Minorities in Academic Healthcare

Career Education and Enhancement for Health
  Care Research Diversity (CEED) Program

   University of Pittsburgh School of Medicine
               November 27, 2007
Stephen B. Thomas, Ph.D.
       Philip Hallen Professor of Community
               Health & Social Justice

         Director, Center for Minority Health
         Graduate School of Public Health
               University of Pittsburgh

1. Racial differences in perceptions of
   disparities in healthcare

2. Evidence of racial/ethnic health disparities

3. Ethnic and racial diversity of the US
   population and of healthcare professionals

4. Strategies for effective cross-cultural
  Do you think the average African American is better off,
  worse off, or just about as well off as the average white
        person in terms of access to health care?




  40                                          Better Off
                                              About the Same
  30                                          Worse Off
  20                                          No Opinion


               Whites   African Americans
Source: Morin, 2001
Accepting Evidence
 Unequal Treatment:
Confronting Racial and
  Ethnic Disparities
    in Healthcare

      Institute of Medicine
  Media Response to Unequal Treatment

New York Times, March 22, “Subtle Racism in Medicine”

“ . . . a disturbing new study by the Institute of
Medicine has concluded that even when members of
minority groups have the same incomes, insurance
coverage and medical conditions as whites, they
receive notably poorer care. Biases, prejudices and
negative racial stereotypes, the panel concludes, may
be misleading doctors and other health
Eliminating Health Disparities Among Racial and
           Ethnic Minority Populations

    •   Infant Mortality
    •   Cancer Screening and Management
    •   Cardiovascular Disease
    •   Diabetes
    •   HIV Infection
    •   Adult and Child Immunization
    •   Mental Disorders
     Centers for Disease Control and
      Prevention’s Guiding Principle

"…The future health of the nation will be
 determined to a large extent by how
 effectively we work with communities to
 reduce and eliminate health disparities
 between non-minority and minority
 populations experiencing disproportionate
 burdens of disease, disability, and
 premature death― [2007]
    Council on Education for Public Health

For more than a decade the accrediting CEPH
has mandated that schools of public health
should reflect the diversity of the regions in
which they are located. CEPH looks for
evidence of an institutional commitment to
diversity in mission statements and goals, and
expects to see plans implemented for the
recruitment of diverse faculty and students
(CEPH, 2005).                                  10
The shortage of minority health professionals
in the U.S is a long-standing problem.
According to one national report, African
Americans, Hispanic Americans, and
American Indians as a group account for
almost 25 percent of the U.S. population, yet
represent less than 9 percent of nurses, 6
percent of physicians, and only 5 percent of
dentists (Sullivan, 2004). This
underrepresentation of minority health
professionals is also reflected in the faculty
profiles of schools of the health sciences. 11
               US Population by Race and Ethnicity
                                                                      American Indian & Alaskan
                                   Black                                      Native
                                   13.4%                                      1.5%


                                                                                              Native Hawaiian & Other
                                                                                                  Pacific Islander

          Non-Hispanic White                                                                   Hispanic
                66%                                                                             14.4%

US Census Bureau. Available at: http://www.census.gov/Press-Release/www/releases/archives/population/006808.html   12
Accessed March 2, 2007.
             Physicians by Race/Ethnicity 2004




                            Native/Alaskan                                  Black
                               Native      Asian                             2%
                               0.06%                     Hispanic
    N=884,974 physicians.

American Medical Association. Available at: http://www.ama-assn.org/ama/pub/category/12930.html.
Accessed March 6, 2007.
                 US Registered Nurse Population
                     by Race and Ethnicity
                                                                                  American Indian or
                                                               Hispanic            Alaskan Native
                                       Asian or Pacific Islander 2%                     0.4%
                                                                                         Two or more races


     N = 2,380,639.

US Department of Health and Human Services, Health Resources and Services Administration.
Available at: http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm.             14
Accessed March 25, 2007.
              Professional Pharmacy Degrees
                   Conferred 2004–2005

                           Asian Americans

                     American Indian
                         Hispanic                                                      Caucasians
                            4%                                                         61%



American Association of Colleges of Pharmacy. Available at:
http://aacp.org/site/view.asp?TRACKID=&VID=2&CID=1285&DID=7369. Accessed March 25, 2007.
September 2004   16
Barriers Encountered by Minority Junior
      Faculty in the Health Sciences

• Being treated as a ―token hire‖ by their
  White peers (Potts, 1992; Turner & Myers,
  1999; Laden & Hagedorn, 2000);

• Experiencing racial discrimination and bias
  (Johnsrud & Sadao, 1998; Peterson et al.,
  2004; Price et al, 2005; Turner & Myers,
             Barriers Continued:
• Feelings of loneliness and isolation (Laden &
  Hagedorn, 2000; Turner & Myers, 1999);

• Difficulty in obtaining research funding
  (Antonio, 2002); a ―chilly climate‖ on campus
  (Turner & Myers, 1999);

• Being treated as ―ethnic specialists‖ by their
  colleagues—that is, being treated as experts
  on minority matters rather than as experts in
  their chosen fields (Garza, 1988).            18
• Some minority faculty expressed the feeling
  that their White colleagues devalue the
  quality of their scholarship (Fenelon, 2003;
  Thomas & Hollenshead, 2001; Turner &
  Myers, 1999).

