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).
