Seventeenth Report
Minorities
in Medicine: An Ethnic and Cultural Challenge for Physician Training,
An Update
April 2005
Table of Contents
(for on-line viewing only) Entire Report in Adobe/.pdf
The
Council on Graduate Medical Education
Members
of the Council on Graduate Medical Education
Executive
Summary
Introduction
Findings and Recommendations
Introduction
Implications
of Changing Demographics in the U.S.
Health Disparities
Influences on Health Disparities
Who Is a URM in Medicine?
Trends in Minority Participation in Medicine
Barriers to the Educational Pipeline
Implications of Cultural Competence
Assessment of COGME's Twelfth Report
Strengthening
the Pipeline to Medical School
Pipeline Programs
Findings
1998 Recommendations To Be Attained
Evaluation Considerations
Overcoming
Barriers to Increasing URM Medical School Applicants
Findings
1998 Recommendations To Be Attained
Evaluation Considerations
Social Marketing
To Increase URMs in the Pipeline
Findings
1998 Recommendations To Be Attained
Evaluation Considerations
Strengthening
the Pipeline to Medical School: Recommendations
Strengthening
Upstream Efforts in Medical Training
Admissions
Findings
1998 Recommendations To Be Attained
Evaluation Considerations
Medical School
Debt and Financial Assistance
Findings
1998 Recommendations To Be Attained
Evaluation Considerations
URMs in Specialties
Findings
1998 Recommendations To Be Attained
Evaluation Considerations
URM Faculty
Findings
1998 Recommendations To Be Attained
Evaluation Considerations
Strengthening
Upstream Efforts in Medical Training: Recommendations
Ensuring
Cultural Competence in Medicine
Changing Demographics
Findings
1998 Recommendations To Be Attained
Evaluation Considerations
Ensuring Cultural
Competence in Medicine: Recommendations
Bibliography
Appendix:
A Review of Educational Pipeline Programs and Collaborations
List of Tables
Table
1. Population Estimates for Hispanic and Non-Hispanic Racial/Ethnic
Groups and Percentages of Total U.S. Population, 2000
Table 2. Population Projections for Hispanic and Non-Hispanic
Racial/Ethnic Groups and Percentages of Total Population, by Decade
Table 3. Percentages of Families Having Children Under
Age 18 Living Below Poverty Level, by Race/Ethnicity and Family Type,
2002
Table 4. U.S. Census Estimates of U.S. Physicians, by
Race/Ethnicity and Gender and Rates per 1,000 Population in Each Group,
2000
Table 5. Percentages of Racial/Ethnic Groups Enrolled
in U.S. Medical Schools, 1998-99 Through 2002-2003 Academic Years
Table 6. Percentages of Racial/Ethnic Groups Enrolled
in U.S. Osteopathic Medical Schools, 1998-1999 Through 2001-2002 Academic
Years
Table 7. Percentage of 1992 High School Graduates, by
Race Ethnicity, Family Income, and Parents' Highest Education Level
Table 8. Debt for Allopathic Medical School Graduates,
by Years in Medical School, 2001
Table 9. Influence of Debt on Specialty Choice for Medical
School Graduates, 2001
Table 10. Average Debt by Practice Specialty Choice
for Medical School Graduates Planning To Practice in an Underserved
Area, 2001
Table 11. Percentages of Undergraduates With Student
Financial Aid, by Family Income and Type of Aid
Table 12. Specialty Plans of URM and Non-URM U.S. Medical
School Graduates, 2001
Table 13. Number and Percentages of U.S. Medical School
Faculty, by Race/Ethnicity, 2002 and 1998 and Percent Change
Table 14. U.S. Osteopathic Medical School Faculty,
by Race/Ethnicity, 2001-2002 and 1998-1999 and Percent Change
The
Council on Graduate Medical Education
The Council on
Graduate Medical Education (COGME) was authorized by Congress in 1986
to provide an ongoing assessment of physician workforce trends, training
issues, and financing policies and to recommend appropriate Federal
and private-sector efforts to address identified needs. The legislation
calls for COGME to advise and make recommendations to the Secretary
of the Department of Health and Human Services (DHHS); the Senate
Committee on Health, Education, Labor, and Pensions; and the House
of Representatives Committee on Commerce. Section 219 of the Department
of Labor, Health and Human Services, and Education and Related Agencies'
Appropriations Act, 2004, Public Law 102-394, 106 Stat. 1825, resulted
in the Secretary of DHHS extending COGME through the end of the fiscal
year.
The legislation
specifies 17 members for the Council. Appointed individuals are to
include representatives of practicing primary care physicians, national
and specialty physician organizations, international medical graduates,
medical student and house staff associations, schools of medicine
and osteopathy, public and private teaching hospitals, health insurers,
business, and labor. Federal representation includes the Assistant
Secretary for Health, DHHS; the Administrator of the Centers for Medicare
and Medicaid Services, DHHS; and the Chief Medical Director of the
Veterans Administration.
CHARGE TO THE COUNCIL
The charge to
COGME is broader than the name would imply. Title VII of the Public
Health Service Act, as amended, requires COGME to provide advice and
recommendations to the Secretary of DHHS and Congress on the following
issues:
- The supply
and distribution of physicians in the United States;
- Current and
future shortages or excesses of physicians in medical and surgical
specialties and subspecialties;
- Issues relating
to international medical school graduates;
- Appropriate
Federal policies with respect to the matters specified in items
1-3, including policies concerning changes in the financing of undergraduate
and graduate medical education (GME) programs and changes in the
types of medical education training in GME programs;
- Appropriate
efforts to be carried out by hospitals, schools of medicine, schools
of osteopathy, and accrediting bodies with respect to the matters
specified in items 1-3, including efforts for changes in undergraduate
and GME programs; and
- Deficiencies
and needs for improvement in databases concerning the supply and
distribution of, and postgraduate training programs for, physicians
in the United States and steps that should be taken to eliminate
those deficiencies.
In addition, the
Council is to encourage entities providing GME to conduct activities
to achieve voluntarily the recommendations of the Council specified
in item 5.
COGME PUBLICATIONS
Reports
Since its establishment,
COGME has submitted the following reports to the Secretary of DHHS
and Congress:
- First Report
of the Council (1988);
- Second Report:
The Financial Status of Teaching Hospitals and the Underrepresentation
of Minorities in Medicine (1990);
- Third Report:
Improving Access to Health Care Through Physician Workforce Reform:
Directions for the 21st Century (1992);
- Fourth Report:
Recommendations to Improve Access to Health Care Through Physician
Workforce Reform (1994);
- Fifth Report:
Women and Medicine (1995);
- Sixth Report:
Managed Health Care: Implications for the Physician Workforce and
Medical Education (1995);
- Seventh Report:
Physician Workforce Funding Recommendations for Department of Health
and Human Services' Programs (1995);
- Eighth Report:
Patient Care Physician Supply and Requirements: Testing COGME Recommendations
(1996);
- Ninth Report:
Graduate Medical Education Consortia: Changing the Governance of
Graduate Medical Education to Achieve Physician Workforce Objectives
(1997);
- Tenth Report:
Physician Distribution and Health Care Challenges in Rural and Inner-City
Areas (1998);
- Eleventh Report:
International Medical Graduates, The Physician Workforce and GME
Payment Reform (1998);
- Twelfth Report:
Minorities in Medicine (1998);
- Thirteenth
Report: Physician Education for a Changing Health Care Environment
(1999);
- Fourteenth
Report: COGME Physician Workforce Policies: Recent Developments
and Remaining Challenges in Meeting National Goals (1999);
- Fifteenth Report:
Financing Graduate Medical Education in a Changing Health Care Environment
(2000); and
- Sixteenth Report:
Physician Workforce Policy Guidelines for the United States, 2000-2020
(January 2005).
OTHER COGME PUBLICATIONS
- Scholar in
Residence Report: Reform in Medical Education and Medical Education
in the Ambulatory Setting (1991);
- Process by
which International Medical Graduates are Licensed to Practice in
the United States (September 1995);
- Proceeding
of the GME Financing Stakeholders Meeting (April 11, 2001) Bethesda,
Maryland;
- Public Response
to COGME's Fifteenth Report (September 2001);
- Council on
Graduate Medical Education & National Advisory Council on Nurse
Education and Practice: Collaborative Education to Ensure Patient
Safety (February 2001);
- Council on
Graduate Medical Education: What is it? What has it done? Where
is it going? 2nd Edition (2001); and 2002 Summary Report (2002).
COGME RESOURCE PAPERS
- Preparing Learners
for Practice in a Managed Care Environment (1997);
- International
Medical Graduates: Immigration Law and Policy and the U.S. Physician
Workforce (1998);
- The Effects
of the Balanced Budget Act of 1997 on Graduate Medical Education
(2000);
- Update on the
Physician Workforce (2000);
- Evaluation
of Specialty Physician Workforce Methodologies (2000); and
- State and Managed
Care Support for Graduate Medical Education: Innovations and Implications
for Federal Policy (2004).
For more information
on COGME, visit the Council's Web site at: http://www.cogme.gov or
contact:
Council on Graduate
Medical Education 5600 Fishers Lane, Room 9A-21 Rockville, MD 20857
Voice: (301) 443-6785 Fax: (301) 443-8890
Members
of the Council on Graduate Medical Education
Members
Chair
Carl J. Getto, M.D.
Senior Vice President Medical Staff Affairs/Associate Dean Hospital
Affairs
University of Wisconsin Hospital & Clinics
Madison, Wisconsin
Vice
Chair
Robert L. Johnson, M.D.
Professor of Pediatrics and Vice Chair, Department of Pediatrics
New Jersey Medical School Division of Adolescent and Young Adult Medicine
Newark, New Jersey
Ms. Laurinda L.
Calongne
President
Robert Rose Consulting
Baton Rouge, Louisiana
William Ching,
Medical Student
New York University School of Medicine
New York, New York
Allen Irwin Hyman,
M.D., FCCM
Executive Vice President and Chief of Staff
Columbia-Presbyterian Medical Center
New York, New York
Rebecca M. Minter,
M.D. VAMC
Ann Arbor Healthcare System
Surgery Service
Ann Arbor, Michigan
Lucy Montalvo,
M.D., M.P.H.
San Diego, California
Angela D. Nossett,
M.D.
Executive Vice President
Committee of Interns and Residents (CIR)
Wilmington Family Health Center
Wilmington, California
Earl J. Reisdorff,
M.D.
Director of Medical Education
Ingham Regional Medical Center
Department of Medical Education
Lansing, Michigan
Russell G. Robertson,
M.D.
Department of Family and Community Medicine
Medical College of Wisconsin
Milwaukee, Wisconsin
Jerry Alan Royer,
M.D., M.B.A.
229 Cascade Falls Drive
Folsom, California
Susan Schooley,
M.D.
Chair, Department of Family Practice
Henry Ford Health System
Detroit, Michigan
Humphrey Taylor,
Chairman
The Harris Poll, Harris Interactive
New York, New York
Douglas L. Wood,
D.O., Ph.D., President
American Association of Colleges of Osteopathic Medicine
Chevy Chase, Maryland
Statutory Members
Cristina Beato,
M.D.
Acting Assistant Secretary for Health and Surgeon General
Washington, D.C.
Mark B. McClellan,
M.D., Ph.D.
Administrator, Centers for Medicare and Medicaid Services
Department of Health and Human Services
Washington, D.C.
Robert H. Roswell,
M.D.
Undersecretary for Health
Veterans Health Administration
Department of Veterans Affairs
Washington, D.C.
Designee of the Acting
Assistant Secretary for Health
Howard Zucker,
M.D., Deputy Assistant Secretary for Health
Department of Health and Human Services
Washington, D.C.
Designee of the Centers
for Medicare and Medicaid Services
Tzvi M. Hefter,
Director
Division of Acute Care
Centers for Medicare and Medicaid Services
Baltimore, Maryland
Designee of the Department
of Veterans Affairs
Stephanie H. Pincus,
M.D., M.B.A.
Chief Academic Affiliations Officer
Department of Veterans Affairs
Washington, D.C.
Staff, Division of Medicine
and Dentistry, Bureau of Health Professions, HRSA Department of Health
and Human Services Rockville, Maryland
Tanya Pagán
Raggio, M.D., M.P.H.
Executive Secretary, COGME, and
Director, Division of Medicine and Dentistry (DMD)
O'Neal Walker,
Ph.D.
Chief, Dental and Special Projects Branch/DMD
Jerald M. Katzoff
Deputy Executive Secretary
C. Howard Davis,
Ph.D.
Staff Liaison
Helen K. Lotsikas,
M.A.
Staff Liaison
Jaime Nguyen,
M.D., M.P.H.
Staff Liaison
Eva M. Stone
Program Analyst and Committee Management Specialist
Anne Patterson
Secretary
Contractor for Report
Preparation
Rhonda Ray, Ph.D.
East Stroudsburg University
Executive
Summary
INTRODUCTION
In 1998, the Council
on Graduate Medical Education (COGME) published its Twelfth Report,
entitled Minorities in Medicine. This report made 21 recommendations
for achieving two goals: 1) increase the number and proportion of
underrepresented minorities (URMs) in medicine and 2) strengthen cultural
competency in physicians. "Underrepresented minorities" refers to
African Americans, Native Americans, Alaska Natives, Mexican Americans,
and Mainland Puerto Ricans—minority groups represented in lower
proportions in the health professions than in the United States (U.S.)
population as a whole (1).1
This report reviews
the literature regarding the advancement of these goals since the
1998 COGME recommendations, assesses the progress made through 2003,
and notes key findings. It also recommends ways to support the academic
pipeline to facilitate minority entry into medical school, strengthen
upstream (institutional and policy) efforts in medical training, and
ensure cultural competence in medicine and medical education.
Increasing the
number of URM students who successfully advance through the elementary,
secondary, and postsecondary academic pipeline is the first step to
enlarge the potential number of these students eligible to enter medical
school. The educational pipeline for URMs, beginning with emphasis
on reading skills in the early elementary grades and continuing through
enrollment in medical training, must be enhanced to increase the number
of URMs in medicine. Barriers to the successful negotiation of that
pipeline are being addressed, but additional efforts are needed to
reduce these barriers further. For example, many obstacles to children's
educational achievement lie in their personal environment, including
poverty (3). Further, African American, Hispanic, and low-income high
school graduates are less likely to be academically well prepared
for college than other groups (4). Overcoming barriers to high school
graduation and facilitating educational attainment for URMs must be
priorities to increase their high school graduation rates, academic
achievement, college admission and graduation, and admission to and
graduation from medical school.
Research indicates
that the greatest barrier to URM admission to medical school is the
low applicant pool of URM college graduates resulting from high attrition
rates in high school and low enrollments in college. Recently, the
rate of medical school applications for URM college graduates has
been similar to or even higher than the application rate for non-URM
college graduates (3). URM college graduates in 2000-2001 applied
to medical school at a rate of 28 per 1,000 graduates compared to
a rate of 25 per 1,000 white college graduates applying to medical
school that year (5,6).2 To increase
the pool of URM medical school applicants, the retention of URM students
must be addressed, at both the high school and undergraduate levels.
Increasing the
number of URM physicians is an important step for improving health
care for minority and underserved populations and, consequently, for
decreasing health disparities, one of the Nation's leading health
priorities (7). Studies have shown that minority patients sometimes
receive less health care and are less satisfied with their care when
their physician is of a different race or ethnicity (8-14). Patients
who lack proficiency in the English language also have less satisfaction
with their health care and more difficulty in obtaining care than
those patients who have no language barriers (8,15-17). Studies also
show that, compared to non-underrepresented physicians, URM physicians
provide more care to minorities, the underserved, the uninsured, those
insured by Medicaid, and low-income persons (18-20). A recent study
has suggested that URM physicians may have more difficulty getting
their patients admitted to hospitals and referring them to specialists
or for testing (21). These studies indicate the need to train more
well-qualified URM physicians and to address systemic and institutional
barriers that URM physicians may face.
The need for additional
well-trained physicians representing URM groups is expected to be
even more critical in the future, as URM populations are projected
to grow more rapidly than non-URM populations (22). However, with
the rapid expansion of minority populations and the lagging growth
of minority physicians in the United States, non-URM physicians will
continue to provide a large portion of health care to racial and ethnic
groups different from their own. To ensure effective and equitable
care for every person, all physicians, regardless of their ethnicity
or race, should be trained to be aware of potential cultural barriers
to quality health care. The need for increased cultural competence
in physicians and practice settings has been widely recognized in
published literature and has been incorporated into medical education
accreditation standards and in graduate medical education outcomes
(23-40). However, the best means for training physicians to be culturally
competent continues to be debated (25). More discussion and research
are needed to determine the most effective methods of cultural competence
training and the desired outcomes for that training.
Promoting diversity
among the physician workforce has been the goal of numerous organizations.
Among the leaders in this effort are the Health Resources and Services
Administration (HRSA), the Association of American Medical Colleges
(AAMC), the Institute of Medicine, the National Medical Association,
the National Hispanic Medical Association, and the Sullivan Commission
on Diversity in the Healthcare Workforce. The efforts of these and
other organizations have called attention to the urgency of diversifying
the physician workforce and training physicians to be sensitive and
effective in serving persons of any race or ethnicity.
Medical training
institutions have also sought to overcome barriers for URMs in medicine
and have made strides in areas such as retention. Data for URM medical
school matriculants beginning their training in 1996 show that 93
percent were either still enrolled or had graduated by their sixth
year, compared to 92 percent of non-URMs who had graduated within
five years (41). Nevertheless, additional strategies and policies
are needed to strengthen the enrollment and retention of URMs in medical
training (42).
The June 2003
Supreme Court ruling determined that race/ethnicity as an admissions
criterion can be justified as a compelling State interest, and approaches
to admissions have been much discussed (42-52). Data show that, among
URM applicants for 2001, 46.0 percent were accepted into medical school
compared to 50.6 percent of non-URMs. African Americans had the lowest
acceptance rate, 42.8 percent, compared to 53.4 percent for Mexican
Americans, 60.4 percent for applicants from Mainland Puerto Rico,
and 51.0 percent for Native Americans. African Americans also had
lower Medical College Admission Test (MCAT) scores than other URM
groups (53). Effective strategies for improving acceptance rates of
URMs, especially for African American applicants, are needed.
The continued
increase in URM populations without a comparable increase in the supply
of URM physicians indicates three important strategies for ensuring
that URM populations have adequate health care: 1) increasing the
number of URM students who successfully advance through the elementary,
secondary, and post-secondary academic pipeline in preparation for
entrance into medical school; 2) overcoming policy or systemic barriers
at the level of medical training institutions, residency programs,
licensing boards, specialty certification boards, and practice settings;
and 3) providing effective cultural competence training for U.S. physicians
to ensure quality health care to people of all cultures.
Summarized below
are key findings regarding achievement of the recommendations in COGME's
1998 report Minorities in Medicine as well as recommendations
for continued progress toward increasing the number of URM physicians
and strengthening cultural competence in U.S. physicians.
FINDINGS AND RECOMMENDATIONS
Strengthening
the Pipeline to Medical School
Findings
- Numerous K-12,
post-secondary, and post-bac-calaureate programs exist to enhance
the academic preparation of URMs and to promote opportunities for
pursuing medical careers (54-79). Among these programs are collaborations
among medical schools, undergraduate and secondary schools, and
community organizations (80-106). Although some of these programs
have been successful in helping to prepare URMs academically for
medical school, inconsistent evaluation of these programs makes
it difficult to compare program outcomes.
- Lack of persistence
in completing high school and failure to enroll in and graduate
from college are the greatest barriers to URM entry into medicine.
URMs compose 30 percent of the U.S. college-age population, but
only 14 percent of U.S. college graduates (3).
- Data from the
National Center for Education Statistics indicate that "family income"
is the most influential factor in determining whether a high school
senior will be "very well qualified" for college, based on class
rank, grade point average (GPA), and scores on standardized tests
(3,4,107).
- Parents' education
and income levels affect academic achievement of children (3,4,107).
Disproportionate numbers of URM children live in single-parent and
low-income households (108), factors contributing to lack of success
in early education, which impacts achievement at all other levels.
- For low-income
high school graduates who are academically well prepared, being
from a low-in-come family has less impact on college enrollment
than whether students take the college entrance examinations and
apply to college (4).
