Quotes from Diversity in Medicine: A Physicians' Perspective

“Diversity represents the individuality of oneself. ... its interpretation lies in the eye of the beholder... The attributes of oneself will be “different” or “similar” depending on the reference point and the prevailing status”

“Coexistence of people of different races, ethnicity, gender, sexual orientation, socioeconomic status, age, physical abilities, religious beliefs, political beliefs or ideologies or other ideologies in the same space with reciprocated understanding and empathy between these groups.”

“a breadth of life experiences, dictated by everything from physical appearance to religion, ethnicity, age and geographic or cultural background."

“melting pot of ideas, cultures,

and ways of life

in which each is represented equally.”

“differences based on racial or ethnic backgrounds, sexual orientations, religion, etc.

but also... more subtle things we don't see... 

(things like socioeconomic status, political beliefs, family upbringing). ”

“. Everyone has something to contribute.

...diversity gives us wisdom and strength.”

“... can help expand ones own thinking

…one can never fully appreciate or understand what others have went through because they themselves never experienced it....

we all can become more enlightened by listening to each other and improve ourselves ”

Diversity in Medicine: A Physicians' Perspective

Challenges of

Diversity in Medicine

Recruitment

Medical School top reported barriers to URM recruitment:

Retention/Promotion in Academic Medicine

• Educational:

low MCAT score (90%)

low undergraduate GPA (60%)

• Socio-cultural:

absence of role models (77%)

lack of peer/community support (45%)

• Financial/economic:

lack of financial aid (48%)

parental income (39%)

• Recruitment/admission:

not enough minority faculty members (71%)

Agrawal J, et al. J Natl Med Assoc 2005;97:1226-31

Themes identified

• Diversity related activities:

Personal commitment

Institutional pressures

• Increasing diversity as an institutional priority:

Gap between intention and implementation

• Discrimination:

Detection and reaction

• Mentorship:

Significant needs and limited choices

Mahoney MR, Wilson E, Odom, KL, Flowers L, Adler Shelley. Acad Med. 2008 August; 83(8): 781-786.

Impact of Diversity in Medicine

Provider

Patient

access and utilization of care

understanding

social determinants of health and population health

health

outcomes

medical

decisions

perception of quality of care

cultural competency

“Diversity underlies the differences in the way we

hear patients’ stories, approach problems, speak and interpret the same information."

Facing the Challenges of Diversity in Medicine

OBJECTIVES

Experiences of Diverse Physicians Working Together

"While we live this reality daily, sometimes I struggle with how this moves the conversation about diversity forward. "

• Define diversity
• UPMC IM resident perspective
• Formal definition

• Share resident experiences with diversity
• Working with colleagues
• Recruitment
• Caring for diverse patients

“there’s a negative connotation to being a white heterosexual male physician when we talk about diversity, particularly

when providing care in underserved or diverse populations –

I think in practice if you’re a caring person and approach the job with sincerity, it doesn’t matter much

– but there is a reverse bias it seems”

Reflection Questions

Were you surprised by the resident quotes? Why or Why not?

Have you ever been discriminated against or witnessed a resident being discriminated against? Has a resident ever come to you to discuss a discriminatory encounter? If so, how did you respond?

What makes you diverse? How have those characteristics impacted you when- caring for patients? working with colleagues?

How often do you consider how others are impacted by their differences?

What do you do to become more aware of your biases?

Importance of

Diversity in Medicine

History of Diversity in Medicine

2000s

1970-1990s

1840-1960s

2004: AAMC clarified definition of URM to

“those racial and ethnic populations that are

under-represented in the medical profession relative to their numbers in the general population.”

1847: The first African American- Dr. David Jones Peck- graduated from American medical school

Backlash against affirmative action resulting in stagnation in enrollment for minorities

1949: The first woman- Dr. Elizabeth Blackwell-graduated from US medical school

“I’m a Christian, and while I have my own questions of faith and beliefs – I think the question of faith is challenging when working with such bright people, many of whom are atheists.  On more than one occasion, particularly in end of life discussions, patients with strong beliefs or those “hoping for a miracle” are portrayed as difficult or made fun of”

1960

2000

1800

1970

URMs for the Underserved

1960-1970s

1990s- 2000s

1991: AAMC “3000 by 2000” initiative

How Diversity Makes Us Smarter

2003: AAMC defines under-represented minority (URM) to consist of 4 groups-

Initiative to increase representation of

minority medical students

• Blacks

• Mexican-Americans

• Native Americans (American Indians, Native Alaskans and Hawaiians)

• Mainland Puerto Ricans

1968: AAMC created a task force to

address minority enrollment

Being around people who are different from us makes us more creative, more diligent and harder-working.

