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Introduction

INSTITUTIONAL AND POLICY-LEVEL STRATEGIES FOR INCREASING THE DIVERSITY OF THE U.S. HEALTH-CARE WORKFORCE

The United States is rapidly transforming into one of the most racially and ethnically diverse nations in the world. Groups commonly referred to as minorities—including Asian Americans, Pacific Islanders, African Americans, Hispanics, American Indians, and Alaska Natives—are the fastest-growing segments of the population and are emerging as the nation’s majority. Since 2000, for example, Hispanics accounted for 3.5 million—or over one-half—of the population increase of 6.9 million individuals in the United States. The number of Asian Americans grew at a larger proportion (9 percent) than any other racial or ethnic group during this same time period. And in at least three states (California, Hawaii, and New Mexico) and the District of Columbia, these groups constitute a majority of the population (U.S. Bureau of the Census, 2003).

Despite the rapid growth of racial and ethnic minority groups in the United States, their representation among the nation’s health professionals has grown only modestly at best over the past 25 years, producing a trend in which the proportion of minorities in the population outstrips their representation among health professionals by several fold.1 Hispanics, for

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This is not meant to imply that racial and ethnic minority patients receive better health care when treated by providers who are of the same race or ethnicity, or that nonminority



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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 1 Introduction INSTITUTIONAL AND POLICY-LEVEL STRATEGIES FOR INCREASING THE DIVERSITY OF THE U.S. HEALTH-CARE WORKFORCE The United States is rapidly transforming into one of the most racially and ethnically diverse nations in the world. Groups commonly referred to as minorities—including Asian Americans, Pacific Islanders, African Americans, Hispanics, American Indians, and Alaska Natives—are the fastest-growing segments of the population and are emerging as the nation’s majority. Since 2000, for example, Hispanics accounted for 3.5 million—or over one-half—of the population increase of 6.9 million individuals in the United States. The number of Asian Americans grew at a larger proportion (9 percent) than any other racial or ethnic group during this same time period. And in at least three states (California, Hawaii, and New Mexico) and the District of Columbia, these groups constitute a majority of the population (U.S. Bureau of the Census, 2003). Despite the rapid growth of racial and ethnic minority groups in the United States, their representation among the nation’s health professionals has grown only modestly at best over the past 25 years, producing a trend in which the proportion of minorities in the population outstrips their representation among health professionals by several fold.1 Hispanics, for 1   This is not meant to imply that racial and ethnic minority patients receive better health care when treated by providers who are of the same race or ethnicity, or that nonminority

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce example, comprise over 12 percent of the U.S population, but only 2 percent of the registered nurse population, 3.4 percent of psychologists, and 3.5 percent of physicians. Similarly, one in eight individuals in the United States is African American, yet less than one in twenty dentists or physicians is African American. These stark figures, in part, have prompted many major health professions organizations and health professions educational institutions (HPEIs) to develop initiatives to increase the proportion of underrepresented minorities (URM)2 in health professions fields. These efforts, however, have met with limited success. To a great extent, efforts to diversify health professions fields have been hampered by gross inequalities in educational opportunity for students of minority racial and ethnic groups. Primary and secondary education for URM students is, on average, far below the quality of education for non-URM students. Proportionately fewer URM students enter higher education than their white or Asian American peers, and an even smaller percentage of these go on to graduate (post-baccalaureate) study. The “supply” of URM students who are well-prepared for higher education and advanced study in health professions fields has therefore suffered. Equally important, however, are efforts to reduce policy-level barriers to URM participation in health professions training, and to increase the institutional “demand” for URM students. For example, several events—including public referenda (i.e., Proposition 209 in California and Initiative 200 in Washington state), judicial decisions (e.g., the Fifth District Court of Appeals finding