Minorities in Medicine...Jose Hawayek, M.D. University of Puerto Rico School of Medicine San Juan, Puerto Rico Gerald Ignace, M.D. Harwood Medical Associates Brookfield, Wisconsin

TWELFTH REPORT OF COGME

COUNCIL ON GRADUATE MEDICAL EDUCATION

Twelfth Report

Minorities in Medicine

M A Y 1 9 9 8



Council on Graduate Medical Education

Twelfth Report

Minorities in Medicine

May 1998

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health ServiceHealth Resources and Services Administration


The views expressed in this document are solely those of theCouncil on Graduate Medical Education and do not

necessarily represent the views of theHealth Resources and Services Administration

nor the U.S. Government.


Table of Contents

List of Tables and Figures ....................................................................................................................... iv

The Council on Graduate Medical Education ...................................................................................... v

Executive Summary ................................................................................................................................. xiImplications of Changing Demographics in the United States .................................................................. xi

The Health Status of Minority Populations ............................................................................................... xiTrends in Minority Participation in Medicine ........................................................................................... xiiPrograms to Increase Minority Representation in Medicine ..................................................................... xii

Recommendations ...................................................................................................................................... xii

Introduction ............................................................................................................................................. 1

Implications of Changing Demographics in the United States .......................................................... 3Who is considered a minority? .................................................................................................................. 3

Implications for cultural competencies in medicine ................................................................................... 4

The Health Status of Minority Populations ......................................................................................... 7Health Status of Black Americans ............................................................................................................. 7Health Status of Hispanic Americans ........................................................................................................ 9Health Status of American Indians/Alaska Natives ................................................................................... 10

Health Status of Asian Pacific Americans ..................................................................................................11Impact of Minority Physicians on Access to Care ..................................................................................... 12

Trends in Minority Participation in Medicine ..................................................................................... 15Allopathic Medical Schools ....................................................................................................................... 15Osteopathic Medical Schools .................................................................................................................... 17

Medical Specialty Interest .......................................................................................................................... 17Career Paths ............................................................................................................................................... 18Medical School Debt ................................................................................................................................. 19

Minority Medical Faculty .......................................................................................................................... 19Future Trends ............................................................................................................................................. 20

Programs to Increase Minority Representation in Medicine ............................................................. 23Federal Programs ....................................................................................................................................... 23Initiatives of the AAMC and Other Non-Governmental Groups .............................................................. 24

Institutional Efforts .................................................................................................................................... 26The Need for a Coordinated National Agenda .......................................................................................... 27Affirmative Action ..................................................................................................................................... 27

Summary .................................................................................................................................................. 29

Recommendations ................................................................................................................................... 31

References ................................................................................................................................................ 35


LIST OF TABLES AND FIGURES

Table 1: Selected Health Indicators by Race/Ethnicity, 1995 ......................................... 8

Table 2: Percent of Medical School Matriculants Expressing an Interest in PrimaryCare by Race/Ethnicity, Selected Years ............................................................ 18

Table 3: Percent of Medical School Graduates Expressing an Interest in Primary Careby Race/Ethnicity, Selected Years ..................................................................... 18

Table 4: Percent of Medical School Graduates Who Completed Primary CarePostgraduate Training by Race/Ethnicity, Selected Years ................................. 18

Table 5: Percent of 1991 Medical School Graduates Expressing Interest in PrimaryCare at Selected Times and Percent Ultimately Trained in Primary Care,by Race/Ethnicity .............................................................................................. 19

Table 6: Change in Numbers and Percents of Faculty Between 1975 and 1995 atU.S. Allopathic Medical Schools by Faculty Race/Ethnicity ............................ 20

Table 7: Estimated Changes in the Number of First-Year GME Residents Required toAttain 218 Physicians per 100,000 Population for 1995 and 2010 ................... 20

Table 8: Federally Sponsored Initiatives to Increase Minority Participation in HealthScience and Medical Careers ............................................................................ 23

Table 9: Efforts by Non-Governmental Bodies to Increase Minorities in Medicine ....... 26

Figure 1: Population Projections by Race and Ethnicity, 2000 - 2050 ............................. 3

Figure 2: Percent Medical School Graduates Planning to Serve in DeprivedAreas, 1984 - 1994 ........................................................................................... 13

Figure 3: Underrepresented Minorities in Allopathic Medical Schools and U.S.Population, 1968 - 1995 ................................................................................... 15

Figure 4: Underrepresented Minority Applicants to Allopathic Medical Schools byRace/Ethnicity, 1990 - 1995.............................................................................. 15

Figure 5: Percent Change in Enrollment From 1990 to 1995 by Race/Ethnicity ............. 16

Figure 6: Underrepresented Minorities in Osteopathic Medical Schools, 1985 - 1995.... 17

Figure 7: Underrepresented Minority Students and Faculty in Allopathic Medical Schools19

Figure 8: Number of Medical Schools With Programs to Expand Minority Participation 25

Figure 9: Underrepresented Minority Matriculants to Allopathic Medical Schools ......... 25


The Council on Graduate Medical Education

The Council on GraduateMedical Education (COGME)was authorized by Congress in 1986

to provide an ongoing assessment of physicianworkforce trends and to recommend appropriatefederal and private sector efforts to addressidentified needs. The legislation calls for COGMEto serve in an advisory capacity to the Secretary ofthe Department of Health and Human Services(DHHS), the Senate Committee on Labor andHuman Resources, and the House of Representa-tives Committee on Commerce. By statute, theCouncil was to terminate on September 30, 1995.It has been extended through the end of FY 1998by appropriations legislation.

The legislation specifies 17 members for theCouncil. Appointed individuals are to includerepresentatives of practicing primary care physi-cians, national and specialty physician organiza-tions, international medical graduates, medicalstudent and house staff associations, schools ofmedicine and osteopathy, public and privateteaching hospitals, health insurers, business, andlabor. Federal representation includes the AssistantSecretary for Health, DHHS; the Administrator ofthe Health Care Financing Administration, DHHS;and the Chief Medical Director of the VeteransAdministration.

Charge to the Council

The charge to COGME is broader than thename would imply. Title VII of the Public HealthService Act, as amended by Public Law 99-272 asamended by Title III of the Health ProfessionsExtension Amendments of 1992, requiredCOGME to provide advice and make recommen-dations to the Secretary and Congress on a widevariety of issues:

1. The supply and distribution of physicians inthe United States.

2. Current and future shortages or excesses ofphysicians in medical and surgical specialtiesand subspecialties.

3. Issues relating to international medical schoolgraduates.

4. Appropriate federal policies with respect tothe matters specified in items 1-3, includingpolicies concerning changes in the financingof undergraduate and graduate medicaleducation (GME) programs and changes in

the types of medical education training inGME programs.

5. Appropriate efforts to be carried out byhospitals, schools of allopathic and osteo-pathic medicine, and accrediting bodies withrespect to the matters specified in items 1 - 3,including efforts for changes in undergraduateand GME programs.

6. Deficiencies and needs for improvements indata bases concerning the supply and distri-bution of, and postgraduate training pro-grams for, physicians in the United States andsteps that should be taken to eliminate thosedeficiencies.

In addition, the Council is to encourageentities providing graduate medical education toconduct activities to voluntarily achieve therecommendations of this Council under item 5above.

COGME ReportsSince its establishment, COGME has

submitted the following reports to the DHHSSecretary and Congress:

• First Report of the Council (1988)• Second Report: The Financial Status of

Teaching Hospitals and theUnderrepresentation of Minorities in Medi-cine (1990)

• Scholar in Residence Report: Reform inMedical Education and Medical Education inthe Ambulatory Setting (1991)

• Third Report: Improving Access to HealthCare Through Physician Workforce Reform:Directions for the 21st Century (1992)

• Fourth Report: Recommendations to ImproveAccess to Health Care Through PhysicianWorkforce Reform (1994)

• Fifth Report: Women and Medicine (1995)• Sixth Report: Managed Health Care: Implica-

tions for the Physician Workforce andMedical Education (1995)

• Seventh Report: Physician WorkforceFunding Recommendations for Department ofHealth and Human Services’ Programs(1995)

• Eighth Report: Patient Care Physician Supplyand Requirements: Testing COGME Recom-mendations (1996)

• Ninth Report: Graduate Medical EducationConsortia: Changing the Governance of


Graduate Medical Education to AchieveWorkforce Objectives (1997)

• Tenth Report: Physician Distribution andHealth Care Challenges in Rural and Inner-City Areas (1998)

• Eleventh Report: International MedicalGraduates, The Physician Workforce andGME Payment Reform (1998)

COGME Research PapersCOGME has recently issued the following

resource papers:• Preparing Learners for Practice in a Managed

Care Environment (September 1997)• International Medical Graduates: Immigra-

tion Law and Policy and the U.S. PhysicianWorkforce (February 1998)


Members, Council on Graduate Medical Education

ChairDavid N. Sundwall, M.D.PresidentAmerican Clinical Laboratory AssociationWashington, D.C.

Vice ChairLawrence U. Haspel, D.O.Senior Vice-PresidentMetropolitan Chicago Health Care CouncilChicago, Illinois

Paul W. Ambrose, M.D.Resident, Dartmouth Family Practice ProgramConcord, New Hampshire

Macaran A. Baird, M.D.Associate Medical Director for Primary CareHealth PartnersBloomington, Minnesota

Regina M. Benjamin, M.D., M.B.A.Family PracticeBayou La Batre, Alabama

JudyAnn Bigby, M.D.Division of General MedicineBrigham and Women’s HospitalBoston, Massachusetts

F. Marian Bishop, Ph.D., M.S.P.H.Professor and Chairman EmeritusDepartment of Family and Preventive MedicineUniversity of Utah School of MedicineSalt Lake City, Utah

Jo Ivey Boufford, M.D.Dean, Robert F. Wagner Graduate School of Public

Service, New York UniversityNew York, New York

Sergio A. Bustamante, M.D.Director, Pediatric Medical EducationChildren’s Regional Hospital at Cooper HospitalCamden, New Jersey

Mr. Richard D. Cordova, M.B.A.Chief Executive Officer, Health Care SystemsSan Francisco General HospitalSan Francisco, California

Ezra C. Davidson, Jr., M.D.Professor, Department of Obstetrics and GynecologyKing/Drew Medical CenterLos Angeles, California

Carl J. Getto, M.D.Dean and Provost, Southern Illinois University

School of MedicineSpringfield, Illinois

Ms. Kylanne GreenSenior ConsultantCoopers and LybrandWashington, D.C.

Ms. Ann KempskiAssistant Director Health PolicyAmerican Federation of State, County and

Municipal EmployeesWashington, D.C.

Designee of the Assistant Secretary for HealthRobert Knouss, M.D.Director Office of Emergency PreparednessHealth Resources and Services AdministrationRockville, Maryland

Designee of the Health Care FinancingAdministration

Ms. Barbara WynnDirector, Plan and Provider Purchasing Policy

GroupCenter for Health Plans and ProvidersHealth Care Financing AdministrationBaltimore, Maryland

Designee of the Department of Veterans AffairsDavid P. Stevens, M.D.Chief Academic Affiliations OfficerDepartment of Veterans AffairsWashington, D.C.

Statutory Members

John Eisenberg, M.D.Acting Assistant Secretary for HealthDepartment of Health and Human ServicesWashington, D.C.

Nancy-Ann Min DeParleAdministrator, Health Care Financing

AdministrationDepartment of Health and Human ServicesBaltimore, Maryland

Kenneth Kizer, M.D., M.P.H.Undersecretary for HealthVeterans Health AdministrationDepartment of Veterans AffairsWashington, D.C.


Minorities in Medicine Work GroupMembers

COGME

JudyAnn Bigby, M.D.Work Group ChairDivision of General MedicineBrigham and Women’s HospitalBoston, Massachusetts

Stuart J. MarylanderVice Chairman, COGMEInformatix, LLCBeverly Hills, California

Eric E. Whitaker, M.D.Former Internal Medicine ResidentUniversity of California at San FranciscoSan Francisco, California

Other Members

Ciriaco Gonzales, Ph.D.Director, Division of Disadvantaged AssistanceBureau of Health Professions, HRSARockville, Maryland

Jose Hawayek, M.D.University of Puerto Rico School of MedicineSan Juan, Puerto Rico

Gerald Ignace, M.D.Harwood Medical AssociatesBrookfield, Wisconsin

Paul Jung, M.D.American Medical Student AssociationReston, Virginia

Erick Munoz, M.D., M.B.A.Associate Dean of Clinical AffairsUniversity of Medicine and Dentistry of New

JerseyNewark, New Jersey

Herbert Nickens, M.D.Vice President, Division of Minority Health,

Disease Prevention and Health PromotionAssociation of American Medical CollegesWashington, D.C.

Eliseo Perez-Stable, M.D.Associate Professor of MedicineDivision of General Internal MedicineUniversity of California, San FranciscoSan Francisco, California

Timothy Ready, Ph.D.Assistant Vice President, Community and

Minority ProgramsAssociation of American Medical CollegesWashington, D.C.

Elena Rios, M.D., M.S.P.H.Medical AdvisorOffice on Womens HealthDepartment of Health and Human ServicesWashington, D.C.

Barbara Ross-Lee, D.O.Dean, Ohio University College of Osteopathic

MedicineAthens, Ohio

Anthony So, M.D., M.P.A.White House Fellow, Office of the SecretaryDepartment of Health and Human ServicesWashington, D.C.

Lois Steele, M.D.Medical Research OfficerIndian Health ServiceTuscon, Arizona

Grace Wang, M.D., M.P.H.Chinatown Medical CenterRoosevelt Island, New York

Tanya Zangaglia, M.D.St. Vincent’s Hospital, AIDS CenterNew York, New York

Retired Members Contributing to TheRecommendations

David A. Kindig, M.D., Ph.D.Past Chair, COGMEProfessor of Preventive MedicineUniversity of Wisconsin, Madison Medical SchoolMadison, Wisconsin

Paul C. Brucker, M.D.President, Thomas Jefferson UniversityPhiladelphia, Pennsylvania

George T. Bryan, M.D.Dean EmeritusUniversity of Texas Medical BranchGalveston, Texas


Jack M. Colwill, M.D.Professor and ChairmanDepartment of Family and CommunityMedicine

University of Missouri-ColumbiaColumbia, Missouri

Peggy Connerton, Ph.D.AFL-CIO Service Employees InternationalUnion

Washington, D.C.

Christine GasicielManager of Health Care PlansGeneral MotorsDetroit, Michigan

Huey Mays, M.D., M.B.A., M.P.H.CEO, American Health EducationAdvancement Decision (AHEAD), Inc.

Philadelphia, Pennsylvania

Elizabeth M. Short, M.D.Associate Chief Medical Director forAcademic Affairs

Department of Veterans AffairsWashington, D.C.