- Although some
programs promote children's interest, academic achievement, and
career choices in science and health (109-116), a need exists for
appropriate organizations to partner with media, advertising and
marketing firms, and video and audio production companies for developing
and disseminating culturally appropriate messages targeted to minority
and disadvantaged youth to encourage academic persistence and achievement
and interest in medical careers.
Recommendations
- Further efforts
are needed to increase the number of URM college graduates to enlarge
the pool of medical school applicants and URM physicians.
- Intense efforts
should focus on retention of URMs in the educational pipeline from
elementary school through secondary school, from entry in and graduation
from undergraduate school, to entry in and graduation from medical
school.
- Research is
needed to understand better the barriers to academic achievement
for URMs at all educational levels. Such barriers include cultural,
linguistic, societal, economic, and systemic. Effective interventions
should be developed and implemented to address disproportionately
high secondary school dropout rates among URMs to increase their
enrollment in college.
- Standards of
achievement and outcome measures are needed to determine which K-12,
post-sec-ondary, and post-baccalaureate programs should be considered
as models for increasing academic achievement of URMs.
- More resources
are needed to facilitate high school guidance counselors to assist
URMs in taking entrance exams and applying to college and to place
URMs in college preparatory schools and programs.
- Organizations
interested and involved in medical training should partner with
media, advertising and marketing firms, and video and audio production
companies to develop and implement effective communication campaigns
targeting minority and disadvantaged youth with messages that encourage
academic achievement, persistence in school, and interest in medicine.
Strengthening
Upstream Efforts in Medical Training
Findings
- The AAMC, the
U.S. Department of Education, the Institute of Medicine, and published
literature have recommended the use of factors other than test scores
and GPAs in medical school admissions and residency placement decisions
(4252). However, a lack of evidence exists to indicate which non-quantitative
factors are being used and to what extent such factors are being
included in admissions/placement decisions.
- Among URM medical
school applicants for 2001, percent were accepted into medical school
compared to 50.6 percent of non-URMs.African Americans had the lowest
acceptance rate, 42.8 percent,compared to 53.4 percent for Mexican
Americans, 60.4 percentfor Mainland Puerto Ricans, 51.0 percent
for Native Americans,51.7 percent for whites, 51.1 percent for Asians,
and percent for applicants from the Commonwealth of Puerto Rico
(53).
- Research suggests
that some residency program directors use scores from Step 1 of
the United States Medical Licensing Exam (USMLE) to determine which
applicants to interview for selection (117,118). African American
applicants in one study were at least three times less likely to
be interviewed (118). Data indicate that URMs usually score lower
than non-URMs on the USMLE and other tests (117,119). Use of USMLE
scores to screen applicants can create barriers for entry into some
residency programs.
- Medical school
debt has been increasing annually, reaching an average of $103,855
for U.S. graduates of allopathic medical schools in 2002 (120).
- Mean educational
debt is generally higher for URMs than non-URMs in medical school,
although mean debt is almost equal for URMs and non-URMs graduating
from private medical schools (121,122).
- Among new medical
school matriculants in 2001, twice as many URMs as non-URMs (30
percent vs. 14 percent) indicated that scholarships would be used
to finance their education. Non-URMs were more likely than URMs
(17 percent versus 6 percent) to report that family members or spouses
would contribute financially to their medical education (123).
- Among 2001
medical school graduates, URMs were more likely to receive scholarship
assistance and more scholarship dollars than non-URMs. Three quarters
of URM medical school graduates in 2001 received scholarship assistance
compared to fewer than half of non-URMs. On average, URM medical
school graduates received $35,000 in scholarships compared to $25,780
for non-URMs (124).
- Twenty-five
percent of URM medical school students matriculate in medical school
for more than 4 years, compared to 10 percent of non-URMs (125).
The greater proportion of URMs than non-URMs who spend more years
in medical school indicates the likelihood of higher mean debt for
URMs.
- More than two
thirds of 2001 URM and non-URM graduates of allopathic medical schools
indicated that debt had no influence on their specialty selection
(126). Osteopathic medical students who were seniors in 2001-2002
also reported that debt level had only a "minor influence" on specialty
choice (127).
- AAMC Graduate
Questionnaire data indicate that for 2001 allopathic medical school
graduates, higher proportions of URMs than non-URMs planned to enter
generalist and surgical specialties, but higher proportions of non-URMs
than URMs planned to enter medical specialties. About the same proportions
of both groups anticipated entry into support specialties (128).
- Nearly half
of URM medical school graduates in 2001 compared to 19 percent of
non-URM graduates planned to practice in underserved areas (128).
- Recruiting
and retaining minority faculty physicians continue to be important
goals, especially as evidence indicates that minority faculty are
more dissatisfied with their careers than non-mi-nority faculty
are (129).
- Seven percent
of allopathic medical school faculties were reported as URMs for
2002, an increase of 33 percent since 1998. However, these data
are inconclusive because race/ethnicity for 4.1 percent of 2002
faculty and for 6.1 percent of 1998 faculty was reported as "Other/Unknown"3
(130,131).
- In 2001, 3.5
percent of osteopathic medical school faculties were reported as
URMs, compared to 3.0 percent in 1998. As for allopathic faculty,
race was reported as "Other/Unknown" for large proportions of osteopathic
medical school faculty: 4.6 percent for 2001-2002 and 5.4 percent
for 1998-1999 (132).
- Few programs
have been reported that support minority medical school students
interested in pursuing an academic career. One such program is the
Fellowship Program in Academic Medicine, funded by Bristol-Meyers
Squibb (133).
- Six Centers
of Excellence in Women's Health offer support to help improve minority
women faculty's career advancement opportunities. The centers recommend
evaluation of progress by establishing target indicators, institutional
support for advancement, retention strategies, and increased research
of issues related to advancement of minority faculty (134).
Recommendations
- Desirable outcome
measures that include non-quantitative considerations for medical
school students should be established and used in admissions decisions.
- Residency program
directors should also consider qualitative as well as quantitative
factors when deciding which residency candidates to interview and
select.
- Qualitative
criteria used in medical school admissions and residency placement
decisions should be documented and assessed to determine which ones
are most predictive of successful outcomes.
- More research
is needed to assess the impact of medical school debt on URMs' decision
to apply to, matriculate into, and graduate from medical school.
- Assessment
of whether increased scholarship assistance rather than loans might
encourage more URMs to pursue medicine as a career would be helpful.
- More research
is needed to evaluate obstacles or motivations for minority entry
into primary care or specialty residency programs. Medical schools
should track medical students' interest in specialties at entry
into medical school, at the beginning of the clinical year, and
at graduation to assess factors that influence choice of specialties
for both URMs and non-URMs.
- Medical schools
should develop and implement plans for recruiting and retaining
minority faculty physicians, including assessing and enhancing the
institutional climate for URM faculty.
- Minority medical
students, residents, and physicians who aspire to serve as faculty
should be identified and mentored early in their careers.
- Interventions
should be developed that encourage physicians to practice in underserved
areas for periods that extend beyond the time commitment of programs
requiring service in exchange for funding opportunities.
- Research is
needed to determine optimal conditions and exposure time required
for medical students to develop and maintain an interest in serving
in underserved communities.
- Strategies
are needed to assess and reinforce the commitment of academic medical
centers to providing care to underserved populations. This commitment
should be integral to the academic environment and mission and should
be fostered by means other than funding incentives.
Ensuring
Cultural Competence in Medicine
Findings
- The need for
cultural competence training in medical education is widely recognized.
This training is increasingly available in various venues and methods
of educational delivery (23-40). Most medical schools report that
they have cultural competence instruction incorporated into required
and elective courses, but few have required courses specifically
dedicated to cultural competence (135).
- Much uncertainty
exists regarding the best way to teach cultural competence to medical
students and residents, and problems with some current instructional
methods have been reported (25,27,28,33,136-142).
- Resources from
both public and private agencies have been devoted to developing
curricula and programs to enhance cultural competence in medical
school and residency training as well as in practices. Publications,
Web sites, audio and satellite broadcasts, and training modules
are available to help educate practitioners about becoming more
culturally competent (24,26,30,31,33-37,143-159).
- Evaluation
is considered critical to any program, yet little information exists
regarding cultural competence evaluation outcomes (33,141).
- Accreditation
standards for both undergraduate and graduate medical education
include cultural competency training (38-40). The American Board
of Medical Specialties and some specialties are also committed to
cultural competency standards (39,160,161).
- Although medical
licensing boards do not test for cultural competence, Step 3 of
the USMLE uses diverse patients as part of the clinical assessment
so that examinees must respond to clinical situations that include
cultural contexts (162).
- Continuing
medical education (CME) does not require education in cultural competency,
but a few medical schools offer CME training in cultural competence
(163-165).
- At least three
States have pending legislation that will mandate that the medical
schools in each State require at least one course in cultural competency
as part of their curricula. Physicians in those States must also
complete cultural competency training for relicensing. Another State
will provide for local and State medical societies to offer a voluntary
cultural competency program for physicians (166-169).
- Quality standards,
including standards for culturally competent care, have been developed
for use by health plans contracting to provide health care services
for Medicare and Medicaid patients (170-173). The National Committee
for Quality Assurance, using the Health Plan Employer Data and Information
Set (HEDIS®) measures, requires managed care organizations to
address members' cultural needs, but does not require assessment
of providers' cultural competence (174).
- Although National
standards exist, research suggests that State contract language
with managed care organizations is vague, making standards difficult
to enforce (175-176).
- Although health
plans generally do not collect 2. Data are needed to determine whether
cultural data on race and ethnicity of patients, research competency
training enables medical students, indicates that data acquired
from other sources residents, and physicians to become more culturcan
provide a means for health care organiza-ally competent and whether
that training affects tions to evaluate quality of care for patients
and patient outcomes. thus determine disparities in health care
of minority patients (177-178)
Recommendations
- The varied
definitions of cultural competence and approaches to cultural competency
instruction indicate a need for further research and discussion
to determine key objectives, desired outcomes and competencies,
and ways to assess progress toward those outcomes in medical education.
A National conference should be held at which these issues can be
more fully addressed.
- Data are needed
to determine whether cultural competency training enables medical
students, residents, and physicians to become more culturally competent
and whether that training affects patient outcomes.
- The Federation
of State Medical Boards should encourage individual State licensing
boards to institute voluntary cultural competency training for physicians.
Introduction
The Council on
Graduate Medical Education (COGME), established by Congress in 1986,
advises the Secretary of the United States (U.S.) Department of Health
and Human Services (DHHS), the Senate Committee on Health, Education,
Labor and Pensions, and the House of Representatives Committee on
Commerce. To ensure health care delivery to the Nation, the Council
makes recommendations regarding the supply and distribution of physicians,
training issues, and appropriate efforts of public and private sectors,
including medical schools, teaching hospitals, and accrediting bodies.
The diversity of the physician workforce, the training of minority
physicians, and the contributions made by minority physicians in providing
health care to medically underserved areas are all-important parts
of COGME's mission.
Since its inception,
COGME has expressed concern that minorities are greatly underrepresented
in medicine and has made recommendations to address the need for a
physician workforce that reflects the Nation's diversity. In 1998,
COGME issued its Twelfth Report, which made 21 recommendations
for increasing underrepresented minorities (URMs) in medicine and
for enhancing the cultural competence of the Nation's physician workforce.
"Underrepresented minorities" refers to African Americans, Native
Americans, Alaska Natives, Mexican Americans, and Mainland Puerto
Ricans— minority groups represented in lower proportions in
the health professions than in the U.S. population as a whole (1).
Despite efforts
during the past 3 decades to increase minority participation in medicine,
some racial and ethnic groups remain underrepresented in medical education
and in medicine, from medical school applicants and faculty members
to practitioners in some specialties and managed care practices. COGME
continues to dedicate its efforts to increasing URMs in medicine both
to enhance equity among persons of all cultures and to address one
of the Nation's health priorities: reducing health disparities among
racial and ethnic groups.
Healthy People
2010, which summarizes the health objectives for the Nation, has
targeted the elimination of health disparities as one of two overarching
National health goals (7). Congress, too, has recently introduced
the Healthcare Equality and Accountability Act to improve the health
care of minorities. This bill establishes a Center for Cultural and
Linguistic Competence in Healthcare within DHHS, creates a National
Working Group on Workforce Diversity to review and recommend workforce
initiatives, and requires health professions schools that receive
Federal funding to submit information for a National database on race
and ethnicity in the health professions (179).
Responding to
the need to improve the health status of minorities, this report reviews
the literature since the 1998 COGME recommendations for increasing
the number of URM physicians and for promoting cultural competence
in health care providers. It assesses progress made through 2003,
notes key findings, and recommends ways to support the pipeline to
medical school, to strengthen upstream efforts in medical training,
and to ensure cultural competence in medicine and medical education.
IMPLICATIONS OF CHANGING
DEMOGRAPHICS IN THE U.S.
Racial and ethnic
minority populations in the U.S. are growing more rapidly than white
populations. U.S. Census Bureau estimates for 2000 indicate that African
Americans, American Indians and Alaska Natives, and Hispanics currently
represent a quarter of the U.S. population, and Asians and Pacific
Islanders compose an additional 4 percent. Whites make up 69 percent
of the Nation's population (see Table 1) (180). However, Census Bureau
projections indicate that some racial and ethnic minority populations
will steadily outpace whites in growth (see Table 2).
By 2010, Hispanics,
African Americans, and American Indians and Alaska Natives are expected
to represent 28 percent of the U.S. population, and Asian Americans
and Pacific Islanders will bring that proportion up to almost a third
of the total U.S. population. By 2050, non-Hispanic whites will comprise
just over half of the Nation's populace, and Hispanics will represent
almost a quarter of the population. Every year from now until 2050,
the Hispanic ethnic group is expected to add the largest number of
people to the Nation's population of all racial or ethnic groups.
African Americans are also expected to increase, but more gradually,
to just over 13 percent of the population. Projections indicate that
Asians and Pacific Islanders will more than double to almost 9 percent.
Native Americans and Alaska Natives are expected to remain about the
same at just under 1 percent of the U.S. population (22).1
The expected increase
in minority populations has several implications for the health of
the Nation. Estimates for 2000 indicate that over a third of Hispanics
are foreign born, suggesting limited language proficiency for a large
portion of individuals of Hispanic ethnicity. Similarly, 62 percent
of Asian Americans and Pacific Islanders were foreign born in 2000,
indicating another large population group for whom English is a second
language (see Table 2) (22). In communicating with health care providers,
these individuals experience language barriers affecting whether they
will seek care, be properly diagnosed, receive appropriate treatment,
and be satisfied with their care (8,9,15-17,181,182).
*Projections for
percent calculations based on 1990 U.S. Census estimates.
As racial and
ethnic minorities increase, a corresponding need exists for increased
numbers of minority physicians from those groups underrepresented
in medicine. Some minorities report more satisfaction with physicians
of their own race or with those who speak their language, and they
select a physician of their own race or ethnicity when given a choice
(8,10,16). Further, differences in health care may result when patients
and physicians have different races or ethnicities (11-15).
Despite the growing
need for more minority physicians, for the foreseeable future, physicians
from non-URM groups will provide care to substantial numbers of patients
who differ from them racially or ethnically.
HEALTH DISPARITIES
To help reduce
health disparities among racial and ethnic groups, more URM physicians
are needed. An increase in racially and ethnically concordant patient-physician
relationships can lead to increased health care and better health
outcomes for underserved and vulnerable populations (18).
The National Center
for Health Statistics (NCHS) reports the following trends regarding
health disparities among racial and ethnic groups:
- The gap in
the life expectancy between African American and white populations
has been narrowing, but remains. In 1990, life expectancy at birth
was 7 years longer for whites than for African Americans. By 2000,
this difference had narrowed to 5.7 years. Preliminary data suggest
that the gap has further narrowed to 5.5 years for 2001.
- In 2001, mortality
was 31 percent higher for African Americans than for white Americans.
This gap represents a decrease from 37 percent in 1990.
- Age-adjusted
death rates for 2001 were greater for African Americans than for
whites by 40 percent for stroke, 29 percent for heart disease, 25
percent for cancer, and nearly 800 percent for HIV disease.
- Despite similar
mammography screening rates for white and African American women,
breast cancer mortality for African Americans has risen far above
that for whites. In 2000, breast cancer mortality for African American
women was 31 percent higher than for whites compared to 15 percent
higher in 1990. Preliminary data for 2001 indicate that this gap
has widened to 34 percent.
- Rates of death
from homicides among both African American and Hispanic males ages
15-24 decreased by about half from the early 1990s. However, these
rates remain substantially higher than rates for young non-Hispanic
white males.
- Although death
rates from HIV disease have declined sharply since 1995 for Hispanic
and African American males ages 25-44, in 2000, HIV was still the
second leading cause of death for Hispanic males in this age group
and the third leading cause for African American males in this age
group. HIV death rates remained much higher for African American
and Hispanic males than for non-Hispanic white males in this age
group.
- Rates of death
from motor vehicle-related injury and from suicide for Native American
males ages 15-24 were about 45 percent higher than rates for white
males in this age group. Despite these disparities, death rates
for Native Americans are known to be underestimated, so this difference
may be even greater.
- Mortality for
Asian males was 40 percent lower than for white males through the
1990s. In 2000, age-adjusted rates for cancer and heart disease
for Asian males were 38-41 percent lower than rates for white males.
Death rates for the Asian population are known to be underestimated,
so this gap may be less than reported.
- Infant mortality
rates have declined for all racial and ethnic groups, but disparities
remain. In 2000, the highest infant mortality rate was for infants
of non-Hispanic African American mothers (13.6 deaths per 1,000
live births), and the lowest was for mothers of Chinese origin (3.5
per 1,000 live births).
- Infant mortality
increases as the mother's education decreases. In 2000, the infant
mortality rate for mothers having fewer than 12 years of schooling
was 58 percent higher than that for mothers who had 13 or more years
of education.
- Early prenatal
care (the first trimester of pregnancy) increased among all racial
and ethnic groups from 1990-2001 but varied from 69 percent for
Native American mothers to 90-92 percent for mothers of Japanese
and Cuban origin.
- In 2001, Hispanics
and Native Americans under age 65 were more likely to have no health
insurance than those in other racial and ethnic groups. Persons
of Mexican origin were most likely to lack health insurance (39
percent), whereas non-Hispanic whites were least likely to lack
insurance (12 percent).
- Among children
under age 18, Hispanic children were more likely to lack a usual
source of health care than non-Hispanic African American children
or non-Hispanic white children (14 percent compared to 7 percent
and 4 percent, respectively).
- Adults ages
18-64 and living below poverty level were over twice as likely to
have no usual source of health care than those living above the
poverty level (27 percent versus 12 percent). Of those living in
poverty, Hispanic adults were twice as likely to have no usual source
of health care as non-Hispanic whites or African Americans (44 percent
versus 22 percent and 21 percent, respectively) (183).
INFLUENCES ON HEALTH DISPARITIES
The reasons underlying
health disparities among racial and ethnic groups are complex and
range from access to health care to the ease with which physicians
treating minority patients can admit their patients into hospitals
or refer patients to specialists or for tests as needed. However,
as Healthy People 2010 notes, education and income levels affect
health and influence health disparities. Education and income are
closely associated and often serve as a proxy for one another because
education levels closely parallel income levels (7).
Death rates vary
by education levels. For 2000, the age-adjusted death rate for 25-64
year olds having fewer than 12 years of education was nearly three
times that for persons in the same age group having 13 or more years
of education (183). More years of education add more years of life.
The average education level in the U.S. population has been increasing
over the past decades and appears to be contributing to slight increases
in life expectancy.
Further, as Healthy
People 2010 notes, "For women, the amount of education achieved
is a key determinant of the welfare and survival of their children.
Higher levels of education also may increase the likelihood of obtaining
or understanding health-related information needed to develop health-promoting
behaviors and beliefs in prevention" (7).
In addition, those
in higher-income brackets experience better health than low-income
persons. For example, 65-year-old men having the highest incomes can
expect to live 3 years longer than those with the lowest incomes (7).