in Hopwood v. Texas), and lawsuits challenging affirmative action policies in 1995, 1996, and 1997—forced many higher education institutions to abandon the use of race and ethnicity as factors in admissions decisions (in some cases temporarily, in light of the June 2003 Supreme Court decision in Grutter v. Bollinger, in which white plaintiffs sued—unsuccessfully—in an effort to halt the University of Michigan’s admissions policies that consider applicants’ race and ethnicity as one of     providers are less capable than minorities of providing high-quality care to these populations. Rather—as will be discussed later in this chapter and throughout the report—greater racial and ethnic diversity in health professions may offer broad benefits to help improve healthcare access for minorities and improve the cultural competency of all health-care providers and the health systems in which they work. 2   URMs are defined as those racial and ethnic populations that are underrepresented in the heath professions relative to their numbers in the general population. This definition allows individual institutions to define which populations are underrepresented in its area of interest. See the subsection on “Which Racial and Ethnic Groups Are Examined?” later in this chapter for a fuller explanation of this definition.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce many factors in the admissions process3), and to curtail race- and ethnicity-based financial aid. Given these problems—an increasing need for minority health professionals, policy challenges to affirmative action, and little progress toward enhancing the numbers of URM students prepared to enter health professions careers—the W.K. Kellogg Foundation requested a study by the Institute of Medicine to assess institutional and policy-level strategies for achieving greater diversity among health-care professionals. Institutional and policy-level strategies are defined as specific policies or programs of health professions schools, associations, accreditation bodies, health-care organizations/systems, or state and federal governments, designed to increase access to health professions careers among underrepresented racial and ethnic minority groups, as a means of increasing the likelihood that “pipeline” efforts4 to increase diversity will succeed. Specifically, the IOM was asked to: assess and describe potential benefits of greater racial and ethnic diversity among health professionals; assess institutional and policy-level strategies that may increase diversity within the health professions, including: modifying graduate health professions training programs’ admissions practices; increasing the emphasis in health professions program accreditation on enhancing diversity in training programs and developing cross-cultural skills and competencies of health professions trainees; improving the campus “climate” for diversity, including efforts to recruit and support URM students and faculty and facilitate learning within a context of diversity; modifying the financing and funding of health professions training in order to reduce financial barriers to health professions training among minority and lower-income students; and 3   In a landmark decision that resolved over five years of litigation—and an even longer period of contentious national debate—the U.S. Supreme Court ruled in Grutter v. Bollinger et al. that the University of Michigan Law School’s consideration of race and ethnicity as one of many factors in the admissions process was lawful, because the practice was narrowly tailored and did not violate the constitutional rights of nonminority applicants. Perhaps more importantly, the Court declared that the university’s position that achieving a “critical mass” of racial and ethnic diversity in its law school was a compelling interest of the law school and the nation—a rationale that will have far-reaching implications, not just for URM students, but also for the nation as a whole. 4   “Pipeline” efforts refer to strategies that aim to increase the numbers of well-prepared URM students (in grades K-16) motivated to enter health professions fields.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce BOX 1-1 Fast Facts—Diversity and Health Care Nearly one in five Spanish-speaking U.S. residents delayed or refused needed medical care because of language barriers (Robert Wood Johnson Foundation, 2001). Nearly 2 in 5 Latinos, 27 percent of Asian Americans, 23 percent of African Americans, and 16 percent of whites reported communication problems with their doctor (Collins et al., 1999). Nearly half of Asian Americans and Pacific Islanders have problems with availability of mental health services because of limited English proficiency and lack of providers who have appropriate language skills (U.S. Surgeon General, 2001). African Americans, Latinos, and Asian Americans with mental health needs are less likely than whites to