Robert L. Summitt, M.D.Dean, College of MedicineUniversity of Tennessee Health ScienceCenter

Memphis, Tennessee

Modena H. Wilson, M.D., M.P.H.Director, Division General PediatricsJohns Hopkins University School ofMedicine

Baltimore, Maryland

COGME Staff

Enrique S. Fernandez, M.D., M.S.Ed.Executive SecretaryDirector, Division of Medicine

F. Lawrence Clare, M.D., M.P.H.Deputy Executive SecretaryDeputy Chief, Special Projects and DataAnalysis Branch

Division of Medicine

Stanford M. Bastacky, D.M.D.,M.H.S.A.

ChiefSpecial Projects and Data Analysis BranchDivision of Medicine

P. Hannah Davis, M.S.Staff Liaison, Minorities in Medicine IssuesStatistician

C. Howard Davis, Ph.D.Staff Liaison, Medical Credentialing andInternational Medical Graduate Issues

Economist

Paul J. Gilligan, M.H.S.Staff Liaison, Competencies for A NewEnvironment

Jerald M. KatzoffStaff Liaison, Physician Workforce andMedical Education Consortia Issues

Helen K. Lotsikas, M.A.Staff Co-Liaison, Competencies for A NewEnvironment

Health Manpower Education Specialist

John Rodak, M.S. (Hyg.), M.S. (H.S.A.)Staff Liaison, Geographic DistributionIssues

Eva M. StoneCommittee Management Assistant

Velma ProctorSecretary


CONTRIBUTIONS

The Council gratefully acknowledges JudyAnnBigby, M.D., Chair, COGME Work Group on Mi-norities in Medicine, for her leadership in the prepa-ration of this report, David A. Kindig, M.D., Ph.D.,past Chair, COGME, and David N. Sundwall, M.D.,current Chair, COGME, for their informative per-spectives and insights. The Council also wishesto acknowledge the assistance of JeannetteSouth-Paul, M.D. and subcontractors, whoprepared the basis of this report under contract.The Council further acknowledges the assistanceof Denise E. Holmes, J.D., M.P.H., Lois

Bergeisen, Timothy Ready, Ph.D., MartinMichaelson, Esq., Eliseo Stable-Perez, M.D.,Ciriaco Gonzales, Ph.D., Ernell Spratley, StaceyWilliams-Diggs, Susan Gaeta, Richard Schmidt,and Judith B. Saks. The Council is grateful to P.Hannah Davis, M.S., of the Division of Medicine,Bureau of Health Professions, HRSA, for herorchestration of the report’s preparation and herdedication to ensuring that it reflects the contribu-tions, comments, and recommendations of thenumerous parties who provided valuable inputinto the development of the report, and to F.Lawrence Clare, M.D., M.P.H., of the Division ofMedicine for his guidence, insight and expertadvice.


Executive Summary

Between the time it issued its firstreport in 1988 and the present, theCouncil on Graduate Medical Education

(COGME) has repeatedly voiced its concern thatminorities are greatly underrepresented in medi-cine, and has made wide-ranging recommenda-tions to address the consequences of a physicianwork force that does not reflect the nation’s racialand ethnic diversity. COGME’s Fourth Report,issued in 1994, argued that efforts to increaseminorities in medicine are justified, not onlybecause the nation values equal opportunity, butalso because the nation’s health depends on aphysician work force that reflects the nation’sincreasingly diverse population.

This report, the twelfth since COGME’sinception, contends that, despite nearly twodecades of efforts to increase minority representa-tion in medicine, many minorities remain criticallyunderrepresented at every level of medicine.COGME’s attention to minority representation inmedicine continues during a period when policychanges severely impact minority physicians andpotentially the health of minority populations.Changes in affirmative action policy have alreadybegun to erode the meager and hard-won gains inthe underrepresented minority physician workforce that have been made in the last 20 years.Unfortunately, these attitudinal shifts occur at atime when disparities in health between minoritygroups and whites are in some instances increas-ing, and the entry of underrepresented minoritiesinto medical schools is losing ground. Moreover,changes in the systems of paying for and providingmedical care, especially under the spreadinginfluence of managed care, will surely impactmany aspects of work force education and prac-tice.

This report focuses on several issuesrelevant to minorities in medicine: the implica-tions for medicine of the nation’s rapidly changingdemographics; the health status of minoritypopulations and the important role minorityphysicians play in improving minority access tocare; trends in minority participation in medicine;and programs that work effectively to increase thelevel of minority participation in medicine. Basedon its findings, the report makes recommendationsto address these issues.

IMPLICATIONS OF CHANGINGDEMOGRAPHICS IN THE UNITEDSTATES

Today, minority populations are the fastestgrowing segments of the U.S. population. BlackAmericans, Hispanic Americans, Asian PacificAmericans, and American Indians/Alaska Nativesmade up 26.4 percent of the U.S. population in1995. By 2010, according to U.S. Census Bureauprojections, these groups will make up 32.0percent of the population, and, by 2050, 47.2percent. Thus, physicians of the next century willprovide care to a population whose characteristicswill differ markedly from those of the populationin the United States today, and who may havesignificantly different patterns of disease andhealth care needs. The report contends that theseprojected demographics call for two parallelresponses: enlisting greater numbers of minorityphysicians into the work force; and training allphysicians to become culturally competent to carefor all populations. Physicians must learn appro-priate communications skills, understand ways toidentify health beliefs in different groups, andunderstand the barriers and biases that limit accessto health care systems.

THE HEALTH STATUS OF MINORITYPOPULATIONS

Black Americans, Mainland Puerto Ricans,Mexican Americans, and American Indians/AlaskaNatives have some of the worst health indicatorsamong U.S. population groups. Some indicatorsof poorer health status, which vary by and withinspecific minority populations, include lower lifeexpectancy, greater prevalence of chronic diseases,and poorer outcomes for pregnancy. In addition,minorities obtain some technological and surgicalprocedures and routine health care preventiveservices less frequently than whites do.

The report contends that physicians fromracial and ethnic minority groups can help im-prove access to care for minority groups. Theseminority physicians are more likely than whitephysicians to practice in underserved areas and aremore likely


achieve equity. Recent court rulings have weak-ened affirmative action measures. California’sProposition 209, prohibiting consideration of raceor gender in education, contracting, or publicemployment, may have produced a far-reachingripple effect on minority student entry in medicalschool. Historically, federal courts have upheldrace-based preferences to cure present effects ofpast discrimination, to address manifest imbalancein the representation of racial groups withinspecific categories, and to foster diversity instudent admissions. Courts have looked morefavorably on programs that: remedy racial imbal-ance and do not simply maintain racial balance; donot violate the rights of non-minorities; haveflexible goals as opposed to quotas; are notarbitrarily structured; are not perpetual; and arealternatives to race-neutral efforts that have failedor are unworkable.

RECOMMENDATIONS

Based on its findings, COGME makes thefollowing recommendations in order to movetoward greater equity for minorities in medicineand to improve the health status of minorities.

GROUP I RECOMMENDATIONS: The last 20years have provided insight into the pro-grams and resources required to facilitateminority entry into medicine. To strengthenand sustain these efforts, and to achieveproportionate minority representation inmedicine, COGME makes the following rec-ommendations:

1. Critically examine the role of standard-ized test scores and grade point averagesfor admission to medical school and resi-dent placement. These measures may bemore predictive of science achievementthan success as a physician. Criteria todetermine alternative characteristics de-sirable in medical students need to be de-veloped.

2. Allow osteopathic medical schools andpartners with osteopathic schools to havefull access to funds to enhance minorityentry into medicine and science careers.

3. Encourage public and private organiza-tions to agree collectively upon a nation-wide strategy for duplicating successfulmodels and dedicate a budget to devel-oping, implementing, and evaluating theimpact of these strategies. Widely dissemi-nate and publicize successful programs.

to care for minority, poor, underinsured, anduninsured persons. At the same time, to ad-equately serve the diverse minority population, allphysicians need to be appropriately trained incultural competency.

TRENDS IN MINORITYPARTICIPATION IN MEDICINE

Minorities are underrepresented at all levelsof medicine. In 1997, black Americans, Hispan-ics, and American Indians/Alaska Natives repre-sented approximately 23.6 percent of the popula-tion, while only 12.2 percent of all enrollees inallopathic medical schools were underrepresentedminorities.* Between 1996 and 1997, there was a7.1 percent decline in underrepresented minoritynew entrants to U.S. medical schools. Moreover,minorities who attend medical school may findthemselves with few minority role models andmentors, since minorities still are greatlyunderrepresented on faculties of U.S. allopathicmedical schools. After reviewing medical schoolenrollments and other data, the report sets newgoals for minority representation in medicine.

PROGRAMS TO INCREASEMINORITY REPRESENTATION INMEDICINE

This section of the report describes effortsdesigned to attract minorities into medicine andsupport them throughout their undergraduate andmedical school education. Successful programsinclude high school and undergraduate science andhealth career programs; articulation agreementsbetween high schools, colleges, and medicalschools; academic enrichment programs; and theinclusion of strong minority affairs offices inmedical schools. Public and private monies havesupported these programs. Admission policiesthat do not rely solely on Medical College Admis-sion Test (MCAT) scores and grade point averagesmay be successful in producing highly qualifiedphysicians.

The report also argues that affirmative actionefforts to address ongoing barriers to minorityentry in medicine continue to be necessary to

* Population percents provided here are for blacks (not ofHispanic origin), American Indians, Eskimos and Aleuts(not of Hispanic origin), and all persons of Hispanic origin.These population groups correspond with those enrolled inallopathic medical schools with the exception of Hispanicenrollees. Only Mexican Americans and Mainland PuertoRicans are counted as Hispanic enrollees, because they areunderrepresented in the medical profession.


4. To continue to make progress toward amore representative participation of mi-norities in medicine, establish a goal of4,500 underrepresented minority medi-cal school matriculants by the year 2010and 6,000 by the year 2020. Resourcesand efforts to achieve these goals shouldreflect an understanding of the enormouschallenges the nation will face in reach-ing these objectives. Appropriate targetsshould be met at every point of the edu-cational pipeline, beginning in middleschool.

5. Encourage and reward collaborative ef-forts to increase the number of academi-cally prepared minority students, be-tween and among institutions at multiplelevels of the education continuum, usinggovernmental matching funds and finan-cial incentives to academic medical cen-ters.

6. Develop partnerships with national andlocal media, advertising agencies, andvideo companies to implement innova-tive, culturally appropriate campaignsdescribing opportunities in science andhealth careers for minority and disadvan-taged children.

7. Support more research to assess the im-pact of rising medical student debt on theentry of minorities into medicine and onthe future impact of such debt on careerchoice and place of service.

8. Assure the availability of financial assis-tance to underrepresented minoritiesthroughout all levels of education throughpublic and private sector scholarshipsand loans.

GROUP II RECOMMENDATIONS: Given thechanging demographics of the U.S., physi-cians will care for increasingly diversepopulations, but the diversity of the physi-cian workforce is not keeping pace with thediversity of the nation. Physicians need tohave competencies that promote high qual-ity care of culturally, racially, and ethnicallydiverse populations. To address issues ofcultural competency in medicine, COGMEmakes the following recommendations:

1. Convene a panel to define and developconsensus on the definition of culturalcompetency in medicine. The PublicHealth Service of the U.S. Department ofHealth and Human Services, the Asso-

ciation of American Medical Colleges(AAMC), the Association of AmericanColleges of Osteopathic Medicine(AACOM), and others concerned withmedical education should participate inselecting members for the consensuspanel.

2. Private and public organizations shouldoffer funding for the development, imple-mentation, and evaluation of curriculaand programs that promote cultural com-petency in medical schools, residencytraining, and practice settings, includingmanaged care.

3. Medical schools, residency programs,medical specialty organizations, and con-tinuing medical education programsshould incorporate, as essential elementsof their required curricula, teachingmethods and experiences that assure cul-tural competency in medicine.

4. The National Board of Medical Examin-ers, the National Board of OsteopathicMedical Examiners, and specialty boardcertification and accreditation bodiesshould review examinations for appropri-ate assessment of cultural competencyand make appropriate changes to reflectassessment of cultural competency. Ac-creditation standards for medical schoolsshould also include an assessment of cul-tural competency.

5. Managed care plans should develop tar-gets for minority physician representa-tion and track their success in achievingthese targets. Measures of quality shouldinclude the ability of managed care plansto deliver culturally competent care withadequate numbers of minority physiciansand staff who demonstrate cultural com-petency.

GROUP III RECOMMENDATIONS: Minoritiesshould have access to all specialties andcareer choices in medicine, including aca-demic medicine. More research is neces-sary to understand the factors influencingminority specialty choice.

1. The Bureau of Health Professions(BHPr), the AAMC, and the AACOMshould sponsor research to identify andeliminate any barriers tounderrepresented minority entry intomedical and surgical specialties. Medi-cal and surgical specialty


organizations and societies should supportresearch to determine whether minoritieshave the same flexibility in selecting theirspecialties as do non-minorities.

2. As COGME and others consider policiesto decrease the number of federally sup-ported positions in specialty graduatemedical education programs, they shouldtrack the impact on underrepresentedminority participation in medical andsurgical specialties and devise and advo-cate remedies for any disproportionateimpact.

3. By 2010, underrepresented minoritiesshould constitute at least 10 percent ofmedical school faculty. Every academicmedical center should have in place spe-cific programs and a dedicated budget foridentifying and supporting underrepre-sented minority students with an inter-est in academic medicine.

4. Managed care organizations should de-velop training and mentoring programsto promote minority physician leadershipin these organizations. These organiza-tions should participate in partnershipsbetween medicine and pre-professionaleducational institutions.

GROUP IV RECOMMENDATIONS: The healthstatus of minority populations may be im-proved by increasing access to medicalcare, by decreasing health professionalshortages in minority communities, and byincreasing minority representation in medi-cine. COGME recommends that:

1. Governmental and private fundingsources should provide resources for re-search to document the impact of minor-ity physicians on minority health status.They should also provide resources to

study the impact of culturally appropri-ate medical education and training onaccess to care and on minority health sta-tus. The targeted minority communitiesshould participate in the design and plan-ning of this assessment.

2. Community service and outreach shouldbe an explicit mission of academic medi-cal centers. These centers should developcriteria to recognize community serviceamong faculty and staff and track theimpact of such recognition on careerchoice and practice location.

GROUP V RECOMMENDATION: Educationalinstitutions, academic medical centers, andothers should continue all constitutionaland legal efforts to increase minorities inmedicine.

1. The AAMC and AACOM, with represen-tatives from the Public Health Service,Office for Civil Rights of the Departmentof Education, and Justice Department,should educate universities and academicmedical centers about effective and legalaffirmative action programs. These bod-ies should develop and issue guidelinesfor judging the constitutionality of affir-mative action programs.

GROUP VI RECOMMENDATION: Given thechanging demographics of the U.S. popu-lation and the past and currentunderrepresentation of minority groups inmedicine, COGME recommends that:

1. The AAMC and the AACOM track andreport the participation in medicine ofvarious racial and ethnic subgroups.Policies to promote minority entry intomedicine should reflect need as portrayedby these data.


