Hey All,
I’ve been reading folks opinions on the soon to be mandated shorter resident work hours with interest and trying to figure how they will affect me when (if) I get to that point. Another thing I would like people to share their thoughts on is the need for diversity in medicine (is there a need) and the disparities in healthcare. Being of (take your preffered pick of labels) hispanic, latino, chicano, mestizo… background it has been of interest to me for some time. Last week we had a talk given on the topic by Levi Watkins. Dr. Watkins was the first african american student to be admitted and graduate from med school here at Vanderbilt. He is now an associate dean at Johns Hopkins med school and proffessor of cardiac surgery. He has an impressive academic and activist record. It was a good talk and he eloquently and passionately stated his belief in the need for a vast increase in the diversity of the racial and cultural backgrounds of people in medicine. In support of his argument he cited; the current predominately white male make up of the current physicians, the projected increases in minority populations (mostly black and hispanic) in the next 50 years, and the documented disparities in the health care given to minorities. He cited some prospective studies in esteemed (i.e. JAMA, NEJM) journals as well as a report published by the National Academy of Sciences Institute of Medicine. Here is a link for that report. http://www.nap.edu/books/030908265X/html/
I would love to hear all thoughts including; is it important, why is it (not) important, how to do it…
Thanks!!!
Hi there,
I think that the face of medicine is becoming more diverse. The make-up of my class that graduated from Howard in 2002 is a good example of the diversity in today’s physician. My class was 40% of African ancestory (African-American, West-Indian, African),30% Caucasian(Middle Eastern), 10% Asian(East Indian, Pakistani), 20% Latino and no Native Americians. We all went our separate ways but most stayed in the Washington-Baltimore area. Three went to Hawaii. Just ten years ago, the ethnic makeup of the graduating class was 95% of Africian ancestory and 5% other.
I look at the racial make-up of the class at UVa that will graduate this year and 22% are minority(African ancestory, Asian, Latino, Native American). There are two African-American attending physicians at UVa (the chairman of Emergency Medicine and one anesthesiologist). There are less than 10 African-American residents total with Surgery having the most (3). There are two Asian surgical residents. There are no Latino attendings; there are lots of Asian attendings.
Some of us choose to get the best training that we can find and take that training back to treat underserved populations. Most of my current patients are underserved because they are disadvantaged financially and educationally. The average educational level of my current patients is 5th grade. Many of my in-patients are Medicaid and Medicare. They are working poor from West Virginia and tobacco farmers from Virginia. Many are Latino who work in the poultry processing plants in Rochingham Country, Va. My very non-diverse attendings spend most of their time treating these educationally and financially underserved folks. The physician salaries are paid by the State of Virginia; so we tend to see more indigent folks than the private hospital here in town. I think we do better medicine for our underserved population than the private hospital does for their monied folks.
There is no way to predict where a person will practice once they are done with residency. My very Caucasian attendings are treating patients who are very poor and fairly diverse but definitely underserved. Many of them have trained at Duke, Harvard, Minnesota, Mayo Clinic, Pittsburgh, University of Pennsylvania and University of Virginia. There is no guarantee that just because a person is of color, they will gravitate toward the inner city or be predisposed to work on patients who are of the same cultural background.
I can tell you that many of my patients are not of the same ethnicity as I am but I have never gotten a complaint or a refusal to accept care from any of them. When folks are sick, they look to anyone who can lend a helping hand. I promise you that they all look the same on the inside. I can’t tell the color of a patient when I am in their abdominal or thoracic cavities. I have seen my attendings work passionately to save patients no matter what the color or ethnicity. Yes, they are a group of white males and asian males but they work just as hard for any patient.
What we do need in medicine is greater access to medical care for some populations.(The working poor) We need a means that will enable some senior citizens and working poor to pay for prescription drugs that are necessary. I have sent patients home with $2,000 worth of antibiotics that I scammed from the drug companies because I knew that the antibiotic was needed and that the patient had no means to pay for the drug out of their pocket. We need preventive medicine available for all populations, not just the monied and insured folks.
