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Physician Supply

PERSPECTIVE

A Recurring Theme: The Need For Minority Physicians

Abstract

 
There is compelling evidence for the need to increase diversity within the physician workforce to ensure high-quality medical education, access to health care for the underserved, advances in research, and improved business performance. To have enough physicians to meet the future needs of the general public, as well as of minority citizens, we must recruit from diverse populations. The need for physicians, particularly under-represented minorities, will continue to grow. Addressing shortages requires inventive efforts to counter obstacles created by the anti–affirmative action movement, as well as strategies to encourage institutions to become more engaged in diversity efforts.

Past minority enrollment. Past efforts to increase minority enrollment in U.S. medical schools fall into four phases: "social activism," from the late 1960s to the mid-1970s; "stagnation," from 1974 to 1990; renewal, from 1990 to 1995; and anti–affirmative action, beginning in 1996.¹

In 1964 only 0.5 percent of the students enrolled in eighty-one of the eighty-three U.S. medical schools were black. Two medical schools, Howard and Meharry, accounted for the other 1.7 percent. By 1974 total minority enrollment had increased to 10 percent. This increase, fueled in part by events of the Civil Rights movement, slowed following the 1978 U.S. Supreme Court’s Bakke decision. The number of minority matriculants remained stagnant until the Association of American Medical Colleges’ (AAMC’s) Project 3000 by 2000 initiative began in 1990.²

In 1990–1994 there was an 8.3 percent average annual rate of growth in the number of minority students entering medical school, peaking at 12.4 percent in 1994. After 1996 the number of minority applicants to allopathic medical schools decreased, as did the number of overall medical school applicants. The current decline in applications has been accompanied by a decrease in enrollment, noted primarily in public medical schools and fueled in part by anti–affirmative action initiatives. These actions include the 1995 decision of the University of California regents to ban race-and gender-based preferences; the 1995 Hopwood v. University of Texas decision of the U.S. Court of Appeals for the Fifth District, which struck down affirmative action programs that take race and ethnicity into account in admissions; and passage of the 1996 California Civil Rights Initiative, which eliminated race-, ethnicity-, and gender-based preferences from governmental functions.³

Racial/ethnic composition. The racial/ethnic composition of the U.S. physician workforce does not reflect that of the general population. While blacks, Hispanics, and Native Americans represented 6 percent of U.S. physicians in 2001, their representation within the general population was 25.7 percent. In 2002, 11.6 percent of matriculating medical students and 5.5 percent of medical school faculty were from these minority groups.⁴ Although this reflects an increase in the number of minority physicians since 1968, there continues to be a large and consistent discrepancy in population parity by race/ethnicity.⁵

Need to increase diversity. There is compelling evidence for the need to increase diversity within the physician workforce, as well as within the medical school student body, faculty, and administration. Diversity ensures high-quality medical education, access to health care for underserved populations, accelerating advances in research, and improved business performance.⁶ Many segments of the U.S. population, particularly minority groups, reside in medically underserved areas and suffer disparate disease burden and negative health outcomes. Black and Hispanic physicians are more likely to provide health care to black and Hispanic patients; serve poor, uninsured, or Medicaid-insured patients; and locate their practices in underserved areas.⁷ The percentage of minority medical school graduates reporting plans to practice in underserved areas is more than four times that of other graduates.⁸ Also, data indicate that there is a positive association between physician-patient racial/ethnic concordance and patients’ receiving preventive care, being satisfied with their care overall, and rating their physicians’ participatory decision-making styles as excellent.⁹

Good signs. The increased representation of minority students enrolled in U.S. K–12 schools could help to increase diversity among physicians. Between 1960 and 1996 there was a 24 percent increase, and the U.S. Census Bureau projects a nonwhite school-age population of 58 percent by 2050. Much of this increase has been the result of a rise in Hispanic and black enrollments by 218 percent and 20 percent, respectively, since 1968.¹⁰

Between 1976 and 1995 the percentage of underrepresented minority individuals enrolled in U.S. undergraduate schools increased from 16 percent to 20 percent. Also, between 1971 and 2000 the percentage of high school completers ages 25–29 with bachelor’s degrees increased for both blacks (11.5–20.5 percent) and Hispanics (10.5–15.4 percent). Between 1976 and 1999 the proportion of minority first-professional students increased from 9 percent to 26 percent.¹¹ Unfortunately, these modest increases have not been accompanied by concomitant narrowing of the K–12 achievement gap among whites, blacks, and Hispanics. As noted by Cooper, blacks and Hispanics disproportionately fail to enter or graduate from college.