Introduction

The Council on Graduate MedicalEducation (COGME), establishedby Congress in 1986, advises the Secre-

tary of Health and Human Services, the SenateCommittee on Labor and Human Resources, andthe House of Representatives Committee onCommerce about physician work force trends andrelated issues in health professions education.COGME also makes recommendations regardingthe supply and distribution of physicians and theappropriate efforts of hospitals, medical schools,and accrediting bodies to deliver health care to thenation. The diversity of the physician work force,the training of minority physicians, and minorityphysicians’ contributions to reducing physicianshortages in certain areas are important topicsdirectly relevant to COGME’s mission.

From the time it issued its first report in1988 until the present, COGME has repeatedlyvoiced its concern that minorities are greatlyunderrepresented in medicine, and has made aseries of wide-ranging recommendations toaddress the consequences of a physician workforce that does not reflect the nation’s diversity.For example, COGME’s Third Report, issued in1992, recommended that the nation providefinancial incentives, including loan and scholar-ship programs, to recruit and retain moreunderrepresented minorities. Its Fourth Report,published in 1994, noted that efforts to increaseminorities in medicine are not only justifiedbecause the nation values equal opportunity, butalso because the nation’s health depends on aphysician work force that reflects the increasingdiversity of the nation.1,2,3,4

Despite two decades of efforts to increaseminority participation in medicine, minoritiesremain critically underrepresented in medicaleducation at all levels, from medical schoolapplicants to faculty. COGME’s continuedattention to minority representation in medicine isespecially critical during a period in our nationwhen rapid changes impact minority physiciansand the health of minority populations. Changes insociety’s political will, generated by changes ingovernment policy and the courts, threaten toerode the meager, hard-won gains in theunderrepresented minority physician work forcethat have been made in the last 20 years. Thesechanges occur at a time when disparities in healthbetween minority groups and whites are in someinstances increasing, while underrepresentedminority entry into medical school is losingground. Moreover, changes in the systems ofpaying for medical care, primarily managed careand the emergence of for-profit medicine, mayhave a substantial impact on minorities.

This report focuses on major issues relatedto minorities in medicine. These issues include:

• the health status of minorities and theimportant role minority physicians play inimproving minority health and access to care;

• recent trends in minority participation inmedicine; and

• a discussion of programs that are effective inimproving minority entry into medicine.

1


2


Today, minority populations are thefastest growing segments of theU.S. population. They will represent a

substantial proportion of the work force of thetwenty-first century in a way that is different fromthe pattern that exists today (Figure 1).

Black Americans, Hispanic Americans,Asian Pacific Americans, and American Indians/Alaska Natives, which made up 26.4 percent ofthe U.S. population in 1995, will grow to 32.0percent of the U.S. population by 2010 and 47.2percent by 2050. Persons of Hispanic origin willbecome the largest minority group, and whites (notincluding Hispanic Americans) will represent asmaller proportion of the total population thanthey do now. Projections by the U.S. CensusBureau indicate that the percentage of whites ofnon-Hispanic origin will decrease from 73.6percent in 1995 to 52.8 percent in 2050. Duringthat same period, the percentage of Hispanics (ofall races) will more than double from 10.2 percentof the population to 24.5 percent. The populationof black Americans (not of Hispanic origin),currently the largest minority group in the UnitedStates, will increase from 12.0 percent to 13.6percent. American Indians/Alaska Natives willincrease only slightly from 0.7 percent to 0.9

Implications of Changing Demographics in theUnited States

percent, but the percentage of Asian PacificAmericans will nearly triple, from 3.3 percent to8.2 percent (Figure 1).5

The population changes will impact someareas of the U.S. more than others, especially inthe next 20-25 years. For example, the U.S.Census Bureau projects that between 1995 and2020, the Hispanic population in the Westernstates will increase by 104 percent, while theNortheastern states will see a 77 percent increasein their Hispanic population. With more than 25million Hispanic residents projected by the year2020, the West will have approximately 1.5 timesthe Hispanic population of the South and morethan three times the Hispanic population of theNortheast. The Asian Pacific American populationwill more than double in each region, with theNortheast and West experiencing the largestproportional increases in that population. TheWest will have more persons of Asian PacificAmerican origin than all other regions combined.Although the population of blacks will increase byabout 30 percent in all regions of the UnitedStates, the South will have the largest percentincrease (37.6 percent), with the result that one-fifth of all Southerners in 2020 will be of African-American origin.6

As these projections indicate, physicians ofthe next century will provide care to a populationwith markedly different ethnic and culturalcharacteristics than the population in the UnitedStates today. In addition to being more diverse, thepopulation will be older. These projected demo-graphic trends will influence significantly thepatterns of disease and the health care needs of thepopulation, and should prompt a reexamination ofthe effectiveness of policies to increase diversity inthe physician work force.

WHO IS CONSIDERED AMINORITY?

The word “minority” has always beendefined in terms of a number or ratio for example,a population subgroup that is less than 50 percentof the total population. In 1970, the Association ofAmerican Medical Colleges (AAMC) coined theterm “underrepresented minority” (URM) to reflectthe disparity between the proportion of health careproviders from certain racial and ethnic groupsand their total proportion in the U.S. population.

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70

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FIGURE 1 – Population Projections byRace and Ethnicity, 2000 - 2050

DecadeSource: U.S. Bureau of the Census, Current Population Reports.

Hispanic

White

Black

American Indian/Alaskan

Native

Asian Pacific American

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* The term “American Indian” refers to enrolled members offederal and/or state recognized tribes as well as people whoare self-identified as “American Indian” on the U.S.Census. Some tribes have a minimum blood quantumrequirement for membership, while others have a simpledescendant requirement. “Alaska Native” refers collectivelyto Eskimos, Aleuts, and American Indians who areindigenous to Alaska (James W. Hampton, MD, 1996).

which met this criterion were black Ameri-cans (born in the United States), Mexican Ameri-cans, Mainland Puerto Ricans (who received alarge proportion of their primary education in thecontinental United States), and American Indians/Alaska Natives.*

The term “underrepresented minority” hasattained more than a numerical connotation,however. The term also refers to groups who havelived in this country a long time (measured indecades, and usually more than 100 years), andwho have experienced educational and economicdisadvantages caused by racism and discrimina-tion. The Federal Government and specifically theU.S. Public Health Service expanded the consider-ation of minority status to include Asian PacificAmericans for those seeking grants or contracts.

Over the last 10 to 15 years, new “minoritygroups” have been emerging in different geo-graphical areas within the United States. Thosegroups include Latinos from the DominicanRepublic, Panama, and Central America; blacksrecently arrived from the Caribbean and Africa;and Vietnamese and other Asians who are disad-vantaged by socioeconomic and language barriers.Some medical schools have defined “minority” inrelation to the geographic trends in their areas.7

The AAMC has recently developed a process totrack the participation in medicine of subgroups ofvarious racial and ethnic groups. This informationwill be extremely helpful in monitoring the entry ofnew minority groups into medicine and in devel-oping appropriate policies regarding minorityentry into medicine.

IMPLICATIONS FOR CULTURALCOMPETENCIES IN MEDICINE

The rapidly changing demographic composi-tion of the U.S. population compels a re-evalua-tion of who will be the physician of the future, andhow that physician’s background and socioculturalexperiences will prepare him or her for under-standing each patient’s needs. When physician andpatient differ with respect to race, ethnicity,language, religion and values, ensuring fair,equitable, and culturally sensitive care is morechallenging.

It is, therefore, essential to increase thediversity of the physician work force in order to

ensure that patients receive culturally appropriateand sensitive care. People who share the samebackgrounds, cultural norms, experiences, andvalues are more likely to feel comfortable witheach other and to communicate better. Thisperception not only influences social interactions,but it deeply affects the very important doctor-patient relationship as well. In a study of personswith Limited English Proficiency (LEP), a recentreport prepared for the Department of Health andHuman Services cites several studies that focus onthe physician-patient interaction when a differentlanguage or culture is involved.8

Effective communication does not take placeif understanding does not result from conversation.Isham states that understanding is largely drawnfrom our background information and priorexperiences.9 According to Woloshin, communica-tion is key to the clinician’s use of the medicalinterview as a tool in patient treatment.10 Althoughinterpreters can assist physicians in communicat-ing with LEP patients and thus overcome lan-guage barriers, recent recommendations suggestthat health care professionals should become moreinvolved in the communication process by seekinga greater understanding of cultural differencesamong their patient populations.11

Because many minorities are still under-represented in the health professions, non-minorityphysicians will continue to care for the growingnumbers of minority persons and must, therefore,become knowledgeable about cultural issues thataffect minority health. Consequently, the bestapproach to treating a diverse population requirestwo parallel efforts: increasing minority represen-tation in medicine; and working to prepare allphysicians to be culturally competent in order tocare for all populations.

As yet, cultural competency as it applies tothe practice of medicine is not well defined, andthere is no consensus about how to teach theknowledge, skills, and attitudes necessary to carefor diverse populations. However, many physi-cians and medical educators would agree thatcultural competency includes certain commonelements: appropriate communication skills; anability to identify health beliefs of different groups;and an understanding of biases and barriers thatinhibit access to health care. Becoming culturallycompetent is viewed as a developmental processwith five elements: a) valuing diversity; b) makinga cultural self-assessment; c) understanding thedynamics when cultures interact; d) incorporatingcultural knowledge; and e) adapting practices tothe diversity of the population in the setting.12 Amajor focus of the recommendations of the PewCommission’s recent report, “Critical

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Challenges: Revitalizing the Health Profes-sions for the Twenty-first Century,” is the need toensure that students represent the ethnic diversityof the country and that practitioners appreciate thegrowing diversity of populations and learn tounderstand health status and health care throughdifferent cultural values.13

The inability of medical systems and medicalproviders to break down barriers posed by race,ethnicity, religion, and economic disparity contrib-utes to a distrust of the medical system by somepatients. Besides understanding cultural differ-ences, physicians must avoid discriminatorybehaviors. Comer and Adams emphasize theimportance of recognizing the impact of racism onthe clinical interaction.14,15

In addition to the shifting demographics ofthe population, the systems for the delivery andfinancing of health care are rapidly changing andaffecting the way in which patients gain access tocare and physicians deliver care. Achievingcultural competency becomes ever more challeng-ing as the penetration of managed care into healthcare delivery increases. Managed care, formerlyconfined to middle class populations, has nowexpanded into more socioeconomically variedgroups. A recent report by Ware and associatessuggests that chronically ill, poor, and elderlypatients may not fare as well as middle classpopulations in managed care.16 While not bearing

directly on the issue of culture, their study sug-gests that managed care organizations may need torevisit their methods of case management whenpresented with populations different from those forwhich the systems of care were developed.

Lavizzo-Mourey and Mackenzie havesuccinctly discussed the changing population inmanaged care as one of two important trends thathave accompanied managed care.17 Culturalcompetency must focus not only on the individualdoctor-patient relationship, but also on broaderhealth issues. Lavizzo-Mourey suggests thatcultural competency involves the integration ofthree population-specific issues:

1. The delivery of culturally appropriate healthcare as related to beliefs and cultural values;

2. An epidemiological perspective on diseaseincidence and prevalence in ethnic subpopu-lations; and

3. Treatment efficacy among different popula-tions.

Given the disturbing trends in the healthstatus of minorities, documented in the nextsection, culturally appropriate health care andepidemiological perspectives on disease arecritically needed to equip physicians with the toolsneeded to provide effective care to all ethnic andcultural populations.

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In 1984, the U.S. Department of Healthand Human Services (DHHS) documented the extent of the disparities in health

among minority groups in the United States. Thereport focused on the minority groups of blacks,Hispanics, American Indians/Alaska Natives, andAsian Pacific Americans. The DHHS Secretary’s1985 report estimated that thousands of excessdeaths in these groups were largely attributable tocancer, cardiovascular disease, diabetes, infantmortality, substance abuse, and violence.18 Eventoday, the overall health status of minorities isworse than that of whites, despite increases inboth the number of physicians nationally andnational health expenditures.

Differences in health insurance coveragecreate real differences in health status among theraces. Lack of access to health services, caused bya lack of insurance or an inability to pay, has beenassociated with disparities in health out-comes.19,20,21 In 1995, 84.6 percent of the U.S.population was covered by health insurance forsome or all of the year. However, while only 14percent of whites were uninsured, 21 percent ofblacks and 33 percent of Hispanics had no healthinsurance that year.22 Moreover, even when incomeis accounted for, studies point to continuedunequal access to certain medical procedures forblacks compared with whites, suggesting thatracial differences in treatment exist and transcendincome.23

At the same time, compared with theirdistribution in the United States, black Americansand Hispanics are overrepresented among thoseinsured by Medicaid. In 1995, 25 percent of the36 million Medicaid recipients were blackAmerican, 17 percent were Hispanic, and 45percent were white. Ayanian et al., found differ-ences between those with private insurance andthose with either Medicaid or no insurance, soMedicaid status per se may not equalize eitheraccess to care or health outcomes.19

Cultural factors also play a central role inminority health care issues, adding weight to theargument that culturally competent physicians willbe necessary to treat minority patients. Theabsence of interpreters when English is not thepatient’s first language, a patient’s lack of affinitywith his physician, differing health practices,psychosocial, and environmental stresses, and avariety of cultural differences have an impact onthe health status of minority persons.24,25,26 Theracial and ethnic groups which make up the

The Health Status of Minority Populationsminority populations in the United States areoverrepresented among the groups that receivedisproportionately fewer health care services.Patients who are less acculturated and less able tospeak English are less likely to receive outpatientcare for physical or emotional problems.

The health status of Americans has beentracked using a variety of indicators that providesome insight into the health problems facing thecountry and some indication of the effectiveness ofprograms to improve the nation’s health. Table 1provides a summary of these indicators for racialand ethnic groups in the United States. A moredetailed discussion of health status among thesegroups follows.

HEALTH STATUS OF BLACKAMERICANS

Blacks (including those of Hispanic origin)are the largest minority group in the United States,comprising 33,144,000 people or 12.6 percent ofthe population, as reported by the U.S. Bureau ofthe Census for 1995. (Non-Hispanic blackscomprised 31,598,000 or 12.0 percent of thepopulation.)27 Diversity exists within the blackpopulation. For example, blacks who emigratedfrom the Caribbean during this century haveretained a specific identity. Although the U.S.Census does not contain detailed data on theproportion of black Americans who are WestIndian or members of other subgroups, majorcultural differences between these subgroups exist.

Like other minorities in the nation, blackAmericans are considerably more likely thanwhites to be poor. In 1995, nearly one-third (29.3percent) of all blacks had annual incomes belowthe poverty level, while just 13.8 percent of allAmericans were poor. Forty-two percent of blackchildren less than 18 years of age were poor—more than two and one-half times the percentage(16 percent) of white children in poverty. Twenty-two percent of black adults 18-64 years old werepoor compared with 9.6 percent of white adults,and 25 percent of black adults 65 years and overwere poor compared with 9.2 percent of elderlywhites.28

Black Americans are not only poorer thanwhite Americans, but they are also sicker. Majordifferences are found in infant mortality, overalllife expectancy, cardiovascular disease, cancer,AIDS, and homicide rates.

