Introduction

Achieving a health care workforce that reflects the diversity of the U.S. population is an explicit goal supported by, among others, the Association of American Medical Colleges (AAMC),(1) the American Medical Association (AMA),(2) and the Institute of Medicine.(3, 4) Expanding the workforce of underrepresented minority (URM) physicians has warranted significant attention. URMs have traditionally included African-Americans, Mexican Americans, Native Americans, and mainland Puerto Ricans. Since 2003, the AAMC has defined “underrepresented” as those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.(5) Several racial and ethnic groups, most notably African-Americans, Latinos, and American Indians continue to be significantly underrepresented in the health professions workforce when compared to their representation in the general U.S. population (Table 1).(6)

Several national programs have sought to expand the URM health care workforce. The AAMC sponsored “Project 3000 by 2000” in the 1990s, which aimed to expand the number of URM medical students to a total of 3000 by Year 2000. While the program did not achieve this goal, it did spawn two other programs still administered by the AAMC that aim to expand diversity. The first, the Health Professions Partnership Initiative (supported by the Kellogg Foundation and the Robert Wood Johnson Foundation), involves collaborative relationships between academic medical centers and schools with large minority student populations at the kindergarten through college level. The aim of this program is to provide academic support and to expose these students to the range of professional opportunities in health care. The second program is the Minority Medical Education Program (also sponsored by the Robert Wood Johnson Foundation). This is an intensive 6-week program targeted at minorities who are interested in becoming physicians to be better prepared academically for the rigors of medical school.

The Federal Government also sponsors programs to enhance health care workforce diversity, including the Health Careers Opportunity Program (HCOP), Centers of Excellence (COE), and Minority Faculty Fellowship Programs (MFFP), each administered through the Health Resources and Services Administration's Bureau of Health Professions (BHPr). The HCOP provides grants to programs with the goal of enhancing diversity across a wide range of health care fields. Programs recruit individuals from disadvantaged backgrounds (including, but not restricted to, racial/ethnic minority groups) and provide them with preparatory training, counseling, mentoring, and exposure to community-based primary health care. COE grants to health professional schools support a range of efforts related to recruiting and training minorities, including faculty development, a focus on minority health issues, improvements in academic and clinical training opportunities, and stipends to minority students served by these programs. In addition to COEs for minorities in general, there are also Hispanic COEs and Native American COEs. Finally, MFFP grants are awarded to institutions in an effort to increase the number of minority faculty. Salary support and training to foster skills that maximize the chances of academic success are provided to faculty fellows. In turn, the fellows provide clinical services in underserved communities, and engage in academic pursuits. In addition to these programs with national scope, there are many ongoing local efforts with similar aims.

Despite a paucity of high quality research on the effectiveness of these diversity-related programs, available data suggest that they are successful in enhancing diversity in health professions schools.(7) Nonetheless, there are significant challenges to achieving this goal, and trend data reveal that progress towards greater diversity in most of the health professions is slow (Figure 1). Furthermore, the current political climate has placed diversity programs at risk. The increasing number of lawsuits and ballot initiatives in recent years challenging or rescinding affirmative action policies, sometimes successfully, provides evidence that the general public may no longer be willing to accept at face value policies and programs intended to increase diversity in higher education or in the professional workforce. As such, diversity programs are under increasing pressure to demonstrate their value.

The purpose of this report is to review the evidence base related to the rationale for diversity in the health professions. The strongest such rationale is that a more diverse health care workforce will lead to improvements in public health. We therefore examined the evidence addressing the contention that health professions diversity will lead to improved population health outcomes. Due to widespread disparities in measures of health and health care for racial and ethnic minority and low socioeconomic status populations,(8, 9) it is critical to understand the state of the science supporting the notion that the health of the population is enhanced, either directly or indirectly, when the health professions more accurately reflect the racial, ethnic, and socioeconomic diversity of the population.

Conceptual Framework

There are no studies that definitively address the association between health professions diversity and health outcomes. Specifically, we know of no randomized controlled trials in which patients or communities have been assigned to receive care from a diverse vs. non-diverse group of health professionals and are then followed for clinical outcomes. In the absence of such direct evidence, examining the association between health professions diversity and health outcomes requires analyzing the links in a “chain of logic” connecting workforce diversity to improved health outcomes.

Before searching for evidence, therefore, we developed a conceptual model of how diversity might lead to improved health outcomes (Figure 2). We derived this model from existing frameworks outlining the rationale for health professions diversity,(3, 4, 10-14) and through discussion with experts in the field. It is important to note that some arguments around diversity focus on the effects of a diverse student body on the quality of health professions education. Our framework does not include this potential effect of student body diversity on education but rather focuses on the effects of workforce diversity on public health. We posit four separate pathways through which diversity in the health care workforce might affect health outcomes:

• Service patterns. Greater diversity among health professionals may lead to greater diversity in the geographic locations where health professionals practice and in the populations they serve. Specifically, health professionals from racial and ethnic minority and socioeconomically disadvantaged backgrounds may be more likely than others to serve racial and ethnic minority and socioeconomically disadvantaged populations, who represent a disproportionately large segment of the Nation’s medically underserved. If this were the case, greater health professions diversity would increase access to health care services for underserved populations, which would in turn lead to improved health outcomes.(15-17)
  
• Racial, ethnic, and language concordance. Increasing the number of racial and ethnic minority health professionals would provide greater opportunity for minority patients to see a practitioner from their own racial or ethnic group, or for patients with limited English proficiency, to see a practitioner who speaks their primary language. Racial, ethnic, and language concordance may improve the quality of communication, comfort level, or trust in patient-practitioner relationships and thereby improve partnership and decision making. This may in turn increase adherence to effective programs or regimens, ultimately resulting in improved health outcomes.
  
• Trust in the health care delivery system. Greater diversity in the health care workforce might increase trust in the health care delivery system. Racial and ethnic minority patients, in particular, may distrust health systems and institutions that are managed and staffed by predominantly White health professionals, due to historical segregation and discrimination. If this were the case, increasing diversity might increase minority populations’ trust, and in turn, their propensity to use services at those systems and institutions. This hypothesis is similar to the concordance hypothesis articulated above, though at a system or institutional rather than interpersonal level.
  
• Professional advocacy. Greater diversity among health professionals may broaden the priorities of the health care delivery system. Specifically, health professionals from racial and ethnic minority and socioeconomically disadvantaged backgrounds may be more likely than others to advocate for and implement policies and programs to improve health care for disadvantaged populations. These programs and policies might expand access to health services or improve quality in the delivery of those services. They may also result in greater emphasis and resources devoted to research, advocacy, or service in areas relevant to minority and other disadvantaged populations. Increased access, quality, and attention to issues relevant to minority and other disadvantaged populations would be expected to improve health outcomes for those populations.