• URM matriculates in 2005-2015 reported interest in practicing in underserved areas

• URM physicians care for more minority and non-English speaking patients with poorer health status in medically underserved areas

• URM physicians have been shown to have better health outcomes and patients’ perception of care

Number of US Medical School Applicants by

Race and Ethnicity, 1977-2011

Diverse groups are better at

• solving complex, non-routine problems
• preparing to anticipate alternative viewpoints, and
• expecting that reaching consensus will take effort

DI·VER·SI·TY

Phillips, KW. Scientific American. October 2014.

Diversity in Medical Education: Facts & Figures 2016, the 19th report

Marrast et al. JAMA Intern Med 2014.

Walker KO, et al. J Natl Med Assoc. 2012

Cooper LA et al. Ann Intern Med 2003;139:907-915

Figueroa O. Med Educ Online 2014, 19: 24891

/dəˈvərsədē, dīˈvərsədē/

Humanism of

Individuality & Sameness

Context

Coexistence & Appreciation of a Spectrum of Differences

“The more time I spend traveling and in medicine,

the more I realize how fluid the concept of diversity is."

“The key is understanding that it is dynamic,

it is constantly changing nature"

 “… It’s all about the different ways that we are or express being human.

Diversity flows from an undercurrent of same-ness. 

It's not about everybody looking or acting in the same way, but

many unique ways of being a loving, communal person.”

“Diversity underlies the differences in the way we

hear patients’ stories, approach problems, speak and interpret the same information."

“… encompasses acceptance and respect.

It means understanding that each individual is unique,

and recognizing our individual differences. 

These can be along the dimensions of race, ethnicity, gender,

sexual orientation, socio-economic status, age, physical abilities, religious beliefs, political beliefs, or other ideologies. 

It is about understanding each other and

moving beyond simple tolerance

to embracing and celebrating the rich dimensions of diversity contained within each individual"

Associated Students of the University of Oregon

Unconscious

(Implicit)

Conscious

(Explicit)

Hoffman W et al. Personality and Social Psychology Bulletin. 31(10):1369-1385

BA Nosek. Journal of Personality and Social Psychology, 74, 1464–1480

https://diversity.ucsf.edu/resources/unconscious-bias

Physician Demographics

Percentage Of Underrepresented Minorities Among Medical School Matriculates and in the U.S. Population, 1950–2001

Patient Demographics

Jordan J. Cohen et al. Health Aff 2002;21:90-102

Diversity in Medical Education: Facts & Figures 2016, the 19th report

2015 Matriculates to US Medical Schools:

Parents’ combined gross income by race/ethnicity

2015 Matriculates to US Medical School:

Amount of premedical educational debt by race/ethnicity

Census.gov July 1, 2015

• Majority come from middle and upper income families

• URMs are more likely to have parents with a gross income under $50,000
• Black/African American (31%)
• Hispanic or Latino (29%)
• Asian (16%)

• Majority have no premedical education debt

• URMs have $25,000 or more non-medical school educational debt
• Black/African American (40%)
• Native Hawaiian/ Other Pacific Islander (34%)
• American Indian/ Alaska Native (30%)
• Hispanic or Latino (23%)

Medical School Graduates

Medical School Faculty

Percentage of full-time US Medical School Faculty by sex, race and ethnicity, 2015

Percentage of US Medical School Graduates by Race and Ethnicity, 2015

Lessons Learned...

7.1%

• Disparities do exist for women and URM
• Addressing it could improve upon some but not all aspects of diversity

19.8%

5.7%

4.6%

• Data limited by how diversity is defined

Percentage of US Medical School Graduates by Sex, 1980- 2015

58.8%

• Main focus: sex and race/ethnicity and attempts to address socioeconomic status

• Does not address: physical abilities, religion, sexual orientation, immigration, ideologies, life experience, etc.

• Males represent more than 60% of Whites, Asians, and multiple race
• Women are the majority among Blacks/African Americans (54.5%) and other race (53.8%)

• Female graduates have increased by 104%
• Male graduates remain the majority in 2015 with 52.4%

Experiences of Diverse Physicians

Caring for Diverse Patients

Experiences of Diverse Physicians

and Recruitment

"I always, always wear my white coat to signify that I'm a physician, since otherwise (esp. with scrubs), people think I'm a nurse when they first meet me.”

“While working in the Birmingham Clinic a middle age Hispanic woman became overjoyed and a bit tearful when I stated that I am one of the physicians at UPMC. She stated how wonderful it was to see a son of immigrants as a physician here in Pittsburgh.” 

“While taking care of a patient ... my intern and I (both women) introduced ourselves as the doctors... and then introduced the medical student (a man). The patient said "Yea so, I'm really gonna have a hard time calling you doctor" to my intern and I. He then proceeded to call the male medical student "Dr."

“A patient asked me for advice on his mood swings because "you are a woman and

women are extremely emotional

so you must deal with this all the time."