• When minority faculty conduct research and
  publish in fields related to social justice or in
  fields that serve their communities. The
  White colleagues of these minority faculty
  often view this kind of scholarship as self-
  serving or too ―subjective‖ (Bernal &
  Villalpando, 2002).                              19
               Research Productivity
Several studies have documented a powerful
association between post-doctoral research training
fellowships and subsequent research productivity in
academic medicine (Kupfer et al. 2002; Kelley &
Randolph 1995; Pincus et al. 1995; Reynolds et al.
1998, 2003; Fischer & Zigmond 1998). The two factors
most consistently associated with dedicated research
status are having had a mentor and having spent at
least two years in a research-oriented post-doctoral
experience. Characteristics of successful post-doctoral
training programs also include personal contact with
senior investigators, an excellent mentoring
relationship, and an academic institution with a critical
mass of senior investigators.
            Institutional Support Matters

The literature on the recruitment and retention of
minority faculty makes a strong case for mentoring
and post-hiring support (Padilla, 1994;CEPH 2006;
Sung 2003; Reynolds et al. 1998). In describing the
need for post-hiring support, Smith (2000) states that
―….the isolation, disinterest in diversity, and racism
that new minority faculty may suffer make getting
tenure a very challenging task.‖ Phillips (2002)
suggest that institutions offer mentoring programs,
support for teaching development and research
funding as post-hiring career development strategies.
         Institutional Support Matters, Cont.

Fischer & Zigmond (1998) asserted that universities
must ―…offer these individuals strategies for coping
with the present demands of scientific life if we are to
increase their participation in all fields of research‖.
   The Summer Research Career Development
 Institute in Minority Health and Health Disparities

We have conducted and evaluated two Summer
SRCDI cohorts in collaboration with Jackson State
University EXPORT Center faculty. The SRCDI is
designed to further educate emerging minority
investigators concerning the ―research survival skills‖
required to be successful in securing faculty
appointments, independent funding and promotion.
The need for strategic career planning and guidance
arises to assist them to achieve funding for their
research as a basis for promotion and tenure.
      Lessons Learned from the Pittsburgh SRCDI

•   Being a trainee or junior faculty member at a major
    institution does not automatically mean that someone
    ⎯ a mentor, a senior faculty member, or even a
    colleague ⎯ will tell you what is necessary for
    success or impart the skills required to succeed.
•   The participants viewed the nurturing offered during
    the Institute as highly valuable.
•   Despite the heterogeneity of the group’s scientific
    interests, there were crosscutting themes related to
    career development needs addressed by the SRCDI.

   News Alert: October 24, 2007
    I am pleased to announce the appointment of Paula
   Davis, M.A., to the newly-created position of assistant
   vice chancellor for diversity for the Schools of the
   Health Sciences, effective November 1, 2007. In her
   new position, Ms. Davis will be responsible for working
   with all six health sciences schools (Dental Medicine,
   Health and Rehabilitation Sciences, Medicine, Nursing,
   Pharmacy, and Public Health) on planning,
   implementing, and monitoring diversity recruitment and
   retention efforts for students and faculty.

Arthur S. Levine, M.D.
Senior Vice Chancellor for the Health Sciences
Dean, School of Medicine
                    Cross-Cultural Communication

                                            •    Expectations
                                            •    Agendas
           Provider                                             Patient
                                            •    Concerns
                                            •    Meanings
                                            •    Values

Carrillo JE et al. Ann Intern Med. 1999;130:829–834.                      30

      • Culture consists of shared values, beliefs,
        and learned patterns of behaviors.

      • Culture is shaped by various factors such
        as proximity, education, gender, age, and
        sexual preference.