receive treatment. If treated, they are likely to have sought help in primary care, as opposed to mental health specialty care, and African Americans are less likely than whites to receive evidence-based mental health care in accordance with professional treatment guidelines (U.S. Surgeon General, 2001). Less than 13 percent of the 8.6 million patients seen in community health centers (CHCs), which primarily serve minority and low-income patients, received preventive and basic dental care in 1998 (Mertz and O’Neill, 2002). About 45 percent of Californians who have low incomes or who have low English proficiency did not receive dental care in the past year (Kaiser Daily Health Policy Report, 2003). An increase of more than 20,000 minority nurses is needed to increase the proportion of minority nurses by just 1 percent (National Advisory Council on Nurse Education and Practice, 2000). considering the application of community benefit principles to improve the accountability of nonprofit, tax exempt institutions (e.g., medical schools and teaching hospitals) to the diverse racial and ethnic communities they serve; and identify mechanisms to garner broad support among health professions leaders, community members, and other key stakeholders to implement these strategies. WHY EXAMINE INSTITUTIONAL AND POLICY-LEVEL STRATEGIES FOR INCREASING DIVERSITY IN HEALTH PROFESSIONS? Historically, the efforts of HPEIs and professional associations to increase the presence of URM students in health professions careers have focused on enhancing students’ preparation to pursue these careers. Appro-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce priately, many of these efforts have focused on improving URM students’ math and science education, particularly at the primary and secondary school levels, “bridging” K-12 training with undergraduate pre-health curricula and graduate training, and other academic and social supports. These programs have achieved some notable successes in a range of health disciplines. The Robert Wood Johnson Foundation-supported Minority Medical Education Program, for example, a 6-week summer intensive medical school preparatory program, has assisted 63 percent of its graduates to gain admission into medical school (Cantor et al., 1998). Institutional and policy-level strategies for increasing diversity in health professions, however, have been relatively understudied. This lack of emphasis may lead to a void of strategies should future policy changes erode efforts to increase diversity (e.g., despite the U.S. Supreme Court decision in the Grutter case reaffirming the use of race/ethnicity in admissions decisions, some opponents of this decision plan to establish ballot initiatives in several states and localities to prohibit higher education institutions from adopting or continuing “race-conscious” admissions policies). As will be discussed in a later chapter (see “Reconceptualizing Admissions Policies and Practices”), “race-neutral” admissions policies, as have been practiced by some states over the past few years, have profoundly changed the land-scape for diversity and have adversely affected health professions’ efforts to increase minority representation in training programs. Failure to address these changes may therefore undercut some of the significant gains achieved by pipeline enhancement programs. This focus is not to diminish the importance of pipeline development efforts. Rather, these strategies should be viewed as complementary. Strategies at the institutional and policy level, in conjunction with pipeline efforts, may have reciprocal effects; for example, the successful development and implementation of institutional and policy-level strategies to increase diversity in health professions may increase the demand for expanded emphasis and investment in pipeline enhancement strategies. WHICH RACIAL AND ETHNIC GROUPS AND HEALTH PROFESSIONS ARE EXAMINED? For purposes of this report, the study committee defines URMs as those racial and ethnic groups that are underrepresented in the heath professions relative to their numbers in the general population. This definition allows individual institutions to define which populations are underrepresented in its area of interest. It is also consistent with the definition of underrepresented minorities recently adopted by the Association of American Medical Colleges (AAMC). Previously, AAMC’s definition was limited to historically disadvantaged groups (i.e., African Americans, mainland Puerto

