Fixing Health Care Disparities Depends in Part on Recruiting More African-American and Hispanic Physicians. How Are Medical Schools Meeting This Challenge?
Cover Story — July 2017
Tex Med. 2017;113(7):26-32.
By Sean Price
When Dekoiya Burton was 10 years old, he had one of those life-changing realizations that often come with a medical calamity.
His mother had just given birth to a younger brother who had no arms or legs. The family already was struggling. His mother and stepfather had broken up, and the family lived in a rundown house in a poor neighborhood of Houston. After his brother's birth, Mr. Burton watched his mom suffer for a year with postpartum depression.
"During that time, she'd walk back and forth in the hallway with [my brother] and just say, 'I'm so sorry. I'm so sorry,'" he said.
Now, 13 years later, Mr. Burton, who is African-American, is an incoming first-year student at The University of Texas at Austin Dell Medical School. He can trace his desire to become a physician directly back to his mother's year of despair. "I felt like the health care system as a whole had failed my family," he said. "And I didn't want any other family to go through that experience."
Unfortunately, health inequalities like this remain common in Texas. A recent report by Episcopal Health Foundation and Methodist Healthcare Ministries of Texas found racial and ethnic health disparities cost Texans about $4.6 billion each year in extra health care costs and lost productivity. They also translate into premature deaths that are a factor in 400,000 lost years of life. (See "A Texas-Size Problem," June 2017 Texas Medicine, pages 41–47.)
There are many ways to combat these health imbalances, says Jamboor Vishwanatha, PhD, director of the Texas Center for Health Disparities at the University of North Texas Health Science Center at Fort Worth and a principal investigator of the National Research Mentoring Network. But he says it's widely acknowledged that the most important single step is to diversify Texas' physician workforce to include more African-Americans and Hispanics.
"First of all, we have to keep up with the demographic changes," Dr. Vishwanatha said. "If we look at where Texas is, we're becoming a majority-minority state, and we need physicians and other health care professionals who are representative of our demographics."
Right now, that's not happening. In 2015, Texas' overall population was about 42 percent white, 40 percent Hispanic, 12 percent African-American, and 6 percent Asian and other groups. But the Texas Health Professions Resource Center reports that Texas' physician population in 2015 was 63 percent white, 8 percent Hispanic, 6 percent African-American, and 24 percent Asian and other groups. (See "Population vs. Physician Population.")
Dr. Vishwanatha lays out several reasons why diversifying the physician workforce is vital for combatting health care inequalities. Minority physicians tend to set up practice in minority neighborhoods, the places where disparities are greatest. Also, as one 2003 Annals of Internal Medicine study found, patients tend to rate visits with doctors of the same race or ethnic group as more satisfying. According to a 2014 report by the Association of American Medical Colleges (AAMC), "It is now fairly accepted that a diverse workforce is a key component in the delivery of quality, competent care throughout the nation."
So why do Texas and the United States as a whole have such a problem reaching that goal?
LaTanya J. Love, MD, vice president for diversity and leadership at The University of Texas Health Science Center at Houston (UTHealth), says diversifying student bodies requires medical schools to work against powerful forces outside of medicine, including problems in public schools, differing family expectations, poverty, and a lot of long-standing prejudice.
"There's no one-size-fits-all solution to this problem," she says.
Figuring It Out
The shortage of minority physicians starts with the nationwide shortage of all physicians. During the past 40 years, the U.S. population and the number of seniors have risen, but the number of doctors has not kept pace. The 1997 Balanced Budget Act put a cap on the number of federally funded medical residency positions, fueling a growing shortage of physicians. AAMC estimates that a shortage of up to 30,800 in 2015 could rise to 104,900 by 2030.
The even-greater shortage of physicians from underrepresented groups is also a national problem. AAMC figures from 2014 (the most recent year available) show that African-Americans made up 13 percent of the U.S. population, but only 4 percent of the physician workforce. Likewise, Hispanics made up 17 percent of the population but only 4 percent of physicians overall.
In recent years, medical schools have stepped up their efforts to improve diversity. In its 2016 report Diversity in Medical Education, AAMC says that "the benefits of diverse and inclusive medical schools are increasingly understood by senior administrators, faculty, and students."
Today, whites make up 44 percent of accepted U.S. medical school applicants. They're followed by Asians at 19.6 percent, African-Americans at 6.4 percent, and Hispanics at 6.3 percent. But progress has been uneven. Medical school applications from Hispanics have set all-time highs, with 4,386 applicants in 2014. African-Americans also hit a new high with 3,990 applicants. Nevertheless, AAMC reported that the number of black male applicants has declined over the last 40 years. In 1978, 1,410 black men applied to U.S. medical schools. In 2014, that number was 1,337.
