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					RECRUITMENT AND
RETENTION OF
UNDERREPRESENTED
MINORITIES IN
CARDIOVASCULAR
MEDICINE Michelle A. Albert MD, MPH
             Assistant Professor of Medicine
                 Harvard Medical School
             Brigham and Women’s Hospital,
             Divisions of Cardiovascular and
                   Preventive Medicine
                        Boston MA
UNDERREPRESENTED                                                  POPULATION PROJECTIONS
MINORITY = URM                                                    FOR THE UNITED STATES BY
                                                                    RACE AND ETHNICITY
  The AAMC
  defines URM as:




                                       Percent of US Population
  • Blacks
  • Mexican
  Americans
  • Mainland Puerto
  Ricans
  • Native American
  / American Indians
  • Native
  Hawaiians




Acosta and Olsen, Academic Medicine 2006
        CVD MORTALITY, RACE/ETHNICITY
                AND GENDER
                                         500

                                         450

                                         400
        Mortality Rate
                         (No./100,000)




                                         350

                                         300

                                         250
                                                                                                            Male
                                         200

                                         150                                                                Female
                                         100

                                          50

                                           0
                                               White   Black   Hispanic     American    Asian/Pacific
                                                                          Indian/Alaska   Islander
                                                                              Native

For Whites and Blacks – Data presented is overall CVD death rates for 2003.
                                                                                    American Heart Association. 2006. Heart
For Hispanics, American Indian/Alaska Natives and Asian Pacific Islander –          Disease and Stroke Statistical Update.
data presented is age adjusted death rate from heart disease, for 2002.
  CVD Mortality Rates,
Race/Ethnicity and Gender
     UNITED STATES, 1980-2001




                         Mensah et al, Circulation 2005;111:1233-1241
               IMPORTANCE
 Provide highest quality of care to all patients
 Ensure comprehensive research agenda
 Just and equitable access to rewarding careers
 Use of the rich and diverse pool of the nation’s
  talent to better manage the health care system
 Significant race/ethnic disparities in morbidity
  and mortality in USA
 URM will comprise a significant component of
  US population

                                   Adapted from Newman et al, Cancer 2003
         URM ENROLLMENT IN MEDICAL
                 SCHOOLS

Acceptance rates for URM and non-URM      Medical school matriculants, 1980-2000
                                          (expressed as a percentage of 1980 matriculants)
applicants to medical school, 1974-2001




                                                                     Francis et al, JACC 2004
Cardiologists in Training (2002):2223




  Source: Cardiology’s Workforce Crisis: A Pragmatic Approach
                35th Bethesda Conference-2003
Distribution of Cardiologists: 21, 726
           TOTAL: 21,726

            Asian                        Hispanic
            13%                             4% Black
                                                 2%




                             White and
                              other
                               81%


 Source: Cardiology’s Workforce Crisis: A Pragmatic Approach
               35th Bethesda Conference-2003
Developing Immediate Use Strategies for Increasing
         URM Cardiovascular Candidates




                  •   Recruitment
                  •   Retention
                  •   Screening
                  •   Barriers for specialty
                      choice and sustainability
BARRIERS TO URM ENTERING INTO
 SUBSPECIALTY (CARDIOLOGY)
• Lack of encouragement
• Lack of role models
• Lack of traditional training
  path (e.g. research
  experience)
• Lack of preparation (e.g.
  poor mentoring and
  feedback in residency,
  steps for corrective action)
• Debt
• Discrimination
Developing Immediate Use Strategies for Increasing
         URM Cardiovascular Candidates




               LEADERSHIP

               RESOURCES

                COMMITMENT
                RECRUITMENT STRATEGIES:
                    Institution Specific
• Identify barriers in the external environment of the program
   • Access non-medical URM professional/non-professional
     networking organizations
   • Faith based liaisons/collaborations
   • Everyday resources
   • Create a recruitment package to reflect the above/invite
     participation in the recruitment process by networking
     organizations

• Identify and address barriers in the internal environment of the
  program:
   • Examine URM trainee experiences on cardiovascular rotations:
       • Timely feedback
       • Minimize isolation
       • Resident self assessment

• Chairperson commitment to diversify program: “more than lip
  service”
     RECRUITMENT STRATEGIES:
         Institution Specific
• Proactive mentoring
  – Cardiovascular faculty
    actively engage URM medical
    students, new residents and
    fellows
  – Mentorship (recognition for
    role, $)
  – Funded positions
    (AHA/ACC/?Min. Org.)
                  RECRUITMENT STRATEGIES:
                          Systemic
• Target potential applicants at URM oriented conferences (e.g. NMA,
  ABC, ISHIB etc.)