These issues cut not so much across racial or ethnic lines but across economic lines. Most of my classmates did not want to practice medicine with underserved populations. It wasn’t an ethnic thing, it is an economic thing. They just want to practice where they can make the most money. I just want to practice where I can have the greatest challenges. I will have a roof over my head and some kind of car in the driveway but I don’t need the country club and I don’t find suburban surgery that much of a challenge. I am far from being a child of the ghetto. My family was neither economically nor educationally deprived but I find that after working with patients in an inner city environment, I can’t wait to get back. I found that most of my classmates who were from economically or educationally deprived backgrounds would never think of going back. Go figure??
Natalie 
Hi there,
I lifted this from the University of Utah’s School of Medicine website. The entire website has some pretty good resources for folks making the application in the future.
This school also posted their demographics and stats for the entering class. While most of the folks come from Utah, there are some seats guaranteed for Idaho because Idaho does not have a medical school.
Natalie
"SELECTING A DIVERSE FRESHMAN CLASS
Applicants who satisfy all of the minimum selection criteria and who are average or excel in five of the eight criteria are considered by the Admissions Committee for selection into the freshman class.
The primary goal of the School of Medicine is to admit a class of students who individually and collectively are among the most capable students applying to medical schools in any given year. A secondary but equal goal of the School of Medicine is to assemble a mix of students with varying backgrounds and experiences who respect and learn from each other. The School of Medicine seeks a balanced but heterogeneous student body that will excel in the art and science of medicine. Like most medical schools, the School of Medicine recognizes that a diverse student body promotes a rich atmosphere of speculation, experimentation and creation conducive to learning. By exposing students to a variety of perspectives, experiences and ideas, the School of Medicine helps to equip students with the tools to deal with a diverse society and patient population.
Students are not selected for admission based upon the applicant’s age, gender, race, religion, sexual orientation, marital status, or disability. These factors in and of themselves do not support a finding of diversity and will not be focused upon or identified as unique characteristics during the admissions process. On the other hand, the fact that someone struggled for years with a significant disability, the fact that someone grew up with parents imprisoned in a prison camp, the fact that someone was presented with unique experiences during a religious mission, the fact that someone came to medical school after pursuing a different career, and other similar circumstances would all be proper areas of inquiry and could be considered as positive factors in the selection process. "
The stats that you cited from Howard are outstanding. It's also good to hear about UVa. How is Howard as a school. I thought that I read sometime back that many of the hospitals programs were in serious trouble and were going to or did lose their accreditization? That seems like that would seriously impair a schools ability to teach.
Vanderbilt is very… shall we say monochromatic. The dean of the shool is however very serious about changing this. He has set a goal of getting Vandy ranked in the top ten and believes, or at least says that increasing the diversity of the student body is a vital part of that.
Also located here in Nashville is Meharry Medical College. I'm mot sure what their make up is. I do know that there mission is to increase the number of African American physicians so I don't know if that means that they are as homegenous as Vanderbilt except that the majority of students are black. I have heard good things about how they treat their students.
I'm glad to hear that you are seeing new and old docs who are committed to providing good care to all. Based on that Institute of medicine report it aounds like there is still a long way to go.
The admissions statement from Uof U is interesting. I have not yet looked at their class statistics but I wonder if they walk the walk. My experience (although admittedly very limited) with Utah and Salt Lake is that it is very white and a bit xenophobic. It has been several years since I've passed through there but I never got a feeling of welcome there.
I would however go to school there especially because of the mountains and the outstanding skiing. I geuss that I would have to set up a serious home brew setup though.
Thansk for your thoughts Natalie. I hope that some other of you folks out there will chime in.
Hi there,
While some of Howard's residency programs were on probation, the medical school got a perfect approval rating from the LCME. This approval rating is good for the next eight years.
The residency programs being on probation affect those people who are currently residents there an do not affect the medical school in any way. It is my understanding that E-medicine and pediatrics are now off probation. Surgery and Internal Medicine were never on probation and in fact, General Surgery got a perfect rating from the accreditation survery done last year. That rating is good for five years.
