Health Care and Cultural Diversity
Thank you Chairman Waters and members of the Pennsylvania House Health & Human Services Subcommittee on Health for inviting the Pennsylvania Medical Society to testify on how to increase the African-American Health Care Workforce. I’m Daniel J. Glunk, MD, president of our organization.
I know it is customary to begin testimony with a thank you, but in this case, I emphatically and most sincerely thank you for the opportunity this provided me personally to research, discuss, analyze, synthesize, and reflect on this important problem. As an organization, we are forced to spend an enormous amount of time and effort trying to resolve critical problems, such as the liability climate and decreased reimbursement that make Pennsylvania a less attractive place to practice medicine. Unfortunately, problems like the one at hand receive less attention than we would wish.
In 2002, the American Medical Association, the National Medical Association, and the National Hispanic Medical Association entered into a memorandum of understanding to work together on Health Disparities. Two years later the Commission to End Health Care Disparities was formed. The Commission developed objectives and began its work. There was a problem, however, for there was an elephant in the room. The National Medical Association was formed in 1895 in response to the racial bias and segregation of the American Medical Association. A panel was convened that reviewed and analyzed the historical documents and published their findings in the July 16, 2008, edition of JAMA.
Last year, the AMA formally apologized to the NMA. The NMA accepted the apology. As a result, the Commission’s important work continues.
According to Pennsylvania Vital Statistics, a publication produced in July 2007 by the Pennsylvania Department of Health, our state’s population by race and origin in 2005 was as follows:
| White |
10,745,507 |
84.0% |
| Black |
1,308,953 |
10.0% |
| Hispanic |
506,084 |
4.0% |
| Asian/Pacific Islander |
244,869 |
2.0% |
The Pennsylvania Department of Health is responsible for a survey of physicians conducted at the time of physician licensing renewals. This report was last produced in December 2007 and recently updated. In 2006 there were 25,883 physicians engaged in direct patient care in Pennsylvania which is a decrease from the 2004 data.
The breakout by race was:
| White |
20,647 |
80.0% * |
| Asian |
3,221 |
12.5%* |
| Black |
775 |
3.0%* |
| Other |
1,175 |
4.6%* |
* Percentages may not equal 100% due to rounding. Additionally, this total does not equal the total number of physicians engaged in direct patient care in Pennsylvania due to technical considerations.
Results from prior surveys also provide interesting comparisons:
|
2002 |
2004 |
| White |
83.8% |
81.0% |
| Asian |
11.3% |
11.6% |
| Black |
2.1% |
2.8% |
| Other |
2.8% |
4.6% |
Clearly, there is under-representation of African-Americans in the physician population when compared to the general population. Interestingly, there appears to be underrepresentation of whites as the percentage of white physicians seems to be slowly declining. Of note is the over-representation of Asians. Unfortunately, data is not available to compare Hispanic physician numbers.
By reviewing current data from the American Association of Medical Colleges (AAMC), we can get a glimpse of what the future workforce might look like. Unfortunately, I couldn’t find data that would track Pennsylvania citizens attending medical school anywhere in the United States. Data is available on Pennsylvania-based medical schools and their student enrollment figures.
In 2008, the breakout by race for matriculants to Pennsylvania-based medical schools was:
| White |
500 |
70.5% |
| Black |
33 |
4.6% |
| Asian |
103 |
14.5% |
| Hispanic |
20 |
2.8% |
| Other |
53 |
7.5% |
When you review statistics on applicants to Pennsylvania-based medical schools, you find similar numbers. Historical data for the past seven years show no significant change in the percentages from year to year regarding applicants by race.
In comparing state population data to state physician data and then to state medical student school enrollment data, blacks, whites, and Hispanics are underrepresented, while Asians seem to have higher percentages of physicians and those studying to become physicians.
On the AAMC’s website, there is a wealth of data which I will summarize with two points: 1) Since 2002 not much has changed in terms of African-American applicants, matriculants, and graduates. 2) Three Pennsylvania undergraduate schools provided 15 or more African-American applicants to medical schools: Temple, Pitt, and Penn.
Many good people and organizations with good intentions have been committed to rectifying this situation and have been at it for many years. The complexity of the issue and hence the solutions beg for a more coordinated and comprehensive approach.
Work and effort has resulted in the development of “pipeline programs” to assist in preparing and motivating people to consider pursuing a career in medicine. A functioning pipeline involves continuous input and has multiple critical junctures. The input is highly dependent on the success of our public education system and is tightly linked to socioeconomics. The lower a student’s socioeconomic status, the more difficult it will be to get a good education and the more difficult it will be to navigate any pipeline.
From the Medical Society’s last State of Medicine report as well as other reports here is what we have discovered:
- A Pennsylvania high school graduate who attends a Pennsylvania medical school and completes their residency in a Pennsylvania program is very likely to stay in Pennsylvania to practice.