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Ricans, and Native Americans, including American Indians, Alaska Natives, and Native Hawaiians). The new AAMC definition takes into account the fact that many other groups, such as subpopulations of Asian Americans, Pacific Islanders, and Latinos, are also poorly represented among health professionals, and many in these communities face barriers to accessing appropriate health care. While the study committee defines URMs broadly, it should be noted that the racial and ethnic groups identified in AAMC’s previous definition of URM groups (e.g., African Americans, some Hispanic/Latino groups, American Indians) are historically underrepresented and face long-standing barriers to greater inclusion among health professionals—including persistent discrimination, educational inequality, and few role models for students of these racial and ethnic groups. The persistent underrepresentation of these groups among health professionals suggests that a sustained emphasis on increasing access to health professions careers among historically underrepresented populations is critically important. The study committee recognizes that a broad range of health professionals contribute invaluably to the health-care enterprise. These disciplines—including dental hygienists, pharmacists, allied health professionals, physician assistants, nutritionists, occupational therapists, and clinical social workers, among many others—are critically important to ensuring that America’s health-care systems provide the best quality health care, health promotion, and disease prevention services. This study, however, will focus on medicine, nursing, dentistry, and professional psychology. This is not to suggest that diversity is unimportant or has already been achieved in other health professions. Rather, this study is limited in its scope because a comprehensive analysis of all health-related fields is not feasible given the time frame of the current study. Over 15 million Americans work in over two-dozen health-care and health-related occupations and an even greater array of specialties and subspecialties (Matherlee, this volume), making the task of assessing health workforce trends daunting. In addition, medicine, nursing, dentistry, and professional psychology are among the largest health professions, and the availability and concentration of diverse professionals in these fields will therefore have significant implications for health service delivery. Furthermore, more complete data are available from these fields to evaluate minority participation and diversity efforts. It is the study committee’s expectation that strategies adopted to increase diversity in these fields may be applicable, in some cases, to other health professions.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce WHY IS RACIAL AND ETHNIC DIVERSITY IMPORTANT IN HEALTH PROFESSIONS FIELDS? The U.S. Supreme Court’s review of the University of Michigan admissions lawsuits prompted an avalanche of amicus brief filings from both proponents and opponents of affirmative action and the use of race and ethnicity in university admissions processes. Many of these arguments have been summarized elsewhere, particularly by the plaintiffs’ and defendants’ respective legal counsel (see especially amicus brief filings at the University of Michigan Internet website http://www.umich.edu/~urel/admissions/legal). The weight of scientific evidence, however, supports the necessity of ensuring that health professionals reflect the diversity of the U.S. population. This evidence (summarized below) demonstrates that greater diversity among health professionals is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better patient–clinician communication. In higher education settings, greater diversity is associated with improved student learning and community participation. Indirectly, evidence suggests that greater diversity can improve the cultural competence5 of health professionals and health systems, and that such improvements may be associated with better health-care outcomes. In addition, greater diversity among health professionals has the potential to improve the clinical research enterprise and to lead to new developments and improvements in health care and how care is delivered. Racial and Ethnic Diversity Among Health Professionals and Access to Health Care for Minority Patients Racial and ethnic minority health-care clinicians are significantly more likely than their white peers to serve minority and medically underserved communities, thereby helping to improve problems of limited minority access to care. Several studies document this trend across a range of health professions, although the bulk of this research has focused on the practice patterns of physicians. Turner and Turner (1996), for example, studied the practice characteristics of psychological service providers, using a random sample of psychologists listing the National Register of Health Service Providers. Racial 5   Cultural competence is defined as “a set of behaviors and attitudes and a culture within the business or operation of a system that respects and takes into account the person’s cultural background, cultural beliefs, and their values and incorporates it into the way health care is delivered to that individual” (Betancourt et al., 2002, p.3).

