A continuation of my new series about promoting diversity among our physicians at BIDMC. Please take a moment to read the thoughtful comments offered by readers after the last post. One commenter questioned the validity of my premise that we want greater diversity, but I am going to proceed on the assumption that we do. Feel free, though, to offer alternative points of view. And please be sure to read Jon's comments on the topic, which gives a helpful national perspective on the pool of applicants to medical school and the resulting difficulty that presents as we move along the pipeline to residency programs.
I promised I would give you some numbers, and here they are, as of November 2007. Thanks to Dr. Rosemary Duda, the Director of our Center for Faculty Development, for assembling these.
We have 744 clinical residents spread throughout our 13 academic departments. As I mentioned below, the gender mix is excellent, but the percentage of underrepresented minorities is small.
Male -- 370 (49.7%)
Female -- 374 (50.3%)
White -- 464 (62.4%)
Black -- 26 (3.5%)
Asian/Pacific Islands -- 193 (25.9%)
Hispanic -- 33 (4.4%)
American Indian -- 0 (0.0%)
Other -- 28 (3.8%)
Here is the pattern among the 487 BIDMC research fellows. Some of these are MDs, and some are not.
Male -- 280 (57.5%)
Female -- 207 (42.5%)
White -- 215 (44.1%)
Black -- 7 (1.4%)
Asian/Pacific Islands -- 234 (48.1%)
Hispanic -- 17 (3.5%)
American Indian -- 2 (0.4%)
Other -- 12 (2.5%)
Acknowledging these numbers, our graduate medical education (GME) office has encouraged the creation and support of a BIDMC Diversity Committee, which is primarily a resident committee, but also has some faculty membership and mentoring. One of our fine young doctors, Sean Kelly, currently serves as faculty advisor and one of our BIDMC residents, Alden Landry, is serving as Chairman of the committee. They collaborate with the Office for Diversity and Community Partnership at Harvard Medical School and the minority affairs and diversity offices at the other HMS hospitals.
Rather than summarizing all their activities, I'll invite Sean and Alden and any other committee members and any of our other residents and fellows to post their own comments. I also invite people at other hospitals here in Boston or elsewhere to post their thoughts on the matter. What works? What doesn't? Are there success stories from elsewhere that can help inform our programs?
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In response to the question that racial and ethnic diversity is a worthy goal of a healthcare institution, I would offer the following study as one way of thinking about how having physicians of many different backgrounds may improve patient care. While it would be ideal to improve education of all physicians to address cultural competence, so far no one has been able to figure out how to do that. So increasing the number of URM physicians may be a first step in the right direction, in the absence of other ways to address some of the problems related to patient/physician relationship.
Patient-centered communication, ratings of care, and concordance of patient and physician race.Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR.
Johns Hopkins University School of Medicine and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland 21205-2223, USA. lisa.cooper@jhmi.edu
BACKGROUND: African-American patients who visit physicians of the same race rate their medical visits as more satisfying and participatory than do those who see physicians of other races. Little research has investigated the communication process in race-concordant and race-discordant medical visits. OBJECTIVES: To compare patient-physician communication in race-concordant and race-discordant visits and examine whether communication behaviors explain differences in patient ratings of satisfaction and participatory decision making. DESIGN: Cohort study with follow-up using previsit and postvisit surveys and audiotape analysis. SETTING: 16 urban primary care practices. PATIENTS: 252 adults (142 African-American patients and 110 white patients) receiving care from 31 physicians (of whom 18 were African-American and 13 were white). MEASUREMENTS: Audiotape measures of patient-centeredness, patient ratings of physicians' participatory decision-making styles, and overall satisfaction. RESULTS: Race-concordant visits were longer (2.15 minutes [95% CI, 0.60 to 3.71]) and had higher ratings of patient positive affect (0.55 point, [95% CI, 0.04 to 1.05]) compared with race-discordant visits. Patients in race-concordant visits were more satisfied and rated their physicians as more participatory (8.42 points [95% CI, 3.23 to 13.60]). Audiotape measures of patient-centered communication behaviors did not explain differences in participatory decision making or satisfaction between race-concordant and race-discordant visits. CONCLUSIONS: Race-concordant visits are longer and characterized by more patient positive affect. Previous studies link similar communication findings to continuity of care. The association between race concordance and higher patient ratings of care is independent of patient-centered communication, suggesting that other factors, such as patient and physician attitudes, may mediate the relationship. Until more evidence is available regarding the mechanisms of this relationship and the effectiveness of intercultural communication skills programs, increasing ethnic diversity among physicians may be the most direct strategy to improve health care experiences for members of ethnic minority groups.