According to the U.S. Census Bureau, in 2002, 34.6 million or 12.1
percent of the U.S. population lived in poverty, an increase of 11.7
percent from the previous year. More than a third of those living
in poverty (12.1 million) were children under age 18 (184).
Education and
income levels differ by race and ethnicity as well as by type of household.
Table 3 shows the percentage of families living below the poverty
level. Households with married couples have the lowest proportion
of poverty for all racial and ethnic groups, and female households
(no husband present) have the highest proportions of poverty. More
families with children under age 18 live in poverty than those families
without children under age 18. Among married couple households, Hispanics
experience higher proportions of poverty than other groups: 17.7 percent
of Hispanic households with children under age 18 live in poverty,
compared to 8.5 percent for African Americans and 4.1 percent for
whites. Of female households having children under age 18 present,
similar proportions for both Hispanic and African Americans live below
the poverty level: 41.4 percent and 41.3 percent, respectively, compared
to 26.2 percent for whites and 21.2 percent for Asians. Male households
(no wife present) having children under age 18 experience less poverty
than female households but more than married-couple households: 26.5
percent for African Americans, 23.6 percent for Hispanics, 19.0 percent
for Asians, and 10.4 percent for whites (108).
*Percentages are
based on total number of families in each group as of March 2003.
Data for Native Americans are not available.
WHO IS A URM IN MEDICINE?
On June 26, 2003,
the Executive Council of the Association of American Medical Colleges
(AAMC) approved a new definition for "underrepresented minorities":
" Underrepresented in medicine' means those racial and ethnic populations
that are underrepresented in the medical profession relative to their
numbers in the general population." Individual medical schools can
use this definition to determine which population groups are underrepresented
in their geographic areas. The AAMC will collect data by population
groups based on the racial and ethnic categories used by the U.S.
Census Bureau (2). Before the new definition, the term "underrepresented
minority" referred to African Americans, Native Americans (American
Indians, Alaska Natives, and Native Hawaiians), Mexican Americans,
and Mainland Puerto Ricans. The research reported in this document
refers to the racial and ethnic groups included in the former definition.
TRENDS IN MINORITY PARTICIPATION
IN MEDICINE
According to U.S.
Census Bureau estimates of U.S. physicians for 2000, 4.4 percent of
physicians are non-Hispanic African Americans, 5.1 percent are Hispanic/Latinos,
and .002 percent are non-Hispanic Native Americans or Alaska Natives.
Thus, these estimates indicate that fewer than 10 percent of U.S.
physicians are URMs. Non-Hispanic whites compose 73.8 percent of physicians,
and non-Hispanic Asians, Native Hawaiians, and Pacific Islanders make
up another 14.9 percent of U.S. physicians (see Table 4) (185).
Rates of physicians
per 1,000 population in each group reveal that non-Hispanic whites
are the most represented population group in medicine: 2.66 physicians
per 1,000 population. Hispanic/Latino physicians are available at
the rate of just over one per 1,000 Hispanic/Latinos. Non-His-panic
African American physicians are available at a rate of fewer than
one physician per 1,000 persons in that group. The rate of non-Hispanic
Native American or Alaska Native physicians per 1,000 persons in these
population groups is .57 (see Table 4) (185).
*Rates are based
on U.S. Census estimates for Hispanic/Latinos and Non-Hispanic/Latinos
by race.
According to the
AAMC, after a 6-year decline in applications to U.S. medical schools,
applicants for the 2003-2004 academic year increased by 3.4 percent
to a total of almost 35,000. Included in this increase was a 5 percent
increase in African American applicants for a total of 2,736, including
a 10 percent increase in female African American applicants for a
total of 1,904. Hispanic applicants also increased by less than 2
percent to 2,483. Despite these gains in number of applicants, the
number of African Americans and Hispanics who matriculated into medical
school decreased. A total of 1,056 African Americans entered medical
school for a 6 percent decline, and 1,089 Hispanics matriculated,
for a decline of almost 4 percent (186).
The number of
medical school applicants peaked in 1996 at about 47,000, but since
then, that number has decreased by as many as 4,000 applicants each
year. The lowest number of applications received was for the 2002-2003
academic year, when 33,625 prospective students applied to medical
school. The decline in male applicants appears to have leveled off
for 2003-2004, when 17,113 males applied, a slight increase over the
17,069 male applicants for 2002-2003 (187).
Since the 1998-1999
academic year, proportions of allopathic medical students by race
and ethnicity have fluctuated slightly, but have remained relatively
stable for most groups (see Table 5). In the 2002-2003 academic year,
7.4 percent of medical students were African American; 2.9 percent
were Mexican and Mainland Puerto Rican; an additional 3.5 percent
were from other Hispanic groups; and 0.9 percent were Native American.
Whites represented 64 percent of medical students in 2002-2003, and
Asians and Pacific Islanders composed another 20.5 percent. Persons
for whom race/ethnicity is unreported can affect percentages, and
1.4 percent of medical students in 2002-2003 had no reported race
or ethnicity. Total numbers of enrolled allopathic medical students
fluctuated slightly during the academic years from 1998-1999 through
2002-2003 from a high to 66,476 in 1998-1999 to a low of 65,963 in
2000-2001 (187).
URMs enroll in
osteopathic medical schools at lower rates than in allopathic medical
schools. However, total enrollment of osteopathic students has been
increasing (see Table 6). During the 1998-1999 school year, 9,882
students (excluding foreign national students) matriculated in osteopathic
medical schools, and African Americans, Native Americans, and Hispanic
students composed 8.7 percent of enrollees. The proportion of students
from these groups was 7.8 percent in 2001, a decrease in percentage
from 1998, but the actual number of URM students remained stable,
increasing from 859 to 861. Total enrollment of osteopathic students
increased by 12 percent to 11,101 students from 1998-1999 through
2001-2002, accounting for the decline in percentage, but not the number
of URMs matriculating in osteopathic medical schools (188).
BARRIERS TO THE EDUCATIONAL
PIPELINE
As a broad measure
to increase minorities in medicine, COGME's Twelfth Report recommended
strategies and initiatives to enhance the educational pipeline to
improve the academic preparation of children and adolescents from
underrepresented population groups. A recent study published in Academic
Medicine reinforces the need to ensure that URM youth can overcome
educational barriers and succeed academically. Data show that if URMs
stay in the academic pipeline, proportions of URM college graduates
who apply to medical school are similar to or even higher than proportions
of white college graduates applying to medical school (3). URM college
graduates in 2000-2001 applied to medical school at a rate of 28 per
1,000 graduates compared to a rate of 25 per 1,000 white college graduates
applying to medical school that year (4,5).2
Increased efforts are needed to ensure that children from URM
groups can succeed in elementary and high school so that they enroll
in and graduate from college. Overcoming these early hurdles will
facilitate increased application and admission to medical school.
*Hispanic includes
all groups reporting Hispanic origin.
Parental education
and parental income affect the academic achievement of students (3,4,107).
According to the U.S. Department of Education, over half of both Hispanic
and non-Hispanic African American high school graduates in 1992 were
from families having incomes under $25,000, compared to a third of
Asian high school graduates and 21 percent of white high school graduates
(see Table 7). Also, for 1992 high school graduates, 15.0 percent
of Hispanics and 16.9 percent of African Americans had parents who
had graduated from college, compared to 36.2 percent of whites and
48.9 percent of Asians (see Table 7). Data also show that high school
graduates who are African American or Hispanic or who come from low-income
families are less likely to be academically well prepared for college.
Even among those who are academically prepared, Hispanic and low-income
students are less likely to take entrance exams and apply for admission
to a 4-year college than other groups (4).
Parents' income
and education are also associated with college enrollment. Data from
the U.S. Department of Education show that 49 percent of 1996 high
school graduates from low-income families enrolled in either 2- or
4-year colleges in the same year after graduation, compared to 63
percent of students from middle-income families and 78 percent of
students from high-income families. These data also indicate that
89 percent of 1996 high school graduates whose parents had completed
at least a bachelor's degree were enrolled in either a 2- or 4-year
college in the academic year after completing high school, compared
to 45 percent of high school graduates whose parents had not completed
high school (107).
However, for high
school graduates who are academically well prepared, being from a
low-income family does not affect college enrollment as much as whether
or not low-income students take college entrance examinations and
apply to college. One study notes, ". . . if low-income students have
an academic record and aptitude test scores which demonstrate even
the minimal qualifications for admission to a 4-year institution,
if they take a college entrance examination, and if they submit an
application for admission, the majority of low-income students enroll
in post-secondary education. . . ."Over 83 percent of academically
prepared low-income students who took the college entrance exams and
submitted a college application enrolled in a 4-year college or university
(4).
In addition to
affecting academic achievement, as Healthy People 2010 notes,
low education and income levels are associated with poor health outcomes
that contribute to health disparities (7). Disproportionate rates
of URM children live in low-income households and single-parent households
(184).
Source: U.S.
Department of Education, National Center for Education Statistics
(NCES), National Education Longitudinal Study: 1988-1994 (NELS:88),
Data Analysis System.
Examining birth
rates for 2000 for unmarried women reveals a disproportionate number
of births to young mothers who are from URM groups. Among Hispanic
women ages 15-17, the birth rate was 51.0 per 1,000 unmarried women
in this group. The birth rate for African American women ages 15-17
was 49.9, and the rate for non-Hispanic white women ages 15-17 was
13.6. For women ages 18-19, the rate for Hispanic unmarried women
was 110.6 per 1,000 unmarried women in this group; for African American
women ages 1819, the rate was 116.9; and for non-Hispanic white women
ages 18-19, the rate was 41.4. In raw numbers, the number of births
to unmarried non-Hispanic white women ages 1517 was 49,964, compared
to 42,789 non-Hispanic African Americans ages 15-17, and 39,466 Hispanic
women (189). These disproportionately high numbers of births to young
unmarried women from groups having relatively low populations indicate
large numbers of children whose mothers often have interrupted their
secondary education and have low incomes. The babies of these young
mothers are also at high risk for infant mortality (183).
Not only does
early parenting create barriers to educational achievement, but the
children of young mothers also face educational barriers because parental
education affects educational achievement (3,4,107). Vigorous efforts
are needed to encourage and facilitate the delay of early childbearing
for young women so that they can stay in the education pipeline. More
education is beneficial for both young women and their children.
Early parenting
for young men as well as young women may also be a factor in early
dropout rates and failure to complete high school and post-secondary
education. Data are available by age for only whites and African Americans.
For 2000, the birth rate for African American fathers ages 15-19 was
40.1 per 1,000 men in this group, compared to 16.8 for white fathers
ages 15-19. For young fathers ages 20-24, who may be bypassing a college
education because of parenting responsibilities, the rate for African
Americans was 133.8, compared to 77.6 for whites. These disparities
suggest a need for further research into young men's attitudes toward
pregnancy prevention, parenting, and the impact of early parenting
on their educational achievement (190).
Further, lack
of language proficiency affects education levels, especially of Hispanics.
A study from the Pew Hispanic Center reports that 33.7 percent of
Immigrant Hispanic/ Latino youth fail to complete high school, compared
to 14.0 percent of Native Hispanic/Latino youth. Because the Hispanic
population is the fastest-growing minority population, this dropout
rate raises concern and also suggests reasons for the lack of a substantial
pool of qualified Hispanic college graduates applying to medical school.
The report states, "A lack of English-language ability is a prime
characteristic of Latino dropouts. Almost 40 percent do not speak
English well. The 14 percent of Hispanic 16-to-19 year olds who have
poor English language skills have a dropout rate of 59 percent" (191).
In the school system, language barriers may be too great for non-English
proficient speakers to negotiate successfully and finish high school.
Efforts to facilitate education of non-English proficient speakers,
especially immigrants, will help increase the numbers of Hispanic
children who stay in school and eventually enroll in post-secondary
education.
Addressing obstacles
to education for URM groups is requisite to increase the proportions
of these groups that enter medicine. Lack of reading skills and low
parental income and education levels influence the academic success
of young children (3,4,107). Ensuring that children read well at an
early age can make a positive difference in their later academic success.
Encouraging and facilitating completion of high school for adolescents
should be a National priority. Ways to reduce barriers for high school
graduates to enter and graduate from college, including financial
constraints, also need to be addressed. Factors that create barriers
at any of these educational levels deserve further attention so that
obstacles to and within the educational pipeline can be removed. Through
increased education, more qualified URMs will be better prepared to
apply to and matriculate in medical school. More education among URMs
should also facilitate a reduction in health disparities as well as
increased life expectancy (7).
IMPLICATIONS OF CULTURAL
COMPETENCE
The rapidly changing
demographic composition of the U.S. population and the continued underrepresentation
of some ethnic and racial groups in medicine compel an examination
of the Nation's future physicians' competencies. Physicians need to
be able to communicate with patients effectively and to overcome any
barriers to quality health care that may result from cultural differences
between physicians and patients. It is imperative that physicians
be aware of how their own background and cultural and economic experiences
have influenced their understanding of patients' needs. When physicians
and patients differ in race, ethnicity, language, religion, and values,
ensuring equitable and culturally sensitive care is challenging but
necessary.
Increasing physician
diversity is a desired objective, but many physicians who are not
underrepresented (e.g., whites and Asians) will be providing a large
portion of care to racial and ethnic groups different from their own.
In addition to the need to recruit and retain minorities that are
underrepresented in medicine, cultural competence must be a part of
medical education and training.
Cultural competence
has many definitions, and most agencies or organizations have their
own perspective of what cultural competence should be (23,24). Although
most medical schools provide some type of cultural competence instruction,
training varies in content and in method of educational delivery (25).
Some schools require cultural competency training, some have elective
courses, and some incorporate cultural issues into course content
(33). However, few models of effective cultural competency curricula
are readily available, and evaluation methods are inconsistent (33,142).
Dissemination of effective cultural competency training is needed.
This training should measurably illustrate that physicians' interactions
with and treatment of patients take into account patients' cultures,
beliefs, values, lifestyles, and family roles. Further, more efforts
are needed to evaluate cultural competence outcomes and to assess
the impact of cultural competence on improved patient satisfaction
and improved health outcomes.
ASSESSMENT OF COGME'S
TWELFTH REPORT
COGME's Twelfth
Report, Minorities in Medicine, notes that the 2 decades before
the 1998 report "provided insight into the programs and resources
required to facilitate minority entry into medicine." The report made
a number of recommendations to "strengthen and sustain these efforts,
and to achieve proportionate minority representation in medicine.
. . ."
The continued
increase in URM populations, without a comparable increase in the
supply of URM physicians, indicates three important strategies for
ensuring that URM populations have adequate health care: 1) increasing
the number of URM students who successfully advance through the elementary,
secondary, and post-secondary academic pipeline in preparation for
entrance into medical school; 2) overcoming policy or systemic barriers
at the level of medical training institutions, residency programs,
licensing boards, specialty certification boards, and practice settings;
and 3) providing effective cultural competency training for U.S. physicians
to ensure quality health care to people of all cultures.
This report reviews
the published literature and other sources to assess the progress
made on the 1998 recommendations for increasing the numbers of persons
from URM groups in medicine. The assessment and review include the
following:
- Findings regarding
ways to improve the academic pipeline leading to medical school;
to enhance the upstream within medical training institutions, accrediting
bodies, and licensing organizations; and to ensure cultural competence
of U.S. physicians
- Assessment
of 1998 recommendations not yet attained
- Evaluation
considerations for future efforts
- New recommendations
Strengthening the Pipeline
to Medical School
PIPELINE PROGRAMS
One of COGME's
recommendations addressed the need for "public and private organizations
to agree collectively upon a Nationwide strategy for duplicating successful
models" of pipeline programs to enhance minority representation in
medicine and to "develop, implement, and evaluate the impact of these
strategies" as well as widely disseminate and publicize successful
programs. In another recommendation, COGME also stressed the importance
of collaborations between and among institutions at various levels
of the educational continuum.
Findings
Numerous pipeline
programs have been funded and created by public and private organizations
to enhance the academic preparation of URMs. From K-12 through medical
school, programs at various stages of the academic process have been
implemented to help strengthen URM students academically and to interest
them in medical careers.
At the National
level, "No Child Left Behind," signed into law in 2002 by President
Bush, attempts to ensure that all students perform successfully in
reading and math (54,55). Other programs such as the Mathematics and
Science Initiative and the Upward Bound Math and Science Program are
specifically designed to enhance math and science skills (56,57).
The White House
has also established several initiatives to improve opportunities
for URMs to gain a post-second-ary education. President Bush signed
the Tribal Colleges and Universities Initiative in 2002 to support
tribal colleges' access to Federal grants and funding opportunities,
to increase the colleges' participation in Federal programs, and to
increase awareness of the role these colleges play (58). In 2002,
the White House also established the "President's Board of Advisors
on Historically Black Colleges and Universities" to make recommendations
to strengthen the capacity of these institutions and to ensure that
they can compete effectively for Federal grants (59). Further, the
White House Initiative on Education Excellence for Hispanic Americans
includes programs to strengthen academic skills and encourage post-sec-ondary
education for Hispanic Americans, one third of whom fail to graduate
from high school (60,61).
The AAMC's Project
3000 by 2000 was an important step in increasing diversity among physicians
by facilitating pipeline and upstream programs at all levels (62).
Also, private organizations like the Lumina Foundation contribute
to programs enhancing the education of disadvantaged and minority
youth. This foundation awarded almost $10 million in grants in 2002
to increase the academic success and college access of underprepared,
inner-city, and low-income students (63).
U.S. medical schools
have developed numerous programs for academic preparation, enrichment,
and retention. The AAMC's Minority Medical Education Program, funded
by the Robert Wood Johnson Foundation, provides intensive 6-week programs
at eleven medical schools. Two thirds of the program's participants
are admitted into medical school (64).
Other programs,
including numerous post-baccalaureate programs or yearlong academic
preparation programs, seek to prepare URM students for admission and
matriculation into medical school (65-79) (see Appendix).
Further, numerous
collaborative programs exist across educational institutions to enhance
the academic preparation and representation of URMs. At the Federal
level, the Health Resources and Services Administration's (HRSA's)
Health Careers Opportunity Program (HCOP) provides assistance to disadvantaged
students to help them enter and graduate from allopathic and osteopathic
schools of medicine as well as other health professions programs (80).
HRSA's Centers of Excellence program helps fund Centers of Excellence
in health professions education for minority students. These Centers
may have one of four designations: Historically Black Colleges and
Universities, Hispanic Centers of Excellence, Native American Centers
of Excellence, and "Other" Centers of Excellence, which must enroll
URMs at rates above the National average (81) (see Appendix).
Many other collaborative
programs exist in which medical schools partner with undergraduate,
secondary schools, and/or community organizations to promote academic
achievement and interest in medical education (66,82-105) (see Appendix).
For example, the AAMC's Health Professions Partnerships Initiative
(HPPI), funded by the Robert Wood Johnson Foundation and the W.K.
Kellogg Foundation, helps increase the participation of URMs in health
professions schools by developing educational partnerships and early
academic intervention programs (32).
Learning from
Others, a recent publication of the AAMC, reviews the literature
on educational partnerships and includes information about HPPI collaborations
to demonstrate how organizations can form effective educational partnerships
(106).
1998 Recommendations To
Be Attained
- Although the
AAMC has published a review of literature of educational pipeline
partnerships (106), no collectively agreed-upon mechanism has been
established to disseminate model pipeline and upstream programs.
Several obstacles to such a dissemination strategy exist:
- Reported pipeline/upstream
programs have varying degrees of success in helping minorities to
be admitted and retained in medical school.
- Standards are
needed to determine which programs should be considered as models.
- Inconsistent
methods of evaluating these programs make it difficult to compare
program outcomes.
Evaluation Considerations
- Research is
needed to understand better the barriers to academic achievement
for URMs at all educational levels so that interventions can be
developed and implemented for targeted groups. Such barriers include
cultural, linguistic, societal, economic, and systemic.
- Research should
be conducted to determine the most effective interventions to achieve
academic success for URMs. Programs and curricula producing high
rates of academically successful URMs should be identified, disseminated
as models, and replicated at the local level. Such programs include
those producing reading and academic achievement in elementary schools;
high enrollment, retention, and achievement in college preparatory,
science, and math courses in high school; high enrollment, retention,
and achievement in undergraduate schools; and admission, retention,
and academic success in medical schools.