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce and ethnic minority psychologists treated more than twice the proportion of racial and ethnic minority patients than nonminority psychologists (24.0 percent vs. 11.7 percent, respectively), and those psychologists who utilized cognitive/behavioral theoretical orientations saw a larger percentage of minority patients than psychologists who used psychoanalytic or other theoretical orientations. These findings are especially important in light of consistent findings that racial and ethnic minority patients underutilize mental health services (U.S. Surgeon General, 2001). Moy and Bartman (1995), in a nationwide survey of households, found that minority patients were more than four times more likely than white patients to receive health care from nonwhite physicians. Medically indigent patients were also between 1.4 and 2.6 times more likely to receive care from minority physicians than were more affluent patients. In addition, minority physicians tended to see patients who were sicker than the patients seen by their white peers. Minority physicians’ patients were more likely to report being in poor health, with more acute complaints, more chronic conditions, and greater functional limitations. These findings held true even after controlling for physician gender, specialization, workplace, and geographic location. Relative to nonminority communities, minority neighborhoods tend to face shortages of physicians, yet physicians of color are disproportionately more likely to serve in these communities. Komaromy et al. (1996), in a survey of over 1,000 physicians in California, found that African American and Hispanic physicians were five and two times more likely, respectively, than their white peers to practice in communities with high proportions of African American and Hispanic residents. Over half of the patients seen by African American and Hispanic physicians, on average, were members of these clinicians’ racial or ethnic group. Hispanic and black physicians tended to practice in areas with fewer primary care physicians per capita, but even after adjustment for the proportion of minority residents in the communities studied, African American and Hispanic physicians were more likely to care for African American and Hispanic patients, respectively. Similarly, Cantor et al. (1996) found that minority and women physicians, as well as those from lower socioeconomic backgrounds, were disproportionately more likely to serve minority, low-income, and Medicaid populations, even after adjustment for physician specialty, practice setting, and practice location. Racial and ethnic minority dentists are also more likely than their white peers to practice in racial and ethnic minority communities. Solomon, Williams, and Sinkford (2001), in a study of African American and white dentists in Texas, found that a larger percentage of African American dentists practiced in communities with a high residential African American population than white dentists. African American dentists were also found

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce to be more likely to practice in communities characterized by lower levels of education and income than white dentists. Similarly, Mertz and Grumbach (2001), in an assessment of the availability of dental services in California, found that approximately one in five California communities—disproportionately minority, low-income, and rural—have a shortage of dentists and that minority dentists were more likely to practice in minority communities. Diversity and Minority Patient Choice and Satisfaction Minority patients who have a choice are more likely to select clinicians of their own racial or ethnic background. Lopez, Lopez, and Fong (1991), for example, in a study of Mexican-American college students, found that these students expressed a clear preference for ethnically similar mental health counselors or psychotherapists. These findings held among both men and women and among those who had and had not sought counseling. Similarly, Bichsel and Mallinckrodt (2001) surveyed a sample of American Indian women living in the Warm Spring (Oregon) Reservation regarding preferences for mental health counseling and found that respondents expressed preferences for female, ethnically similar counselors who understand and are sensitive to the respondents’ culture. Saha et al. (2000) investigated whether minority patients tend to see physicians of their own race because of convenience (e.g., location) or as a matter of choice. Using data from a national survey of heath-care consumers, the authors found that African American and Hispanic patients who had a choice of clinician were more likely to choose a physician of their own race or ethnicity. Among Hispanic patients, over 40 percent responded that the physician’s ability to speak the patient’s language was a significant consideration in choosing a physician. These associations remained even after controlling for the physician’s office location (e.g., location in a predominantly minority neighborhood). In light of these findings, it is not surprising that racial and ethnic minority patients are generally more satisfied with the care that they receive from minority physicians. Saha et al. (1999), for example, found that African American