Thursday, December 06, 2007

Physician diversity -- Part I

As my loyal readers know, I don't hesitate to brag about BIDMC when I think we are deserving, but I also write about areas where we need to improve. This is one of those latter topics. I can't cover it all in one post, so I will follow up with more in coming days and weeks.

Here's the issue. If you were to look at the mix of patients here, it would feel like a mini-United Nations in terms of the racial mix. But, if you look at the medical staff -- full-fledged physicians, fellows, and residents -- it looks different, with under-represented minorities being a very small percentage of our trainees and attending physicians. (By the way, on the proportion of men and women, the story is better.)

This is a general problem in medicine nationally (with little progress notwithstanding well intentioned efforts). It is a bigger problem in Boston than other places, and I believe it may be a bigger problem at BIDMC compared to some other places in Boston. "Why here?" is the question I'd like to explore with you, and I'll give you real numbers and other facts in future posts, along with how we are trying to do better.

For today, let's start with the beginning of the physician pipeline. Harvard Medical School does quite a good job in recruiting a diverse entering class. Here is an article from a few years ago documenting this, showing about 19% minority admissions. Those students spend a lot of their time in the Harvard hospitals (BIDMC, MGH, Brigham & Women's, etc) doing their clinical rotations. I think it is fair to say that they love the time spent at BIDMC because we have great teachers and give them a great educational experience.

Then the students apply for residency programs. The minority students are in great demand, and they do very well in terms of the "match" process that characterizes the residency selection program. Many HMS graduates want to stay in Boston, but there has always been a tendency among them to seek the residency programs that have greater prestige. MGH in particular has always been viewed that way. But the other thing that happened here from 1996 on was the financial disaster following the merger of the BI and the Deaconess. For years, the local pool of HMS applicants that might have been interested in BIDMC, including the minority applicants, essentially dried up. Simply put, they feared that this hospital would not be around much longer. So the primary source of minority medical students that were most familiar with our hospital and comfortable with our faculty basically disappeared. And since residents serve as a major source of faculty recruits going forward, if this pipeline dries up, you start behind in terms of expanding the number of young minority faculty members.

With the financial recovery of the BIDMC and the reinvigoration of our clinical and education programs, we are back to being seriously considered by HMS graduates as they apply for the residency training. That should help. But it does not address the full range of concerns.

In the next postings, I will cover more of this topic and also will move up the pipeline and successively cover junior faculty, senior faculty, and chief-of-service issues.

16 comments:

Airwick said...

To me, as a patient, the diversity of the doctors and staff of the facility is completely irrelevant. The only thing that matters to me is competency! Can the doc/nurse/tech do the job? If so, then I will be happy.

By 'do the job' - I mean that their medical skills should be top notch and beyond reproach, they should have excellent bedside manner and service skills, they should make patients feel as comfortable through the process as possible (regardless of the patient's diversity status), and should be able to communicate effectively (without heavy accents or other language barriers).

If diversity happens by the natural forces of selecting the most qualified people, great. But otherwise, I would prefer that the process otherwise ignore diversity.

While diversity is a cause that most people (and the media) seem to cheer for, and I'm sure it helps the hospital in some survey or another, I'm not convinced that anything other than competency should matter in the hiring process of doctors, teachers, or any other profession.

As you continue posting on the topic, I would be very interested to hear you comment on why you feel diversity (in its own right) is something that should be prioritized. More specifically - why shouldn't the hiring process be color-blind, gender-blind, etc, and only focus on the ability to do the job?

Or - depending on how you are defining the words, is someone's diversity status somehow a component of their individual competency? And a corollary, even if the individual's diversity status doesn't affect their individual competency, what tangible benefits does a diverse staff bring to the hospital as a whole?

I'd love to have my mind changed by a clear, convincing argument.

Paul Levy said...

I don't think I will be able to change your mind, but I will set forth my beliefs. I think there is an inherent value in diversity. I also think there is a value to patients if, for no other reason, it can make them feel more comfortable to see more people of their race in a clinical setting. There may also be actual clinical improvements if patients and doctors are able to better relate to one another: I don't think we can ignore the fact that race can be a factor in such relationships.

I would agree with you that competence has to be a key determinant in selection of staff. In my HMS example, you can be pretty sure that all the graduates are competent.

Jon said...

As one of your residents, I'm looking forward to the rest of these posts. This is a very interesting topic.