Does BIDMC have a specialty clinic just for women? I know, because I'm a patient there, that the Brigham does, and all 3 of my cardiologists are minority women. I'm not sure how it happened, but Dr. Paula Johnson, the head of the women's cardiology unit, has seemingly worked hard to find women of color within the Harvard teaching community. When I think about it, every single one of my doctors, primary care and specialists alike are women of color. Including my opthamologist I see in your own hospital.
My cardiologists refer me to other physicians, so perhaps you might go to the source and discuss with Dr. Johnson how she finds and hires so many outstanding women of color.
Do you have any idea what the makeup of the national pool of clinical residents and research fellows is? I wholeheartedly support the effort to increase diversity, but if the bottom line is no Krakozhians are seeking residencies or research fellowships, there's not much that you can do about that.
anon 9:44 -- That was the heart of Jon's point, too.
margalit -- Thanks for the lead.
anon 6:10 -- Thank you.
I think it will be very interesting to include some Data showing how many of the clinical resident and researchers are foreigners. I think you will be surplice to notice that BIDMC research is running by foreigners.
Foreign students have always been important contributors to research programs at US academic medical centers, and I have no reason to believe that BIDMC is noticeably different from other places in Boston. What is your point in raising that issue?
To the extent that we, as a society, think it is desirable to attract both more minorities and more people from the bottom half of the income distribution to apply to medical school in the first place, I think we should reassess how we finance medical education. Specifically, I think we would be better off if much more of the cost of medical school, as well as the salaries and benefits for interns and residents, were paid with federal tax dollars.
Taxpayer financing of medical education, at least for the most part, could produce the following benefits, in addition to a more diverse population attracted to the medical field: (1) doctors would not have to charge as much if they emerged from their medical education with far less debt or none at all and (2) Academic Medical Centers could charge rates much closer to those of community hospitals if most of the (fully allocated) cost of educating new doctors were paid for with resources separate and apart from charges for medical services provided to patients.
Excellent points, Barry.
Here is a link to an article our chief of orthopaedics recently wrote on this subject:
http://www.jaaos.org/cgi/content/full/15/suppl_1/S49?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=gebhardt%2C+m&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&fdate=9/1/2007&resourcetype=HWCIT. Mark Gebhardt, "Improving diversity in orthopaedic residency programs," The Journal of the American Academy of Orthopaedic Surgeons. Volume 15, September 1, 2007.
I think that we should also give greater scrutiny to the student applications received at medical schools. This week is the second time recently that I heard two people talking on the "T" about how it is easier to go to med school than to pursue other professions, so they might as well go through the training (they were both minority women). I have always thought that med training was one of the hardest to go through, and those who have such a degree should feel both proud of their accomplishments and priviledged to work in this capacity with the public. Is this the new generations view of medicine? If so, I hope that I always find a doctor who is in my generation or older! Given our need for more doctors and nurses, as a country we cannot afford to waste a space in our training programs.
Regarding the need to increase the diversity of our medical teams - yes, it is needed, and in order for it to happen we need to increase our science training to all students in ALL school systems across the country, and increase the governmental funding to these programs. I am a majority person who has vast experience in hiring personnel in hospitals, and work to hire a diverse population.
I think Barry should run for Congress. Seriously. (:
I would like to first say thank you to Paul Levy for creating this forum for an open discussion at our hospital.
I am a minority resident physician at BIDMC and also the Chair of the Diversity Committee. I have been working with Dr. Sean Kelly and the Graduate Medical Education office for the past seven months to revamp this committee.
The goal of our committee is to improve the recruitment and retention of under-represented minorities to BIDMC. We are part of a renewed effort by the medical center to increase diversity among the housestaff and faculty. We feel this will improve the strength of our medical center by allowing us to give improved care to our diverse patient population as well as to bring various perspectives to bear on our unified goal of delivering the best medical care in Boston. We will accomplish this by creating a supportive environment for underrepresented minorities through mentoring and recruitment. We also look to ultimately become involved in community outreach to underserved populations in the Boston area.
We recently invited Dr. Louis Sullivan, former Secretary of Health and Human Services and founding president of Morehouse School of Medicine, to speak at BIDMC about the Sullivan Commission Report and how our hospital and we as physicians could deliver better care to our patients through diversity and cultural competency.
We also participated in the Student National Medical Association (SNMA) Region VII Conference Recruitment Fair. During the fair we distributed information about the various training programs offered at BIDMC. We were able to interact with over a hundred minority medical students in New England.