- Data on issues
of English proficiency in education need to be collected to increase
achievement and retention of racial and ethnic minority youth who
lack English proficiency.
- Additional
research is needed to show that successful partnerships among educational
institutions lead to successful educational practices that support
the pipeline to medical training.
- Objectives
for pipeline programs as well as evaluation indicators of success
should be established to help determine what constitutes a successful
program at the institutional, regional, State, and/ or National
levels.
OVERCOMING BARRIERS TO
INCREASING URM MEDICAL SCHOOL APPLICANTS
COGME also recommended
continued progress toward a more representative participation of minorities
in medicine, including a goal of 4,500 new URM medical school matriculants
by the year 2010 and 6,000 by the year 2020. This recommendation stressed
the need to apply resources and efforts toward "the enormous challenges
the Nation will face in reaching these objectives." Further, COGME
advised that "appropriate targets should be met at every point of
the educational pipeline, beginning in middle school."
Findings
The goal of 4,500
new URM matriculants by 2010 and 6,000 by 2020 seems unlikely to be
fulfilled, given current trends. In 2001, a total of 1,786, or 10.9
percent of first-year allopathic medical school matriculants, were
identified as URMs. An additional 250 students were reported as having
"Unknown Race/Ethnicity" and/or "Unknown Citizenship." The 2001 total
of URM matriculants represents a slight increase over the previous
2 years—1,739 and 1,741, respectively. First-year URM allopathic
medical school matriculants peaked in 1994 and 1995 with 2,026 and
2,025 students, representing 12.4 percent and 12.5 percent, respectively,
of new matriculants in those years (192).
Osteopathic medical
schools reported 261 first-year URMs in 2001, the highest number since
1997, when 264 URMs started osteopathic medical training.3
URMs represented 8.6 percent of total first-year enrollment
of osteopathic medical school students in 2001. An additional 81 (2.7
percent) first-year students in 2001 were classified as "Other and
Unknown" (other than URMs, white non-Hispanic, and Asian/Pacific Islander)
(193).
Consequently,
a total of 2,047 medical students identified as URMs (less than half
the target number) began allopathic and osteopathic medical training
in 2001. An additional 331 students had no identified race/ethnicity.
A total of 7,394
URMs matriculated in allopathic medical schools in 2002, or 11.2 percent
of total matriculants for that year. An additional 1,680 students
had no reported race/ ethnicity and/or known citizenship. Total URM
allopathic matriculants peaked in 1997 with a total of 8,254, or 12.3
percent of total matriculants. The number of enrolled URMs has declined
since that time, but 2002 also saw the largest number on record with
no reported race/ethnicity (1,680) (194). In 2001, 861 URMs matriculated
in osteopathic medical schools, and an additional 361 were of "Other
and Unknown" race/ethnicity (188).
Providing insight
into why more URMs are not applying to medical school, Richard Cooper's
2003 study of educational trends for the four major U.S. racial and
ethnic groups—whites, African Americans, Hispanics, and Asians—
indicates that, "for each, the major hurdles to medical school are
a high school diploma and a bachelor's degree soon thereafter." Once
those hurdles have been surpassed, Cooper found, rates of application
to medical school are about the same for African Americans, Hispanics,
and whites (3). URM college graduates in 2000-2001 applied to medical
school at a rate of 28 per 1,000 graduates, compared to a rate of
25 per 1,000 white college graduates applying to medical school that
year (5,6).4 Rates are slightly higher
for Asians. In fact, higher proportions of Asian college graduates
than any other group apply to medical school. Although the other groups
have experienced fluctuations, Hispanics have generally had the next
highest proportions of college graduates applying to medical school
(3).
Even after 1995,
after court decisions that challenged affirmative action, rates of
acceptance of applicants into medical school did not decline, but
the rate of African American and Hispanic applicants decreased. Data
show that, among URM applicants for 2001, 46.0 percent were accepted
into medical school compared to 50.6 percent of non-URMs. African
Americans had the lowest acceptance rate, 42.8 percent, compared to
53.4 percent for Mexican Americans, 60.4 percent for applicants from
Mainland Puerto Rico, and 51.0 percent for Native Americans. African
Americans also had lower Medical College Admission Test (MCAT) scores
than other URM groups (53). Although African Americans and Hispanics
represent 30 percent of the college-age population, they compose only
14 percent of medical school applicants, largely due to "progressive
attrition along the path from grade school through college" (3).
Since the mid-1980's,
Cooper notes, K-12 achievement levels have slipped, continuing the
achievement gap between URMs and whites and Asians. Parental income
and parental education affect the academic achievement of students
(3,4,107). Over half of both Hispanic and African American high school
graduates in 1992 were from families having incomes under $25,000,
compared to a third of Asian high school graduates and 21 percent
of white high school graduates (4). Cooper observes, "Poverty weighs
particularly heavily on single-mother families, which account for
43 percent of black families and 23 percent of Hispanic families but
only 13 percent of white and Asian families." Financial limitations
contribute to an inability to enroll in college or stay in college
as well as matriculate into medical school (3).
For 1992 high
school graduates, 15.0 percent of Hispanics and 16.9 percent of non-Hispanic
African Americans had parents who had graduated from college, compared
to 36.2 percent of whites and 48.9 percent of Asians. According to
data from the U.S. Department of Education, high school graduates
who are African American or Hispanic or who are low income are less
likely to be academically well prepared for college than others. Further,
even among those who are academically prepared, high school graduates
who are Hispanic or low income were less likely to take entrance exams
and apply for admission to a 4-year college (4).
Research from
the U.S. Department of Education also shows that fewer African Americans
and Hispanic high school students than whites and Asians take high-level
math and science courses. However, students who enrolled in algebra
in the eighth grade were more likely to take high-level math courses
in high school and to apply to a 4-year college than students who
did not complete algebra as an eighth-grader even if they took a high-level
math course in high school (195).
For high school
graduates who are academically well prepared, being from a low-income
family does not affect college enrollment as much as whether low-income
students take the college entrance examinations and apply to college.
A U.S. Department of Education study notes, ". . . if low-income students
have an academic record and aptitude test scores which demonstrate
even the minimal qualifications for admission to a four-year institution,
if they take a college entrance examination, and if they submit an
application for admission, the majority of low-income students enroll
in post-secondary education. . . ." Most, over 83 percent, enroll
in a 4-year college or university (4).
The ability to
persist through college is another factor affecting applicants to
medical school. Cooper notes, "Among students who enroll full-time
in 4-year colleges soon after high school, 77 percent of Asians and
67 percent of whites were still enrolled or had graduated three years
later" compared to 52 percent for African Americans and 53 percent
for Hispanics. Low-income affects men more than women. Men enter college
less frequently than women immediately after graduating from high
school and drop out more frequently as well. The ability to persist
through college correlates with family income and the rigor of the
high school curriculum. Lower persistence at all levels of rigor characterizes
students "whose families are low-income, whose high schools served
a large
percentage of low-income children, or whose parents had no education
beyond high school" (3).
Cooper further
observes that reading proficiency can determine later academic success.
He adds that cultural factors influence educational achievement and
notes characteristics such as a greater number of hours spent watching
television among African American and Hispanic adolescents compared
to whites and Asians (3).
Increasing the
number of qualified African American and Hispanic applicants to medical
school will require efforts at many levels. Unless educators address
the academic achievement and retention of URM students, both at the
high school and undergraduate levels, the pool of URM medical school
applicants will not increase. Further, programs such as "A Better
Chance," which targets talented URMs for enrollment in college preparatory
schools, are needed to enhance academic opportunities for minority
youth (105).
1998 Recommendations To
Be Attained
- Based on current
trends, the goals of 4,500 new matriculants by 2010 and 6,000 by
2020 are not achievable in the near future.
- Appropriate
targets for URM educational attainment at every point of the educational
pipeline need to be set and met.
Evaluation Considerations
- Efforts need
to focus on retaining URMs in the educational pipeline all the way
through medical school and on intervening in processes that undermine
retention and academic achievement.
- To understand
why URMs are not entering medical schools in the numbers previously
anticipated, the processes, obstacles, motivators, and facilitators
for individuals going through the educational pipeline need to be
better understood and addressed. Interventions are needed to address
factors that prevent URMs from completing high school and entering
and graduating from college. Dropping out of the educational pipeline
is the greatest barrier to URMs' entry into medicine. Education
and income levels of parents affect academic achievement of their
children. Disproportionate numbers of URM children live in single-parent
and/or low-income households, a factor contributing to lack of success
in early education and influencing achievement at all other levels.
- Standards of
achievement and outcome measures are needed for evaluation of K-12,
post-second-ary, and post-baccalaureate programs that seek to increase
academic achievement of URMs.
- Research is
needed to determine reasons academically prepared URMs may fail
to take entrance exams and apply to college.
SOCIAL MARKETING TO INCREASE
URMs IN THE PIPELINE
COGME's 1998 report
recommended the development of partnerships among National and local
media, advertising agencies, and video production companies to create
and implement innovative, culturally appropriate campaigns to promote
science and health careers for minority and disadvantaged children.
Findings
Some innovative
campaigns have been established to encourage science and health careers
for minority and disadvantaged children:
- Kids into
Health Careers is a program sponsored by DHHS's HRSA to encourage
grant recipients to work with school systems to promote health and
science. The program's objective is to "(1) encourage and inform
minority and disadvantaged teenage students of educational and career
opportunities in health professions; and (2) assist minority and
disadvantaged students in planning and preparing for post secondary
education in the health care professions." The Kids into Health
Careers' Web site includes visual aids and talking points to assist
volunteers. The program disseminates four basic messages:
- Jobs are
available in health care.
- Qualifying
for them is achievable.
- Financial
assistance is available.
- Many minority
and disadvantaged people lack health care (109).
- Another HRSA
campaign is the Health Careers Adopt-A-School Program, which encourages
partnerships between schools and businesses to enhance students'
academic performance and career awareness. The program provides
support for school partners to initiate activities that motivate
students, enhance their academic success, build one-on-one relationships,
encourage students to adopt safer and healthier lifestyles, and
foster career goals in science, technology, and health. Suggested
projects include serving as speakers, mentors, or tutors; hosting
career fairs; sponsoring awards for academic improvement; providing
financial assistance to cultural events; donating school supplies
and equipment; recognizing outstanding teachers; and providing "mini-grants"
for teachers (110).
- The American
Medical Association's (AMA's) Minority Affairs Consortium sponsors
the AMA Doctors Back to School program, which encourages physicians,
residents, and fellows to serve as models and mentors to children
from URM groups. Health providers interact with children in schools
and community organizations and share their history and practices
to promote interest in health careers and to emphasize that pursuit
of a medical career is a worthwhile and attainable goal (111).
- The Association
of American Medical Colleges sponsors an annual "Minority Student
Medical Career Awareness Workshop and Recruitment Fair," during
which high school and college students are provided information
and encouragement to pursue careers in medicine (112).
- The Society
for Advancement of Chicanos and Native Americans in Science (SACNAS)
has initiated a number of activities for minority children to encourage
interest and achievement in science. Among these activities is the
SACNAS Biography Project, which makes available the life stories
of minority scientists, mathematicians, and engineers so that students
can see their own potential in these individuals' careers. The K-12
Education program supports educators with teacher workshops that
"have grown into a National effort to support superior pre-college
education in the sciences for Native American/Alaska Natives, Chicano/Latino,
African American and Pacific Island students." SACNAS receives support
from a number of sources, including the Indian Health Service and
the National Institutes of Medicine (113).
- The University
of Washington's Making Connections, Making Choices program has a
Brain Power Van that visits schools so that students learn more
about neuroscience through the van's personnel and exhibits. The
program also provides a speaker's bureau so that researchers can
engage students' interest in science. These programs are part of
a larger program to promote science education (114).
- The National
Native American Youth Initiative is a weeklong event in Washington,
D.C., for Native American students ages 16-18. A cooperative agreement
between the Office of Minority Health and the Association of American
Indian Physicians funds this intense academic enrichment program
that seeks to motivate Native American students to stay in the academic
pipeline and pursue a health professions career. Students learn
the program material through lectures, field trips, and tutorials
and are presented with an overview of health sciences and biomedical
research (115).
- The American
Association for the Advancement of Science joined with the Nation's
largest African American sorority, Delta Sigma Theta, and the Delta
Research and Education Foundation, to produce an innovative radio
program that targeted minority youth to encourage them to aspire
to science careers. Funded by the National Science Foundation, the
program, called Delta SEE Connection, conducted radio interviews
with scientists and engineers to introduce children to the scientists
as role models (116).
1998 Recommendations To
Be Attained
- Although some
programs promote children's career choices in science and health,
partnerships with media, advertising and marketing firms, and video
and audio production companies are needed to help develop and disseminate
culturally appropriate messages targeted to minority and disadvantaged
children.
Evaluation Considerations
- Research should
be conducted on target audiences to determine whether medical and
other health professions messages are sufficiently culturally specific,
whether they are being received by sufficient numbers of the target
audiences, whether they are having the desired effect, and whether
the channels and media being used are the most effective for the
target audiences.
STRENGTHENING THE PIPELINE
TO MEDICAL SCHOOL: RECOMMENDATIONS
- Further efforts
are needed to increase the number of URM college graduates to enlarge
the pool of medical school applicants and URM physicians.
- Intense efforts
should focus on retention of URMs in the educational pipeline from
elementary school through secondary school, from entry in and graduation
from undergraduate school, to entry in and graduation from medical
school.
- Research is
needed to understand better the barriers to academic achievement
for URMs at all educational levels. Such barriers include cultural,
linguistic, societal, economic, and systemic. Effective interventions
should be developed and implemented to address disproportionately
high secondary school dropout rates among URMs to increase their
enrollment in college.
- Standards of
achievement and outcome measures are needed to determine which K-12,
post-sec-ondary, and post-baccalaureate programs should be considered
as models for increasing academic achievement of URMs.
- More resources
are needed to facilitate high school guidance counselors to assist
URMs in taking entrance exams and applying to college and to place
URMs in college preparatory schools and programs.
- Organizations
interested and involved in medical training should partner with
media, advertising and marketing firms, and video and audio production
companies to develop and implement effective communication campaigns
targeting minority and disadvantaged youth with messages that encourage
academic achievement, persistence in school, and interest in medicine.
Strengthening
Upstream Efforts in Medical Training
Many of COGME's
recommendations addressed ways for medical training institutions,
accrediting bodies, and licensing boards to overcome systemic and
policy barriers to entry into medicine and to facilitate URM matriculation
and graduation from medical school and entry into residency programs
and specialties.
Medical training
institutions have sought to overcome barriers for URMs in medicine
and have made strides in areas such as retention. Data for URM medical
school matriculants beginning their training in 1996 show that 93
percent were either still enrolled or had graduated by their sixth
year, compared to 92 percent of non-URMs who had graduated within
5 years (41). Nevertheless, as a recent Institute of Medicine report
discusses, additional strategies and policies are needed to strengthen
the enrollment and retention of URMs in medical training (42).
ADMISSIONS
One of COGME's
1998 recommendations addressed the need to examine the role of standardized
test scores and grade point averages (GPAs) in medical school admissions
and residency placement. The recommendation also indicated the need
to develop criteria for determining desirable characteristics in medical
students to use in admissions and placement decisions.
Findings
Despite controversy
regarding the fairness of affirmative action programs (196), considerable
published literature stresses the need for medical education programs
to use factors other than standardized test scores and GPAs as criteria
for admission. The desirability and benefits of a diverse classroom,
as well as the inequities of K-12 education, have been cited as reasons
to support affirmative action (44,197,198).
In June 2003,
the U.S. Supreme Court ruled that race could be used as a factor in
admissions decisions, thus ruling in favor of the continued use of
affirmative action policies. As the Supreme Court decision affirmed
and as research supports, a diverse medical school student body can
be considered a compelling State interest: minorities serve minority
and underserved communities at higher rates than non-mi-norities do;
a diverse student body helps increase sensitivity of non-minority
medical students to diverse populations; and more minority physicians
help ensure the health care of minority populations (43).
After the 2003
Supreme Court decision, the AAMC produced guidelines to help medical
schools assess their admissions policies. These guidelines ask that
medical schools consider the extent to which diversity is a "compelling
interest" for the school, ways that the school can "demonstrate diversity
as a compelling interest," and the framework of the "school's narrowly
tailored policies" (43).
Among the recommendations
in the AAMC guidelines is the need to find "workable race-neutral
policies" rather than race-conscious policies. Use of qualitative
or non-quantita-tive factors in admissions decisions is one such race-neutral
policy (43). An important race-neutral reason to include non-quantitative
factors in admissions policies is that medical school graduates are
increasingly expected to have qualitative competencies (45). For example,
the Accreditation Council on Graduate Medical Education (ACGME) emphasizes
medical education outcomes of communication skills and professionalism,
which include ethics, cultural competence, and a committed and responsible
relationship to patients and the profession (40).
Use of such factors
as GPAs and MCAT scores as the main admissions criteria results in
less diverse medical students or residents. URMs have traditionally
not performed as well on quantitative measures as non-URMs (46). Also,
use of Step 1 scores from the United States Medical Licensing Exam
(USMLE) to decide which residency applicants to interview, a practice
of some residency program directors, results in a lower number of
minority residents in those programs (118).
As one author
observes, quantitative measures, such as MCAT scores, do not necessarily
predict who will become the best physicians (48). The MCAT was developed
in 1928 and has been revised four times since then. These revisions
"demonstrate that the definition of aptitude for medical education
reflects the profession's social mores and values of the time" (199).
Nevertheless,
research suggests that quantitative measures are correlated with certain
aspects of academic success. One study indicates that scores on the
COMLEX exam taken by osteopathic medical students correlated with
GPAs as well as performance in medical school coursework (200). Yet
another study notes that URMs at one medical school answered more
exam questions incorrectly in basic science courses than non-URMs
did. The author adds that the attrition rate for these URM medical
students was four times that for non-underrepresented groups (201).
Debate continues
about which factors other than GPAs and test scores should be incorporated
into medical school admissions or residency placement. One article
notes that "we know that quantitative factors are not good predictors
of success, but we don't know which qualitative ones are better" (46).
An alternative
way to rethink admissions is to examine methods of stratifying population
groups. For example, one study advocates use of socioeconomic and
disadvantaged status rather than race or gender as the criterion (49).
The University of Massachusetts Medical School uses criteria such
as oral and written communication skills, community service, and extracurricular
activities (47). The AAMC's Expanded Minority Admissions Exercise
suggests such factors as "leadership," "determination and motivation,"
"social interest," and "maturity and coping capability" (50).
The U.S. Department
of Education also encourages innovation in admissions criteria for
institutions striving to diversify their student body. Some examples
of such innovative programs include use of socioeconomic status as
a preference, recruitment of students from schools not usually considered
to be "feeder schools," "skills development" programs and partnerships
to improve academic performance of students at traditionally low-performing
schools, and admission plans created for top-ranking high school students.
The U.S. Department of Education report on race-neutral approaches
stresses that until race-neutral criteria are fully implemented and
evaluated, the extent of their success remains unknown (52).
Among URM medical
school applicants for 2001, 46.0 percent were accepted into medical
school, compared to 50.6 percent of non-URMs. African Americans had
the lowest acceptance rate, 42.8 percent, compared to 53.4 percent
for Mexican Americans, 60.4 percent for applicants from Mainland Puerto
Rico, 51.0 percent for Native Americans, 51.7 percent for whites,
51.1 percent for Asians, and 49.7 percent for applicants from the
Commonwealth of Puerto Rico (53).
1998 Recommendations To
Be Attained
- Criteria are
needed for determining alternative characteristics desirable in
medical students other than those characteristics revealed by quantitative
measures.
Evaluation Considerations
- A need exists
for documented assessment of various non-quantitative admissions
criteria to indicate those most predictive of successful outcomes.
Measures could be developed to capture qualitative or non-quantitative
factors being used in medical school admissions/residency placement
decisions. For example, data on first-year medical school matriculants
might indicate the proportion of students who have health care experience
or those who majored in disciplines other than biological sciences.
Selected non-quantita-tive criteria could then be reported Nationally
along with quantitative measures such as average MCAT scores.