"We've actually lost ground in terms of the number of black men in medical school," Marc Nivet, PhD, an executive vice president at UT Southwestern Medical Center and AAMC's former chief diversity officer, told AAMCNews. "We're suffering from continued challenges that black men face up and down the continuum of education. Even though we have more black men in college and graduating college than we've ever had before, we don't have enough of them studying in disciplines that traditionally lead to medicine."
In Texas, growth in minority enrollment in medical schools has mirrored the national trends. Texas figures reported by the Texas Higher Education Coordinating Board show that in 2011 whites made up 50.6 percent of medical students; Asians, 25.2 percent; Hispanics, 12.9 percent; and blacks, 5 percent. By 2016, those numbers had changed to 44 percent for whites, 27.3 percent for Asians, and 16.5 percent for Hispanics. Blacks had dropped to 4.6 percent.
William Lawson, MD, associate dean for health disparities at Dell Medical School, says racial imbalances seen in medical schools are aggravated by geographic trends that occur once those medical students become physicians. Most doctors of all races choose to live in big cities, not small towns. Because there's already a doctor shortage, black and Hispanic patients in small towns and rural areas struggle the most to find doctors like themselves.
Clashes of Culture
John English, MD, works at Bethesda Health Clinic, a faith-based clinic that serves low-income patients in Tyler. Dr. English, who is white, says his patients are about 40 percent Hispanic, 40 percent white, and 20 percent African-American. He says middle-age men are easily his most difficult patients. Many of them suffer from chronic conditions such as hypertension and diabetes, and they often resist making return visits even after being diagnosed. One group of men is especially difficult in this regard, Dr. English says.
"Probably the biggest challenge we have, I think if we asked all our staff, particularly with diabetes, I think it's got to be African-American men," he said.
Damon Tweedy, MD, an African-American psychiatrist at Duke University Medical Center, explained in a May 15, 2015, New York Times opinion piece that widespread mistrust of doctors among African-Americans has deep roots and often tragic consequences.
"Much of this is rooted in a dark history of experimentation on black people without their consent [the four-decade-long Tuskegee syphilis study is the most notorious modern-day example]," Dr. Tweedy wrote. "Too often, however, this mistrust is to the patients' detriment. I've met countless black people who have either delayed or refused needed treatments because they were skeptical about their physician's motives and honesty. Some wound up far sicker than they should have been; others died."
Dr. Lawson says evidence backs up some reasons for minority mistrust of physicians in many cases. For instance, academic studies have shown that African-Americans and Hispanics still are systematically undertreated for pain. A 2016 study by the University of Virginia found that many medical students and residents did this because of false beliefs about biological differences between the races.
"A number of medical students had misconceptions about black people," Dr. Lawson said. "They believed that black people had thicker skin than whites and were less susceptible to pain."
Pedro Mancias, MD, professor of pediatrics and assistant dean for diversity and inclusion at UTHealth, says simple cultural misunderstandings also can fuel minority mistrust. "I am originally from the Rio Grande Valley, and there are certain ways we view illness and health," he said. "Our views may not be similar to how Houstonians, Asians, or African-Americans think."
Dr. Mancias explained, "Many Latinos in the Rio Grande Valley use home remedies such as drinking herbal teas or using traditional 'cures' for illnesses, such as passing a raw egg over a child's head when they are ill to cure 'el mal de ojo' (evil eye). A physician who disregards these practices as unscientific will not have much credibility with many patients and their families."
(TMA provides resources and a continuing medical education course that can help physicians better understand these cultural differences. See "TMA on Cultural Competency.")
Expanding the Pipeline
Dr. Love says efforts to recruit more black and Hispanic students at Texas medical schools have become stronger in the past 20 years, and they continue to improve. There are now several programs designed to boost minority involvement in medical schools. The best known in Texas is the Joint Admission Medical Program. Created by the Texas Legislature in 2003, it provides mentoring and summer programs that help economically disadvantaged students prepare for medical school.
She says just as important have been efforts to diversify faculty at Texas medical schools. The UT System, which encompasses six of the 11 Texas schools, recently passed its own "Rooney Rule." It's based on the National Football League's regulation designed to increase the number of minority candidates for head coaching jobs. Since 2016, UT System institutions have had to include a candidate from an underrepresented group in the final round of interviews for all senior administrative positions.
"If we can diversify leadership, I think that helps when you're trying to recruit a diverse pool of physicians as well," Dr. Love said.