While we strive to make an impact, we realize there may be limitations to what we can accomplish. As we are a committee made up mostly of residents, we must sacrifice our precious free time to attend meetings and activities of our committee. Because there are only a few of us, we can easily be stretched thin. We have to remember that our reason for being at BIDMC is to train to be the best physician and that must come first and we will be of no use to our community if we do not accomplish that goal first.
We also have financial constraints that limit the number of activities that we can do. We depend on the generosity of various departments, including the GME and the Community Benefits office, to fund our activities.
Delving further into the issue of diversity, there are many short term and long term goals that BIDMC should strive for if our hospital is truly focused on this cause. Thanks to blogs like this, we have accomplished the first goal, which is to recognize that our hospital is falling short on housestaff and faculty diversity. Now that the problem has been recognized, we can begin to discuss the reason for the problem, and solutions as well. We should look to get advice from our Harvard affiliates, MGH and BWH, to learn what they have done to address this issue. We should support our current residents and faculty and their efforts, including those of the Diversity Committee.
Other short term goals that we can accomplish include recruitment at minority medical student conferences (as we recently did at the SNMA conference) and becoming more active in the Visiting Clerkship Program (VCP) offered through HMS. We can actively recruit medical students to our hospital through the various interests groups at medical schools.
Our long term goals could include creating a full-fledged and adequately funded Office of Diversity, or Multi-cultural Affairs, at BIDMC. The goal of this office would be to recruit minority residents, physicians and researchers to BIDMC, ensure cultural competency of all physicians and address the healthcare needs of the underserved in our community.
As another blogger mentioned, the ceiling that everyone in healthcare hits is that there is a small number of minority physicians being produced each year. This corresponds to a small number of minority medical students and applicants to medical school. In order to truly increase diversity in medicine, we must address the reasons why there are only small numbers of minorities interested in medicine as a career.
We as a hospital should also develop “pipelines” to medicine that stretch beyond HMS and extend through the colleges and universities in Boston down to the high schools and elementary schools in the surrounding cities. The goal of the pipelines should be to increase the interest in medicine as a career and to provide opportunities to expose minorities to medicine. We can work with the minority student organizations at HMS and the pre-medical interest groups of colleges and universities in the area. We can send our physicians to the high schools to give talks on their careers. We can develop summer programs for interested students. We can continue to participate in programs like the Red Sox Scholars, which match BIDMC mentors with local underprivileged youths. Many of our doctors, nurses and staff participate in programs such as these, including our CEO. This work needs to continue.
We as a committee have a number of projects in planning with the hopes of increasing diversity of the housestaff at BIDMC for the better of our patients. Thanks to the GME and our active faculty and resident members, we are making small steps toward our goals.
The reason why I asked is because as you said foreign students have always been important contributors to research programs, however BIDMC is not taking care of them as it should. Every year BIDMC loses very successful researchers due to the lack of a career path and retention strategy. Some of them leave the institution taking with them very important awards including federal dollars which brings to BIDMC a 70% IDC.
In addition, some of BIDMC researches are not being compensated correctly due to the lack of a mandatory research salary structure. A researcher with 15 years of great academic and bench research track get paid less than a similar researcher with 5 years academic and bench research track.
I consider this a BIDMC culture; internal promotions are very difficult and sometimes imposable. BIDMC recruit external investigators almost without looking or considering our internal candidates.
Also, I would like to capture your attention that this not only happening at the research level, but at the entire institution.
LS
Sorry, but I don't see how that is consistent with what you said before: "I think it will be very interesting to include some Data showing how many of the clinical resident and researchers are foreigners. I think you will be surplice to notice that BIDMC research is running by foreigners."
In any event, though, I would like to learn more. Perhaps you can send me an email with details.
The first comment, Anonymous 6:10, has a wonderful point about how increasing diversity can improve health care: that is, under-represented minorities, by virtue of being representatives of a group or culture, are valuable assets to their institutions or workplaces. As a member of an "over-represented" minority, I can't help but be wary of superficial talk about diversity, but I believe you have established a meaningful and thoughtful dialogue here. Instead of arbitrarily saying "We need this number of under-represented minority physicians in order to achieve 'diversity'" (at the expense of replacing equally or perhaps more qualified majority or over-represented minority candidates), I think that it is much more useful to using Anon's positive reasoning to say, "We are searching for candidates that bring a variety of assets to our institution, including diversity of culture (which is currently in short supply)." In other words, it does not seem possible to solve the problem of a lack of diversity without acknowledging and reinforcing the value of diversity.
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