I'd like to remind everyone that diversity has, ahem, diverse meanings. Race or ethnicity is only one component. As you mentioned gender is another. I would suggest sexual orientation is an important third. Not to mention religion, and perhaps even political leaning. Life experiences are also a large source of diversity, though hard to quantify.

I would also agree that diversity, for diversity's sake, has a value in the medical center.

In my program, I feel that we have a great diversity with regards to gender, religion, sexual orientation, geographic origin and certainly in life experience. However, ethnically, we are less diverse than on those other fronts. I am not sure why, but I have a couple ideas.

First, we have a pretty small sample size (roughly 30 people) so I might just be wrong based on statistics and small sample size.

Moreover though, I think that while HMS has a very large minority student population, most medical schools do not. In fact, I think its fair to compare it to the NFL, where the lack of African-American head coaches has been a topic of discussion for years. In that arena, it especially jarring, because most players are AA, but only account for around 10% of head coaches over the past few years.

Just quickly googling, I found some recent stats on medical student applications and admissions (http://www.aamc.org/data/facts/start.htm):

42,300 total applicants for 17,759 spots, meaning 42% get in.
48% of applicants were women, making up 48% of matriculants.

There were about 3245 african american applicants. That means 7.7% of applicants were AA. However 2005 data states that about 13.8% of the country is AA.

About 1,280 AA matriculants.
Meaning 39% get in, and they comprise about 7% of the medical student population.

My very quick analysis of this situation is that AA applicants get in at a slightly lower rate than the overall applicant pool. However, AA students apply to medical school at a MUCH lower rate than other ethnic groups. Glancing at the data it looks like a similar trend holds for hispanic-identifying students.

This means that any residency program attempting to get a mirror-image of the US population in regards to race and ethnicity will have a tough task, as the their applicant pool only has half of the AA graduates it would need to provide that mirror image.

I think this is a problem. The main solution seems to be to increase the number of minority applicants, and also to ensure that they are well prepared to succeed in their applications. Now, as to the myriad reasons for lower applications and how to help... well.. thats beyond this post.

My question to you: Do you have data on the ethnic/racial composition of the residency applicants to BIDMC's multiple programs? You surely have the data on your current residents. And you can easily get the data on the schools they come from. This can tell you where the recruitment sticking point is.

Looking forward to more!

Paul Levy said...

Thanks very much, Jon. Many good observations that help frame the issue better than I did. Stay tuned!

Anonymous said...

When you say diversity is reassuring to people, do you mean a black person should get a black doctor, a woman a female gynocologist, etc? Or just see people "like them" passing in the halls? I am not sure I get this. I agree with the comment on heavy accents. Often, in my experience, this comes up with hospitalists. At your most vulnerable--you're sick enough to be in the hospital--you cannot understand the stranger who is suddenly in charge of your total well-being.

Laura said...

Airwick,

I would love to try to give you that "clear, convincing argument" that can change your mind, but I probably can't give you the kind of evidence that you're looking for in the space of this blog comment.

So for why diversity matters in addition to competency, perhaps I can point you toward some of the literature out there about racial/ethnic disparities in health care. In 2003, the Institute of Medicine released "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" in which they reviewed over 100 studies and found that minorities are less likely than whites to receive needed services, even after taking into account access related factors (such as insurance status, patient income, etc). That report is well over 700 pages, but the IOM has put out report briefs on their website (~8 pages, so it's well worth the read).

Written for providers:
http://www.iom.edu/Object.File/Master/4/175/Disparitieshcproviders8pgFINAL.pdf

Written for consumers/patients:
http://www.iom.edu/Object.File/Master/4/176/PatientversionFINAL.pdf

They suggest several sources of health care disparities, including provider bias, prejudice, and stereotyping that affect the quality of care (e.g. diagnoses made, treatment plans) for minorities. The IOM point out that clinicians of course have patients' best intentions at heart. However, it's more complicated than that...here is an excerpt from the patient version of the report brief:

"But almost everyone stereotypes others, even though most people don’t even realize they do it. And, unfortunately, we live in a society that is still affected by negative attitudes between different racial and ethnic groups. So even people who would never endorse explicitly biased stereotypes – who truly believe that they do not judge others based on social categories – have been unconsciously influenced by the implicitly biased stereotypes in American society."

Anyway, I highly recommend reading those briefs. The ideas and evidence presented there may shape your conclusions about the links between diversity, competency, and medicine.

Paul Levy said...

To me, the desirability of having greater diversity is all so self-evident that I have trouble expanding on what I have said. Would anyone else like to comment?

Anonymous said...