Addressing the shortages. Addressing the shortages of minority physicians will require inventive efforts to counter the obstacles created by the anti–affirmative action movement, as well as an array of strategies designed to encourage institutions to become more engaged in diversity efforts. These include not only civil rights and equal opportunity approaches but also creative use and expansion of existing financing, regulatory, and community benefit mechanisms to encourage active participation of medical schools. Such efforts need to address failures in the K–12 educational system; pipeline shortages; lack of science exposure, opportunity, and mentoring for minority and disadvantaged students; and elimination of disparate health burdens in minority and impoverished communities.¹² Current mechanisms such as minority supplements offered by the National Institutes of Health and the Agency for Healthcare Research and Quality, K–12 educational initiatives supported by the National Science Foundation, and workforce development programs such as the Health Careers Opportunity Program of the Health Resources and Services Administration should be expanded. Graduate medical education funding could be modified to provide incentives to programs that successfully address areas such as cultural competency, health disparities, and workforce diversity. Accreditation bodies should require documentation and monitoring of efforts related to cultural competency and workforce diversity for both students and faculty.

The success of efforts to address the overwhelming need to bring more minority individuals into the physician workforce will require mechanisms that recognize the need for multifaceted approaches, that provide monitoring of progress, and that incorporate accountability for the achievement of outcomes.

Editor's Notes

Top Editor's Notes NOTES

 
Joan Reede is associate professor of medicine and dean for diversity and community partnership at the Harvard Medical School in Boston. Health Affairs invited her response to the paper by Richard Cooper, which precedes this Perspective.

NOTES

Top Editor's Notes NOTES

 

1. H.W.Nickens, T.P. Ready, and R.G. Petersdorf, "Project 3000 by 2000 Racial and Ethnic Diversity in U.S. Medical Schools," New England Journal of Medicine 337, no. 7 (1994): 472–476.
2. Ibid.
3. D.M.Carlisle, J.E. Gardner, and H. Liu, "The Entry of Underrepresented Minority Students into U.S. Medical Schools: An Evaluation of Recent Trends," American Journal of Public Health 88, no. 9 (1998): 1314–1318[Abstract/Free Full Text]; and K.Grumbach et al., "Trends in Underrepresented Minority Participation in Health Professions Schools," in The Right Thing to Do—The Smart Thing to Do: Enhancing Diversity in Health Professions, ed. B. Smedley et al. (Washington: National Academies Press, 2001), 185–207.
4. American Medical Association, "Total Physicians by Race/Ethnicity, 2001," Table 1.19, in Physician Characteristics and Distribution in the U.S., 2003/2004 Edition (Chicago: AMA, 2003); Association of American Medical Colleges, "FACTS: Applicants, Matriculants, and Graduates," Applicant Matriculant File, www.aamc.org/data/facts/start.htm (8 May 2003); and AAMC, "Distribution of U.S. Medical School Faculty by Sex and Race/Hispanic Origin," Table 8, in AAMC Faculty Roster, 31 December 2002, www.aamc.org/data/facultyroster/usmsf02/02table8.pdf (8 May 2003).
5. D.L.Libby, Z. Zhou, and D.A. Kindig, "Will Minority Physician Supply Meet U.S. Needs?" Health Affairs (July/Aug 1997): 205–214; and M.L.Rivo and D.A. Kindig, "A Report Card on the Physician Work Force in the United States," New England Journal of Medicine 334, no. 14 (1996): 892–896.[Free Full Text]
6. J.J.Cohen, "The Consequences of Premature Abandonment of Affirmative Action in Medical School Admissions," Journal of the American Medical Association 289, no. 9 (2003): 1143–1149.[Abstract/Free Full Text]
7. See, for example, H.K.Rabinowitz et al., "The Impact of Multiple Predictors on Generalist Physicians’ Care of Underserved Populations," American Journal of Public Health 90, no. 8 (2000): 1225–1228; [Abstract/Free Full Text]J.C.Cantor et al., "Physician Service to the Underserved: Implications for Affirmative Action in Medical Education," Inquiry 33, no. 2 (1996): 167–180[Web of Science][Medline]; and E.Moy and B.A. Bartman, "Physician Race and Care of Minority and Medically Indigent Patients," Journal of the American Medical Association 273, no. 19 (1995): 1515–1520.[Abstract/Free Full Text]
8. R.Steinbrook, "Diversity in Medicine," New England Journal of Medicine 334, no. 20 (1996): 1327–1328.[Free Full Text]
9. S.Saha et al., "Patient-Physician Racial Concordance and the Perceived Quality and Use of Health Care," Archives of Internal Medicine 159, no. 9 (1999): 997–1004[Abstract/Free Full Text]; and L.Cooper-Patrick et al., "Race, Gender, and Partnership in the Patient-Physician Relationship," Journal of the American Medical Association 282, no. 6 (1999): 583–589.[Abstract/Free Full Text]
10. G.Orfield, "Our Resegregated Schools," Principal 79, no. 5 (2000): 6–11.
11. U.S. Department of Education, National Center for Education Statistics, The Condition of Education 2002: Trends in Graduate/First-Professional Enrollments, Pub. no. NCES 2002-025 (Washington: U.S. Government Printing Office, 2002); The Condition of Education 2000: Undergraduate Enrollment of Minority Students, Pub. no. NCES 2002-065 (2000); and Indicator of the Month: Educational Attainment, Pub. no. NCES 2000-010 (2000).
12. Community Catalyst, The Color of Medicine: Strategies for Increasing Diversity in the U.S. Physician Workforce (Boston: Community Catalyst, 2002).

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