patients who receive care from physicians of the same race were more likely than African Americans with nonminority clinicians to rate their physicians as excellent in providing health care, in treating them with respect, in explaining their medical problems, in listening to their concerns, and in being accessible. In addition, the investigators found that although Hispanic patients who received care from Hispanic physicians did not rate their doctors as significantly better than Hispanic patients with non-Hispanic health-care clinicians, patients with an ethnically concordant provider were more likely to be satisfied with their overall health care. Similarly, Cooper-Patrick and her colleagues (1999) found that minor-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce ity patients’ ratings of the quality of their health care were generally higher in racially and ethnically concordant than racially and ethnically discordant settings. Using a measure of physicians’ participatory decision-making style, Cooper-Patrick surveyed over 1,800 adults who were seen in 1 of 32 primary care settings by physicians who were either African American (25 percent of the physician sample), white (56 percent), Asian American, (15 percent), or Latino (3 percent). Overall, African American patients rated their visits as significantly less participatory than whites, after adjusting for patient age, gender, education, marital status, health status, and length of the patient–physician relationship. Patients in race- and ethnic-concordant relationships, however, rated their visits as significantly more participatory than patients in race- and ethnic-discordant relationships. In addition, Cooper and Roter have found, through independent ratings of videotaped clinical encounters, that physician visits by African American patients were longer, were characterized by less physician dominance of the discussion, and were more patient-centered when the physician was African American than when the physician was white (Cooper and Roter, 2003). Similarly, LaVeist and Nuru-Jeter (2002) examined predictors of racial concordance between patient and clinician and the effect of race concordance on satisfaction among a sample of white, African American, and Hispanic patients. Among all racial and ethnic groups, patients who reported having at least some choice in selecting a physician were more likely to have a race- or ethnic-concordant physician. Having a race-concordant physician was also associated with higher income for African Americans and not speaking English as a primary language among Hispanics. After adjusting for patients’ age, sex, marital status, income, health insurance status, and whether the respondent reported having a choice in physician, African American patients in race-concordant relationships were found to report higher satisfaction than those African Americans in race-discordant relationships. Furthermore, Hispanic patients in ethnic-concordant relationships reported greater satisfaction than patients from other racial and ethnic groups in similarly concordant relationships. Diversity and Quality of Health Care for Minority Populations Racial and ethnic minorities tend to receive a lower quality of health care than nonminorities. Much of this disparity may be explained by the overrepresentation of some minority groups among the uninsured, given that uninsured and underinsured individuals face greater difficulties in accessing care and are less likely to receive needed services. Yet a large body of research demonstrates that even when insured at the same levels as whites, minority patients receive fewer clinical services and receive a lower

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce quality of care (Institute of Medicine, 2003a). This disparity is apparent across a range of disease areas (e.g., diabetes, cancer, HIV/AIDS) and clinical services, and in a range of clinical settings (e.g., teaching and non-teaching hospitals, public and private clinics). At least some of these disparities may result from aspects of the clinical encounter and attitudes, both conscious and unconscious, of health-care clinicians (Institute of Medicine, 2003a), raising the question of whether greater diversity among health-care professionals may help to mitigate health-care disparities. While no direct link has been established as yet between diversity among health-care clinicians and health outcomes for patients, research indicates that health-care processes and outcomes are influenced by cultural and linguistic barriers that minority clinicians are sometimes able to address. Perez-Stable, Napoles-Springer, and Miramontes (1997), for example, assessed the effects of ethnicity and language concordance between patients and their physicians on health outcomes, use of health services, and clinical outcomes among a sample of Spanish-speaking and non-Spanish-speaking Hispanic and non-Hispanic patients with hypertension or diabetes. Of the 74 Spanish-speaking Latinos, 60 percent were treated by clinicians who spoke Spanish, while 40 percent were treated by non-Spanish-speaking clinicians. After controlling for patient age, gender, education, number of medical problems, and number of prescribed medications, the authors found that having a language-concordant physician was associated with better