- Desirable outcome
measures should be examined and perhaps redefined to incorporate
non-quan-titative or qualitative considerations. "Success" is generally
defined in terms of quantitative measures such as proportions of
students who pass coursework or board exams or those who perform
well on Step 1 of the USMLE. If a desired outcome is a caring physician,
then criteria indicating that outcome should be included in admis-sions/residency
placement decisions.
MEDICAL SCHOOL DEBT AND
FINANCIAL ASSISTANCE
COGME recommended
assessing the impact of rising medical student debt on the entry of
minorities into medicine; determining the influence of debt on career
choice, including choice of practice location; and ensuring the availability
of financial assistance to URMs across educational levels, including
medical school.
Findings
Both the AAMC
and the American Association of Colleges of Osteopathic Medicine (AACOM)
collect debt information through surveys of medical school graduates
(AAMC) or seniors (AACOM). Medical school debt has been increasing
annually, reaching an average of $103,855 for U.S. graduates of allopathic
medical schools in 2002 and $131,200 (including undergraduate debt)
for osteopathic medical seniors in 2001-2002 (120,202). The reality
of rising medical school costs may deter students from ever applying
to or matriculating in medical school.
Mean educational
debt is generally higher for URMs than for non-URMs in public allopathic
medical schools (203). However, mean debt is almost equal for URMs
and non-URMs who graduate from private medical schools (122). Medical
school students, especially URMs, accumulate more debt the more years
they spend in medical school. For non-URMs, debt fluctuates according
to the number of years in medical school but is consistently lower
than debt for URMs. One quarter of URM medical school students matriculate
in medical school for more than 4 years, compared to a tenth of non-URMs
(204). The greater proportion of URMs than non-URMs who spend more
years in medical school increases the likelihood of higher debt levels
and higher mean debt for URMs as a group (see Table 8).
Despite the increase
in debt, data from the 2001 graduates indicate that debt was not a
factor in choice of specialty for 66.3 percent of URMs and for 69.8
percent of non-URMs. The average debt for these URM respondents was
$97,664 and for non-URMs, $89,582 (see Table 9 above) (126).
Source: AAMC
2001 Graduate Questionnaire.
| TABLE 9 Influence
of Debt on Specialty Choice for Medical School Graduates, 2001(126)
|
| Degree of Influence |
URM Average Debt |
Percentage of Respondents
|
Non-URM Average Debt |
Percentage of Respondents
|
| None |
| Minor |
| Moderate |
| Strong |
Source: AAMC
2001 Graduate Questionnaire.
Similar proportions
of both URMs (16.1 percent) and non-URMs (16.8 percent) indicate that
debt had a "minor influence" on their choice of specialty. The average
debt for these respondents was $113, 494 for URMs and $100,480 for
non-URMs, 16 percent and 12 percent higher, respectively, than debt
for those graduates who reported that debt was not a factor in specialty
choice.
Almost 12 percent
of URMs said that debt was a "moderate influence" on their specialty
choice, and these physicians had an average debt of $123,600. About
9 percent of non-URMs reported that debt was a moderate influence,
and the average debt for this group was similar to that of URMs, $122,861.5
Only 5.9 percent
of URMs and 4.5 percent of non-URMs indicated that debt was a "strong
influence" on their choice of specialty, and this group had the highest
debt of all. URMs for whom debt was a "strong influence" had an average
debt of $119,006, and non-URMs in this group had a higher mean debt
of $125,265 (126).
The AAMC also
reports the amount of debt by practice specialty and anticipated practice
location. The amount of educational debt for graduates planning to
practice in an underserved area was similar to the debt for those
who did not plan to practice in an underserved area: $102,163 versus
$103,394 for URMs and $99,532 versus $97,628 for non-URMs (205).
For 2001 graduates
planning to practice in an underserved area, those planning to serve
in a primary care specialty had the lowest average debt (see Table
10) (205). Data from the AAMC 2001 Graduate Questionnaire indicate
that almost half of non-URMs and 39.2 percent of URMs planning to
practice in underserved areas selected primary care specialties. Over
a quarter of URMs and 17.4 percent of non-URMs intending to practice
in an underserved area selected surgical specialties (206). Of those
graduates planning to locate in an underserved area, support specialties
had the highest average debt, $121,692 for URMs and $108,914 for non-URMs
(205). Similar proportions of both URMs and non-URMs (just under 16
percent) who anticipated locating in underserved areas chose support
specialties (206).
| TABLE 10
Average Debt by PracticeSpecialty Choice for Medical School Graduates
Planning To Practicein an Underserved Area, 2001 (205,206) |
| Specialty Choice |
URM
|
Non-URM
|
Average
Debt |
Percentage
of Respondents |
Average
Debt |
Percentage
of Respondents |
| Primary Care |
| Medical |
| Surgical |
| Support |
Source: AAMC
2001 Graduate Questionnaire.
Like allopathic
medical students, osteopathic medical students also experience high
debt levels. Seniors in 20012002 had an average debt of $131,200,
a 2 percent increase from 2000-2001, when the average debt for graduating
seniors was $128,700.6 Nevertheless,
this debt increase was moderate compared to the prior year when mean
debt was $121,000. Thus, during a 2-year period, debt for senior osteopathic
medical students increased by $10,000, or 8 percent (190). For senior
URMs in 2001-2002, debt averaged $135,400, which represents a decrease
from $138,400 the previous year; for whites, the mean debt was $135,700,
an increase from $130,300, and for Asians, $107,800, a decrease from
$114,000 the previous year (207).
Information regarding
factors influencing specialty choice reveals that debt level had very
little influence on the choice of specialty for 2001-2002 osteopathic
medical school seniors, regardless of race or ethnicity and regardless
of whether they were planning to practice in a primary care specialty
or a non-primary care specialty. The most important factor listed
by senior osteopathic medical students planning primary care specialties
was a preference for working with a "person or patient more than techniques,"
followed closely by "intellectual content of the specialty." Lifestyle
ranked third and was an especially high priority for URMs and Asians
who were planning to practice in primary care specialties. For seniors
planning to practice in non-primary care specialties, "intellectual
content" most influenced specialty choice, followed by "skills [and]
abilities" required of the specialty (127).
According to the
AAMC, almost three quarters of 2001 URM allopathic medical school
graduates and slightly fewer than half of 2001 non-URM graduates received
scholarship assistance while in medical school. URM graduates received
an average of almost $35,000 in scholarships, compared to $25,780
for non-URMs. For 2001 graduates attending private medical schools,
URMs received an average of $6,000 more in scholarships than non-URMs,
and for 2001 public school graduates, URMs received an average of
$7,000 more than non-URMs (124).
Although similar
proportions of new allopathic medical school matriculants (60 percent)
indicate that their medical education will be financed through loans,
30 percent of URMs stated that scholarships will help pay for their
education compared to 14 percent of non-URMs. Seventeen percent of
non-URMs indicated that family or spouses will help finance their
education compared to 6 percent of URMs (123).
Among osteopathic
medical school seniors, 42.3 percent of URMs received scholarships,
and the average scholarship amount was $38,600. Among whites, 34.7
percent received scholarships at an average of $39,500, and 20.3 percent
of Asians received scholarships at an average of $38,000 (208).
According to available
survey estimates from the U.S. Department of Education for the 1999-2000
school year, URM undergraduates received more aid of any type, more
Federal assistance, and more grants than non-URMs (209). In addition,
URM master's and doctoral students, as well as URM first professional
degree students, received more financial assistance in dollars than
non-URM students (210).
Further, data
collected for 1995-1996 indicate that the percentage of undergraduates
who received financial aid was inversely proportional to family income
(see Table 11). Seventy percent of students whose families had incomes
below $20,000 in 1994 received financial aid, 66 percent of which
included grants. In contrast, 28 percent of students whose family
income was at least $100,000 received financial aid, 17 percent of
which included grants (107).
TABLE
11 Percentages of Undergraduates With Student Financial Aid,
by Family Income and Type of Aid(107) |
| Family Income (in 1994)
|
Any
Aid* |
Grants
|
Loans
|
| Less than $20,000 |
| $20,000-$39,900 |
| $40,000-$59,900 |
| $60,000-$79,900 |
| $80,000-$99,900 |
| $100,000 or more |
*Includes grants, loans, and
other types of aid such as work-study. Source: NCES, 1995-1996
National Postsecondary Student Aid Study (NPSAS:96).
1998 Recommendations To
Be Attained
- More research
is needed to determine the impact of medical school debt on URMs'
decisions to apply to or matriculate into medical school.
Evaluation Considerations
- Current mechanisms
for evaluating the impact of debt on URMs may not fully capture
important considerations. Data are needed to assess the impact of
potential indebtedness on selecting medical school as a career option
in the first place. Assessing students who possess the requisite
academic credentials but who elect other career options may be helpful.
- Research to
assess whether increased scholarship assistance rather than loans
might encourage more URMs to elect to pursue medicine as a career
would be useful.
URMs IN SPECIALTIES
COGME's recommendations
also included a need to identify and eliminate barriers to URM entry
into medical and surgical specialties. COGME encouraged medical and
surgical specialty organizations and societies to assist in ensuring
that URMs have the same flexibility in selecting specialties that
non-URMs have.
Findings
The AAMC collects
data by specialties for medical school graduates, and the AACOM collects
specialty data for osteopathic medical school graduates (128,211).
AAMC data from the 2001 Graduate Questionnaire reveal that, although
a higher percentage of URMs than non-URMs graduating in 2001 planned
to pursue generalist or surgical specialties, a greater proportion
of non-URMs than URMs planned to pursue medical specialties. Proportions
choosing support specialties were similar for both groups (see Table
12) (128).
| TABLE 12
Specialty Plans of URM and Non-URM U.S. Medical School Graduates,
2001 (128) |
| Type of Specialty |
Percentage of URMs |
Percentage of Non-URMs
|
| Generalist |
| Medical |
| Surgical |
| Support |
Source: AAMC.
2001 Graduate Questionnaire.
Potential barriers
to minority entry into some specialties include board exam information
and feedback procedures. The USMLE provides standardized feedback
to examinees, including strengths and weaknesses, particularly important
for those who fail the exam, yet feedback to examinees from specialty
board exams is inconsistent or nonexistent. Similarly, specialty boards
have inconsistent levels of information regarding preparation for
board certification exams (212). Minorities and older examinees in
one study were more likely to fail certification exams, and passing
rates are correlated with performance in medical and residency training
(213). Inadequate information regarding preparation for board exams,
as well as feedback upon failure of these exams, can create obstacles
for examinees seeking to become certified in some specialties. Also,
a need for more academic support in medical training for both minorities
and older students is indicated.
Further, research
suggests that some residency program directors use scores from Step
1 of the USMLE to determine which applicants will be interviewed for
selection. Depending on the threshold of scores used to select interviewees,
African American applicants in one study were three to six times less
likely to be interviewed by these programs (118). The use of USMLE
scores to screen applicants for residencies can create obstacles for
minority entry into some residency programs. Also, some residency
program directors use the selectivity of applicants' medical schools
to help narrow applicant pools, another factor that may result in
fewer minorities in those residencies (47).
The results of
the American College of Surgeons' annual survey of residents enrolled
in surgical graduate medical education each year for 1994-1995 and
1995-1996 indicate that few minorities reported entry into surgical
specialties in those years. Of the 5,541 residents who were surgical
specialists in 1994-1995, 301 (.05 percent) reported that they were
African American and 218 (.04 percent) reported that they were Hispanic.
In 1995-1996, 305 (.06 percent) of 5,397 surgical residents were African
American, and 226 (.04 percent) were Hispanic. The report noted that
"although recruitment of the most highly qualified US and Canadian
medical school graduates has been a source of pride to the profession,"
a strong need exists to increase diversity of surgical residents (214).
However, a recent
study of efforts to recruit students into surgical residencies at
the Robert Wood Johnson Medical School was extremely successful in
increasing the number of students who pursued surgical residencies
and who were matched into those residencies. The proportion of students
accepted into surgical residencies increased from 18 percent during
1993-1997 to 22 percent from 1999-2003. By 2003, the proportion of
graduating seniors matched into surgical residencies increased to
26 percent. Over a quarter of those matched into surgical residencies
were URMs, and 19 percent spoke English as a second language. Further,
the quality of students accepted into surgical residencies remained
high (215).
1998 Recommendations To
Be Attained
- A need continues
for research into obstacles and motivations for minority entry into
residencies or specialties.
Evaluation Considerations
- Tracking interest
in specialties at entry into medical school, at the beginning of
the clinical year, and at graduation would be helpful to examine
factors influencing specialty choices for both URMs and non-URMs.
A multivariate analysis can help determine relative influence of
various factors.
- Tracking barriers
to and motivators for entering specialties would be helpful to examine
factors influencing specialty choices for both URMs and non-URMs.
- Residency program
directors should be encouraged to use factors other than exam scores
or selectivity of medical schools in selecting applicants for interviews.
URM FACULTY
One of COGME's
recommendations addressed the need to increase proportions of URM
medical school faculty to 10 percent of total faculty. The recommendation
also suggested that "every academic medical center should have in
place specific programs and a dedicated budget for identifying and
supporting underrepresented minority students with an interest in
academic medicine."
Findings
According to the
AAMC Faculty Roster in 2002, 6.9 percent of allopathic medical school
faculty reported that they were URMs. In 1998, 5.9 percent of faculty
was URMs. However, these data should be viewed cautiously because
of the large proportion of faculty for whom race/ethnicity was reported
as "Other/Unknown": 4.1 percent in 2002 and 6.1 percent in 1998 (130,131).
The number of
reported allopathic medical school faculty increased from 87,230 in
1998 to 98,802 in 2002. Numbers of faculty increased for all identified
racial/ethnic groups except for Native Americans, who decreased from
123 to 105. The proportion of white faculty members decreased from
78.3 percent to 76.9 percent, whereas the proportion of Asian faculty
members increased from 9.6 percent in 1998 to 11.5 percent in 2002
(see Table 13) (130,131).
| TABLE 13
Number and Percentages of U.S. Medical School Faculty, by Race/Ethnicity,
2002 and 1998 and Percent Change (130,131) |
| Race/Ethnicity |
2002 |
1998 |
Percent Change |
| Total |
Percent* |
Total |
Percent* |
| Native American |
| African American |
| Mexican American |
| Puerto Rican |
| Other Hispanic |
| Total URM Faculty |
| White |
| Asian |
| Multiple Races |
| Other/Unknown |
| Total |
*Percentages do not equal
100 because of rounding. Sources: AAMC Faculty Roster, December
31, 2002; AAMC Faculty Roster, December
31, 1998.
Data reported
for osteopathic medical school faculty for 2001 indicate that 3.5
percent were URMs compared to 3.0 percent in 1998. As for allopathic
faculty, large proportions of osteopathic medical school faculty were
reported as "Other/Unknown": 4.6 percent for 2001 and 5.4 percent
for 1998. From 1998-2001, total faculty members in osteopathic medical
schools decreased 1 percent from 2,586 to 2,561. The reported total
of African American faculty decreased from 46 to 43, and the number
of white faculty decreased from 2,253 to 2,204 (see Table 14) (132).
However, as researchers
at a recent conference at Dartmouth University note, increasing numbers
of URM faculty only partly solves the problem of increasing diversity
among faculty. A more important issue is the need for exchanging ideas
and experiences and for examining tenure criteria, which have been
largely determined by tenured faculty, the majority of whom continue
to be white and male. Minority faculty is expected to carry out traditional
demands of research and also to advocate for diversity and to represent
minorities. Academic institutions should examine the climate of their
institutions to determine whether they truly provide opportunities
for minority faculty members to share power with their non-minority
colleagues (216).
Research indicates
that minority faculty should be recruited and mentored early in their
careers, but few programs have been reported that focus on supporting
URM students interested in academic medicine. However, one such program
is the Fellowship Program in Academic Medicine, supported since 1990
by $5 million grants from the Bristol-Myers Squibb Company. This program
seeks to increase minority physician representation among medical
school faculty and in biomedical research. The Fellows are selected
from sec-ond-year, third-year, or fourth-year minority medical students
who are nominated by medical school deans. These candidates are reviewed
and selected by a committee of medical school faculty and biomedical
researchers. The Fellows propose and conduct research during an 8-
to 12-week period, during which they work closely with a faculty mentor
(133).
The Minority Medical
Faculty Development Program, established by the Robert Wood Johnson
Foundation, offers 4-year postdoctoral research fellowships to minority
physicians. The program seeks to increase minority faculty who progress
successfully through the ranks of academic medicine by supporting
research opportunities. As many as 12 Fellows are appointed with an
annual stipend of $65,000 plus an additional $26,350 to support research
expenses. The Fellows work with faculty mentors as well as National
Advisory Committee mentors and attend an annual meeting where research
presentations and career development workshops are conducted (217,218).
Female minorities
often have unique obstacles to advancing as faculty members in medical
education. To address barriers for minority faculty women, six National
Centers of Excellence in Women's Health use the following strategies
to support female minority faculty:
- Funding
- Awards
- Leadership
symposiums
- Mentoring programs
- Faculty development
workshops
The Centers also
offer assistance in the promotions process and in targeted retention
and recruitment initiatives and have formed a committee addressing
female minority faculty concerns. They stress the need to establish
and track diversity indicators, provide institutional support as faculty
move through the promotion process, commit to institutional strategies
to recruit and retain minority faculty, and conduct research on ways
to overcome barriers to advancement (134).
One study indicates
that URM medical school faculty are more dissatisfied with their careers
than non-URM faculty are (129). Increased efforts are needed to ensure
that the institutional climate of medical training institutions fosters
career growth and satisfaction for URM faculty.
1998 Recommendations To
Be Attained
- More complete
reporting of faculty by race/eth-nicity is needed to determine progress
made in increasing URM faculty. Race/ethnicity for a large percentage
of faculty is reported as "Other/ Unknown."
- Recruiting
and retaining minority physicians as medical school faculty continue
to be important goals, especially as evidence indicates that minority
faculty are more dissatisfied with their careers than non-minority
faculty.
Evaluation Considerations
- Programs like
the Centers of Excellence in Wom-en's Health or the Fellowship Program
in Academic Medicine can provide valuable "lessons learned" for
institutions attempting to enhance opportunities for minority medical
school faculty. Collecting and reviewing data on the outcomes of
such programs (e.g., numbers recruited, numbers retained, and satisfaction)
are essential for developing new initiatives or refining ongoing
ones.
| Race/Ethnicity |
2001-2002 |
1998-1999 |
| Total |
Percent |
Total |
Percent |
| Native American/ Alaska Native |
| African American |
| Hispanic |
| Total URM Faculty |
| White |
| Asian |
| Multiple Races |
| Other/Unknown |
| Total |
*Full- and part-time,
all ranks.
Data are not available.
Source: AACOM, Annual Osteopathic Medical School Questionnaire,
2001-2002 and 1998-1999 Academic Years.
- Separating
the category "Other" from "Unknown" race/ethnicity of faculty for
reporting purposes might provide a better representation of the
proportion of faculty who are minorities and would indicate more
accurately the proportion of faculty who fail to report their race.
- Establishing
and tracking diversity indicators for minority faculty recruitment,
tenure, and promotion would help foster commitment to having a diverse
faculty and would also help document obstacles for minority faculty
that should be addressed.
STRENGTHENING UPSTREAM
EFFORTS IN MEDICAL TRAINING: RECOMMENDATIONS
- Desirable outcome
measures that include non-quantitative considerations should be
established for medical school students and then used in admissions
decisions.
- Residency program
directors should also consider qualitative as well as quantitative
factors when deciding which residency candidates to interview and
select.
- Use of qualitative
criteria in medical school admissions and residency placement decisions
should be documented and assessed to determine which ones are most
predictive of successful outcomes.
- More research
is needed to assess the impact of medical school debt on URMs' decision
to apply to, matriculate in, and graduate from medical school.
- Assessment
of whether increased scholarship assistance rather than loans might
encourage more URMs to pursue medicine as a career would be helpful.
- More research
is needed to evaluate obstacles or motivations for minority entry
into primary care or specialty residency programs. Medical schools
should track medical students' interest in specialties at entry
into medical school, at the beginning of the clinical year, and
at graduation to assess factors that influence choice of specialties
for both URMs and non-URMs.