The University of Maryland's General Surgery program was cited and placed on probation for Q2d call (illegal now); Yale's General Surgery residency was also on probation. The residency programs generally do not affect the medical school as medical student education and residency education are totally separate entities no matter what medical school you attend.
Natalie
Hi everyone,
I thought I’d chime in on this one.
I was fortunate enought to grow up with a Mom that was a public health nurse and I most remember her taking me on some of her home visits to see patients. Without a doubt, the poor in this country are not receiving adequate health care.
Based on my expereinces as a volunteer in public health clinics, I always thought I would become a public health physician specializing in either family medicine or preventitive medicine. Being at the NCI has recharged my “need for research” but ironically, I’m looking to spend the year I apply to medical school (2003) at a health department as an epidemiologist. There’s just something about public health that I love and for me serving the disadvantaged is certainily a big part of it.
I also think it’s strange that of the 15 or so minority MD’s and DMD’s I know, only 2 of them work in disadvanataged communities.
Kim
When citing diversity statistics, I think you should not include Asians.
The fact of the matter is that Asians are far over-represented in the medical profession, even moreso than caucasians.
| QUOTE (MD/PhD slave @ Oct 28 2002, 12:37 PM) |
| When citing diversity statistics, I think you should not include Asians. The fact of the matter is that Asians are far over-represented in the medical profession, even moreso than caucasians. |
Hi there,
While Asians are not an under-represented minority, they are a minority in the population of the United States and Canada. In that sense, I consider them a minority and I do include them in people of color as they are not white. For the sake of diversity stats, medical schools and medical education consider them minorities but not under-represented minorities.
I don't think that ethnicity or diversity has anything to do with excellence in medicine and should not be a deciding factor in medical education. When I look at the performance and abilities of my medical students at UVa where minorities are well-represented, I see no difference in ability between Asian, Caucasian, African-American and Latino. The students have more in common (work ethic) than not in common. They all make the same third-year medical student mistakes and they are all equally interested in becoming the best physicians that they can be.
Cheers and good wishes!
Natalie
| QUOTE (njbmd @ Oct 28 2002, 07:15 PM) |
| I don't think that ethnicity or diversity has anything to do with excellence in medicine and should not be a deciding factor in medical education. |
Is that to say that you don't believe that there is a need for more African Americans, Hispanics (including Mexican American, Cuban Amer, Puerto Rican), insert other underrepresented group... in medicine?
| QUOTE (dmaes @ Oct 29 2002, 10:55 AM) | ||
Is that to say that you don't believe that there is a need for more African Americans, Hispanics (including Mexican American, Cuban Amer, Puerto Rican), insert other underrepresented group... in medicine? |
Hi there,
I don't see a correlation between increasing the numbers of any under-represented minority just for the sake of seeing larger numbers of physicians of diverse ethnicity. I do think that any under-served group deserves wider access to excellent medical care. I did not see too many of my URM classmates flocking to treat the underserved. I actually observed the opposite situation in that most chose specialties based on lifestyle in locations where they would not have to deal with underserved populations. Almost every one of the Caucasian graduates in my class is a Public Health scholar and will treating the underserved in primary care after finishing residency.
Admission to medical school should not be based on ethnicity but based on a sincere desire to contribute to the medical profession (by compassionately treating patients or by research) and the ability to complete a rigorous medical curriculum. There are no ways to predict either of these two qualities based on ethnicity.
My chief resident when I was a fourth year medical student was Caucasian but fluent in Spanish. Dr. Blattau was one of the best residents that I ever worked under. She is white with ethnicity of German and English. She was born in Pennsylvania (upper middle class) and attended medical school at Pitt. She is now running a clinic in Adams Morgan where most of her patients are Latino. They love her medicine and she provides excellent medical care.
Disparities in healthcare exist because few physicians want to do what Dr. Blattau does so very well. She wanted the challenges of working with an underserved population. My residency director is Dr. Bruce Schimer. He is a world-renowed laproscopic surgeon. His practice involves mostly poor, white super-obese female patients from rural central Virginia and south-central West Virginia. He is caucasian but his patient population is economically and educationally disadvantaged. He could be making millions in a suburban hospital with an insured moneyed population but he practices at the University of Virginia and is dedicated to this patient population. He also performs plenty of lap choles and hernia repairs on poor Latino and African-American patients too.