patient self-reported physical functioning, psychological well-being, health perceptions, and lower pain. In addition, as noted above, some research indicates that minority physicians display better process-of-care behaviors with minority patients than nonminority clinicians (Cooper-Patrick et al., 1999). Hispanic patients display better satisfaction and adherence to treatment plans when their physician not only speaks Spanish, but also shares the same cultural background (Perez-Stable et al., 1997). These “intermediate” outcomes may affect patients’ health care outcomes, in that patient satisfaction is associated with greater patient compliance with treatment regimens, participation in treatment decisions, and use of preventive care services (Betancourt et al., 2002). Diversity and Quality of Training for All Health Professionals Racial and ethnic minority patients, when given a choice, tend to choose health-care clinicians from similar backgrounds, as noted above. But because the proportion of racial and ethnic minority health-care clinicians is low relative to the proportion of racial and ethnic minorities in the general population (see below), it is clear that all health-care professionals must

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 1-6 Distribution of U.S. medical school faculty by race/ethnicity, 1980 to 2001. SOURCE: AAMC Faculty Roster System, December 2001. Reprinted, with permission, from the Association of American Medical Colleges, 2004. Copyright 2004 by AAMC. FIGURE 1-7 U.S. medical school graduates, 2001. SOURCE: AAMC Student Record System, April 2002. Reprinted, with permission, from the Association of American Medical Colleges, 2004. Copyright 2004 by AAMC.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 1-8 Allopathic medical school URM application, acceptance, and matriculation trends. SOURCE: Grumbach et al., 2001. constituted approximately 10 percent of medical graduates in 2001 (Figure 1-7; AAMC, 2002). The majority of these URM students (65 percent) were African American, with smaller percentages of Mexican American students (22.6 percent), mainland Puerto Ricans (6.4 percent), and Native Americans (5.9 percent). Trends from 1980 to 2001 revealed an increase in the number of URM graduates until 1998, with a gradual decline since that year. Trends in URM medical school applicants indicate an increase from the late 1980s to the mid-1990s (Figure 1-8). Since 1996–1997, there has been a steady decline. There were 6,663 URM applicants in 1996. By 2000, the number of applicants decreased to 5,511, which represents a 17 percent decrease. The decline in applicants corresponds to a decline in the number of acceptances and matriculants during the same period of time. Dentists URM Participation in the Dental Workforce As in nursing and medicine, racial and ethnic minorities in dentistry are underrepresented compared to their proportions in the general population. Approximately 13 percent of dentists are nonwhite (Mertz and O’Neil, 2002), and African Americans, American Indians, and Hispanics constitute only 6.8 percent of the dental workforce (see Figure 1-9).

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 1-9 Variations in racial/ethnic representation in dentistry, 1996–1999. SOURCE: Valachovic et al., 2001. Reprinted, with permission, from the American Dental Education Association, 2004. Copyright 2004 by ADEA. URM Participation in Dental Education Among first-year dental students in 1999, 34 percent were nonwhite. Of this percentage, however, less than one-third (10.2 percent of the total student enrollment) were from URM groups. As in medicine, the number of URM matriculants in dentistry has declined in recent years. Matriculants dropped by 23 percent: from 525 in 1989 to 404 in 1999 (Figure 1-10). Other figures indicate a slight increase in the percent of URM graduates since 1999 (Figure 1-11). URM Participation Among Dental School Faculty Trends in the percentage of minority full-time faculty indicate that the number of URM faculty remained low and relatively stable during the 1990s (Figure 1-12). Between 1990 and 1998, the percentage of Native American faculty increased very slightly, from 0.3 percent to 0.6 percent. The percentage of African American faculty hovered around 5 percent during these 8 years and the percentage of Hispanic faculty remained stable at approximately 3 percent.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 1-10 Dental school matriculants. SOURCE: Grumbach et al., 2001. FIGURE 1-11 Underrepresented minority graduates in U.S. dental education programs: Black, Hispanic, Native American. SOURCE: Total Minority Enrollment in U.S. Dental Education Programs, 1997–2003. American Dental Association Survey Center, Surveys of Predoctoral Dental Education. Reprinted, with permission, from American Dental Association, 2004. Copyright 2004 by ADA.