- Medical schools
should develop and implement plans for recruiting and retaining
minority faculty physicians, including assessing and enhancing the
institutional climate for URM faculty. Indicators and targets for
recruitment, tenure, and promotion of minority faculty should be
established and tracked.
- Minority medical
students, residents, and physicians who aspire to serve as faculty
should be identified and mentored early in their careers.
- Interventions
should be developed that encourage physicians to practice in underserved
areas for periods that extend beyond the time commitment of programs
requiring service in exchange for funding opportunities.
- Research is
needed to determine optimal conditions and exposure time required
for medical students to develop and maintain an interest in serving
in underserved communities.
- Strategies
are needed to assess and reinforce the commitment of academic medical
centers to provision of care to underserved populations. This commitment
should be integral to the academic environment and mission and should
be fostered by means other than funding incentives.
Ensuring
Cultural Competence in Medicine
CHANGING DEMOGRAPHICS
In its 1998 report,
COGME noted that, given the changing demographics of the U.S., physicians
will care for increasingly diverse populations. Because the diversity
of the physician workforce is not keeping pace with the diversity
of the Nation, physicians need to have competencies that promote high-quality
care of culturally, racially, and ethnically diverse populations.
COGME also made recommendations addressing ways to ensure cultural
competence in physicians, including the need to arrive at a consensus
regarding the definition of cultural competency in medicine; to develop,
implement, and assess cultural competency training; and to incorporate
cultural competency in accrediting standards for medical academic
institutions, licensing board criteria, and quality standards for
managed care.
Findings
Although no formal
panel has been convened to reach a consensus definition of cultural
competence, much discussion has occurred during recent years regarding
what cultural competence is or should be. Indeed, based on the complexity
and variety of perspectives of cultural competence, the possibility
of reaching a single consensus seems unlikely. As the National Center
for Cultural Competence at Georgetown University States, "many definitions
of cultural competence are emerging in the literature yet none is
accepted as the gold standard'" (23). Further, Lisa Tedesco, in an
essay published in The Right Thing to Do, The Smart Thing to Do,
states that a consensus on definitions of cultural competence is "a
distant goal" (219). Cindy Brach and Irene Fraser with the Agency
for Healthcare Research and Quality (AHRQ) also state, "Every organization
and author define cultural competency somewhat differently" (24).
Nevertheless,
some definitions of cultural competence have emerged. The most common
definition used is one developed by T.L Cross and associates in a
1989 report (220). DHHS's Office of Minority Health (OMH), in its
National Standards for Culturally and Linguistically Appropriate
Services in Health Care, borrows Cross's concept of "cultural
and linguistic competence": "a set of congruent behaviors, attitudes,
and policies that come together in a system, agency, or among professionals
[and] that enables effective work in cross-cultural situations" (26).
Other definitions
include one from the National Center for Cultural Competence, which
defines cultural competence as effective provision of services to
individuals within a larger family, community, and cultural milieu.
This organization stresses the need for physicians to understand their
own culture, to acknowledge a "patient's different culture, value
systems, beliefs, and behaviors," to be aware that "cultural difference
is not synonymous with cultural inferiority," and to learn about patients'
culture in order to provide optimal health care (23).
Despite the lack
of uniformity in definitions of cultural competence, the desirability
of cultural competency training in medical education is recognized,
and this training is increasingly available in various courses and
educational delivery methods (23-40). However, the limitations of
some methods of incorporating cultural competence into medical training
curricula are also apparent. As Michael Whitcomb, Editor of Academic
Medicine, states, "it is not yet clear how best to teach students
how to begin acquiring the knowledge, skills, and attitudes they need"
to develop relationships with culturally diverse patients (25).
The various perspectives
expressed in the published literature affirm that approaches to teaching
and assessing cultural sensitivity, cultural awareness, and other
key issues involved in being "culturally competent" are in a pioneering
stage. Much discussion in the literature revolves around the best
means to change attitudes and the best way to measure those changes,
both in the medical school environment and in practice settings (27-29,136-142,221-224).
Since the 1998
COGME report, private and public organizations have sponsored numerous
initiatives to develop and implement curricula and programs promoting
cultural competency. A brief summary of cultural competence initiatives
include many developed or sponsored by HRSA:
- The Provider's
Guide to Quality and Culture, an electronic resource that includes
a self-assessment, cultural competence information and pointers,
information about patient-provider relationships, audio clips of
providers' perspectives, and resources (143).
- The Cancer
Diagnostic Guide, which addresses culturally competent approaches
to cancer prevention and treatment and assists providers in effective
cross-cultural communication (225).
- The Minority
AIDS Initiative, which provides funding for organizations to help
fight AIDS. Funded programs incorporate cultural competent activities
(225).
- Be Safe,
a cultural competence guide for African Americans, which provides
information about the management and treatment of African American
patients with HIV/AIDS (225).
- "Cultural Workshops
for Providers" to meet specific needs of the AIDS Education and
Training Centers (225).
- A 2003 Satellite
Broadcast, entitled "Cross-Cultural Communication in Health Care:
Building Organizational Capacity," which focuses on language services
in health care and provides a six-step model for planning and managing
these services (144).
- Indicators
of Cultural Competence in Health Care Delivery Organizations: An
Organizational Cultural Competence Assessment Profile, which
offers a systematic approach to cultural competence in com-munity-oriented
organizations (145).
- A review of
literature that examines information to help assess cultural competence
in health care delivery settings (146).
- A cultural
competency program that seeks to promote cultural competence and
demonstrate its effectiveness in increasing health care access and
decreasing health disparities (147).
- "Cultural Competence
Workshops and Technical Assistance" (148).
- A 2002 conference,
entitled "Bridging Cultures & Enhancing Managed Care," at which
presentations were made addressing provision of cultural and linguistic
competence in managed care (149-153).
- A "Cultural
Competence Works" competition for HRSA grantees that have successfully
made cultural competence an integral part of their organizations
(154).
The AHRQ has also
produced reports on cultural competence: Can Cultural Competency
Reduce Racial and Ethnic Health Disparities? A Review and Conceptual
Model, Reducing Disparities through Culturally Competent Health Care:
An Analysis of the Business Case and, recently, the National
Healthcare Disparities Report (24,155,156).
In addition to
Federal efforts, private organizations have launched numerous cultural
competence initiatives:
- An online cultural
competence-training module at the National Center for Cultural Competence
at Georgetown University (157).
- The California
Endowment's report Principles and Recommended Standards for Cultural
Competence Education of Health Care Professionals, which includes
standards for content, methods, and evaluation of cultural competency
training (30).
- The Committee
on the Health Professions Education Summit's report, which advocates
five basic competencies in health professions education (31).
- The AAMC's
"Tool for Assessing Cultural Competency Training," which is being
developed to help medical schools assess their cultural competency
curricula (32).
- The Commonwealth
Fund's report Cultural Competence in Health Care: Emerging Frameworks
and Practical Approaches, which helps health care organizations
improve health care by overcoming cultural barriers (33).
- The AMA's Cultural
Competence Compendium, a compilation of efforts, tools, presentations,
reports, and articles promoting cultural competence (34).
- The American
Association of Health Plans' (AAHP's) 2003 audio conference entitled
"The Case for Cultural Competencies in Health Care" (35).
- Kaiser Permanente's
A Provider's Handbook on Culturally Competent Care: African American
Population and A Provider's Handbook on Culturally Competent
Care: Latino Population and training modules entitled "Introduction
to Diversity," "Culturally Competent Care: Cultural Awareness,"
"Culturally Competent Care: Cultural Knowledge," and "Culturally
Competent Care: Cultural Skills" (36,37,158).
- An initiative
launched in 2002 by the National Medical Association, the AMA, and
other specialty groups to educate physicians about health care disparities,
particularly for heart disease (159).
Information from
the Liaison Committee on Medical Education, Part II of the Annual
Medical School Questionnaire, reveals that almost all U.S. medical
schools provide required and/or elective training in cultural competency
or topics related to cultural competency. Of the 125 academic health
centers reporting for 2000-2001, however, only three required a separate
course in cultural diversity, 112 incorporated cultural diversity
as part of a required course, 21 offered an elective course in cultural
diversity, and 43 included cultural diversity as part of elective
coursework (135). Studies also indicate that some residency programs
are incorporating training that promotes cultural competence in residents
(227229). Further, continuing medical education (CME) courses in cultural
competence are emerging (164,165).
Much progress
has been made toward including cultural competence in accreditation
standards for both undergraduate and graduate medical education. The
Licensing Committee on Medical Education (LCME) has explicit accreditation
standards that include cultural competency for medical education (38).
Also, the ACGME has developed an Outcomes Project that stresses six
areas of competency for residents, one of which, "Professionalism,"
includes demonstrating "sensitivity and responsiveness to patients'
culture, age, gender, and disabilities" (39,40). The American Board
of Medical Specialties supports these outcomes, and some specialty
organizations have adopted guidelines that include cultural competency
training (160,161).
Although licensing
boards do not test for cultural competence, Step 3 of the USMLE uses
diverse patients as part of the clinical assessment so that examinees
must respond to clinical situations that include cultural contexts
(162). The Accreditation Council for Continuing Medical Education
does not require specific competencies (163).
New York has pending
legislation that mandates that the medical schools in the State require
at least one course in cultural competency and that physicians must
complete cultural competency training for relicensure (166). New Jersey
has pending legislation that requires cultural competency training
for physicians to be licensed or relicensed (167). California and
Illinois have bills pending that provide for State medical societies
to offer voluntary cultural competency programs for physicians (168,169).
Although some
managed care plans have developed strategies for increasing minority
physician representation and culturally competent care in their practices,
continued efforts to increase minority physician representation in
managed care are needed.
Kaiser Permanente
has established a National Diversity Department, but this large managed
care organization acknowledges difficulty in recruiting minority physicians
(230). To facilitate cultural competence in its organization, Kaiser
Permanente has created its own Institute for Culturally Competent
Care and has Centers of Excellence for African Americans, for Latinos,
and for linguistic services. This health plan also has received an
AAHP grant for Innovation in Quality Improvement (35).
As managed care
increasingly provides health care for large portions of the U.S. population,
much effort has been made to develop, implement, and assess cultural
competence strategies and to evaluate cultural competence in managed
care organizations. The Centers for Medicare and Medicaid Services
(CMS) commissioned the AHRQ to develop guidelines to provide assistance
to managed care plans: "Oral, Linguistic, and Culturally Competent
Services" and "Providing Oral Linguistic Services" (171-172). In addition,
CMS has established and updated its Quality Improvement System for
Managed Care Standards and Guidelines (173).
Further, the George
Washington University Center for Health Services Research and Policy,
in consultation with HRSA and Resources for Cross Cultural Health
Care, has developed a technical assistance document, "Optional Purchasing
Specifications: Cultural Competence in the Delivery of Services Through
Medicaid Managed Care," to help States that contract with managed
care organizations for provision of services for Medicaid-eligible
individuals (175).
Other efforts
also seek to ensure that managed care organizations respond to the
cultural needs of enrollees in health care plans. According to the
National Committee for Quality Assurance, the Health Plan Employer
Data and Information Set (HEDIS®) has no measures that assess
the cultural competence of providers, but the "accreditation standards
require organizations to address members' cultural needs and preferences."
Further, an organization must assess "the cultural, ethnic, racial
and linguistic needs of its members and adjust the availability of
practitioners within its network if necessary." Organizations must
also "have quantifiable and measurable standards for the number and
geographic distribution of primary care providers and specialty care
providers" (174).
However, the lack
of data on race and ethnicity in health plans creates a barrier to
assessing the quality of care for minority patients. The Minority
Health Report Card Project, a collaborative effort of Michigan State
University, the Henry Ford Health System, Lovelace Clinic Foundation,
the University of Texas School of Public Health, and eight health
plans, was developed in 1998 to assess health care disparities among
different racial/ethnic groups in managed care. Managed care plans
usually do not collect data by race, but the project determined other
ways to assess health care quality for racial and ethnic groups (177,178).
Research also
shows that, although Federal regulations require each State to submit
a cultural competence plan for provision of services, States have
varying contract requirements for their Medicaid managed care organizations.
Some States collect data, but do not use this information to assess
compliance with cultural competence standards. In some States, no
specific penalties exist, and compliance is not enforced (176).
1998 Recommendations To
Be Attained
- A need exists
to determine desired outcomes for cultural competence instruction
as well the most effective methods to teach and assess cultural
competence for medical students and residents.
- Evaluation
is considered critical to any program, and much information is available
regarding evaluation of cultural competence and cultural competency
training. Nevertheless, a lack of information exists regarding results
of evaluation.
Lack of evaluation
or training outcomes contributes to the uncertainty about how and
what to teach medical students regarding cultural competence and
about whether and to what extent cultural competency training improves
health care.
- Few medical
schools have required courses specifically dedicated to cultural
competence. Standards are needed for incorporating cultural competence
training into medical school curricula.
- The extent
and kind of cultural competency training in residencies and CME
need to be identified.
- Not only are
specific targets for increasing minority physician representation
in managed care not being met, but managed care plans appear to
have difficulty recruiting minority physicians because of low numbers
of minority physicians entering the health care workforce.
- Although National
standards exist, State contract language requiring cultural competence
in managed care organizations needs to be specific and enforced.
Evaluation Considerations
- The varied
definitions of cultural competence and approaches to cultural competence
instruction suggest a need for further research and discussion to
determine key objectives, desired outcomes, and ways to measure
progress toward those outcomes in medical education. A National
conference should be held at which these issues can be more fully
addressed.
- A need exists
for more models that can be applied to classroom and other training
venues for health care providers. Such models might include sample
cultural competence courses, course syllabi, or other modes of education
delivery; methods of implementing cultural competence training and
practice; and more assessment of problems with and successes of
various methods of cultural competency training.
- Evaluation
data need to be collected and disseminated regarding the impact
of cultural competence curricula and training. Several kinds of
evaluations are needed:
- Assessment
of participants' responses to cultural competence programs:
To what extent do educators encounter student resistance to
the importance of cultural competency training, particularly
when such training must compete with other training priorities,
including basic sciences and clinical clerkships?
- Assessment
of learners' perceptions of their training: Have they attained
the knowledge, skills, and attitudes that will help them provide
culturally competent care?
- Assessment
of the impact of cultural competency training program: Do patients
believe they have been treated in ways that indicate culturally
competent providers and organizational policies that reduce
cultural or language barriers to health care?
- Prioritization
of the objectives of cultural competency training to determine
the most appropriate outcomes measures: Is the objective to
provide better care, to attract more patients from certain cultural
groups, to retain patients already receiving care, or some combination
of these outcomes?
- A need exists
to identify desired competencies for cultural competency training
across the continuum of medical education (undergraduate through
CME). Also, the best ways to ensure that medical students and physicians
attain these competencies and the most effective ways to assess
the extent to which they achieve those competencies need to be identified.
- The "hidden
curriculum" should be assessed. What are learners' attitudes about
the importance of cultural competence? A well-established formal
curriculum may be undermined in the informal networks of student
life, and those factors should be recognized and assessed.
- Health care
organizations that manage care need to have aggressive plans for
recruiting minority physicians.
- The National
Committee for Quality Assurance requires managed care organizations
to address members' cultural needs and desires. A summary of how
those standards are being met would be helpful.
- More research
is warranted to assess the extent that States evaluate their cultural
competence monitoring
and enforcement procedures. Clear indicators for accountability
and penalties in their contracts with managed care organizations
need to be developed.
- Health care
organizations should be encouraged to use existing data from other
sources to identify and address disparities in access to care and
quality of care for patients at these organizations.
ENSURING CULTURAL COMPETENCE
IN MEDICINE: RECOMMENDATIONS
- The varied
definitions of cultural competence and approaches to cultural competence
instruction indicate a need for further research and discussion
to determine key objectives, desired outcomes and competencies,
and ways to assess progress toward those outcomes in medical education.
A National conference should be held at which these issues can be
more fully addressed.
- Data are needed
to determine whether cultural competency training enables medical
students, residents, and physicians to become more culturally competent
and whether that training affects patient outcomes.
- The Federation
of State Medical Boards should encourage individual State licensing
boards to institute voluntary cultural competency training for physicians.
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APPENDIX:
A Review of Educational Pipeline Programs and Collaborations
PIPELINE PROGRAMS
Project 3000 by 2000
The Association
of American Medical Colleges' (AAMC's) Project 3000 by 2000 helped
increase diversity in medical schools by facilitating and encouraging
pipeline and upstream programs at all levels. Together with the National
Science Foundation (NSF), the National Institutes of Health (NIH),
and other organizations, Project 3000 by 2000 promoted the need and
opportunities for minority students in science and health. Based on
surveys from the 125 United States (U.S.) allopathic medical schools,
medical school partnerships and opportunities for high school students
increased between 1990 and 1995, as excerpted below:
- Science education
partnerships with local school districts increased from 8 to 72.
- Magnet health
science high schools increased from 8 to 44.
- Classroom-based
academic enrichment programs for high school students increased
from 44 to 82.
- Laboratory
internships for high school students remained high at 102.
- Academic enrichment
programs for college students increased from 59 to 77.
- Postbaccalaureate
programs increased from 26 to 47.
- Articulation
agreements coordinating curriculum and/or admissions with an undergraduate
college and/or a high school increased from 3 to 59 (62).
Further, this
project helped increase diversity in medical schools. When the program
began in 1991, a total of 1,584 underrepresented minorities (URMs)
matriculated in medical school, and in 1994, that number had increased
to 2,024. Further, surveys from the 125 U.S. allopathic medical schools
indicate that, between 1990 and 1995, the number of postbaccalaureate
programs increased from 26 to 47; and "articulation agreements coordinating
curriculum and/or admissions with an undergraduate college and/or
a high school increased from 3 to 59" (62).
Lumina Foundation Programs
The Lumina Foundation
offers assistance to increase opportunities for minorities in undergraduate
colleges and universities. Among the Lumina Foundation's 2003 projects
are many that enhance the pipeline to medical school:
- The Council
of Independent Colleges received a $67,300 grant to commission a
collection of essays from college presidents discussing effective
ways to recruit and educate disadvantaged students.
- A $329,100
grant was awarded to Berea College to study the relationship between
"labor, work and service in student persistence and success."
- Brevard College
received $1.4 million to support "Hallmarks of Excellence in the
First College Year," a program that seeks to "establish standards
for success in first-year programs" and to design an evaluative
process for colleges to reach those standards.
- The National
College Access Network, which identifies successful college access
programs and establishes a "national blueprint" for similar programs,
was awarded $124,500.
- The American
Association for Higher Education received $4,515,200 to improve
academic achievement for African American, Hispanic/Latino, and
Native American students attending institutions that serve minorities.
These institutions will use information from the National Survey
of Student Engagement to enhance teaching, curricula, and learning
environments for improving those students' academic success.
- The American
Association of Community Colleges was awarded $305,200 to help community
college students complete baccalaureate degrees.
- The Indiana
Humanities Council was awarded $436,300 to test a family-intervention
program addressing the "college-going behavior of low-income and
first-generation students and students of color."
- The Regents
of the University of California received $250,000 "to document the
relationship between access program intervention and success in
college."
- Indiana University
and Purdue University were awarded $100,000 for programs aiming
to increase the success of African American and Latino freshmen
in introductory courses.
- Purdue University
won a $100,000 grant for a "multicultural learning" communities
project and for evaluation of its success in increasing the persistence
of participating students.
- The Trustees
of Indiana University received a $100,000 grant to enhance student
success through engaging first-generation students in "service learning"
projects in introductory courses.
- A $100,000
grant was awarded to the University of Notre Dame to increase student
persistence by creating intensive interactive learning in an introductory
genetics class. The program emphasizes historically underserved
students (63).
Health Careers Opportunity
Program
The Health Resources
and Services Administration's (HRSA's) Health Careers Opportunity
Program (HCOP) provides assistance to disadvantaged students to help
them enter and graduate from a health or allied health professions
school. Grants are available to allopathic and osteopathic schools
of medicine, allied health programs, and public or private nonprofit
health and educational organizations. To meet HCOP objectives, grantees
must conduct the following activities:
- Recruit disadvantaged
individuals.
- Facilitate
entry of disadvantaged individuals.
- Provide counseling,
mentoring, and other services.