• Conferences:

       • Joint sponsorship of URM trainees to AHA/ACC by
         AHA/ACC/Minority organizations

       • Biennial Conference for URM sponsored by AHA/ACC

                  » Target group: URM medical students, residents and fellows
                  » Others: senior faculty
                  » Topics to address:

       • Why choose a cardiovascular subspecialty
       • Emphasize diversity of career opportunities
       • Establish mentor-mentee (national/local) for those interested
       • Address how to prepare successful applications for cardiovascular fellowships (?
         additional clinical / research experiences required)
       • Conference self assessment
      Recruitment: Conferences cont’d

• ACC/AHA should engage URM trainees in society
  activities early on (e.g. travel awards, mentorship,
  race/ethnic population committees)
        RECRUITMENT STRATEGIES:
                           Systemic

• Target historically URM institutions – create an alliance
  between selected URM institutions and traditional
  majority institutions

   – Choose a consortium of non-URM institutions in different
     categories (private/state)
   – Each majority institution commits to a “pre-defined URM
     representation goal” at 5yrs; 10 yrs.
   – Faculty advisors that includes cardiovascular dept. chairs and
     deans of medical schools
   – Co-mentored opportunities
   – Research opportunities
                 RETENTION

•   Mentorship
•   Inclusive environment
•   Faculty
•   Examine how to develop URM leaders in
    academic medicine
A LOOK AT ACADEMIC FACULTY PROMOTION


 Assistant professors: RR=0.68 (0.59-0.77)
 Associate professors: RR=0.81 (0.65-0.99)




URM – Underrepresented minority, including black, Mexican American, Puerto Rican, Native Americans and Native Alaskans.
                                                                                                      Fang et al, JAMA 2000;284:1085-1092
            PREDICTORS OF PROMOTION

              Characteristic                          Assistant Professors, RR                 Associate Professors, RR
  Race/Ethnicity
    Asian                                                                  0.91*                                0.97
     URM                                                                   0.68*                               0.81*
     Other Hispanic                                                        1.03                                 0.92
  Sex – Male                                                               1.21*                               1.12*
  Tenure Status – Tenure                                                   1.56*                               1.54*
  NIH Awards
     RO1                                                                   1.68*                               1.63*
     Other                                                                 1.36*                               1.16*




URM – Underrepresented minority, including black, Mexican American, Puerto Rican, Native Americans and Native Alaskans.
* Statistically significant - 99% confidence interval does not cross 1.0
                                                                                                      Fang et al, JAMA 2000;284:1085-1092
MINORITY FACULTY HOLDING SENIOR RANK

                                                                          OR
                                                                                             P value
                                                                       (95% CI)
                                                                                   Model 1
          Black                                                     0.33 (0.17-0.63)          <0.001
          Hispanic                                                  0.36 (0.12-1.08)            0.07
          Asian                                                     0.58 (0.30-1.12)            0.10
                                                                                   Model 2
          Underrepresented minority                                 0.29 (0.16-0.54)          <0.001
          Non underrepresented minority                             0.64 (0.34-1.20)            0.17




Underrepresented minority = black, Mexican American, Puerto Rican


                                                                                             Palepu et al, JAMA 1998;280:767-771
                         Academic Activities and Productivity
                                                              White           Black            Asian            Hispanic
                    Characteristic
                                                            (n=1463)         (n=154)          (n=136)            (n=54)
  Time spent in the following, %
    Patient care                                                 31.8            39.9            32.3              39.1
    Administration                                               18.4            20.5            16.0              13.1
    Teaching                                                     19.9            20.5            17.6              19.3
    Research                                                     29.3            18.5            33.2              26.8
  Hours per month in committees, mean (SD)                   13.0 (17.8)     13.7 (18.0)     14.0 (17.9)        10.8 (17.2)
  Felt pressure to serve in committee because of
                                                                 1.9             49.4             7.4              35.2
  race or ethnicity, %
  Current research support, %
    Government†                                                  65.8            64.0            55.8              64.3
    Private Foundation                                           46.1            44.0            58.1              50.0
    Industry                                                     37.7            40.0            39.5              35.7
  Number of publications, median (IQR)
    First author                                              10 (2-20)        2 (0-7)         6 (1-15)         4.5 (1-12)
    Any author                                                18 (4-45)        4 (0-15)       10 (2-30)         12.5 (2-29)
† Includes Grants from the NIH, Agency for Health Care Policy and Research, Health Care Financing Administration, Veterans’
Affairs, Military and other federal, state and local government sources