Carrillo JE et al. Ann Intern Med. 1999;130:829–834.
                        Cultural Groups


                                         Social                     Religious

US Department of Health and Human Services, Office of Minority Health. National Standards for Culturally
and Linguistically Appropriate Services in Health Care. Final Report, March 2001. Washington DC: US Dept of Health   32
and Human Services Washington, DC; 2001.
                                 Cultural Competence

                              The ability to understand
                              and respond effectively
                              to the cultural and linguistic
                              needs of patients during the
                              healthcare encounter

US Department of Health and Human Services, Office of Minority Health. National Standards for Culturally             33
and Linguistically Appropriate Services in Health Care. Final Report, March 2001. Washington DC: US Dept of Health
and Human Services; 2001.
                                 Patient-Centered Care

                        Care that respects and responds
                               to individual patient
                         preferences, needs, and values

Institute of Medicine. Available at: http://books.nap.edu/catalog/10027.html. Accessed April 2, 2007.   35
          Factors That Impact Patient-Provider
          Communication in the Clinical Setting

Communication Patient-Provider                                                                  Models of
   Styles     Communication                                                                     Illness and

Ngo-Metzger Q et al. Cultural Competency and Quality of Care: Obtaining the Patient’s Perspective.
The Commonwealth Fund; October 2006. Commonwealth Fund publication 963.
       Patient-Provider Communication Styles

                            Verbal                                             Nonverbal

               • Directions                                             • Body language
               • Information                                            • Facial expressions
               • Clarification                                          • Gestures
               • Reassurance
               • Agreement
Ngo-Metzger Q et al. Cultural Competency and Quality of Care: Obtaining the Patient’s Perspective.   37
The Commonwealth Fund; October 2006. Commonwealth Fund publication 963.
    Explanatory Model of Illness and Disease

            The meaning of the illness for the patient

          CAUSE                     SEVERITY           PROGNOSIS

             = How the illness impacts the patient’s life

Carrillo JE et al. Ann Intern Med. 1999;130:829–834.
                           Negotiating Treatment

           Issues to Consider:

           • The patient’s explanatory model
           • Role of the family in decision-making
           • Use of complementary and
             alternative medicine (CAM)

Misra-Hebert AD. Cleve Clin J Med. 2003;70:289, 293, 296–298.   39
                        Patients’ Perceptions of the
                            Healthcare System

                                          Minority patients


1. Cooper LA et al. Ann Intern Med. 2003;139:907–915.
2. Johnson RL et al. J Gen Intern Med. 2004;19:101–110.       40
                             Communicating Across
                               Linguistic Barriers

             US Limited English Proficient Population

           2000: 7% of the population (21.4 Million)

           2010 (projection):10% of the population
                             (28.4 Million)

US Census Bureau. Available at: http://www.census.gov/Press-Release/www/releases/archives/population/006808.html   41
Accessed March 2, 2007.
                          Challenges of
                   Cross-Cultural Communication

        • Minorities in ethnic-discordant
          relationships with physicians report a
          negative perception of the healthcare
        • It is impractical to learn every aspect of
          each culture that could influence the
          clinical encounter.2

1. Johnson RL et al. J Gen Intern Med. 2004;19:101 - 110.   42
2. Carrillo JE et al. Ann Intern Med. 1999;130:829 - 834.
                  Becoming Culturally Competent

                                    Four Dimensions:
                                     • Knowledge
                                     • Attitudes
                                     • Skills
                                     • Behaviors

Beach MC et al. The Role and Relationship of Cultural Competence and Patient-Centeredness in Health Care Quality.   43
The Commonwealth Fund; October 2006. Commonwealth Fund publication 960.
     Cultural Competence Training Programs

    Perception                      Individuals from diverse                              to symptoms,
    of health                         cultures and beliefs
                                            systems                                       diseases, and
    and illness

Liaison Committee on Medical Education. Available at http://www.lcme.org/functionslist.htm. Accessed May 20, 2007
                  Cultural Competency Training:
                   Implementation Challenges

                             • Educational Barriers

                             • Professional Barriers

Hobgood C et al. Acad Emerg Med. 2006;13:1288–1295.
              A Balance: Avoiding Stereotypes

            Acquiring                                                          attitudes and
           knowledge                                                             skills not
            of specific                                                       specific to any
          cultural groups                                                       particular

Beach MC et al. The Role and Relationship of Cultural Competence and Patient-Centeredness in Health Care Quality.
The Commonwealth Fund; October 2006. Commonwealth Fund publication 960.
                        Steps Toward Successful
                      Provider Cultural Competency

                 • Personal self-reflection
                 • Avoiding stereotyping

Like RC et al. Available at: http://www.stfm.org/corep.html. Accessed March 6, 2007.   47
                   Cultural Competency Training:
                            Critical Steps

               ―…valid measures of competence are
               used to assess progress and guide

                    Connecting training with clinician
                    behavioral changes and these with
                    patient outcomes

1. Hobgood C et al. Acad Emerg Med. 2006;13(:1288 - 1295.
2. Thom DH et al. BMC Med Educ. 2006; 6:38.

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