- Disseminate
financial aid information.
- Expose students
to primary health care in public or private community-based facilities.
- Partner with
other institutions of higher education, school districts, and other
community-based organizations to develop a more competitive applicant
pool.
Grantees are expected
to take a "comprehensive approach" that includes formal partnerships
with a network of entities working together in a geographic region.
The partnership plan must include a health or allied health program,
an undergraduate institution, school districts, a community-based
organization, formal signed agreements, and activities fostering cultural
competence. The HCOP provided approximately $1.58 million to support
five 3-year grants at an average of $316,000 per year (80).
Centers of Excellence
HRSA's Centers
of Excellence program helps fund centers of excellence in health professions
education for minority students. Schools of medicine, dentistry, pharmacy,
and graduate programs in behavioral or mental health are eligible
for support for 3-year projects. The grants support the enhancement
of diversity in the health professions through six legislative requirements
that applicants must address:
- Creating a
competitive applicant pool
- Improving academic
performance
- Supporting
faculty development to train, recruit, and retain URM faculty
- Attending to
minority health issues in clinical training, curricula, and information
resources
- Supporting
faculty and student research in minority health
- Providing community-based
training in clinics serving large numbers of minority patients
Grants may also
be used to provide stipends for minority students underrepresented
in the health professions (81).
Centers of Excellence
may have four designations: Historically Black Colleges and Universities
(HBCUs), Hispanic Centers of Excellence, Native American Centers of
Excellence, and "Other" Centers of Excellence, which must enroll URMs
at rates above the National average. The Hispanic and Native American
Centers of Excellence are required to form alliances with other community-based
organizations that serve those minorities or to partner with other
institutions of higher education that have high enrollments of those
minority groups. The HBCUs and the "Other" Centers of Excellence are
encouraged to partner with appropriate entities to conduct program
activities. The Centers of Excellence program provides approximately
$15.2 million in FY 2003 for 10 grants, each an estimated $640,000
annually, to help fund programs of excellence in health professions
education for minority students (81).
Health Professions Partnerships
Initiative
Grants from the
Robert Wood Johnson Foundation and the W.K. Kellogg Foundation helped
create the Health Professions Partnerships Initiative (HPPI), an AAMC
initiative to increase the participation of URM students, especially
African Americans, Hispanics, and Native Americans, in health professions
schools. The initiative develops educational partnerships and early
intervention programs among medical schools, other health professions
schools, undergraduate colleges, and K-12 schools with the intent
of improving students' academic performance and developing their interest
in health careers (32).
Minority Medical Education
Program
The Minority Medical
Education Program (MMEP) is a pipeline initiative sponsored by the
AAMC and funded by the Robert Wood Johnson Foundation to facilitate
the admission of promising minority students into medical schools
by providing an intensive 6-week enrichment summer program. The success
of the program is indicated by the admission of 63 percent of participants
into medical school. Eleven medical schools conduct the MMEP:
- University
of Alabama School of Medicine
- Baylor College
of Medicine and Rice University
- Case Western
Reserve University School of Medicine
- Chicago Summer
Science Enrichment Program
- Columbia University
College of Physicians and Surgeons
- Duke University
School of Medicine
- Fisk University
and Vanderbilt University Medical Center (The College Fund/UNCF
Summer Premedical Institute at Fisk University and Vanderbilt University
Medical Center)
- New Jersey
Medical School
- University
of Virginia School of Medicine
- Western Consortium
(University of Washington School of Medicine and the University
of Arizona College of Medicine)
- Yale University
School of Medicine (64)
University of California,
Davis, Postbaccalaureate Program
A replicable 10-week
summer postbaccalaureate program to assist disadvantaged students,
including URM Californians who were rejected by all medical schools
to which they applied, has been established at the University of California,
Davis (UC-Davis) . The program targets those students likely to practice
in medically underserved communities or among disadvantaged populations.
The curriculum addresses study skills, test-taking skills, Medical
College Admission Test (MCAT) and math review, and critical reasoning
and problem-solving skills. Students also identify their two weakest
areas on the MCAT and work on those topics in review sessions. Participants
take the Summer MCAT exams and confer with a counselor regarding their
progress. They then enroll at UC-Davis for the next academic year
as limited-status students taking courses uniquely suited to each
student's needs. The program has improved students' MCAT scores, and
from 1991-1999, 104 of the 115 participants were accepted by various
medical programs, 93 of which were major U.S. medical schools (65).
Southern Illinois University's
Medical/Dental Education Preparatory Program
The Medical/Dental
Education Preparatory Program of the Southern Illinois University
(SIU) School of Medicine has provided a yearlong academic preparation
course for more than 1,000 minority and disadvantaged students since
1972. Of current students, 95 percent are URMs. During its history,
68 percent of students have been accepted into professional schools,
92 percent of which were medical schools. The core curriculum focuses
on basic chemistry, physics, and biology along with more advanced
science courses. Students also improve reading, writing, test-taking,
and interview skills. After completing the core curriculum, students
take advanced premedical courses at the SIU Carbondale campus. The
program is funded through State allocations and Federal grants (66).
University of Michigan's
Postbaccalaureate Pre-medical Fellowship Program
The University
of Michigan's Postbaccalaureate Premedical Fellowship Program (UM-PB)
is a yearlong academic enrichment program that provides opportunities
for enhancing the academic preparation of those desiring to matriculate
in medical school. Program participants must be either URMs or disadvantaged
persons. The success of the program was evaluated by examining the
academic outcomes of enrolled students at the University of Michigan
Medical School from 1993-1996. Of these students, 15 had completed
the UM-PB, 58 had finished postbaccalaureate work elsewhere, and 443
were traditional medical school students. The traditional students
had significantly higher GPA's than the other two groups, and the
UM-PB students had lower scores on the MCAT exam than the other groups.
However, both postbaccalaureate groups demonstrated competency in
the first year of medical school coursework consistent with the traditional
students (67).
University of North Carolina's
Medical Education Development Program
The Medical Education
Development Program (MEDP), a joint program of the University of North
Car-olina's medical and dental schools, is an intensive 9-week program
for URMs and economically disadvantaged students who have shown potential
to complete medical or dental school. A follow-up study of 371 participants
in the program between 1980 and 1989 revealed that 76 percent were
accepted into medical school, and 88 percent of those graduated from
medical school. The acceptance rate of the MEDP URM participants was
significantly higher than the National acceptance rates for both URMs
and non-URMs (68).
University of Illinois
at Chicago College of Medicine's Program for At-Risk Students
Eighty-nine URMs
who matriculated in the University of Illinois at Chicago College
of Medicine as "at-risk" students were studied to determine the influence
that advisors or mentors may have had on them. "At risk" was defined
as likely to experience academic difficulty. These students were later
classified either as "no delay" (having passed all courses as well
as Step 1 and Step 2 of the USMLE) or as "de-lay/withdrawn." Twenty
students from each of these groups were randomly selected, and those
agreeing to participate were interviewed about their mentors. Of the
nine "no delay" respondents, seven had physician mentors, and two
had no mentors. Of the 13 "delay/withdrawn" respondents, three had
physician mentors, five had other mentors, and five had no mentors.
Although conclusions were inconsistent, those who had physician mentors
experienced less academic difficulty (69).
University of Rochester
School of Medicine's Medical Student Mentoring Program
The Medical Student
Mentoring Program at the University of Rochester School of Medicine
was funded by the New York State Department of Health in response
to the needs of URM and non-URM faculty to help facilitate the success
of URMs in medical school. The program was conducted during the 1995-1996
and 1996-1997 academic years. Of the 28 URM students in the first-
and second-year classes, 23 were assigned a mentor, and 21 met with
their mentors at least once. Mentors attended two mentor development
workshops. Students were invited to attend monthly discussion meetings
or "reflection groups" at which URM faculty, residents, and advanced
students shared their experiences as minorities. An average of eight
students attended each meeting. The program was evaluated by surveys
of both mentors and URM students. Of the 23 students in the first
cohort, 16 (70 percent) completed the survey, and 11 (73 percent)
of the 15 mentors replied to the survey. Twelve of the students evaluated
the reflection groups and had attended an average of six sessions.
Using a scale of 1 (not at all valuable) to 7 (very valuable), students'
assessment resulted in a mean score of 4.2
for the overall value of the meetings, 5.0 for valuable insights from
faculty presentations, 4.9 for discussions during faculty presentations,
and 4.8 for discussions during clinical students' presentations. The
lowest mean score was 3.8 for helpfulness in handling racial or cultural
bias, a rating that prompted a shift in emphasis of discussions the
following year. Students met with mentors an average of three times
during the academic year. Mentors stated that they had discussed a
range of topics, including racial issues, with some success, and students
considered mentors' "openness and honesty as critical factors in facilitating
discussion of this potentially sensitive issue" (70).
University of Virginia's
Medical Academic Advancement Program
To increase its
minority and disadvantaged medical school matriculants, the University
of Virginia created the Medical Academic Advancement Program, a 6-week
summer residential program enrolling approximately 130 students annually
in a program designed to help prepare students for the MCAT exams.
The program has admission requirements, including a minimum 3.0 GPA,
and uses lectures, problem solving, simulated MCAT examinations, and
small-group activities such as clinical visits. Between 1984 and 1999,
of the 1,497 participants, 80 had graduated from the University of
Virginia School of Medicine, and 174 were currently attending the
medical school (71).
University of Illinois
at Chicago's Urban Health Program
The Urban Health
Program at the University of Illinois at Chicago attempts to increase
the number of URMs who graduate from the College of Medicine. The
program has four goals: "1) identify a potential qualified pool of
minority students and nurture . . . [them], 2) increase the acceptance
and enrollment rates for qualified minority students, 3) . . . facilitate
the graduation of qualified minority students, and 4) train . . .
culturally sensitive physicians dedicated to health care delivery
in medically underserved areas." The program uses the AAMC's MedMAR
list to identify Illinois students taking the MCAT and recruits them
for application. It monitors the application process and provides
an "open house" to promote the school to URMs. Upon admission, a pre-matriculation
program helps prepare them for the rigors of medical school, and additional
academic support is offered in the form of small group review sessions
and preparation for the USMLE Step 1 and Step 2. The program's success
is indicated by the 695 URMs who matriculated between 1989 and 1998
with a 90 percent retention rate (72).
East Carolina University
School of Medicine's Summer Program for Future Doctors
The Summer Program
for Future Doctors at East Carolina University School of Medicine
helps URMs and disadvantaged students prepare for entry into medical
school. The program admits as many as 24 students into an intensive
8-week summer program that focuses on science instruction, MCAT preparation,
learning skills, and communication and writing skills. From 1994-1997,
the program had 69 participants, 51 of whom applied to medical school.
Twenty-four of these were accepted, and 17 of this group were URMs.
Twelve other participants chose other health professions (73).
University of Michigan
School of Medicine's Academic Support Program
The University
of Michigan's School of Medicine has created an Academic Support Program
designed to intervene when a student has academic difficulties. Referrals
into the program may come from the student, academic advisor, or faculty
member. Reasons for intervention include failed academic coursework
or failure of Step 1 of the USMLE exam. Once a student is referred,
an assessment is conducted at the Office of Services for Students
with Disabilities. The student is interviewed by a clinical psychologist,
completes behavioral screening checklists, and sometimes takes an
academic achievement test. Action is recommended based on the evaluation.
The student is sometimes referred to other agencies within the university,
such as the University Health Center, and ultimately referred back
to the medical school for academic support. During 1994-1998, 28 students,
24 of whom were URMs, were referred to the program. The difficulties
arose during either the first year in coursework or the third year
with the USMLE testing. Of the 28 students, 26 either graduated or
continued progress with their studies. None received probation again.
Two discontinued the program for academic reasons (74).
Ohio University College
of Osteopathic Medicine Programs
The Ohio University
College of Osteopathic Medicine has one of the strongest minority
representations of all osteopathic medical schools. Enrollment of
URMs increased from 11 percent in 1982-1983 to 23 percent in 1997-1998.
The College has six programs that support minority students in undergraduate
school and medical school. The Summer Scholars Program seeks to strengthen
the academic preparation of URMs for medical school admission. Of
the 210 students who participated by 1998, 78 had matriculated in
the medical school, and 33 had graduated. The Academic Enrichment
Program assists matriculating students with issues ranging from academic
difficulties to financial aid. Approximately 22 students per class
participate. The Prematriculation Program enrolls students admitted
to the medical school and helps them prepare for their first year.
In 1998-1999, all but 6 of the 28 eligible students participated.
Program Ex-CEL supports URMs at Ohio University to enhance their academic
preparation and increase interest in going to medical school. The
Summer Enrichment Program is an optional 6-week program to assists
URMs who plan to study premed at Ohio University. The Postbaccalaureate
Program provides academic enrichment for students who have applied
to medical school but were not admitted. Each program targets a different
group, but all attempt to increase the number of URM physicians (75).
Wayne State University's
Postbaccalaureate Program
The first postbaccalaureate
program in the Nation was created in 1969 at Wayne State University
specifically to assist African American students who had applied but
failed to be admitted to medical school. Students were guaranteed
admission to the medical school if they maintained a B average as
a postbaccalaureate student. The yearlong program has evolved as successes
and failures have been analyzed. Participants take courses in inorganic
chemistry, biochemistry, and other sciences and also improve their
academic skills. By 1997, the medical school had graduated 493 African
American students, 30 percent of which (160 students) had entered
the program through the postbaccalaureate program (76).
University of South Florida
College of Medicine's Summer Pre-Matriculation Program
The University
of South Florida College of Medicine initiated the Summer Pre-Matriculation
Program (SPP) in response to the academic difficulties experienced
by URMs entering in 1995. Of 13 matriculating URMs, 6 failed at least
one course in the first semester. All URMs of the 1997 entering class
were encouraged to attend, and all entering students were eligible.
Of the 14 participating students, 5 were URMs. After the first semester,
all but one SPP student received a B or better in gross anatomy, compared
to 80 percent of the class as a whole. The one student received a
C, whereas 17 percent of the class received a C and two failed. In
biochemistry, both the SPP and class average was 87. Again, all but
one SPP student received a B or better, and the one student received
a C. In human embryology, all but two SPP students received a B or
better, and the two made a C, whereas 37 percent of the class received
a C and two failed. The program seeks to strengthen the academic preparation
of students so that they can successfully navigate their first year
of medical school (77).
University of Medicine
and Dentistry—New Jersey Medical School Programs
The University
of Medicine and Dentistry—New Jersey Medical School has 11 different
programs to increase the number of URMs entering medical school, several
of which target students from eighth through twelfth grades. Programs
exist for academic enrichment and promotion of interest in health
careers for levels extending from the eighth grade to first-year medical
and dental students. In addition, a Saturday Science Academy is open
to students from eighth through twelfth grades. Two programs target
Hispanic students, the Hispanic Center of Excellence Summer Youth
Program and Infomed, which offer informational seminars and monthly
workshops to help Hispanic students improve their chances of success
in medicine and health professions. Undergraduates have an opportunity
to participate in the Students for Medicine and Dentistry Program
to enhance academic and non-academic skills, and first-year medical
students make the transition between undergraduate school and medical
or dental school with the assistance of the Freshman Introduction
to Resources, Skills, and Training course. From 1972-1998, a total
of 1,722 students were involved in the pre-college programs; 1,875
participated in the college programs, and 683 participants attended
the pre-matriculation programs (78).
Other Precollege Programs
A 1998 article
discusses 27 precollege programs seeking to increase diversity in
medicine. These programs are classified by five characteristics:
- "Academic enhancement":
programs that enhance students' academic skills
- "Motivation":
programs that encourage students to consider a medical career
- "Mentorship":
programs that provide students with a mentor in a medical student,
physician, or other health care worker
- "Research apprenticeship":
programs that offer students laboratory research experience
- "Academic partnership":
alliances between medical schools and school systems to improve
students' prospects for success in health careers
Of the 27 programs
described in the article, most are academic enhancement programs.
Evaluation is an important component of any program, and only 12 of
the 27 programs had evaluation components. Further, only five programs
attempted to assess the quality of the program using formative research
methods such as pre- and post-test scores. A lack of comparison or
control groups also limited conclusions about causal effects of these
programs (79).
COLLABORATIVE PROGRAMS
The AAMC's Health Professions
Partnerships Initiative
Grants from the
Robert Wood Johnson Foundation and the W.K. Kellogg Foundation helped
create the Health Professions Partnerships Initiative (HPPI), an AAMC
initiative to increase the participation of URM students, especially
African Americans, Hispanics, and Native Americans, in health professions
schools. The initiative develops educational partnerships and early
intervention programs among medical schools, other health professions
schools, undergraduate colleges, and K-12 schools with the intent
of improving students' academic performance and developing their interest
in health careers (32).
The AAMC has published
Learning from Others, a literature review of HIPPI partnerships
and guide to forming partnerships to enhance academic opportunities
for URMs (106). Another study assessing the qualities of successful
HIPPI programs revealed the following criteria as predictive of successful
HIPPI collaborations:
- "Vision and
commitment to community"
- "Willingness
to listen to partners and respect them"
- "Leaders and
staff who foster the program through commitment and consistency"
- "Prior experience
in diversity programs"
Characteristics
of school districts and individual schools involved in successful
partnerships include the following:
- "Vision and
leadership"
- "Selection
of strong schools"
- "Support of
teachers"
- "Strategies
to involve parents and families"
The study concludes
that more research is needed to show that successful partnerships
lead to successful educational practices that support the pipeline
to health professions education (86).
Medical College of Georgia's
Health Science Learning Academy
A Health Professions
Partnership Initiative at the Medical College of Georgia's (MCG's)
Schools of Medicine and Nursing has created an alliance consisting
of the College, two Augusta high schools attended primarily by URMs,
three HBCUs, the Fort Discovery National Science Center of Augusta,
community service organizations, and MCG student organizations. The
high school science program, called the Health Science Learning Academy
(HSLA), seeks to enhance students' academic preparation and interest
in science and health. The HSLA began with ninth graders and expanded
during its second year to include ninth through twelfth graders. Enrichment
classes, offered for 3 hours on 18 Saturday mornings during the academic
year, include work in SAT preparation, English composition, math,
and biology. Since its inception in 1996-1997, 203 students have participated,
and the 38 students who completed all 4 years have enrolled in college.
The mean SAT score for those students was 1,066, compared to the mean
of 923 for all college-bound students at the participating high schools
(82).
Southern Illinois University's
Summer Programs
Southern Illinois
University offers two summer programs to pre-college minority and
disadvantaged students. The Health/Science Careers Pathway (HSCP)
Program provides high school minority students opportunities to increase
their awareness and interest in health and science professions. The
Summer Research Apprenticeship Program matches disadvantaged high
school students with faculty mentors in a research laboratory. Students
learn lab safety, conduct hands-on research, collect data, and produce
and present a research paper. A Science on Saturday program was also
initiated for middle school students who received tutoring from students
in the MEDPREP program, a postbaccalaureate preparation program to
facilitate admission to medical school (66).
Baylor College of Medicine
and University of Texas-Pan American's Premedical Honors College
Baylor College
of Medicine (BCM), together with and the University of Texas-Pan American
(UT-PA), has created the Premedical Honors College (PHC), a combined
Bachelor of Science-Medical Doctor (B.S.-M.D.) program that seeks
to increase the number of physicians providing care to Tex-as's underserved
communities. Since its beginnings in 1994, the program has had 159
matriculants and 71 graduates, and 60 of these have matriculated in
medical school. By comparison, in 1994, only four students from all
five South Texas colleges (30,000 students) were accepted into medical
school.
The Texas legislature
has acknowledged the program's success and has passed a bill to replicate
the program in the Joint Admission Medical Program (JAMP). PHC students
are 95 percent Mexican American, indicating that, as of 2001, the
PHC produced over 40 percent of the 386 Mexican American medical school
matriculants nationwide.
The program targets
13 South Texas counties, all of which are designated as medically
underserved, and 11 of which are designated health professions shortage
areas. The program is open to all high school students, who, upon
acceptance into the program, attend college at UT-PA and receive conditional
acceptance to BCM. The students must meet certain requirements, such
as maintaining an overall GPA of 3.2 and a science GPA of 3.0. In
addition to coursework, they receive tutoring and support services,
enrichment activities, clinical activities, and mentoring. They also
attend summer enrichment programs throughout their college years.