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Infant Mortality: The infant mortality rateof blacks is more than double that of whites.29 In1995, the rate was 14.9 deaths per 1,000 birthsfor blacks, and 6.3 for whites. The ratio of blackto white infant mortality has increased for much ofthe last 10 years because white infant mortalityrates have declined more rapidly than black rates.Nearly 60 years ago, in 1940, the ratio of black towhite infant deaths was 1.6, but it grew to 2.4 in1995. Low birth weight is a major risk factor forinfant mortality. The percent of low birth weightinfants born to black mothers is more than twicethe percent born to white mothers.30 Even whenincome differences are factored in and financialaccess to prenatal care is assured, black womenuse prenatal care later and less often and give birthto a higher proportion of low birth weight ba-bies.31,32 Murray and Bernfield suggest that lowermarriage rates, child care problems, transportationdifficulties, work schedule complexities, anddifferences in the perceived value of prenatal careare possible factors related to lower levels ofprenatal care among black women.

Life Expectancy: In 1995, the estimated lifeexpectancy for black males was 65.4 years,compared with 73.4 years for white males. Blackfemales fare better than black males: their lifeexpectancy is 74.0 years, although this rate is less

than the 79.6 years for white fe-males.33 The gap between black menand white men has increased in recentyears because the rise in life expect-ancy of black men has leveled off.34

Cardiovascular disease, homicide,cancer, and infant mortality accountfor three quarters of the difference.There are also important differences indeath rates among blacks dependingon the geographical areas where theylive in the United States. For example,the annual excess mortality rate forblack men living in Harlem wasdramatically higher than for black menof similar economic status living inBlack Belt Alabama (1,296 vs. 338per 100,000 population of therespective communities). Differencesin death rates among areas of thecountry are thought to relate todifferences in availability of healthcare resources, housing conditions,relative crowding, and crime rates.35

Cardiovascular disease: In1993, the age-adjusted death ratesfrom cardiovascular disease were267.9 for black men versus 190.3 forwhite men, and 165.3 for blackfemales compared with 99.2 for white

females. Among black men, the age-adjusted deathrate from stroke was 1.9 times that of white men;among black women, it was 1.8 times that ofwhite women.36

Cancer: Blacks have higher cancer rates andhigher mortality from cancer than do whites. Theysurvive fewer years with the disease. Between1970 and 1993, mortality rates from malignantneoplasms increased 21 percent for black men and10 percent for black women, compared with only 1percent for white men and 2 percent for whitewomen.37 Although black women have lowerincidence of breast cancer than white women, theyhave higher age-adjusted mortality rates from thedisease.38 Mortality rates for blacks are also higherthan whites for cancer of the cervix, esophagus,larynx, lung, pancreas, and prostate, and formultiple myeloma.39

AIDS: The 1995 prevalence rates per100,000 population of AIDS cases indicate a farmore severe health burden upon blacks (males/females, 199.5/61.2) than whites (males/females,36.1/3.7). Between 1992 and 1993, the number ofAIDS cases increased by 124 percent among blacksaged 13 and older, compared with 114 percent forthe same age group of whites. (The number ofAIDS cases in 1994 fell for both races, but at alower rate for blacks than for whites.)

TABLE 1 – Selected Health Indicators by Race/Ethnicity, 1995

AmericanIndian/AlaskaNative1

HispanicBlackWhiteAsianPacific

American

Infant Mortality Rate 2 .....

% Live Births w/ PrenatalCare in First Trimester

Life Expectancy at Birth(M/F, years) ...............

Age-Adjusted MortalityRate 3 .........................

1 American Indian/Alaska Native (AI/AN) data are from 1991-93 and are for Indian HealthService populations

2 Per 1,000 live births3 Per 100,000 population

* Male and female combined

NA = not available

6.3 14.9 6.9 8.8 5.5

83.5 70.3 70.4 62.0 77.6

73.4/79.6 65.4/74.0 NA *73.2* NA

477.6 758.6 378.7 594.1 293.2

Sources:Monthly Vital Statistics Report; Vol 45 no 3, Supp 2, NCHS, 1996 [for all white, black, andHispanic statistics and APA age-adjusted mortality rate].

1996 Trends in Indian Health, IHS [for AI/AN statistics on infant mortality rate, life expectancy,and age-adjusted mortality rate].

Regional Differences in Indian Health, 1996, IHS [for AI/AN percent of live births with prenatalcare in first trimester].

Health US, 1995 [for APA percent of live births with prenatal care in first trimester].

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Black and Hispanic women comprised only22 percent of the female population, but 76percent of 1994 AIDS cases among women.Eighty-four percent of all children with AIDS wereeither black or Hispanic.40 Other sexually transmit-ted diseases are also disproportionately repre-sented among blacks. In 1994, blacks accountedfor 81 percent of the total reported cases ofgonorrhea and 87 percent of all reported cases ofprimary and secondary syphilis. The rates per100,000 of congenital syphilis among blacks,Hispanics, and whites were 202.1, 66.9, and 4.2,respectively.41

Homicide: The age-adjusted homicide deathrates in 1993 were almost eight times higher forblack men than for white men ( 70.7 vs. 8.9), andmore than four times higher for black women thanfor white women ( 13.4 vs. 3.0).42

Significant disparities exist between blacksand other groups in other conditions and conse-quences of health status. In 1993, the estimatedprevalence of diabetes mellitus in blacks andMexican Americans was 9.6 percent, comparedwith 6.2 percent in whites.43 In 1994, blackworkers (civilian, non-institutional population)had 18.4 restricted activity days per person,compared with 15.7 for white workers.44 In 1994,blacks missed 4.0 days of work, compared with3.0 days missed by whites.45

The American Medical Association’sCouncil on Ethical and Judicial Affairs has framedthe disparities in the quality of health statusamong black and white Americans as indicative ofdifferences in both need and access.46 Whileeconomic circumstances clearly contribute to thelack of access to health services, even those blacksabove the poverty level have less access to medicalcare than do their white counterparts. Recentstudies suggest that even when blacks gain accessto the health care system, they have fewer ambula-tory visits and are less likely than whites to receivecertain surgical and other therapies. Comparedwith their white counterparts, black Medicarerecipients are less likely to undergo mammogra-phy, to receive influenza vaccination, to undergopercutaneous transluminal coronary angioplasty,and to undergo coronary artery bypass surgery.47

Black and white Medicare patients in theUnited States experienced differential rates inobtaining coronary artery bypass graft surgery. Sexand age-adjusted rates were computed for 1986;the rate of performance of this surgery for whiteswas 27.1 per 10,000 and for blacks was 7.6 per10,000. There are other technological and surgicalprocedures, such as operations on the musculosk-eletal system, which minorities obtain less

frequently than whites.48 The studies offer fewclues as to the reasons for these disparities,although some researchers suggest culturaldifferences, unspecified patient preferences, orsimply a lack of information by black patients.Conscious or unconscious racism by somephysicians also is posed as at least a possiblealternative explanation.49

HEALTH STATUS OF HISPANICAMERICANS

Hispanic Americans are the second largestminority in the United States, with 26,936,000residents (of any race) in 1995 or 10.2 percent ofthe population.50 The term “Hispanic” recognizesthe similarities of people with Spanish as theirnative language, overlapping culture, and aconnection to origins in Spain. Many Hispanicgroups prefer the term “Latino” as recognition oftheir Latin American roots, which can includeIndian and African influences.

Hispanics are one of the fastest growingpopulations in the United States, having increasedby more than 50 percent between 1980 and1990.51 In 1990, of the 22.4 million Hispanics (ofany race) then in the United States, 60.4 percentwere of Mexican origin, 12.2 percent were PuertoRican, 4.7 percent were Cuban, and 22.8 percentwere from Central America, South America, orother countries.52 Hispanics are also diverse interms of socioeconomic status, the circumstancesunder which they came to the United States, andlevels of acculturation. In 1995, 40 percent ofHispanic children under age 18 were poor, as were25 percent of Hispanic adults age 18-64, and 23percent of Hispanics 65 years and older.53 Overall,Hispanics have the highest rate of being uninsuredof any racial/ethnic group in the United States.Cuban Americans, who have the highest incomes,are more likely than other Hispanics to haveprivate health insurance, while Mainland PuertoRicans, with the lowest incomes, are most likely touse Medicaid.54,55 However, recent immigrationpatterns may change socioeconomic groupingsamong Hispanics. Newly arrived Cubans, who arenot as well off financially as established Cubans,may have higher percentages lacking healthinsurance.

Based on data from the Hispanic Health andNutrition Examination Survey (HHANES),Hispanics are half as likely as whites to cite aregular source of health care and twice as likely touse the emergency department as a source ofprimary care. Hispanic patients who speak Englishare more likely to have a regular source of medicalcare, compared with those who speak onlySpanish.56,57

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Health data on Hispanics have only recentlybecome available, due to the earlier lack ofHispanic identifiers on state and national instru-ments used to track health indicators. Deathcertificate data became available in 1988. Hayes-Bautista indicates that by cause of death “Latinosalso have lower age-adjusted death rates due toheart disease, strokes, and cancers [than Anglos’],again, about equal to Asians.” One possibleexplanation offered is that Hispanic families “. . .are more likely than any other group, Anglo, black,or Asian, to be a classic nuclear family.” Latinosalso were found to have high participation in thelabor force. However, Hispanics have highermortality rates due to cirrhosis, cancers of thestomach, esophagus, pancreas, and cervix, andviolent deaths. Hispanic males with MainlandPuerto Rican and Cuban roots have higher rates ofsuicide than white males.58

Although Hispanic women are less likelythan whites to receive prenatal care in their firsttrimester of pregnancy, they have relatively lowrates of premature birth and low birth weightbabies. Puerto Rican women have the highestpercent of low birth weight babies among His-panic women and the highest infant mortality rate.Mexican Americans have the lowest percent oflow birth weight babies, while Cuban Americanshave the lowest infant mortality rates, lowest bothfor all Hispanics and for most racial groups.59 AsHispanic women become more acculturated, theirrisk of giving birth to low birth weight babiesincreases, making the overall Hispanic infantmortality rate of 6.9 similar to the white rate.Immigrant Hispanic women had better birthoutcomes than their U.S.-born counterparts, whichsuggests that acculturation to United Statescustoms and certain lifestyle decisions may alsocarry certain risks.60,61

In general, Hispanics are three times morelikely than whites to have diabetes and to sufferend organ complications. Hispanics are also atincreased risk for hypertension, tuberculosis,HIV infection, and alcoholism. Hispanic ratesfor communicable diseases, such as measles,shigellosis, giardiasis, and hepatitis A, weremuch higher than those for whites and blacks,but lower than those for Asians. The rate forsexually transmitted diseases, such as gonor-rhea and syphilis, is approximately twice thatof whites but less than that of blacks.

Mainland Puerto Ricans have the worsthealth status among all Hispanics in the U.S., asdefined by the prevalence of chronic disease andincidence of acute medical conditions.

HEALTH STATUS OF AMERICANINDIANS/ALASKA NATIVES

American Indians/Alaska Natives are thesmallest and most diverse of all American under-represented minority groups.* The population ofAmerican Indians/Alaska Natives increased fromapproximately 300,000 at the turn of the centuryto nearly 2.0 million in 1995.62 In 1990, AmericanIndians were 0.76 percent of the U.S. population;Eskimos, 0.02 percent; and Aleuts, 0.01 percent.63

American Indians/Alaska Natives consist of morethan 500 tribes and village units, with about halfthe population living outside of reservations.64

They are younger, less educated, less likely to beemployed, and poorer than the general population.In 1990, 30.9 percent of American Indians/AlaskaNatives were below the poverty level, including 29percent of those aged 65 and over and 39 percentunder 18 years old.65

The Indian Health Service (IHS), an agencyof the Public Health Service within DHHS, isresponsible for providing health services toAmerican Indians and Alaska Natives that aremembers of federally recognized tribes. The IHScarries out its responsibility through IHS andtribally operated hospitals and health centers. InFiscal Year 1997, the IHS service population(those eligible for IHS services) is approximately1.43 million, more than half the total AmericanIndian/Alaska Native population.66 The data onAmerican Indian and Alaska Native healthindicators are based on this service population.

In spite of the IHS service system, access tohealth care for American Indians/Alaska Nativesis difficult because of the geographic isolation ofvillages and communities, large reservations, andpoor transportation and communications systems.Travel may require long distances on dirt roads orby air. In the past 20 years, however, IHS effortshave contributed significantly to improved health,especially

* There are differences in the name this group is called, butthere should be no difference in the selection of personsincluded in counts. American Indian/Alaska Native is theterminology used by the Indian Health Service. The U.S.Bureau of the Census calls the same group AmericanIndain, Eskimo, or Aleut. Data on Vital Statistics from theNational Center for Health Statistics uses the termAmerican Indian, but footnotes that the term includesEskimos and Aleuts. Data for “Health U.S.” from NCHSuses the term American Indian or Alaska Native. TheAssociation of American Medical Colleges uses the termNative American to describe American Indians and AlaskaNatives. For consistency purposes throughout this report,the term American Indian/Alaska Native is used.

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among infants and pregnant women.Advances in sanitation and disease control haveprovided effective management of infectiousdiseases such as tuberculosis and pneumonia.67

In calender years 1991-1993, the leadingage-adjusted cause of death among AmericanIndians and Alaska Natives residing in IHSservice areas was cardiovascular disease, followedby malignant neoplasms and accidents. Theaccident mortality rate among American Indians/Alaska Natives was 2.8 times higher than the U.S.average. Deaths from motor vehicle accidentsaccounted for more than half the accidents; the ratefor such deaths was three times higher than therate of motor vehicle accident deaths for thegeneral population. The age-adjusted mortalityrates from alcoholism were a devastating 465percent higher for American Indians/AlaskaNatives than for the U.S. population; tuberculosis,425 percent higher; diabetes, 166 percent higher;suicide, 46 percent higher; and homicide, 39percent higher.68

Suicide and alcohol abuse account for anunacceptable level of preventable mortality,especially among young men. Alcohol abuse alonehas been considered the number one healthproblem of American Indians and Alaska Natives.Abuse of other drugs has also been documentedand, in some communities, abuse of inhalantscontinues to be a problem. However, traditionalceremonial and selected cultural practices have hadsome success in curtailing alcohol abuse.

In calendar years 1991-93, the age-adjustedmortality rate from diabetes for American Indians/Alaska Natives was 2.7 times that of the U.S. forall races and 3.0 times that of whites. Furthermore,the high incidence of diabetes results in a largenumber of American Indians/Alaska Natives withend stage renal disease that requires hemodialysis.Malignant neoplasms have increased amongAmerican Indians/Alaska Natives in the past 20years, and cancer is the second leading cause ofdeath in American Indians/Alaska Nativewomen.69

Only 62.0 percent of American Indian/Alaska Native women receive care in the firsttrimester of pregnancy.70 However, the low birthweight rate is 5.8 percent, and the infant mortalityrate decreased to 8.8 in calendar years 1991-93from 22.2 in calendar years 1972-74. Still,American Indians/Alaska Natives have the highestrate of Sudden Infant Death Syndrome in thecountry—1.8 times greater than that of the generalpopulation.71

Professionals working with AmericanIndians/Alaska Natives must be educated aboutand respectful of the cultural traditions of their

unique heritage. The traditional healing practicesof many American Indian/Alaska Native culturesshare a common concept of “wellness,” the beliefthat the mind, body, and spirit are all one andcannot be separated one from the other. A circle,which has no beginning or end, symbolizesharmony and balance of all things. The fourdirections, the four winds, and the four elements(fire, water, earth, and air) are symbolic of the fourcomponents of health: physical, mental, emotional,and spiritual.

