changes.

People need to take the next steps in creating inclusive medical education, she said. One updated approach incorporates the idea of cultural humility, or the "ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person]."¹³

"When I sit across from a patient, I am not striving toward competency," said Dr. Nunez-Smith. "I am striving toward humility, toward being open. Every patient has an identity. Everybody has a culture and a lived experience that is informing their health."

Recognizing that people have different experiences – and that patients and providers have unconscious biases – is central to the idea of diversity and inclusion.

"When we talk about diversity, we are really talking about a diversity of perspective, a diversity of biases," Dr. Nunez-Smith explained. "We have to own up to the fact that we all cognitively shortcut to certain thoughts and developed biases. There should be no presumption that a person of color is going to be any less biased than anyone else."

Diversity 2.0, and Beyond …

To conceptualize diversity's broader relevance to health care and medical education, AAMC developed a three-phase paradigm (a framework borrowed from technology company IBM) for incorporating diversity in medical schools and teaching hospitals – what AAMC has termed the "diversity operating system" or DOS.

The first iteration of these efforts, DOS 1.0, included "somewhat isolated efforts aimed at removing social and legal barriers to access and equality, with institutional excellence and diversity as competing ends. … DOS 2.0 kept diversity on the periphery but raised awareness about how increasing diversity benefits everyone," Marc A. Nivet, EdD, former chief diversity officer at AAMC, wrote in a commentary introducing the Diversity 3.0 Learning Series. "In the DOS 3.0 paradigm, diversity and inclusion are integrated into the core workings of the institution and framed as integral to achieving excellence."¹⁴

The Diversity 3.0 Learning Series lineup features a series of webinars that delve into the new paradigm, including topics such as "Attracting Black Men to Medicine: Physicians' Call to Action" and "A Leader's Role in Addressing LGBT Health."¹⁵

"With this next step, institution leaders must look critically at their internal structures, policies, and programs, and ask, ‘Are we doing the best we can to be inclusive?'" Dr. Castillo-Page explained. "It also means investigating what is going on outside the institutions' doors and asking, ‘Are we engaged with our community? How is our institution perceived by the community?'"

To have diversity and inclusion be a central part of excellence, the efforts must be intentional and persistent, said Dr. Churchwell. "You have to think about diversity every moment of every day," he said. "If not, you will fall back into the process of doing things out of habit that were formed in your unconscious-bias brain. You have to be intentional about building programs to populate your candidate pool and creating a nurturing environment for those students within your institution and community."—By Leah Lawrence 

References

1. Institute of Medicine. In the nation's compelling interest: ensuring diversity in the health-care workforce. Washington, DC: National Academies Press; 2004.
2. Supreme Court of the United States. Fisher v. University of Texas at Austin et al. No 14-981. Accessed January 19, 2017, from https://www.supremecourt.gov/opinions/15pdf/14-981_4g15.pdf.
3. American Association of Medical Colleges. AAMC statement on the Supreme Court ruling in Fisher v. University of Texas at Austin. Accessed January 19, 2017, from https://www.aamc.org/newsroom/newsreleases/462622/fisher_texas_scotus_06232016.html.
4. American Society of Hematology. Statement from ASH, AACR, AACI, ASTRO, ASPHO, and LUNGevity Foundation on the administration's executive order on immigration. Accessed February 1, 2017, from http://www.hematology.org/Newsroom/Press-Releases/2017/7076.aspx.
5. S. Census Bureau. QuickFacts. Accessed January 25, 2017, from https://www.census.gov/quickfacts/table/PST045216/00.
6. American Association of Medical Colleges. FACTS: applicants, matriculants, enrollment, graduates, M.D.-Ph.D., and residency applicants data. Accessed January 25, 2017, from https://www.aamc.org/data/facts.
7. Guevara JP, Adanga E, Avakame E, et al. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310:2297-304.
8. National Institutes of Health. Glossary. Accessed January 18, 2017, from https://diversity.nih.gov/find-read-learn/glossary.
9. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583-9.
10. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Aff (Millwood). 2000;19:76-83.
11. Casagrande SS, Gary TL, LaVeist TA, et al. Perceived discrimination and adherence to medical care in a racially integrated community. J Gen Intern Med. 2007;22:389-95.
12. Saha S, Guiton G, Winners PF, et al. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA. 2008;300:1135-45.
13. Hook JN, Davis DE, Owen J, et al. Cultural humility: measuring openness to culturally diverse clients. J Couns Psychol. 2013;60:353-66.
14. Nivet M. Commentary: Diversity 3.0: a necessary systems upgrade. Academ Med. 2011;86:1487-9.
15. Association of American Medical Colleges. Diversity 3.0 learning series. Accessed January 25, 2017, from https://www.aamc.org/initiatives/diversity/learningseries/.