Here's an interesting link regarding a gay patient which may provide some insight into diversity:

http://patients.about.com/b/a/000021.htm

Anonymous said...

I too think greater diversity is self-evident. In response to anonymous (10:51) -- I think it's not so much that a black person should get a black doctor, or a woman should get a female gynecologist, but that if I WANTED a black doctor, I should be able to find one. If I WANTED a female gynecologist, I should be able to find one. That said, if I am both black and female, and I think I would feel most comfortable with a black female gynecologist because I think she would understand me more than say, a white male doctor, then I should be able to find a black, female, gynecologist.

Diversity is not just about language barriers. Hospitals are all for patient-centered care right? In that case, why should some minority groups have less choice in doctors and less choice in their health care than others?

Istvan said...

I try in a very simple way. When you travel abroad and hear familiar language and see familiar faces, it makes you feel better or even safer. That is what everyone may feel when sees somebody like him or her. It is so evident.

jz-md said...

I'm a physician trying to understand the patient's preferences on this. Many, many, many times, patients specifically request a female doctor. I have never known a patient to ask for an AA or gay, lesbian doctor.

As a physician I believe the only diversity that matters is socioeconomic diversity. Physicians tend to be a very judgmental regarding the problems of the poor.

John Norris said...

If I'm treating someone not of my ethnicity* it would be great to be able to chat with someone who could better relate. A diverse staff and an environment that allows for that sort of discussion would be of benefit to all.

*By ethnicity I really mean class, sexual orientation, immigrant background, pretty any sort of way folks relate to the world.

Airwick said...

I'm enjoying reading the comments above, and just finished reading both the doctor and patient versions of the IOM report.

I found the lack of specifics in the report to be troubling. There certainly is a lot of work that needs to be done to continue to study these issues.

However - the main take away that I understood from reading those reports is that what is needed most is education, on both sides of the provider/patient relationship. Doctors need to better understand the intrinsic motivations and world views of their patients. Similarly, patients need to better understand how the medical system works, why compliance with the prescribed treatment is necessary, and how to reliably report and communicate the signs and symptoms of their condition.

Unless I am mistaken, the report did not suggest that the hiring of a more diverse staff should be the priority. Rather - a multi-facet approach to collecting more data and education seems to be their recommendation.

My reluctance to embrace the idea that hiring to meet the statistical diversity levels should be a priority is that it does nothing to improve the care provided by the non-minority providers. And yes, I admit that there is certainly some room for improvement.

I think most would agree that their are differences in how individual patients react to their interactions with the medical system. Some of those differences likely have a ethnic/racial/gender/other component, others are based on socioeconomic factors, others based on their past life experiences with doctors and the world at large, and others are just are a result of their own personality and learning style.

Continuing my original thoughts about competence as a primary factor - in my opinion any doctor that does not take ALL of these potential differences into account is NOT competent. In my opinion, even the best 'book smart' and technically proficient doctor is not competent if they cannot relate and communicate well to their patient.

Mr. Levy - as you continue on the subject, besides hiring and recruitment, I would very much like to hear more about how your institution is working on continuing education to improve the care offered by ALL of the providers to ALL of your patients.

Barbara Kivowitz said...

I am in violent agreement with Paul. The tremendous advantages a diverse medical staff brings to a health care institution are undeniable.

The more interesting question to me is why is it so difficult to achieve. The reputation of the hospital is one factor. I would also like to know:
How diverse is the board and the executive level? Is diversity a key strategic goal? Do managers at all levels have diversity objectives written into their performance measures? Are there real grievance systems in place and are they used successfully by the people who have grievances? Are diversity and diversity-conscious behaviors topics that are discussed at meetings and other forums? What is in place, beyond a few hours of diversity training, to help all hospital staff be aware and to make the hospital truly respectful and welcoming to a diverse staff? And, what can the hospital do to impact the community outside the hospital, politically, socially, and economically, to help Boston become a better environment for people who are traditionally marginalized?

I am not in any way implying that the hospital is neglectful in any of these areas. I am truly interested in learning more and look forward to your responses, Paul, to these questions.

I deeply appreciate that you raise this issue.

Paul Levy said...

Dear Airwick,

I have written extensively on that topic of quality improvement. See many, many posts below.

Barbara,

Please stay tuned on many of those topics. But also please remember that many of the decisions with regard to physician recruitment are not within the purview of the management. Physicians are not employees of a hospital.

Apollo said...

Looking forward to the rest of the series - this is a fascinating topic!