HEALTH STATUS OF ASIAN PACIFICAMERICANS

Asian Pacific Americans, the third largestminority group in the United States, consisted in1995 of 9,357,000 people (including those ofHispanic origin) or 3.6 percent of the U.S.population. (Excluding those of Hispanic origin,the 1995 population of Asian Pacific Americanswas nearly 9 million, or 3.3 percent of the U.S.population.)72 They speak more than 30 differentlanguages and represent many distinct cultures.

Any examination of issues related to AsianPacific Americans must recognize that thiscategory is to some extent an arbitrary grouping.Statistical data on Asian Pacific Americansrepresent a pooling of information and mask theproblems which are evident if information isanalyzed according to subgroups or length of timein the United States. The Asian Pacific Americanpopulation includes persons from 28 Asiancountries and 25 identified Pacific Island cultures.Chinese, Filipinos, and Japanese still rank as thelargest groups, although Southeast Asians,Indians, Koreans, and other groups recently haveregistered much faster growth.73 The Asian PacificAmerican population also includes small NativeHawaiian and American Samoan subgroups.

Over each of the past two decades, the AsianPacific American population has doubled, from1.5 million in 1970 to 3.6 million in 1980, andagain to 7.0 million in 1990.74 Two-thirds ofAsian Pacific Americans were born abroad, and39 percent of all APAs entered the United Statesfrom 1980 to 1990. The immigration of newgroups, some with little linguistic or culturalconnection to earlier waves of Asian immigrants,has fueled the rapid growth of the Asian PacificAmerican population. Census data report that 35.4percent of Asian Pacific Americans have limitedcommand of the English language.75 The economicand educational stratification of Asian PacificAmericans is often tied to their length of residencein this country.

11


The largest proportion of Cambodian,Laotian, and Hmong immigrants has come to theU.S. since 1980. These groups have among thehighest family poverty rates (42.6 percent, 34.7percent, and 63.6 percent, respectively), whileother Asian American subgroups such as Filipinosand Japanese have among the lowest rates (5percent and 3 percent). The proportion of Viet-namese Americans 25 years and older (many ofwhom have been in this country since the VietnamWar) who completed high school was 61.2percent, a rate comparable to that of blacks in1990. In contrast, other recent immigrant sub-groups—Cambodian (34.9 percent), Hmong (31.1percent), and Laotian (40.0 percent)—hadsignificantly lower high school completion ratesthan Hispanic Americans (49.8 percent).76

Table 1 suggests that the health status ofAsian Pacific Americans is superior even to thatof whites. These data can be misleading. The mostdisadvantaged subgroups of Asian-PacificIslanders have the lowest mean age; many areyoung immigrants. By failing to account for theseyounger groups of immigrants, who carry adisproportionate burden of disease, the age-adjusted mortality figure is misleading. As thesedisadvantaged subgroups age, the age-adjustedmortality figure is likely to rise dramatically.

Aggregate health data on all Asian PacificAmericans, a heterogeneous group, mask instatistical averages significant health problems insome of this population, preventing subgroupswith poor health indicators from being identified.For example, the Commonwealth of Massachu-setts reports that, in 1995, statewide low birthweight rates were 6.3 percent overall: 5.7 percentfor whites, 11.7 percent for blacks, 7.4 percent forHispanics, and 6.8 percent for Asians. However,the low birth weight rate for Cambodians was10.1 percent. Cambodians had the worst maternaland child health indicators among Asian Ameri-cans in Massachusetts.77

Important ethnic differences in risk factorsindicate that Asian Pacific American groupsshould be targeted for public health effortsconcerned with obesity, hypertension, hypercholes-terolemia, and smoking. Although documentationof health status for Asian Pacific Americans islimited by data collection (reporting in thiscategory is only a recent phenomenon), there iscause for concern. Conditions endemic in thecountry of origin and case rates for tuberculosisand hepatitis B among Asian Pacific Americansare greater than for other minority groups. Theprevalence rates for tuberculosis per 100,000 are44.5 for Asian Pacific Americans, versus 29.1 forblacks, 20.6 for Hispanics, and 14.6 for AmericanIndians/Alaska Natives.

IMPACT OF MINORITY PHYSICIANSON ACCESS TO CARE

The lack of providers in disadvantaged areashas been one of the most important impedimentsto health care access for minority populations. In1985, Keith et al. studied the effects of affirmativeaction in medical schools. This study did notactually report on the relative success of affirma-tive action programs on the production of minorityphysicians, but focused instead on the practicelocation decisions of minority physicians. Pre-sumptively, if affirmative action or any otherincentive program were to prove successful atincreasing the number of minority graduates, thenindeed minority populations would be highly likelyto be more adequately served than at present.Keith found that minority graduates practiced infederally designated health-manpower shortageareas almost twice as often as non-minoritygraduates (11.6 percent vs. 6.1 percent).78 Thisgeneral trend held true for physicians practicingprimary care, obstetrics and gynecology, internalmedicine subspecialties, and general and subspe-cialty surgery. Keith also found, similar to paststudies, that minority physicians tended to servemembers of their own racial or ethnic populationgroup more than members of other groups. Thus,increasing the population of medical practitionersin one racial or ethnic group will not necessarilyserve the access needs of other minority groups.

More recently, Moy and Bartman found, byreviewing data from the 1987 National MedicalExpenditure Survey, that minority patients weremore than four times more likely to receive carefrom non-white physicians than were whitepatients not of Hispanic origin.79 Low-income,uninsured, and Medicaid patients were also morelikely to receive care from non-white physicians.Minority physicians appeared to care for sickerpatients than did white physicians. Individualswho said they received care from black, Hispanic,and Asian American physicians were more likelyto report poor health, report functional limitations,visit an emergency department, or be hospitalized.Beyond the central theme in this study thatminorities are more likely to seek the services ofminority physicians the study points to anotherissue: that minority physicians are more likely tosee relatively severer illness in their patientprofiles and are relatively more likely to receivelower patient fees and to deliver more free care,factors that may contribute to dissatisfaction withmedicine.

Kamaromy et.al. reported that a recent studyof 718 primary care physician practices in 51communities in California in 1993 found thatblack physicians practiced in areas where thepercentage 12


communities in California in 1993 foundthat black physicians practiced in areas where thepercentage of black residents was nearly five timeshigher than in communities where non-blackphysicians practiced.80 Similarly, Hispanicphysicians practiced in areas where the percentageof Hispanic residents was twice as high as in areaswhere non-Hispanic physicians practiced. Morepointedly, black physicians cared for nearly sixtimes as many black patients as did other physi-cians, and Hispanic physicians cared for threetimes as many Hispanics as did other physicians.Black physicians cared for more patients coveredby Medicaid, and Hispanic physicians cared formore uninsured patients.

Proposals to increase health care delivery tothe underserved have emphasized increasing thenumber of generalist physicians. However, thisgoal can be met only if generalists are willing topractice among the underserved, and specialistsare also available to these communities. Recently,in spite of overall trends away from practicing inunderserved communities, substantial proportionsof underrepresented minorities considering careersin the medical, surgical, and support specialtiesindicated plans to practice in such areas. Forexample, in 1994, more than 40 percent of blackmedical school graduates planned to practice in anunderserved area (Figure 2 ).81

Rivo and Satcher emphasize the need to

increase underrepresented minorities in themedical profession as an important way toimprove both access to care and the health statusof the nation’s underserved populations.82 In theU.S. in 1990, white, non-Hispanics comprised75.7 percent of the population but 80.5 percent ofall physicians. In sharp contrast, black Americanscomprised 11.8 percent of the population, but only3.6 percent of all physicians; Hispanic Americansconstituted 9.0 percent of the population, but only4.9 percent of all physicians; and AmericanIndians/Alaska Natives constituted 0.7 percent ofthe population, but only 0.1 percent of all physi-cians.83,84 Physician shortages exist in many commu-nities around the country. However, such shortagesare especially acute in every specialty and subspe-cialty in black, Hispanic, and American Indian/Alaska Native communities.

In addition to practicing more in minorityand underserved areas, minority physicians canhelp to reduce language and cultural barriers tocare and provide needed community leadership.There are numerous anecdotes of minority healthprofessionals’ abilities to enhance the “userfriendliness” of health services for minorities and,hence, the accessibility of those services. Minorityphysicians increase the cultural sensitivity in theway such services are organized and delivered.

●●●●●

●●●●●

▲▲▲▲▲

✧✧✧✧✧▲▲▲▲▲

70

60

50

40

30

20

10

01984

FIGURE 2 – Percent Medical School GraduatesPlanning to Serve in Deprived Areas, 1984 - 1994

Year

Source: AAMC, Student and Applicant Information Management System.

Black

Mexican American

White

Other

Perc

en

t o

f G

rad

uate

s

❆❆❆❆❆

✧✧✧✧✧

❆❆❆❆❆

●●●●●

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

✧✧✧✧✧ ✧✧✧✧✧✧✧✧✧✧ ✧✧✧✧✧ ✧✧✧✧✧ ✧✧✧✧✧

✧✧✧✧✧ ✧✧✧✧✧ ✧✧✧✧✧ ✧✧✧✧✧●●●●● ●●●●● ●●●●● ●●●●● ●●●●● ●●●●●

●●●●● ●●●●● ●●●●●

❆❆❆❆❆❆❆❆❆❆ ❆❆❆❆❆ ❆❆❆❆❆

❆❆❆❆❆❆❆❆❆❆

❆❆❆❆❆ ❆❆❆❆❆ ❆❆❆❆❆ ❆❆❆❆❆

▲▲▲▲▲

▲▲▲▲▲▲▲▲▲▲ ▲▲▲▲▲

▲▲▲▲▲▲▲▲▲▲

▲▲▲▲▲ ▲▲▲▲▲

▲▲▲▲▲▲▲▲▲▲

13


14


❖❖❖❖❖❖❖❖❖❖❑❑❑❑❑

As we move into the next century,disparities in minority health statusand the continued underrepresentation of

minorities among practicing physicians presentsignificant challenges to the nation. The trends

Trends in Minority Participation in Medicine

described in this section make it clear that thenation must set new goals and devise new strate-gies to achieve the goals for minority representa-tion in medicine for the next century to ensure bothequity and the nation’s health.

ALLOPATHIC MEDICAL SCHOOLS

Applicants: Between 1968 and 1995, thepercentage of underrepresented minority appli-cants to medical school increased from approxi-mately 3 percent to 11 percent. During this sameperiod, the proportion of underrepresentedminorities in the population increased fromapproximately 15 percent to 21 percent.85 Al-though minorities have made gains, the percent ofunderrepresented minority medical school appli-cants has not kept pace with the growth in theminority population (Figure 3).

Preliminary data for 1997 show thatunderrepresented minority applicants remained at11.0 percent of the applicant pool. The 1997 U.S.minority population (blacks, Hispanics andAmerican Indians/Alaska Natives) was 23.6percent.* 86

Although applications from all underrepre-sented minority groups combined increasedbetween 1990 and 1995, applications decreasedamong some minority groups. The total number ofblack applicants declined from 3,659 in 1994 to3,595 in 1995, a decrease of nearly 2 percent.87

Although there were more than 2.7 million PuertoRicans living in the continental United States in1995, their percent of applicants to medical schoolremains discouragingly low (Figure 4).88

Between 1996 and 1997, all applicants tomedical school declined 8.4 percent while under-represented minority applicants declined 11.1percent.†89 Although the 2.7 percent difference maynot be construed as a huge gap, it further hindersprogress

❖❖❖❖❖

FIGURE 4 – Underrepresented Minority Applicants toAllopathic Medical Schools by Race/Ethnicity,

1990 - 1995

9

8

7

6

5

4

3

2

1

0

❖❖❖❖❖

▲▲▲▲▲

1990

YearSource: AAMC: Project 3000 by 2000, Progress to Date,

Year Four Program Report, April 1996

Black

Mexican American

Mainland Puerto Rican

American Indian/Alaska Native

❆❆❆❆❆

❆❆❆❆❆

Perc

en

t o

f A

pp

lican

ts ▲▲▲▲▲

1991 1992 1993 1994 1995

▲▲▲▲▲ ▲▲▲▲▲▲▲▲▲▲ ▲▲▲▲▲

▲▲▲▲▲

❆❆❆❆❆ ❆❆❆❆❆ ❆❆❆❆❆ ❆❆❆❆❆ ❆❆❆❆❆

❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖

* The categories of “underrepresented minority” and“minority” are not strictly comparable. Theunderrepresented minority applicants to allopathic medicalschools are blacks, American Indians/Alaska Natives,Mexican Americans, and Mainland Puerto Ricans.Minority population percentages provided here are forblacks (not of Hispanic origin), American Indians,Eskimos, and Aleuts (not of Hispanic origin), and allpersons of Hispanic origin. Native Hawaiian applicants arein the URM category American Indian/Alaska Native, whilecounted in the U.S. population as Asian Pacific Americans.

† The 1996 and 1997 statistics exclude foreign applicants,who in prior years had been distributed into the appropriateracial categories.

❑❑❑❑❑

❑❑❑❑❑ ❑❑❑❑❑ ❑❑❑❑❑ ❑❑❑❑❑ ❑❑❑❑❑

▼▼▼▼▼ ▼▼▼▼▼▼▼▼▼▼

✧✧✧✧✧

✧✧✧✧✧

★★★★★

▼▼▼▼▼

1968

FIGURE 3 – Underrepresented Minorities inAllopathic Medical Schools and U.S. Population,

1968 - 1995

YearSource: AAMC Section for Student Services

U.S. Population

Applicants

1st Year Enrollees

Graduates

▼▼▼▼▼

1972 1978 1982 1986 1990 1995

25

20

15

10

5

0

●●●●●

Perc

en

t o

f M

ino

riti

es

★★★★★ ★★★★★★★★★★

★★★★★★★★★★

★★★★★★★★★★

●●●●●

●●●●● ●●●●● ●●●●● ●●●●●

▼▼▼▼▼ ▼▼▼▼▼

▼▼▼▼▼

✧✧✧✧✧ ✧✧✧✧✧ ✧✧✧✧✧✧✧✧✧✧ ✧✧✧✧✧●●●●●

15


toward minorities gaining par representationin the profession. The numbers of AmericanIndian/Alaska Native, Mexican American, andMainland Puerto Rican applicants had the largestproportional declines, ranging from 14 to 17percent.