- A Pennsylvania high school graduate who eventually applies to medical school has a high likelihood of getting accepted.
- Pennsylvania has a lower percentage of its high school graduates who will go on to apply to medical school (rank 38/50).
- Pennsylvanians are becoming a smaller percentage of our medical schools’ classes.
We must ask more of our educational system so that students are prepared and motivated to seek careers in medicine. More must be expected of our undergraduate schools also. Getting into medical school is highly competitive and our students should be positioned as strong candidates. If you recall, three schools in Pennsylvania do this well and we need to learn why they are successful and transfer that knowledge.
Other successful efforts center on role models and mentoring. These efforts must begin early and continue throughout a person’s education and career. Due to the under-representation of African-Americans in all phases, this cycle is all the more important to correct. The American Medical Association has been active in this regard with its “Doctors Back to School” mentoring program developed by the Minority Affairs Consortium. The Pennsylvania Medical Society is also expanding its mentoring efforts. We recently learned from the Department of Health that the Governor’s School for Health Care will be continued through the University of Pittsburgh. Working with the Department and the new school, now called The University of Pittsburgh Health Career Scholars Academy, the Medical Society is engaged in becoming more involved in its mentoring efforts. We will also work to assure that under-represented minorities are a target for participation.
Finally, as you know, it’s not unusual for medical students to graduate with huge student loans. I’ve heard stories of student debt that frankly I find frightening, with some students owing more than $200,000.
This legislative session there are bills in both the House and the Senate offering loan forgiveness for those medical students from Pennsylvania studying in Pennsylvania medical schools if they decide to stay in our great state and practice their newly acquired skills. So, I ask this committee to work with Representative Shapiro, the prime sponsor on the student loan forgiveness bill, and consider offering language that would be helpful in promoting physician diversity.
As we know from data compiled by the state Department of Health, there has been a decrease in the total number of physicians engaged in direct patient care. We must continue to make Pennsylvania an attractive place to learn, teach, and practice medicine. It will do no good for Pennsylvania to produce more African-American physicians if they cannot sustain a practice due to Medicaid payments that rank nationally near the bottom or due to unfair insurance company contracting. It will do us no good if the medical liability climate, both real and perceived, directs them to practice elsewhere. If we fail in taking a comprehensive approach, then we will fail in breaking the cycle. For just as the input to the pipeline affects the output, the output circles back and affects the input.
For the Pennsylvania Medical Society, the issue of cultural diversity, both within the physician population and in the delivery of health care, is an important issue taken seriously. In fact, looking at past resolutions from our House of Delegates, this is an issue that can be traced back to 1977.
More recently, in 2005, our House of Delegates passed several resolutions and recommendations on cultural diversity that led to the formation of our Task Force on Cultural Competency and Medical Diversity in 2006. That task force developed our “Statement of Principles for Cultural Competency” which is meant as a guide for individual physicians and organizations to support both the delivery of health care to a diverse population as well as encouraging community members from a diverse background to pursue health care as a career.
As a direct result of actions taken a few years ago, I’m happy to announce that we’ve started a Physician Award for Cultural Diversity as well as a Community Award for Cultural Diversity. The first recipients are scheduled to be named this year.
Also, through our Patient Advocacy Council, the Pennsylvania Medical Society is currently offering a special one-time grant of $5,000 to a project that demonstrates diversity in medicine.
We have initiated other programs to enhance cultural diversity. Through our Institute for Good Medicine, a project with the Cancer Society is underway that in part will help educate Hispanics, both physicians and patients, on colon cancer. Also through our Institute for Good Medicine, we’ve helped the South Central Pennsylvania Workforce Investment Board with its career day, talking to many inner city students about health care careers. Several schools from the Philadelphia area participated in this event.
To summarize, I would like to read two paragraphs from Malcolm Gladwell’s most recent book, entitled “Outliers.”
“Biologists often talk about the ‘ecology’ of an organism: the tallest oak in the forest is the tallest not just because it grew from the hardiest acorn: it is the tallest also because no other trees blocked its sunlight, the soil around it was deep and rich, no rabbit chewed through its bark as a sapling, and no lumberjack cut it down before it matures.
We all know that successful people come from hardy seeds. But do we know enough about the sunlight that warmed them, the soil in which they put down the roots, and the rabbits and lumberjacks they were lucky enough to avoid?”
The Pennsylvania Medical Society recognizes that African-American youths are an untapped resource in enriching the pipeline of students that can be mentored, nurtured, and trained to become the physicians that deliver optimal care to the citizens of our Commonwealth. We know that you must measure not simply by how far you’ve travelled, but more importantly, by how far you still need to go. As scientists, we understand ecology and complexity. As a profession, we understand the moral and ethical imperatives. As an organization, we stand ready.
Last Updated: 6/17/2009