Despite this progress, Dr. Love says serious obstacles stand in the way of kids from underrepresented groups getting ready for medical school. It starts with underperforming public schools in low-income neighborhoods.
"There's definitely a disparity in the educational system for students who come from predominantly African-American and Hispanic communities," Dr. Love said. "A lot of these kids have never seen a doctor who looks like them. They don't have any in their family, and they're not exposed to it. The pipeline programs have to start so young so that you can get these kids on the right track."
Manuel de la Rosa, MD, is provost and vice president for academic affairs at Texas Tech University Health Sciences Center in El Paso. He says that in his experience, the decision to become a physician needs to be made for most students by fifth grade.
"And it's made by your parents, with or without any knowledge [by the student]," he said. "Because if [the parents] don't undertake a conversation at the end of fifth grade about taking pre-algebra in seventh grade so that you can take algebra in eighth grade, you're not going to be able to take calculus in high school. And if you are from a culture that doesn't understand the importance of STEM [science, technology, engineering, and math] in careers, and your mom and dad have limited experience with those career paths, you're not going to make that decision."
Dr. de la Rosa says many parents of low-income students automatically write off the idea of medical school for their child. They often have little experience with college and worry about their child staying in school for so long without a steady job. These parents naturally worry about the high cost of medical school and fear that their child won't fit in.
"They feel awkward about school," he said. "I'm not seeing it as much as I used to, but they feel awkward because their [child] will be one of two or three ethnic minorities in the school they aspire to go to."
Dr. de la Rosa says medical school aspirations also can be undermined by subtle cultural expectations. He says this was highlighted recently by a group of four kids he had worked with from an economically depressed neighborhood. All four were high-achieving students who had grown up together. All four were accepted to the prestigious Massachusetts Institute of Technology (MIT) ― but only one decided to go there. The other three chose to attend a local college.
"It's not money, believe it or not," he said. "It would have cost them less money to go to MIT than to the regional university here. But it was a cultural thing. [People they knew asked,] 'Why are you going so far away?' It's that mindset and expectation that we're trying to combat."
Nevertheless, he says he sees tangible signs of progress. Dr. de la Rosa points out that Texas Tech's most recent class is 20-percent Hispanic and that other medical schools around Texas are developing similarly diverse classes while expanding programs that bring in black and Hispanic students. (See "Texas Medical School Enrollment Trends, by Race/Ethnicity, 1991–2016.")
"I think the change is on its way," he said. "I'm not saying it's easy. It's not going to happen in one or two generations. But it's going to happen."
Sean Price can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
TMA on Cultural Competency
TMA Patient Safety Resource Center on Cultural Competency
TMA continuing medical education course in cultural competency
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TMA Minority Scholarships
Since 1999, TMA has offered scholarships to first-year African-American, Hispanic, and Native American medical students. The 2017 Minority Scholarship Program is made possible with a grant from the TMA Foundation thanks to the TMAF Trust Fund of Dr. Roberto J. and Agniela (Annie) M. Bayardo; the TMAF Patrick Y. Leung, MD, Minority Scholarship Endowment; and generous gifts from H-E-B and physicians and their families. To make a tax-deductible donation, visit the TMA website.
In Their Own Words
Dekoiya Burton is one of 12 Bayardo scholars who won a 2017 TMA Minority scholarship. Applicants wrote essays explaining how they would achieve the TMA vision of improving health for all Texans. Here are excerpts from some of those essays.
Lucia Guerrero, Baylor College of Medicine
Although I was born in El Paso, I spent the first eight years of my life in Mexico. I grew up in two health care systems. In one, the extensive waits at Juarez's "Seguro Popular" delayed consultation and discouraged the pursuit of preventive care. … The other [in the United States] was filled with cutting-edge technology and procedures. … But for the uninsured, the exceptional American health care system was that of a developing country: inaccessible, inefficient, and unaffordable.
Yajaira Jimenez, Texas A&M College of Medicine
I come from a medically underserved border town. Living here has made me understand the struggle that many people go through to obtain medical attention, my family included. … My mother was recently diagnosed with lupus and has to travel an hour just to see her doctor for a checkup due to the lack of doctors where we live. I would like to help other families like my own, who do not have easy access to medical attention due to the shortage of physicians in their community.
Sandrine Defeu, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine
As a child of Africa, I saw the devastating impact of poverty, malnutrition, and limited medical resources on local families who did not have access to affordable health care. … When I moved to the United States to attend college, I was excited by the opportunity to live in a nation with a strong economy and a world-class health care system. Ironically, I have observed health care disparities in Texas that are comparable to those in Cameroon.
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