Since the program's initiation, declared premed majors at UT-PA have
doubled, and graduates matriculating in medical school have increased
seven-fold (83).
Ohio State University's
Young Scholars Program
The Young Scholars
Program seeks to motivate URMs and disadvantaged youth of Ohio to
enroll in post-secondary school. Students are nominated for the program
when they are in the sixth grade, when students and parents sign a
contract that promises admission into Ohio State University as a freshman
and a loan-free financial aid package that stipulates a GPA requirement
of 2.0 or better to maintain the assistance. Students must participate
in year-round and summer activities, complete college preparation
courses, and maintain a minimum 3.0 GPA in high school. Participants
attend the University's Summer Institute for 1 to 3 weeks to complete
coursework and career exploration. The first group of Young Scholars
enrolled in 1994. After 2 academic years, their retention rate was
72 percent. The rate for the campus as a whole was 70 percent. A comparison
group adjusted for family income, race, gender, and high school GPA
had a retention rate of 62 percent (84).
University of Washington
School of Medicine's Washington, Wyoming, Alaska, Montana, Idaho Program
The Washington,
Wyoming, Alaska, Montana, Idaho (WWAMI) program, which provides regional
medical education for States nearest to the University of Washington
School of Medicine, attempts to increase primary care physicians in
this largely rural and underserved region. The program has established
collaborative programs with K-12 and undergraduate students to enhance
recruitment of students. The Minority Medical Education Program allows
students to come to the University of Washington campus every summer
for 6 weeks of science courses, health care lectures, MCAT preparation,
and information about application and admission to medical school.
The Medical Scholars Program began outreach work with students from
rural areas and from URM groups. This program promotes health careers
through "a week-long immersion in medicine'." Further, Federal grant
funds and matching funds from the University developed enrichment
courses for high school minority, disadvantaged, and rural students.
The University of Washington is also a designated Center of Excellence
for Native Americans and recruits this URM group into health care
careers, conducts research in Native American health issues, and provides
faculty development for Native American physicians (85).
Four Directions Summer
Research Project
The Four Directions
Summer Research Project is a summer program designed for Native American
undergraduate students to perform research at Harvard Medical School.
The program is designed and run by Native American physicians and
medical students within the Harvard Medical community. The program,
which has had over 75 participants in 10 years of existence, seeks
applicants interested in improving the health status of Native Americans
(87).
University of Minnesota's
Native Americans into Medicine Programs
Native Americans
into Medicine is a 6-week summer enrichment program of the Center
of American Indian and Minority Health at the University of Minnesota
(UM). Open to college students or high school graduates preparing
to enter college, the program provides a curriculum in introductory
science courses like anatomy and microbiology and allows students
to explore careers in medicine and health (88). The UM INMED program
is a summer Preceptorship open to students who are at least 14 years
old and who are planning to enroll in post-secondary education. It
is a 4- to 6-week program in which students work with health care
providers and gain an overview of Native American health from the
provider's perspective (89).
University of Louisville
School of Medicine's Professional Education Preparation Program
The University
of Louisville School of Medicine started activities to increase minority
matriculation as early as 1981 through the Professional Education
Preparation Program, enhanced in 1996 by a Health Professions Partnership
(HPP) grant. In this program, the medical school has increased its
partnership with the Jefferson County Public Schools, which educates
large numbers of African American students. Partner Schools in this
county participate in the Comprehensive Partnership for Minority Student
Achievement, an NSF project that focuses on science and math preparation
for URM students. The HPP enhances science education across the continuum,
including math and chemistry instruction at the high school level.
HPP students attend a summer enrichment program before they enter
undergraduate school. When students prepare to take the MCAT exam,
they participate in the MCAT Undergraduate Training Conference. All
URM students are invited to participate in a prematriculation program
during the summer before their medical school coursework begins. They
can also participate in a structured preparation course for the USMLE
Step 1 exam (90).
Colorado Medical Explorers
Program
Manual High School
in Colorado, a school with a high minority population, reformed its
science education curriculum with assistance from the University of
Colorado's Health Sciences Center. This partnership promotes science
education and has components to stimulate interest in science and
careers in medicine. The Medical Explorers program provides ninth
graders with a weekly yearlong experience in science and health. All
students are invited to participate, and in its first year, the program
had 16 applicants. In addition, sixth graders have an opportunity
to do hands-on activities during 10 yearly outreach trips. This medical
partnership promotes science education and "a rich diversity of students
who pursue careers in medicine" (91).
Boston University School
of Medicine's CityLab
CityLab, a centralized
biotechnology learning laboratory at the Boston University School
of Medicine, assists in promoting science education for students and
teachers in Boston area junior high and high schools. Funded by NIH,
the lab's goal is to provide students with first-hand experience in
science. Students working in the lab learn that they can understand
science and pursue careers in science and health. Able to accommodate
200 students weekly, CityLab served 16,000 students and 1,200 teachers
between 1992 and 1999. Some teachers have even started CityLab satellites
at their own schools. Students and teachers have responded positively
to CityLab, and satellites have been replicated across the U.S. (92).
University of California,
San Francisco's Medteach Program
Medteach, a partnership
of the University of California, San Francisco (UCSF), and San Francisco's
public middle schools, is a program in which three to five volunteer
first-year medical students teach lessons on biology and health to
assigned classes 10 to 12 times during an academic year. Coordinated
by UCSF's Science and Health Education Partnership (SEP), the medical
students align their lessons with the teacher's classroom plans and
receive feedback from the teachers as well as advice from the SEP
staff. The program has been popular, as indicated in the number of
requests by teachers for a Medteach team. The program served approximately
350 sixth graders in 1997-1998. Some key reasons for its success include
a sustained relationship between teachers and medical student teams;
consistency of teams to facilitate small groups; access to materials,
tools, and models; financial support; and a committed SEP coordinator
who provides lesson plans, support, and feedback. Those desiring to
replicate the program should consider the following advice:
- Become familiar
with the local public schools.
- Identify a
committed group of volunteers.
- Seek out resources
for support.
- Visit teachers
and classrooms (93).
New York's Rural Partnership
for Science Education
The Rural Partnership
for Science Education is an alliance of rural students and teachers
in 10 New York State school districts and several New York institutions:
the Research Institute of Bassett Healthcare (an academic medical
center affiliated with the Columbia University College of Physicians
and Surgeons), Hartwick College, the State University of New York
at Oneonta and its biological field station, the Science Discovery
Center in Oneonta, Corning Science Products Division in Oneonta, the
Clark Scholarship Foundation, and the New York Academy of Sciences.
The program is designed to stimulate the interest of students and
teachers in science and to enhance the teaching and learning of science.
One-week summer workshops are offered to approximately 70 teachers
each year. Students from grades three through eight also participate
in weeklong summer exploration camps. Surveys of elementary students
of teachers who have attended Partnership workshops indicate that
these students' rating of science is significantly higher than ratings
of students of non-attendees. Another instrument, the Chil-dren's
Academic Intrinsic Motivation Inventory, measures student motivation
in five areas—general studies, science, reading, math, and social
studies. Partnership schools administered these surveys to seventh
graders each year from 19921996, and results consistently showed that
science had the highest mean score. Further, the program coordinator
visits classrooms during the year to present lessons, and pre- and
post-tests for these lessons show that students move from pre-test
averages of 54-66 percent correct to post-test mean scores of 76-93
percent correct (94).
Louisiana State University
School of Medicine's Enrichment Activities for Minority Youth
The Louisiana
State University (LSU) School of Med-icine's Office of Community and
Minority Health Education, supported by HRSA's Health Careers Opportunity
Program, provides enrichment activities for minority high school students
in the New Orleans area. The initiative includes outreach to science
clubs; "Awareness Days," when health professionals make presentations
and science demonstrations or provide tours of the medical school
or labs; "Competition Day," when students compete in academic skills
events; and an 8-week High School Summer Science Program. Students
must be admitted to the summer program, and 70-118 students have participated
annually since 1990; 90 percent of participants are African American.
Students each have a faculty mentor from the LSU School of Medicine
and, based on the student's interest, is assigned to clinical or basic
science research sites. Students work at the sites for 8 hours Monday
through Thursday and for 4 hours on Friday, when they spend the afternoon
at lectures covering such topics as the admissions process and financial
aid. A 1997-1998 survey of participants from 1985-1997 revealed that
282 of 594 respondents had science or pre-health professions undergraduate
majors, and 31 were enrolled in or had graduated in medicine (95).
John Burns School of Medicine's
Summer Program for the Enhancement of Basic Education
The John Burns
School of Medicine, Hawaii's only medical school, houses the Ho'ola
Post Baccalaureate Program and the Native Hawaiian Center of Excellence,
both funded by HRSA's Division of Disadvantaged Assistance. The center
targets Native Hawaiians in public schools to try to increase their
enrollment in medical school. In 1992, the center initiated a 6-week
Summer Program for the Enhancement of Basic Education, but only one
Native Hawaiian was admitted during the first 3 years because of lack
of competitiveness. With additional funding, six positions were set
aside for Native Hawaiians, who, upon admission, are required to fulfill
the program's academic requirements. After special recruitment of
Native Hawaiians, the six set-aside positions were utilized, and soon
thereafter, Native Hawaiians were admitted into the program through
the regular admissions process. In 1995, 1996, and 1997, eight Native
Hawaiians participated each year. Of the 1995 group, all went to college,
three in pre-med; of the 1996 group, all went to college, five in
pre-med. All members of the 1998 group were attending college at the
time the program was reported; two were planning to major in pre-med.
One received a prestigious Regents Scholarship by the University of
Hawaii at Manoa. The program illustrates the need to develop a pathway
for Native Hawaiians and other URMs as early as elementary school
(96).
Modern Genetics Program
The Modern Genetics
Program is a hands-on science education program conducted through
a partnership of Washington University scientists, "implementation
specialists" at the Mathematics and Science Education Center of the
Cooperating School Districts of St. Louis, project evaluators from
Southern Illinois University at Edwardsville, and high school biology
teachers in St. Louis, Missouri. Participating schools represent diverse
student bodies. Project staff include a part-time scientist, a full-time
implementation specialist, and a half-time evaluator. The implementation
specialist meets weekly with teachers and provides supplies and logistical
support. Teachers and key personnel participate in monthly workshops
and also attend a 2-week summer workshop. Pre- and post-tests that
assessed knowledge and knowledge gains of students indicate that,
in 1995-1996, of 62 biology classes having 1,275 participants, 60
classes showed statistically significant gains. During the following
year, 64 classes having a total of 1,322 students participated, and
all classes showed significant increases in knowledge. All classes
also showed gains in positive attitudes toward science (97).
Baylor College of Medicine's
My Health My World Project
Baylor College
of Medicine's My Health My World Project seeks to improve science
education and to close the achievement gap in science that appears
early in elementary school for URM groups, who were outperformed by
whites and Asians at all grades tested (fourth, eighth, and tenth)
in the 1996 National Assessment of Academic Progress science evaluation.
Modeled on the National Science Education Standards, the project makes
materials available and trains teachers in elementary science education.
The project unit materials are age appropriate and focus on the relationship
of the environment and health. They include "an adventure storybook,
a language arts supplement, a guide to hands-on science activities,
and a colorful mini-magazine, Explorations. . . ." At the time
the program was reported, one project unit had been field tested each
year by over 1,000 students from kindergarten through grade five,
and 1,380 teachers had attended workshops. Teachers' ratings of the
field testing are uniformly high, and when students are asked to draw
or write about something they have learned, 87 percent of students
responded with key content points either in drawings or in writing
(98).
University of California,
Los Angeles, School of Medicine's Interactive Multi-media Exercises
Project
The University
of California, Los Angeles (UCLA), School of Medicine has developed
an Interactive Multi-me-dia Exercises (IMMEX) Project to facilitate
teachers' work in developing students' problem-solving skills. Most
students in the project are in the Los Angeles Unified School District,
an urban educational system with an enrollment of over 800,000 students,
60 percent of whom have limited language proficiency, and 70 percent
are URMs. The goal of IMMEX is to increase students' interest and
achievement in science and math. A 4-week IMMEX Training Institute
brings teachers and UCLA faculty and staff together to create software
that will enable students to gain problem-solving skills. Teachers
receive a stipend to attend and receive unlimited use of the software.
From 1993 to July 1998, 275 teachers from 67 schools participated
in activities. Preliminary testing showed that students who performed
IMMEX problem solving as part of classroom activities scored significantly
better "on an independent test of problem-solving skills" than a class
not exposed to IMMEX problems (99).
West Virginia University's
Health Sciences and Technology Academy
The Health Sciences
and Technology Academy was formed to help increase the number of health
professionals in the State of West Virginia, most of which is rural.
The academy is a partnership among West Virginia University (WVU)
(including the Health Sciences Center, the College of Arts and Sciences,
and the College of Human Resources and Education) and secondary-school
teachers, health care professionals, and other community leaders.
Targeting URMs in high school, the academy sponsors community-based
extracurricular activities and a Summer Institute on the WVU campus.
The institute recruits students to participate in leadership development
and science activities during 1- to 3-week periods during the summer.
Clubs meet during the school year either weekly or bi-weekly, and
secondary science teachers coordinate activities and are a major influence
in academic enrichment for students. Retention of students in the
academy increased from 54 percent to 75 percent from the 1995 group
to the 1996 group. Of the original cohort, 26 students were retained,
and 11 more were recruited to add to this group. At the time the program
was reported, all 37 students had applied and been accepted to college.
Responding to whether the academy had increased their interest in
health careers, approximately 72 percent responded "yes" for each
year's program activities, and 80 percent responded "yes" for the
Summer Institute. The West Virginia Legislature has passed a bill
that will allow tuition and fee waivers for students who complete
the academy (100).
University of Texas at
Houston Health Science Center's Intercon Network
The University
of Texas at Houston (UT-Houston) Health Science Center has partnered
with other post-second-ary institutions throughout Texas, such as
the University of Texas at El Paso, the University of Texas Pan-American,
and Texas Southern University, to increase the enrollment in medicine
of disadvantaged persons, who are often African American or Hispanic
in Texas. In 1998, 108 students from those universities enrolled in
research or professional internships at UT-Houston. The university
has also partnered with inner-city, suburban, and rural K-12 school
districts in an "InterCon" network and conducts a high school science
internship, a professional development program for teachers, a curriculum
development program for high school medical sciences and technologies,
and other innovative programming. The projects to promote science
education in K-12 will help meet the goal of the UT-Houston Health
Sciences Center to recruit more minorities into medicine and the goal
of the Texas Higher Education Coordinating Board to enroll more disadvantaged
Texans in graduate and professional schools (101).
Meharry Medical College's
Health Careers Opportunity Pre-Baccalaureate Program
Meharry Medical
College has had an academic enrichment program to improve the academic
preparation of undergraduate students for medical school since 1969.
In 1997, the Biomedical Sciences Program merged with other programs
and now functions as the Health Careers Opportunity Pre-Baccalaureate
Program. The original program is described as targeting sophomores
and prejuniors to provide them with scientific knowledge to consider
medical and dental training, to facilitate their admission into health
professions programs, to foster awareness of these programs, and to
provide minority role models. Students for the program were recruited
from feeder schools from which most of the matriculating medical students
graduate. Information was mailed to health career advisors at all
HBCUs. Applications included faculty letters of recommendation and
career goals expressed in writing, and program participants had to
have a B average overall and a B in science and math. Pre-tests, post-tests,
and weekly exams were conducted to measure the effect of coursework
on performance. Tracking was used to evaluate long-term effects of
the program. Of 1,025 former participants to whom evaluations were
mailed, 445 (43 percent) responded to the survey. Seventy percent
had applied to professional schools, 83 percent of which were medical
schools, 15 percent were dental schools, and 2 percent were graduate
schools. Of those applying to medical school, 198 (77 percent) were
admitted, and all had graduated. The 46 who applied to dental schools
were all admitted, and all graduated. Of those applying to graduate
schools, all had received Ph.D.'s in biomedical sciences (102).
Trinity College's Consortium
on High Achievement and Success
Trinity College
in Hartford, Connecticut, has joined with over 30 other colleges and
universities to form the Consortium on High Achievement and Success,
a group dedicated to facilitating the success of minority students
at predominantly white college campuses. Trinity College has created
the Barrier Course Project, which provides supplemental instruction
for students struggling in science classes. The program also trains
teachers to provide encouraging feedback, and students also learn
to study and work collaboratively (102).
University of Alabama
at Birmingham School of Medicine's Bridge to Health Care
The Center for
Community Outreach Development at the University of Alabama at Birmingham
School of Medicine has created the Bridge to Health Care, a project
that seeks to increase minority participation in medicine by providing
academic enrichment and laboratory and clinical setting experiences
for fifth-, seventh-, and ninth-grade students in the Birmingham City
Schools. The medical school credits the program's success to the strong
partnership with the school system and also the school's dedication
to the community. For example, students learn about such diseases
as diabetes and sickle cell disease, which affect their own communities
disproportionately. The students are exposed to health information
and to medical career information that can influence their future
(103).
Mount Sinai School of
Medicine's Pre-College Programs
The Mount Sinai
School of Medicine collaborates with the Gateway Institute for Pre-College
Education to encourage students living in the school's New York City
community to attend college and pursue professional careers. The institute
works with 10 high schools, targeting the preparation of minority
and low-income students for professional careers, including science
and medicine. The medical school also provides college preparatory
curriculum to the Queens Gateway to Health Sciences Secondary Schools
and the Life Sciences Secondary School in east Harlem. The program
enables students who may not have high academic qualifications, but
who are highly motivated, to pursue careers in science or health (103).
Doctor's Academy
Sunnyside High
School's "Doctor's Academy" is a program initiated in 1999 by the
Latino Center for Medical Education and Research, which is on the
Fresno campus of the University of California, San Francisco. The
program helps disadvantaged students primarily from minority backgrounds
to get intensive academic preparation for college and, eventually,
medical careers. Students in the academy take an extra class at the
end of the day and focus on college preparatory courses. They also
have after-school, weekend, and summer internships. During the summer
before their senior year, they intern with a physician mentor. The
$1.2 million funneled into the program by the Latino Center comes
from such sources as HRSA grants, California State funds and California
Endowment funds, the AAMC's Health Professions Partnership Initiative,
and W.K. Kellogg Foundation donations. This highly competitive program
graduated its first 32 students in June 2003 (104).
The Leadership Alliance
The Leadership
Alliance, a consortium of 31 U.S. research and teaching academic institutions,
seeks to promote the participation of underserved and underrepresented
students in graduate studies, including doctoral programs, and in
research. The alliance provides educational opportunities through
undergraduate internships and mentoring, graduate support and fellowships,
faculty development opportunities, and research exchanges (231).
Annual Biomedical Research
Conference for Minority Students
The Annual Biomedical
Research Conference for Minority Students is a National conference
that promotes advanced studies in the biomedical sciences to minority
students. The conference is sponsored by The National Institute of
General Medical Sciences, Division of Minority Opportunities in Research
Program, and is managed by the American Society for Microbiology.
At the conference, students participate in scientific sessions, professional
development workshops, and poster sessions and exhibits. The students
also have opportunities to network and to benefit from faculty mentoring
(232).
Footnotes from
Executive Summary
1 On June 26, 2003, the Executive Council
of the Association of American Medical Colleges (AAMC) approved a
new definition for "underrepresented minorities": "those racial anIndividual
medical schools can use this definition to determine population groups
underrepresented in their geographic areas (2).
2 Rates were computed using the data sources
indicated.
3 "Unknown" indicates that race/ethnicity
was not reported.
Footnotes from
Report
1 These expected population trends may
be underestimated. The 2000 census shows retrospectively that earlier
estimates for 2000 have been underestimated by over 6,000,000. New
projections based on 2000 census estimates are currently unavailable.
2Rates
were computed using the data sources indicated.
3
URM data collected for osteopathic medical students include
African Americans, Native Americans, and all students who report an
ethnicity of Hispanic origin.
4
Rates were computed using the data sources indicated.
5
Data collected from Facts and Figures, AAMC. Lois Colburn.
May 11, 2004.
6
These figures include undergraduate debt.