One encouraging trend is a relativelysustained acceptance rate of underrepresentedminority applicants to medical schools. Theoverall applicant pool today is greater than it wasin 1989. While the acceptance rate for all medicalschool applicants declined to 37.2 percent in 1995from 63.1 percent in 1989, for underrepresentedminorities, the acceptance rate declined to 42.3percent in 1995 from 53.4 percent in 1989, a lessprecipitous drop.90 By 1997, preliminary datashowed the acceptance rate for URMs steady atapproximately 41.5 percent, but the acceptancerate for all applicants rose to 40.2 percent, thusnarrowing the gap of a relatively higher URMacceptance rate.91

Matriculants: Between 1990 and 1995, thetotal number of underrepresented minority first-year (new entrant) matriculants in allopathicmedical schools grew from 1,470 to 2,010 (anincrease from 9.2 percent to 12.4 percent) (Figure3). The representation of black matriculantsincreased from 6.6 percent to 7.9 percent. The

representation of Mexican Americans nearly doubledfrom 1.6 percent to 2.9 percent, and small percentageincreases were also observed for Mainland PuertoRicans and American Indians/Alaska Natives.Between 1994 and 1995, however, the total numberof underrepresented minority matriculants showed nogrowth.92 Furthermore, preliminary data show thatbetween 1996 and 1997, there was a 7.1 percentdecline in underrepresented minority new entrants toU.S. medical schools; their number fell from 1,906 to1,770, declining to a representation of merely 11.0percent. By contrast, there was only a negligible dropin the total number of new entrants in all racial/ethniccategories between 1996 and 1997.93

Total Enrollment: Between 1990 and 1995,the total number of students from underrepresentedminority groups enrolled in allopathic medicalschools increased from 6,084 to 8,062 (an increasefrom 9.3 percent to 12.0 percent of total enrollment).American Indians/Alaska Natives and MexicanAmericans had the largest percentage increases inenrollment. However, there was no growth in the totalnumber of Mainland Puerto Ricans enrolled inallopathic U.S. medical schools during this five-yearperiod (Figure 5).94

By 1997, underrepresented minority studentsstill made up only 12.2 percent of all U.S. medicalschool enrollments. Total enrollment of black students

fell nearly 2 percentfrom 1996, and that ofMainland PuertoRicans dropped 2.5percent. Only the totalenrollments of Ameri-can Indians/AlaskaNatives and MexicanAmericans increased,as they had between1990 and 1995.*95

Nearly 97 percentof all 1992 matricu-lants were still activelyenrolled at the begin-ning of

* The 1996and 1997 statisticsexclude foreignapplicants, who inprior years had beendistributed into theappropriate racialcategories.

Black

American Indian/Alaska

Native

Mexican American

Mainland Puerto Rican

White

Asian Pacific American

Commonwealth Puerto

Rican

Other Hispanic

-10

FIGURE 5 – Percent Change in EnrollmentFrom 1990 to 1995 by Race/Ethnicity

Percent Change

Source: AAMC Facts and Figures IX

+6.0

+10.3

+34.6

�6.9

0

+59.5

+80.9

+25.8

0 10 20 30 40 50 60 70 80 90

1990 1995

4,241 5,337

277 501

1,109 1,769

457 455

47,893 44,594

8,436 11,352

796 878

1,176 1,247

Enrollment

16


their fourth year of medical school. Thedismissal rates for all racial/ethnic groups de-clined, compared with those matriculating in1988. For underrepresented minorities, only 1percent of the 1992 matriculants, compared withapproximately 4 percent of 1988 matriculants,were dismissed by the beginning of the fourthacademic year.96 However, of the 1992 matricu-lants, only 61 percent of the underrepresentedminority students graduated from medical schoolin four years compared with 84 percent of the non-underrepresented minority students.97

Graduates: The 1995 graduating class wasmade up of 10.2 percent underrepresented minori-ties. This is a slight improvement over 1990,when they were 8.6 percent of the graduatingclass. While blacks, American Indians/AlaskaNatives and Mexican Americans increased theirrepresentation during this time, Mainland PuertoRicans showed no growth.98

OSTEOPATHIC MEDICAL SCHOOLS

Overall, underrepresented minority enroll-ment in osteopathic medical schools increasedbetween 1985 and 1995. After rising from 8.7percent of the applicant pool in 1985 to a high of13.2 percent in 1989, URM applicants to schoolsof osteopathic medicine receded to 9.4 percent by1995 (figure 6). From 1985 to 1995, the propor-tion of blacks rose from 3.8 percent to 4.3 percentof all applicants, Hispanics declined from 4.4

percent to 4.0 percent, and American Indians/Alaska Natives more than doubled from .5 percentto 1.2 percent. At the same time, Asian PacificAmerican representation increased from 6.1percent to 19.0 percent of all applicants.99 (AsianPacific Americans are not included as underrepre-sented minorities.)

The percentage of URM students amongfirst-year students increased from 6.6 percent in1985 to 10.0 percent in 1995, the highest propor-tion reached during this period. Blacks represented4.8 percent, Hispanics 4.0 percent, and AmericanIndians/Alaska Natives 1.2 percent of first-yearenrollment in 1995. First-year enrollment of AsianPacific Americans in osteopathic medical schoolsincreased from 4.0 percent in 1985 to 12.0 percentin 1995.100

The URM proportion of total osteopathicmedical school enrollment increased steadily from1985 to 1990, from 5.0 percent to 7.8 percent, andremained at that level until 1995 when it rose to8.7 percent. In that year, blacks were 3.8 percent,Hispanics 3.9 percent, and American Indians/Alaska Natives 1.0 percent of total osteopathicmedical school enrollment, while Asian PacificAmericans made up 11.0 percent.101

The percent of underrepresented minoritygraduates fluctuated from year to year between1985 and 1995. In 1985, only 3.5 percent of thegraduates were underrepresented minorities. Theproportion reached a high of 8.7 percent in 1992,then dropped to 6.4 percent in 1995. AsianAmericans were 10.4 percent of the 1995 graduat-ing class.102

MEDICAL SPECIALTY INTEREST

Data from the AAMC’s yearly medicalschool matriculation and graduation question-naires are helpful in understanding the medicalspecialty interests of underrepresented minorityand other students, and how those interests changeover time. Between 1987 and 1990, interest inprimary care among first-year matriculants from allracial and ethnic groups declined, with the biggestdrop observed among Mexican Americans (Table2). The trend for Mexican-American matriculantshad reversed by 1994, while black matriculatingstudent interest in primary care continued todecline between 1990 and 1994.

The medical school graduating classes of1987, 1991, and 1995 had higher percentages ofstudents expressing interest in primary care thanthe matriculating classes of 1987, 1990 and 1994did. Graduates in the class of 1995 had a substan-tially

■■■■■

14

12

10

8

6

4

2

0

❍❍❍❍❍

❑❑❑❑❑

●●●●●

1985

FIGURE 6 – Underrepresented Minorities inOsteopathic Medical Schools, 1985 - 1995

YearSource: AACOM Annual Statistical Reports

1st Year Enrollees

Total Enrollees

Applicants

Graduates

●●●●●

■■■■■

Perc

en

t o

f M

ino

riti

es

1987 1989 1991 1993 1995

●●●●●

●●●●●

●●●●●

●●●●● ●●●●●

❍❍❍❍❍

❑❑❑❑❑ ❑❑❑❑❑

❑❑❑❑❑

❑❑❑❑❑

❑❑❑❑❑❑❑❑❑❑

■■■■■

■■■■■■■■■■ ■■■■■

■■■■■

❍❍❍❍❍

❍❍❍❍❍❍❍❍❍❍

❍❍❍❍❍

❍❍❍❍❍

17


higher interest in primary care than thegraduating class of 1991. For all three graduatingclasses, Mexican Americans had the highestinterest in primary care (Table 3).

Table 4 shows data about primary carechoice by physicians who graduated from medicalschool in 1987 and 1991 and subsequentlycompleted residency training. For the 1987graduate cohort, a higher percentage of blacks andMexican Americans, when compared with whites,

TABLE 2 – Percent of Medical School MatriculantsExpressing an Interest in Primary Care*

by Race/Ethnicity, Selected Years

Other

1987 ..............

1990 ..............

1994 ..............

* General internal medicine, general pediatrics, and family practice

28.7 33.9 26.8 25.7

24.2 24.8 23.1 20.9

17.7 29.6 29.7 18.0

WhiteMexicanAmericanBlackYear of

Matriculation

Source: AAMC

completed primary care training. For the 1991graduates, the differences in primary care interestby race/ethnicity had narrowed.

Linking the available data to follow onecohort, the graduating class of 1991 (matriculatingin 1987), shows that the pattern of primary careinterest did not diminish by graduation for whitesas it did for all other racial/ethnic groups. Al-though all racial/ethnic groups’ participation inprimary care rose by the completion of graduatemedical education (GME) compared to theirexpressed interest at the time of graduation, therise was sharpest for non-whites (Table 5). Thispattern raises the question of whether there werefewer opportunities outside primary care forminorities. Were minorities choosing generalistcareers or entering them because they could notgain entry to the specialty residencies of theirchoice? As COGME and others consider policiesto decrease the number of federally supportedpositions in specialty GME programs, they shouldtrack underrepresented minority participation inmedical and surgical specialties.

CAREER PATHS

As noted earlier in this report, physiciansfrom racial and ethnic minority groups comparedwith white physicians are more likely to practice inareas where there is a shortage of health profes-sionals and to care for minority, poor,underinsured, and uninsured persons.

Nearly 39 percent of 1995 underrepresentedminority graduates, compared with only 10 percentof other 1995 graduates, indicated on an AAMCquestionnaire at the time of their graduation thatthey planned to practice in a socioeconomicallydeprived area. Those figures indicate that bothgroups are thinking more about serving tradition-ally underserved populations than they did in1991, when 34 percent of underrepresentedminority graduates and 7.5 percent of non-underrepresented minority graduates indicatedsuch an interest. Of the 1995 underrepresentedminority graduates who planned to practice in anunderserved area, nearly two-thirds were planningnon-generalist careers. The reverse proportion heldfor non-underrepresented graduates.103

Underrepresented minority students whograduated between 1980 and 1989 and expressedan interest in academic medicine were less likelyto have gained a faculty position by 1995 than allother graduates with an interest in academicmedicine (15.1 percent vs. 23.6 percent).Underrepresented minority graduates who did notexpress an interest

Source: AAMC

TABLE 3 – Percent of Medical School GraduatesExpressing an Interest in Primary Care*


Other

1987 ..............

1991 ..............

1995 ..............


29.3 38.0 29.9 26.8

25.8 26.7 26.2 21.9

34.0 42.0 34.0 30.1


Graduation

TABLE 4 – Percent of Medical School Graduates WhoCompleted Primary Care* Postgraduate Training


Other

1987 ..............

1991 ..............


30.9 42.7 27.3 25.1

32.9 33.0 30.0 28.1


Graduation

Source: AAMC

18


in academic medicine at the time of gradua-tion were also less likely to have obtained a facultyposition than all others (8.5 percent vs. 10.3percent).104

MEDICAL SCHOOL DEBT

The average debt of medical school graduateswith loans increased between 1981 and 1995. In1981, the average debt for both underrepresentedminority and white indebted students was nearly$20,000. By 1995, average debt levels hadincreased approximately 250 percent, reaching anaverage $71,364 debt for underrepresentedminorities and $68,910 for non-minorities.105 Thegreater length of time between matriculation andgraduation is one of the factors contributing to thedifferential in debt level for underrepresented

minority students. In addition, 40 percent ofunderrepresented minority students rely onhigh-cost, unsubsidized loans, compared with35 percent of all students.106

More than 83 percent of graduatingunderrepresented minorities, compared with 51percent of non-underrepresented minorities,reported receiving scholarships or grantsduring medical school. Underrepresentedminorities are more likely than non-URMs toreceive assistance through School-basedScholarships for the Disadvantaged, FinancialAid for Disadvantaged Health ProfessionsStudents (FADHPS), National MedicalFellowships, the Exceptional Financial Needprogram, and the National Health ServiceCorps. Majority students are more likely toreceive need-based school scholarships, school

merit scholarships, and Armed Forces scholar-ships.107

MINORITY MEDICAL FACULTY

Minorities seeking role models on thefaculties of U.S. allopathic medical schools willnot find many, since minorities continue to begravely underrepresented on those faculties.Although underrepresented minority medicalfaculty increased from 2.7 percent in 1975 to 3.8percent in 1995, the increases have not kept pacewith percentage increases in underrepresentedminority medical student enrollment (Figure7).108,109,110,111,112

Overall, the number of faculty at U.S.medical schools increased from 40,578 to 82,512,with the faculty composed mostly of whites(33,309 in 1975 and 65,895 in 1995). Thenumber of underrepresented minority faculty thusrepresented a small percentage of faculty both in1975 and 1995 (Table 6). In 1995, blacks were2.5 percent of medical school faculty, PuertoRicans, 0.8 percent, Mexican Americans, 0.3percent, and American Indians/Alaska Natives,0.1 percent. Asian Pacific Americans’ representa-tion grew from 5.9 percent in 1975 to 8.6 percentin 1995.

Furthermore, the distribution of minorityfaculty is decidedly uneven. Almost 20 percent ofblack faculty are at traditional minority medicalschools (Howard University, Meharry MedicalCollege, Morehouse School of Medicine, andDrew/UCLA School of Medicine). More than 50percent of Puerto Rican faculty are at the Universi-ties of Puerto Rico, Ponce, and/or Central DelCaribe Schools of Medicine. In contrast, 74percent of medical schools

12

10

8

6

4

2

0

FIGURE 7 – Underrepresented Minority Students andFaculty in Allopathic Medical Schools

Source: AAMC Faculty Roster System

Perc

en

t o

f M

ino

riti

es

1975

8.1

1980 1990 1995

2.7

URM FacultyURM Students

2.73.3 3.8

89.3

11.4

Year

TABLE 5 – Percent of 1991 Medical School GraduatesExpressing Interest in Primary Care* at Selected

Times and Percent Ultimately Trained inPrimary Care, by Race/Ethnicity

Other

1987 Matriculation .....

1991 Graduation ........

Completion of GME � .

* General internal medicine, general pediatrics, and family practice�Graduate medical education

28.7 33.9 26.8 25.7

25.8 26.7 26.2 21.9

32.9 33.0 30.0 28.1

WhiteMexicanAmerican

Black

Source: AAMC

19


have 25 or fewer underrepresented minorityfaculty in their institutions.113

In 1995, underrepresented minority facultywere also less likely than white faculty to holdpositions in basic science departments at medicalschools not including Howard, Meharry, More-house, and the Puerto Rico schools (7.7 percentvs. 16.4 percent).114 Nor are underrepresentedminority faculty proportionately represented acrossfaculty ranks: in 1995, 2.5 percent of medicalschool faculty were black, but only 1.0 percent ofProfessors and 2.0 percent of Associate Profes-sors, compared with 3.3 percent of AssistantProfessors and 4.8 percent of Instructors.115

FUTURE TRENDS

In 1995, there were 24,797 first-yearresidents participating in GME (66.5 percent

white, 21.4 percent Asian PacificAmerican, 5.7 percent black, 6.1percent Hispanic, and 0.2 percentAmerican Indian/Alaska Na-tive).116 Table 7 shows the poten-tial impact of decreasing first-yearGME residents between 1995 and2010 to achieve a physician-to-population ratio of 218 per100,000 population. The upperpart of the table shows the impacton the racial/ethnic distribution ofresidents if the current distribu-tions are maintained. The lowerpart demonstrates the impact ifracial parity (a racial/ethnicdistribution of physicians equiva-lent to the general population)were to be achieved.