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 1-12 Minority full-time faculty in U.S. dental schools. SOURCE: Haden et al., 2000. Reprinted, with permission, from the American Dental Education Association, 2004. Copyright 2004 by ADEA. Psychologists URM Participation in the Psychology Workforce Minority representation in the field of psychology is disproportionately low (Figure 1-13; Rapopor et al., 2000). Among all psychologists, 3.4 percent are African American, 3.4 percent are Hispanic, and 2.2 are Asian/ Pacific Islander. The percentage of American Indian/Alaska Native psychologists is less than 1 percent. URM Participation among Psychology Faculty URMs are similarly underrepresented among faculty in departments of psychology (Figure 1-14). Among full professors, 94.1 percent are white, 1.7 percent are Asian, 2 percent are Hispanic, 1.9 percent are African American, and 0.3 percent are American Indian. Among all tenured professors, 2.5 percent are African American, 2.3 percent Hispanic, and 0.3 percent American Indian. However, URM faculty have slightly higher representation among tenure track professors (5.1 percent black, 4.6 percent Hispanic, and 0.9 percent American Indian). URM Participation in Psychology Graduate Education The percentage of URM graduate students in departments of psychology is greater than percentage of URM faculty. During the 2002–2003 academic year, 7 percent of first-year students in programs that offered a Ph.D. were African American, 6 percent were Hispanic, 1 percent were

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 1-13 Employed doctoral psychologists (percent), 2001. SOURCE: National Science Foundation/Division of Science Resources Statistics, 2001 Survey of Doctorate Recipients. Native American, and 1 percent classified themselves as multiracial (Figure 1-15). Among 2000 graduates from clinical psychology programs, the largest subfield of practitioners, 5 percent were African American, 7 percent were Hispanic, and less than 1 percent were Native American. SUMMARY African Americans, American Indians and Alaska Natives, and many Hispanic/Latino populations are grossly underrepresented among the nation’s physicians, nurses, dentists, and psychologists. These populations also experience generally poorer health status and face greater difficulties in accessing health care. Consequently, many health professions leaders have called for an expansion of efforts to increase diversity among health-care professionals as one means of assisting in the effort to increase access to health care for all populations and to close the health gap between minorities and nonminorities. Recent policy developments, however, have had and may continue to have a significant negative impact on the ability of health professions train-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 1-14 Academic rank of faculty in departments of psychology by race/ ethnicity, 2002–2003. SOURCE: Faculty Salary Survey, 2002–2003. Academic Rank and Tenure Status of Faculty in Graduate Departments of Psychology by Race/Ethnicity, 2002–2003. Reprinted, with permission, from the American Psychological Association, 2004. Copyright 2004 by APA. ing programs and higher education institutions to admit URM students into the health professions training pipeline. The U.S. Supreme Court decision in the Grutter v. Bollinger lawsuit reaffirmed that higher education institutions may consider applicants’ race or ethnicity as one of many factors in admissions decisions. But as a result of public referenda, judicial decisions, and lawsuits challenging affirmative action policies in 1995, 1996, and 1997, many higher education institutions abandoned (in some cases, temporarily) the use of race and ethnicity as factors in admissions decisions. To add to this challenge, significant financial disparities persist between minority and nonminority students, leaving many URM students with fewer financial resources to pursue careers in health professions. It is therefore important to assess whether opportunities exist at the level of higher education institutions, health professions leadership and accrediting bodies, and state and federal policy to reduce barriers to minority participation in health professions. This chapter has presented a review of evidence regarding the impor-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 1-15 Race/ethnicity of newly enrolled students in doctoral departments of psychology, 2002–2003. SOURCE: Graduate Study in Psychology, 2004. Compiled by APA Research Office. Reprinted, with permission, from the American Psychological Association, 2004. Copyright 2004 by APA. tance of diversity in health professions. This evidence demonstrates that greater diversity among health professionals is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better patient–clinician communication. Indirectly, this evidence suggests that greater diversity can improve the cultural competence of health professionals and health systems and that such improvements may be associated with better health-care outcomes. In addition, greater diversity among health professionals has the potential to improve the clinical research enterprise and to lead to new developments and improvements in health care and how care is delivered. Subsequent chapters of this report will explore the potential value of specific institutional and policy-level strategies to increase diversity in the health professions. These strategies include efforts to reconceptualize admissions procedures for health professions education programs, to improve public and private financing of health professions education, to place greater emphasis on faculty and student diversity in program accreditation stan-

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