“when interviewing for residency and fellowships a few programs made a spectacle of 'diversity'. While other applicants were interviewing with people who had research or specialty interests that matched theirs

I was frequently paired with someone who only had one thing in common with me - darker skin. This made me feel like this was the only part of me that was important to [them].”

“because of my darker skin...I am very frequently reminded that others see me as "different"... patients will comment with ...

"What exactly are you?", "Your people have come so far, good for you!"”

“I was once told by a patient

"that people like you have it a little easier to get into medicine now.

It's hard these days for white men to get anything."

“as an intern there was a patient who, on rounds, when assessing orientation was asked "Who is the President?" to which the patient replied with a racial slur in reference to President Obama. Everybody seemed very uncomfortable but no one said or did anything."

“as a third year student ... a sick elderly white male veteran would not let me assess him because of my skin tone. He would often make comments-- " I killed someone who looks just like you" even while on rounds.”

“the patient... took one look at me when I walked in the exam room and exclaimed “Oh, hell no, I ain’t gonna be examined by no little girl Jackie Chan.” I was stunned.”

“In medical school very few physicians looked like me, I definitely wanted to be in a place [for residency] where there was more diversity and where I did not feel like a token representation for my race.”

Algorithm to Consider a Patient’s Request for Physician Reassignment Based on Race or Ethnic Background in an Emergency Setting

Paul-Emile K, et al. NEJM 2016; 374:708-711

Etsemaye P. Agonafer MD, MPH

2017

References

QUESTIONS

Special Thanks to...

All of the residents who shared their perspectives

Dr. Eloho Ufomata

Drs. Peggy Hasley, Gaeten Sgro, Meshe Chonde, Nick Duca, Molly Fisher and Emily Guhl

Dr. Shanta Zimmer

UCLA/CDU PRIME, Cohort 2

• Drs. Kene Ojukwu, Antonette Ajayi-Johnson, and Angelico Razon

Were you surprised by the resident quotes? Why or Why not?

Associated Student of University of Orgeon.- Diversity Initiative http://gladstone.uoregon.edu/~asuomca/diversityinit/definition.html

Hoffman W et al. Personality and Social Psychology Bulletin. 31(10):1369-1385

BA Nosek. Journal of Personality and Social Psychology, 74, 1464–1480

https://diversity.ucsf.edu/resources/unconscious-bias

AAMC. Underrepresented Minority Definition. https://www.aamc.org/initiatives/urm/

Bergen, Jr SS. Underrepresented Minorities in Medicine. JAMA. 2000;284(9):1138-1139. doi:10.1001/jama.284.9.1138

http://jamanetwork.com/journals/jama/article-abstract/193031

Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000—Racial and Ethnic Diversity in US Medical Schools. NEJM 1994; 331:472-476

Figueroa, O. The significance of recruiting underrepresentd minorities in medicine: an examination of the need for effective approaches used in admissions buy higher education institutions. Med Education Online. 2014, 19:2481

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156603/

United States Census Bureau https://www.census.gov/quickfacts/table/PST045215/00

PEW Research Center. Religious Landscape Study. 2014

Cohen JJ, Gabriel BA, Terrell. The Case for Diversity in the Health Care Workforce. Health Affairs. 21:5 (2002):90-102 http://content.healthaffairs.org/content/21/5/90.full

AAMC Diversity in Medical Education: Facts & Figures 2016. 19th report https://www.aamc.org/initiatives/diversity/179816/facts_and_figures.html

Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority Physicians’ Role in the Care of Underserved PatientsDiversifying the Physician Workforce May Be Key in Addressing Health Disparities. JAMA Intern Med. 2014;174(2):289291.doi:10.1001/jamainternmed.2013.12756

Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003;139:907-915

https://www.ncbi.nlm.nih.gov/pubmed/14644893

Phillips, KW. How Diversity Makes Us Smarter. Scientific American. October 2014. https://www.scientificamerican.com/article/how-diversity-makes-us-smarter/

Agrawal J, et al. Progress and pitfalls in underrepresented minority recruitment. J Natl Med Assoc 2005;97:1226-31

Mahoney MR, Wilson E, Odom, KL, Flowers L, Adler Shelley. Minority Faculty Voices on Diversity n Academic Medicine: Perspectives from One School. Acad Med. 2008 August; 83(8): 781-786.

https://www.ncbi.nlm.nih.gov/pubmed/18667896

Paul-Emile, K, Smith AK, Lo B, Fernandez Alicia.Dealing with Racist Patients. NEJM 2016; 374:708-711. http://www.nejm.org/doi/full/10.1056/NEJMp1514939#t=article

Have you ever been discriminated against or witnessed a resident being discriminated against? Has a resident ever come to you to discuss a discriminatory encounter? If so, how did you respond?

What makes you diverse? How have those characteristics impacted you when- caring for patients? working with colleagues?

How often do you consider how others are impacted by their differences?

What do you do to become more aware of your biases?