The medical trainingestablishment faces a dauntingtask to achieve representation ofminorities proportional to theirrepresentation in general society.The projections in Table 7demonstrate that the number offirst-year residents required toachieve proportional representa-tion for blacks, Hispanics, andAmerican Indians/Alaska Nativeswould have to be more than 6,000first-year residents by the year2010, more than double their 1995number. Achieving this growth ishighly unlikely, given the slow rateof increase in minority schoolmatriculants observed over the

TABLE 6 – Change in Numbers and Percents ofFaculty Between 1975 and 1995 at U.S. Allopathic

Medical Schools by Faculty Race/Ethnicity

Black ....................................

Mexican American .................

Puerto Rican .........................


White ....................................

Asian Pacific American ..........

1,346 0.7

205 0.2

391 0.1

78 0.0

32,586 -2.2

4,739 2.7

Change inPercents

Change inNumbers

Source: AAMC Faculty Roster System

TABLE 7 – Estimated Changes in the Number ofFirst-Year GME 1 Residents Required to Attain

218 Physicians per 100,000 Populationfor 1995 and 2010

White ....................................


Black ....................................

Hispanic ................................


16,493 11,871 -4,623 -28

5,303 3,817 -1,486 -28

1,423 1,024 -399 -28

1,522 1,095 -427 -28

56 40 -16 -28

20101995

Source: Libby DL, Zijun Z, and Kindig D. Will MinorityPhysician Supply Meet US Needs? Health Affairs. July/

August 1997.

AbsoluteChange

PercentChange

Maintaining current racial/ethnic distribution

20101995 AbsoluteChange

PercentChange

Achieving racial/ethnic parity

White ....................................


Black ....................................

Hispanic ................................


16,493 9,655 -6,838 -40

5,303 1,731 -3,522 -67

1,423 2,690 1,269 89

1,522 3,590 2,068 136

56 40 123 220

%

%

1 General internal medicine, general pediatrics, and family practice

20


Although attaining 6,000 newly graduatedunderrepresented minority physicians in the year2010 seems infeasible, that goal could be reachedby the year 2020 and, hence, should be an objec-tive for the longer term. If the AAMC were tomeet its objective to achieve 3,000 matriculants by2000, which doubles its 1990 number of matricu-lants, then perhaps this growth rate could besustained for several more decades to achieve

4,500 matriculants by 2010 and 6,000 by 2020. Along-term commitment to such a program wouldultimately give underrepresented minorities theopportunity to achieve proportional representationin the physician work force. Efforts to increaseminorities in medicine must continue withabsolute commitment in order to maintain the gainsthat have been achieved, to avoid decreasingrepresentation, and to strive toward proportionalrepresentation in the future.

21


22


FEDERAL PROGRAMS

The Federal Government has engaged in anextensive, ongoing effort to increase minorityparticipation in medicine since the late 1960s.Federal programs have been authorized underTitles VII and VIII of the Public Health ServiceAct, as well as under the Health Manpower Act,the Disadvantaged Minority Health ImprovementAct, and other statutory authorities. Table 8

Programs to Increase Minority Representation inMedicine

describes current Federal programs. Many of theseinitiatives are designed to enhance the academicabilities of underrepresented minority students andother disadvantaged groups who are not ad-equately prepared for college through our nation’spublic school systems. The programs’ goals are tooffer academic enrichment that enables students tocompete successfully for admission to colleges andmedical schools. Financial assistance can alsoenhance access to education.

TABLE 8 – Federally Sponsored Initiatives to Increase Minority Participation inHealth Science and Medical Careers

HEALTH CAREERS

OPPORTUNITY

PROGRAM (HCOP)POST BACCALAURE -ATE PROGRAM

Undergraduate stu-dents and post bacca-laureates not admittedto medical school

TARGET

In 1990-94, 71% wereadmitted to medicalschool117

In 1993, 77% enteredmedical school118

Title VII, section 740of Public HealthService Act, Bureau ofHealth Professions

Began in 1978, pre-ceded by the SpecialHealth Careers Oppor-tunity Grant

SCOPE/EVALUATION AUTHORITY/SPON-SOR

COMMENTS

CENTERS OF

EXCELLENCE

PROGRAM

Underrepresentedminority students inschools of medicine,dentistry and phar-macy

In 1996-97, 4,537 URMstudents in COEschools


Grants to schools ofmedicine, dentistryand pharmacy

FACULTY LOAN

REPAYMENT PRO-GRAM

Faculty positions forhealth professionalsfrom disadvantagedbackgrounds

In FY1997, 23 partici-pants (18 URMs)In FY 1996, 27 partici-pants (24 URMs)


Up to $20,000 in loanrepayment per year ofservice for faculty inhealth professionsschools

MINORITY FACULTY

FELLOWSHIP

PROGRAM

Fellows trained topursue academiccareers

2 candidates each inFY1995 and FY1996


Provides 50% offellow�s salary inmatching funds (up to$30,000)

NATIONAL HEALTH

SERVICE CORPS

SCHOLARSHIP

PROGRAM

Entering medicalstudents interested inprimary care

In 1996, 415 physi-cians were serving inclinical practice

Title III, section 338 ofPublic Health ServiceAct, Bureau of Pri-mary Health Care

NATIONAL HEALTH

SERVICE CORPS

LOAN REPAYMENT

PROGRAM

Physicians in primarycare residencies orpractices

In 1996, 1,230 physi-cians were serving inclinical practice

Title III, section 338 ofPublic Health ServiceAct, Bureau of Pri-mary Health Care

MINORITY ACCESS

TO RESEARCH

CAREERS

College students injunior and senioryears, graduates andfaculty

In 1996, 30% of URMparticipants withbaccalaureates inbiomedical sciencesentered medicalschool

National Institutes ofHealth, NationalInstitute of GeneralMedical Science

Institutional grant toschools with URMs.Mission is to increasenumber of URMS inbiomedical research

23


TABLE 8 (Continued)

M INORITY

BIOMEDICAL

RESEARCH SUPPORT

PROGRAM

Undergraduate andgraduate students,faculty, and collegesand universities

TARGET

In 1997, $32.4 millionfunded 105 programs



SCOPE/EVALUATION AUTHORITY/SPON-SOR

COMMENTS

BRIDGES TO THE

BACCALAUREATE

DEGREE

2-year junior orcommunity collegestudents

From 1992-1996,approx 1,200 studentswere supported



BRIDGES TO THE

DOCTORATE DE-GREE

Graduate students From 1992-1996,approx 200 studentswere supported



K-12 SCIENCE

EDUCATION PRO-GRAM

High school students,and teachers andcounselors of K-12students

From FY 1980-1997approx 20,000 stu-dents were supportedIn FY1997, $3.83million funded 145active grants

National Institutes ofHealth, NationalCenter for ResearchResources

Replaced MinorityHigh School StudentResearch ApprenticeProgram in FY1995

SCIENCE EDUCA-TION PARTNERSHIP

AWARDS

K-12 students In FY1997, $2.42million funded 12active grants

National Institutes ofHealth, NationalCenter for ResearchResources

Grant programs forpartnerships

NATIONAL &MARC PREDOC-TORAL FELLOWSHIP

AWARDS FOR

MINORITY STU-DENTS

Ph.D. or MD/Ph.D. orequivalent programstudents

In 1997, approx 200students were sup-ported

National Institutes ofHealth, Trans-NIH

Mission is to increasethe number of URMsin biomedical andbehavioral research

RESEARCH SUPPLE-MENTS FOR UNDER-REPRESENTED

M INORITIES

High school, college,and graduate stu-dents, grad-uateresearch assistants,postdoctorates andfaculty

From FY1989-1996,6,973 individuals weresupported

National Institutes ofHealth, Trans-NIH

For individuals inter-ested in biomedicaland behavioral re-search careers

INITIATIVES OF THE AAMC ANDOTHER NON-GOVERNMENTALGROUPS

The Association of American MedicalColleges (AAMC) has monitored and vigorouslyresponded to the underrepresentation of minoritiesin medicine for some time. In 1970, with theNational Medical Association and others, theAAMC began a campaign known as Project 75.Its goal was to expand underrepresented minoritymedical school enrollment to 12 percent in order toachieve parity with the minority populationthroughout the nation. In 1978, the AAMCidentified the limited pool of underrepresentedminorities as the main obstacle to increasingminority matriculants, and urged medical schoolsto establish partnerships with colleges and senior

high schools to encourage and prepare moreunderrepresented minorities for careers in medi-cine.

In 1991, the AAMC launched Project 3000by 2000. The goal of this project is to increase thenumber of underrepresented minorities enteringmedical school to 3,000 annually by the year2000. The target number, 3,000, constitutingapproximately 20 percent of matriculants, reflectsthe combined presence of underrepresentedminorities in the U.S. population. To implementProject 3000 by 2000, the AAMC established anational network of community partnerships,comprised of secondary school systems that havehealth science magnet programs, science highschools, colleges, and academic health centers.Since the program began, the

24


number of medical schools that haveestablished partnerships with these institutions hassignificantly increased (Figure 8).

As a result of this comprehensive, well-organized effort, Project 3000 by 2000 met itsgoals for the first three years. However, thenumber of underrepresented minority matriculants

stayed virtually level between 1994 and 1995(Figure 9), and fell from 1995 to 1997. Thechallenges remain.

The AAMC also provides leadership inother areas designed to promote entry ofunderrepresented minorities into medicine:

The Expanded Minority AdmissionsExercise: This workshop programis designed to help admissionscommittees recognize minoritystudents who have the potential tosucceed in medical school despitelower test scores and grade pointaverages (GPAs). The workshopteaches admissions committeeshow to consider other qualities ina student (a positive self concept,an ability to focus on long-rangegoals, a support system, leadershipabilities, a background of commu-nity service, and demonstratedinterests in medicine) that maypredict success in medical school.

Health Professionals forDiversity: In August 1996, morethan 30 of the nation’s leadingmedical, health, and educationassociations formed this coalitionto help ensure freedom to considerrace, ethnicity, and gender asfactors in the admissions process.This coalition believes that: 1)gender, racial, and ethnic diversityis key to an effective work force ofhealth care providers; 2) themedical profession cannot achievediversity without affirmativeaction; and 3) the dismantling ofaffirmative action will result inserious consequences to ournation’s health.

Minority Faculty Develop-ment Program: This programtargets minority faculty at U.S.medical schools and providestraining and mentorship forresearch careers in academicmedicine. It emphasizes grantwriting skills and an understandingof the grant making process.

Table 9 provides a briefdescription of national effortssponsored by other non-govern-mental organizations, some inpartnership with governmentalprograms.

Sci Ed Partnership

Magnet School

HS Academic Enrichment

High School Lab

College Academic

Enrichment

Post Baccalaureate

Articulation Agreement 0

FIGURE 8 – Number of Medical Schools WithPrograms to Expand Minority Participation

Number of Medical Schools

Source: AAMC Project 3000 by 2000 Progress to Date, Year Four Program Report, April, 1996

1995

1234567890123456789012345678901212345678123456789012345678901234567890121234567812345678901234567890123456789012123456781234567890123456789012345678901212345678

20

123412341234 1990

40 60 80 100 120

121212

123456789011234567890112345678901

123456789012345678901234123456789012345678901234123456789012345678901234

12345678901234567123456789012345671234567890123456712345678901234567

123451234512345

123451234512345

FIGURE 9 – Underrepresented Minority Matriculants toAllopathic Medical Schools

YearSource: AAMC Project 3000 by 2000 Progress to Date, Year Four Program Report, April 1996

Nu

mb

er

of

Matr

icu

lan

ts

20001990 1991 1992 1993 1994 1995 1996 1997 1998 1999

3,000

2,500

2,000

1,500

1,000

500

0

1,4701,584

1,827 1,8632,014 2,010

Project 3000 Goal

25


INSTITUTIONAL EFFORTS

In 1970, the AAMC Executive Councilurged allopathic medical schools to establishoffices of minority affairs. Presently, all 126allopathic medical schools have a designatedrepresentative to the Minority Affairs Section ofthe AAMC’s Group on Student Affairs, whichrepresents the activities of offices of minorityaffairs. Those offices are generally responsible forrecruiting premedical students and organizingsummer college enrichment and prematriculationprograms to support and enhance the academicsuccess of matriculating minority medical stu-dents. Minority affairs offices also provideacademic support services and counseling, andhelp students adapt to the academic demands andthe sometimes unwelcoming environment of themedical school.

Articulation agreements between educationalinstitutions are one way to support minoritystudents with an interest in science along thelength of the educational pipeline. These agree-ments make it easier for students to progress fromhigh school to college, and from college to medicalschool. Articulation agreements enable coordina-tion of curricula to avoid redundancy and providestudents with advanced standing at the nexteducational level; guarantee admission to students,contingent on acceptable academic performance;and/or provide financial aid. Brown UniversitySchool of Medicine, Baylor College of Medicine,and Boston University School of Medicine areexamples of schools that have successful articula-tion programs.

Colleges of osteopathic medicine have beenparticipating in the Health Careers Opportunity

TABLE 9 – Efforts by Non-Governmental Bodies to Increase Minorities in Medicine

ROBERT WOOD JOHNSON

FOUNDATION

TARGET PROGRAM COMPONENTS COMMENTS

Minority MedicalEducation Program

Undergraduates Educational assistanceenrichment

Minority FacultyDevelopment Program

Junior faculty Financial support for re-search and mentorship

Goal is to increase minority facultyin senior ranks of academic medicine

Health ProfessionsPartnership Initiative(jointly funded by theKellogg Foundation)

Middle schoolthrough college

Creation of community-wideeducation partnerships toimprove science curricula,provide mentorship, developscience faculty, etc.

1. Partnership with AAMC2. Award to academic medical

centers3. Requires participation of a

nursing and medical school, thepreprofessional program of anundergraduate college, and atleast one K-12 school system

4 Focus on education reform

HOWARD HUGHES

MEDICAL INSTITUTE

Elementary and highschool students

Hands-on research experi-ence and science education

Partnerships with academic medicalcenters

JOSIAH MACY, JR.FOUNDATION

Medical students Scholarships and supportfor minority affairs offices

High school students Magnet high school program

VENTURES IN EDUCATION Elementary and highschool students

Enhanced science curricu-lum

MINORITIES IN MEDICINE

PROGRAM

High school students Links tenth and eleventhgraders to academic medi-cal centers

26


Program. The Ohio University College ofOsteopathic Medicine is the one osteopathicschool currently designated as a Center of Excel-lence.