                                                                                            Palepu et al, JAMA 1998;280:767-771
        Demographics, Specialty Choices and Compensation:
                      1,807 Full Time Faculty
                                                                    Majority         URM              Other Minority        P value
                                                                    Faculty          Faculty          Faculty
                                                                    (n=1,463)        (n=195)          (n=149)
Female, %                                                           51               38              57                    .002
US born, %                                                          87               73               19                    .001
Professional father, %                                              63               47              62                    .001
Board certified, %                                                  94               87              91                    .016
PhD or MD/PhD, %                                                    41               22              39                    .001
Department affiliation
  Primary care, %                                                   34               38               33
  Medical specialty, %                                              19               33               21
  Surgical specialty, %                                             20               17               18
  Basic Science, %                                                  27               11               29
Time in
  Patient care, %                                                   32               40              32                    .001
  Research, %                                                       29               20              33                    .001
Adjusted mean compensation, $                                       108,000          112,000          102,000               .21
Need to supplement income, %                                        41               61              41                    .013
Finances affect professional career development choices, %          40               60              36                    .001
 URM   Faculty differed significantly from majority and other-minority faculty on pairwise testing    Palepu et al, Academic Med 2000
           BRIGHAM AND WOMEN’S HOSPITAL:
             SENIOR FACULTY EXPERIENCE
                          Strategies to improve URM faculty leaders
•   Training of search committees to recognize        •   Serving as co-investigators in clinical trials
    and address bias in the search process;               with established investigators; Providing an
    Policy statement on this issue                        opportunity to author manuscripts

•   Providing assistance in obtaining skills          •   Improve minority representation in clinical
    necessary to attract NIH/Industry support             trials and cohorts

•   Ability to take ownership of academic             •   Formal training in clinical investigation /
    component of clinical trial (sub-                     clinical trial design
    study/ancillary analysis) and take it to
    completion (high quality manuscript)
                                                      •   Building relationships with clinical/industry
                                                          leaders through formal and informal
•   Identification of individuals for steering            symposia
    committee and other leadership roles
                                                      •   Established investigators should take the
•   Ongoing and equitable financial support in            lead in introducing and reinforcing the
    both early and mid-years                              recognition of minority faculty within their
                                                          senior peer group of investigators;
                                                          Regional/national exposure for highly
•   Address the larger problem – commitment to            qualified individuals
    higher quality public education at the earliest
    levels, and providing true equal opportunity
                                                      •   Affiliation with a large research group
                                                                                             Albert, MA 2007
         TEMPLATES FOR SUCCESSFUL
         RETENTION OF URM FACULTY
• UCSD Hispanic Center of Excellence (HCOE):1993
• National Center for Leadership in Academic
  Medicine (NCLAM):1998

• Data:
   – Number enrolled = 140 junior faculty
   – Number completed = 112 junior faculty
   – URM =13.4%
   – Others 86.6%
• Following the institution of NCLAM, URM junior
  faculty retention in academic medicine went from
  75% (1991-1996) to 93% (1999-2005)*
* Not statistically significant     Daley et al, J Natl Med Assoc 2006
                NCLAM: Activities Required
• 12 half-day faculty development workshops on goal setting and preparing
  the academic portfolio, principles of teaching and learning, leadership
  styles, negotiation skills, stress, grant resources, conflict resolution,
  presentation skills etc

• Structured 7-month , one on one instrumental mentoring program
  (averaging 12 hours/month)

• Two hour academic performance counseling session

• A professional development project
                 THE SEVEN “        P ”RINCIPLES
    STRATEGIES FOR INCREASING MULTICULTURAL
                 INVESTIGATORS

•P atient Care & P opulations
•P ipeline – nurture, develop and promote mature investigators

•P rocesses – understanding how selection occurs

•P ositioning / P osturing – networking

•P redicting P riorities – understand NIH/Industry research priorities

•P ressure Application

•P ersonal Economics
                                                           Albert, MA 2007
   Need for Program Assessment
 Create databases to track the success of
  programs designed to promote URM
  faculty retention

 Public reporting of institution performance
  (all / top NIH$)
THE OFT FORGOTTEN GROUP:
UNDER-REPRESENTED MINORITY WOMEN
    DISTRIBUTION OF US MEDICAL SCHOOL
                 FACULTY




%




                     Wong et al, J Women’s Health & Gender-Based Medicine 2001
    Landscape for URM Women Faculty

• Slower growth in faculty positions than other
  women
• Most of growth in historically black medical
  schools
• Connections to larger women’s initiatives
  weak
• Significant financial obstacles
Thank you

				
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