Medical school admissions committees needto evaluate alternative, non-traditional criteria forselecting medical school acceptances. Admissionspolicies that do not rely solely on Medical CollegeAdmission Test (MCAT) scores and grade pointaverages may be successful in producing highlyqualified physicians.119

Over the past 20 years, researchers havedescribed many of the factors that help to attractand retain minority students in courses that leadtoward health careers. Two recent publicationsfrom the Institute of Medicine and the Henry J.Kaiser Foundation summarize past and currentefforts to increase minorities in medicine and thecomponents of successful efforts.120,121

THE NEED FOR A COORDINATED

NATIONAL AGENDAThe nation would benefit from a comprehen-

sive approach to recruit and engage underrepre-sented minority students in sciences early (at theelementary school level) and maintain and supportthem as they advance along the educationalpipeline to medical school and beyond.

One of the most significant obstacles toreaching parity of minority representation isinadequate preparation of minority students inmathematics and science during high school.Black, Hispanic, and American Indian/AlaskaNative students take fewer advanced mathematicsand science courses in high school than white andAsian students.122 In addition to the relative lack ofacademic preparation, minority students mayexperience science anxiety and frustration withtraditional teaching methods. These students findthat they lack the skills to meet the academicchallenge confronting them in mathematics andscience classes.

Currently, the number of blacks, Hispanics,and American Indians/Alaska Natives who majorin science during college is similar to the numberwho apply to medical school. Therefore, theapplicant pool is as large as it can be at present.The problem lies in the overall size of the pool ofunderrepresented minority college graduates.Among 18 year olds, only 10.7 percent of blacksand 8.6 percent of Hispanics eventually earnbachelor’s degrees, compared with 28.2 percent ofwhites.123

Future efforts should concentrate on collabo-rations among college faculty, K-12 students and

teachers, strategies to improve K-12 instructionfor minority students, and partnerships involvingthe private sector, school campuses, and communi-ties. Colleges and medical schools must continueacademic enrichment programs and support.Academic medical centers must make a commit-ment to the communities they serve by linking toelementary, secondary, and undergraduate pro-grams designed to promote science and healthcareers. Financial barriers must be addressed, andappropriate and adequate financial aid madeavailable in the form of scholarships, loans, andservice opportunities. Thus, the ingredients ofsuccessful programs include solid academicpreparation at the precollege level, high-caliberundergraduate college curricula taught in asupportive environment, experiential hands-onlearning, availability of accurate, reliablecounseling and resource materials, financialsupport, and social access to overcome thepressure of “culture shock” and isolation oftenexperienced by minorities studying in majorityinstitutions.124

AFFIRMATIVE ACTION

Affirmative action has played an importantpart in increasing minority representation inmedicine, but these policies and programs arechanging to reflect the times. Affirmative actionprograms were developed and widely implementedby government, business, and educational institu-tions in the 1970s and 1980s in an effort toremedy discrimination against and exclusion ofracial and ethnic minorities. As the data presentedin this report suggest, affirmative efforts toovercome barriers to minority entry in medicineare necessary to achieve equity and address theneeds of the diverse population of the UnitedStates. A recent report from the University ofCalifornia at Davis, detailing 20 years of experi-ence with affirmative action, demonstrates theeffectiveness of these efforts in producing success-ful physicians.125

The courts have influenced and will continueto influence the design and viability of affirmativeaction in education and employment. Just as theBakke decision affected admission policies andenrollment patterns almost 20 years ago, so toowill recent cases influence our society’s institu-tions today and in the future. Recently, courts haveruled against minority-targeted scholarships(Podberesky v. Kirwan), required more specificcriteria to justify set-asides for minority contrac-tors (Adarand Constructors v. Peña), and ruledthat race could not be considered in the law schooladmissions process simply to further diversity(Hopwood v. Texas). 27


In a key recent decision involving affirma-tive action in education, Hopwood v. Texas, fourunsuccessful white applicants challenged theadmission policy of the University of Texas LawSchool, which had used a bifurcated reviewprocess in an attempt to make its student bodyracially reflective of the state. The federal appealscourt ruled that the law school could not use raceas a factor in admissions simply to further diver-sity. It reasoned that diversity focuses on, ratherthan disregards, race and treats minorities as agroup, rather than as individuals. The U.S.Supreme Court declined to review the case. In thewake of Hopwood, a similar action was filedagainst the University of Michigan in October1997 by two unsuccessful applicants for under-graduate admission.

While a number of state legislatures are nowconsidering measures that would alter the existingaffirmative action landscape, the nation’s mostethnically diverse state, California, is the site ofseveral important activities in this area. In 1995,the Board of Regents of the University of Califor-nia voted to prohibit its schools from consideringrace or ethnicity in the admission of students. Inthe fall of 1996, the voters of California approvedProposition 209, which prohibited the state andlocal governments from granting preferentialtreatment based on race or sex in education,contracting, or public employment. Proposition209 took effect in August 1997 and has withstoodjudicial challenge. A similar, yet broader anti-affirmative action proposal at the federal level, theCivil Rights Act of 1997, has been reintroduced inCongress.

The dire implications of these decisions forfuture admission policies of medical and other

health professions schools, and post-secondaryeducation in general, cannot be overstated. Thesedecisions will make it harder to reach the goal ofproportional representation in the medical profes-sion. In fact, their impact may have been immedi-ate. From 1996 to 1997, underrepresentedminority applicants to medical schools fell 11.1percent, and the acceptance rate ofunderrepresented minority applicants fell 6.8percent.

These recent actions will compel someinstitutions to develop new affirmative efforts tolift ongoing barriers of minorities in academia andmedicine in a way that will not violate constitu-tional tenets. Historically, federal courts haveupheld race-based preferences to cure presenteffects of past discrimination, to address manifestimbalance in the representation of racial groupswithin specific categories, and to foster diversityin student admissions. According to Michaelson,courts have looked more favorably on programsthat remedy racial imbalance and do not simplymaintain racial balance; do not violate the rights ofnon-minorities; have flexible goals as opposed toquotas; are not arbitrarily structured; are notperpetual; and are alternatives to race-neutralefforts that have failed or are unworkable.126

Recent judicial decisions suggest that thesole (and quite narrow) justification for using racethat courts will find acceptable is to remedy pastwrongs on behalf of the precise, individual entity(e.g., a lone law school rather than a state’s entireeducation system). On the other hand, whileHopwood prohibits the use of race per se as afactor in admission, it allows schools to continueto weigh other factors that often correlate withrace.

28


Despite nearly two decades ofefforts to increase minorityrepresentation in medicine, black

Americans, Mexican Americans, Mainland PuertoRicans, and American Indians/Alaska Nativestoday continue to remain underrepresented at everylevel of medicine. While past efforts to increaseminorities in medicine have been effective, theyhave not addressed fully some of the underlyingproblems that prevent underrepresented minoritiesfrom participating more equally in medicine. Thenation has not made concerted efforts to improvemathematics and science curricula in minoritydominated schools and communities and toaddress the costs of education. Nor has the nationengaged in a concerted, coordinated, well-fundedeffort to address the underrepresentation ofminorities in medicine in spite of overwhelmingevidence of the need for such efforts to improvethis situation. Therefore, although much is knownabout the types of programs that are effective inimproving minority entry into medicine, the effortsmade have not kept pace with the obstaclesminorities face in succeeding academically at everylevel.

Poor minority health status looms as achallenge to a nation that is becoming increasingly

Summary

diverse. Managed care and other trends in thehealth care system are forcing rapid changes in asystem that has not served minorities well.Minority physicians from every racial and ethnicgroup have demonstrated a willingness to care forsome of the sickest and most underserved popula-tions of patients. Increasing minority representa-tion in medicine is but one way to improve accessto care for minority populations. Non-minorityphysicians must develop cultural competency inmedicine, since they are and will continue to bethe major providers of care for minority popula-tions.

Recent anti-affirmative action effortsthreaten to exacerbate an already dire situation.Affirmative action has been wrongly characterizedas being limited to programs that favor minoritygroups over others. Affirmative action programsaimed at increasing minority entry into medicinehave focused on academic enrichment and supportof minority students at all levels of education inorder to better prepare them for the academicrigors of college and medical school. Both thepublic and private sectors should make concertedefforts to educate the public about the needs of theminority community and the underrepresentationof minorities in medicine.

29


30


Based on its findings, COGMEmakes the fol-lowing recommendations in order to move toward greater

equity for minorities in medicine and to improvethe health status of minorities.

GROUP I RECOMMENDATIONS: The last 20years have provided insight into the pro-grams and resources required to facilitateminority entry into medicine. To strengthenand sustain these efforts, and to achieveproportionate minority representation inmedicine, COGME makes the following rec-ommendations:

1. Critically examine the role of standard-ized test scores and grade point averagesfor admission to medical school and resi-dent placement. These measures may bemore predictive of science achievementthan success as a physician. Criteria todetermine alternative characteristics de-sirable in medical students need to be de-veloped.

2. Allow osteopathic medical schools andpartners with osteopathic schools to havefull access to funds to enhance minorityentry into medicine and science careers.

3. Encourage public and private organiza-tions to agree collectively upon a nation-wide strategy for duplicating successfulmodels and dedicate a budget to devel-oping, implementing, and evaluating theimpact of these strategies. Widely dis-seminate and publicize successful pro-grams.

4. To continue to make progress toward amore representative participation of mi-norities in medicine, establish a goal of4,500 underrepresented minority medi-cal school matriculants by the year 2010and 6,000 by the year 2020. Resourcesand efforts to achieve these goals shouldreflect an understanding of the enormouschallenges the nation will face in reach-ing these objectives. Appropriate targetsshould be met at every point of the edu-cational pipeline, beginning in middleschool.

5. Encourage and reward collaborative ef-forts to increase the number of academi-

cally prepared minority students, be-tween and among institutions at multiplelevels of the education continuum, usinggovernmental matching funds and finan-cial incentives to academic medical cen-ters.

6. Develop partnerships with national andlocal media, advertising agencies, andvideo companies to implement innova-tive, culturally appropriate campaignsdescribing opportunities in science andhealth careers for minority and disadvan-taged children.

7. Support more research to assess the im-pact of rising medical student debt on theentry of minorities into medicine and onthe future impact of such debt on careerchoice and place of service.

8. Assure the availability of financial assis-tance to underrepresented minoritiesthroughout all levels of education throughpublic and private sector scholarshipsand loans.

GROUP II RECOMMENDATIONS: Given thechanging demographics of the U.S., physi-cians will care for increasingly diversepopulations, but the diversity of the physi-cian workforce is not keeping pace with thediversity of the nation. Physicians need tohave competencies that promote high qual-ity care of culturally, racially, and ethnicallydiverse populations. To address issues ofcultural competency in medicine, COGMEmakes the following recommendations:

1. Convene a panel to define and developconsensus on the definition of culturalcompetency in medicine. The PublicHealth Service of the U.S. Department ofHealth and Human Services, the Asso-ciation of American Medical Colleges(AAMC), the Association of AmericanColleges of Osteopathic Medicine(AACOM), and others concerned withmedical education should participate inselecting members for the consensuspanel.

2. Private and public organizations shouldoffer funding for the development, imple-mentation, and evaluation of curricula

Recommendations

31


surgical specialties and devise and advo-cate remedies for any disproportionateimpact.

3. By 2010, underrepresented minoritiesshould constitute at least 10 percent ofmedical school faculty. Every academicmedical center should have in place spe-cific programs and a dedicated budget foridentifying and supporting underrepre-sented minority students with an inter-est in academic medicine.

4. Managed care organizations should de-velop training and mentoring programsto promote minority physician leadershipin these organizations. These organiza-tions should participate in partnershipsbetween medicine and pre-professionaleducational institutions.

GROUP IV RECOMMENDATIONS: The healthstatus of minority populations may be im-proved by increasing access to medicalcare, by decreasing health professionalshortages in minority communities, and byincreasing minority representation in medi-cine. COGME recommends that:

1. Governmental and private fundingsources should provide resources for re-search to document the impact of minor-ity physicians on minority health status.They should also provide resources tostudy the impact of culturally appropri-ate medical education and training onaccess to care and on minority health sta-tus. The targeted minority communitiesshould participate in the design and plan-ning of this assessment.

2. Community service and outreach shouldbe an explicit mission of academic medi-cal centers. These centers should developcriteria to recognize community serviceamong faculty and staff and track theimpact of such recognition on careerchoice and practice location.

GROUP V RECOMMENDATION: Educationalinstitutions, academic medical centers, andothers should continue all constitutionaland legal efforts to increase minorities inmedicine.

1. The AAMC and AACOM, with represen-tatives from the Public Health Service,Office for Civil Rights of the Departmentof Education, and Justice Department,

competency in medical schools, residencytraining, and practice settings, includingmanaged care.

3. Medical schools, residency programs,medical specialty organizations, and con-tinuing medical education programsshould incorporate, as essential elementsof their required curricula, teachingmethods and experiences that assure cul-tural competency in medicine.

4. The National Board of Medical Examin-ers, the National Board of OsteopathicMedical Examiners, and specialty boardcertification and accreditation bodiesshould review examinations for appropri-ate assessment of cultural competencyand make appropriate changes to reflectassessment of cultural competency. Ac-creditation standards for medical schoolsshould also include an assessment of cul-tural competency.

5. Managed care plans should develop tar-gets for minority physician representa-tion and track their success in achievingthese targets. Measures of quality shouldinclude the ability of managed care plansto deliver culturally competent care withadequate numbers of minority physiciansand staff who demonstrate cultural com-petency.

GROUP III RECOMMENDATIONS: Minoritiesshould have access to all specialties andcareer choices in medicine, including aca-demic medicine. More research is neces-sary to understand the factors influencingminority specialty choice.

1. The Bureau of Health Professions(BHPr), the AAMC, and the AACOMshould sponsor research to identify andeliminate any barriers tounderrepresented minority entry intomedical and surgical specialties. Medi-cal and surgical specialty organizationsand societies should support research todetermine whether minorities have thesame flexibility in selecting their special-ties as do non-minorities.

2. As COGME and others consider policiesto decrease the number of federally sup-ported positions in specialty graduatemedical education programs, they shouldtrack the impact on underrepresentedminority participation in medical and

32


should educate universities and academicmedical centers about effective and legalaffirmative action programs. These bod-ies should develop and issue guidelinesfor judging the constitutionality of affir-mative action programs.

GROUP VI RECOMMENDATION: Given thechanging demographics of the U.S. popu-lation and the past and current underrepre-

sentation of minority groups in medicine,COGME recommends that:

1. The AAMC and the AACOM track andreport the participation in medicine ofvarious racial and ethnic subgroups. Poli-cies to promote minority entry into medi-cine should reflect need as portrayed bythese data.

33


34


References

1. Council on Graduate Medical Education. FirstReport of the Council. U.S. Department ofHealth and Human Services, Public Health Ser-vice, Health Resources and Services Adminis-tration, Rockville, MD, 1988.

2. Council on Graduate Medical Education. Sec-ond Report. U.S. Department of Health andHuman Services, Rockville, MD, 1990.

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