Diversity for its own sake does not translate into more physicans providing healthcare for underserved populations. I chose Howard University College of Medicine because of its diverse student population. Learning medicine is such an enviornment was stimulating and great for emphasizing the things that we have in common as opposed to differences. I also learned that being in such a diverse medical class and treating an underserved inner city population had the effect that most people in my class would never want to treat inner-city or under-served patients after medical school. I was a distinct anomaly in my class.
After spending four years with some of my URM classmates, I believe that the greatest myth at Howard was that it was fufilling it's mission to educate URM physicians who would serve in underserved communities. While the numbers of URMs are higher, almost none of them elect to serve the underserved. I see similiar characteristics in the UVa medical students that I have encountered. All of the URMs are headed for the lifestyle specialties and the the non-trad caucasians are looking into primary care in underserved populations. Go figure?????
Natalie
| QUOTE (njbmd @ Oct 30 2002, 04:00 AM) |
| After spending four years with some of my URM classmates, I believe that the greatest myth at Howard was that it was fufilling it's mission to educate URM physicians who would serve in underserved communities. While the numbers of URMs are higher, almost none of them elect to serve the underserved. |
Howdy Nat!
I suspect that one of the big reasons that it doesn't matter how hard schools recruit URM to serve in underserved areas, the reality of >$100,000 in debt hits home right around the time students have to rank residencies.
Take care,
Jeff
Hey Natalie,
Thanks for the comments. I first want to give the correct link for the IOM report. It is Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care The link I originally gave was for what seems like an admnistrative evaluation of the actual report. I’m sorry for the mix up. I will edit my original post to correct it. Anyway I digress.
For once I generally disagree with you. There are a few reasons why. You make the statement “Diversity for its own sake does not translate into more physicans providing healthcare for underserved populations.”, which I don’t believe is true. Despite the two great examples of white physicians (your Howard classmates and Dr. Blattau) working to provide equal access to healthcare, that is not generally the trend. A quick medline search search shows unequivocally that minority physicians are more likely serve minority and other underserved populations. In a study of Hispanic versus white physicians “Hispanic generalists established practices in areas in which the percentages of the population that were (1) below poverty level, (2) Hispanic, (3) Hispanic and below poverty level, and (4) white, non-Hispanic, and below poverty level were greater than in areas in which white, non-Hispanic primary care physicians practiced.” J Health Care Poor Underserved 2001 Aug;12(3):342-51. In another study"Communities with high proportions of black and Hispanic residents were four times as likely as others to have a shortage of physicians, regardless of community income. Black physicians practiced in areas where the percentage of black residents was nearly five times as high, on average, as in areas where other physicians practiced. Hispanic physicians practiced in areas where the percentage of Hispanic residents was twice as high as in areas where other physicians practiced. After we controlled for the racial and ethnic makeup of the community, black physicians cared for significantly more black patients (absolute difference, 25 percentage points; P < 0.001) and Hispanic physicians for significantly more Hispanic patients (absolute difference, 21 percentage points; P < 0.001) than did other physicians. Black physicians cared for more patients covered by Medicaid (P = 0.001) and Hispanic physicians for more uninsured patients (P = 0.03) than did other physicians." N Engl J Med 1996 May 16;334(20):1305-10. I think that this kind of data is a powerful indicator that there is a need for an increase in the numbers of minorities in medicine. Also, although this is just a supposition, increased numbers of minority physicians would further mitigate disparities because people tend to seek out physicians of their own race (see Health Aff (Millwood) 2000 Jul-Aug;19(4):76-83 among others).
Another reason I disagree with you is something you hit on in a couple of your posts. You said “I chose Howard University College of Medicine because of its diverse student population…The make-up of my class that graduated from Howard in 2002 is a good example of the diversity in today’s physician. My class was 40% of African ancestory (African-American, West-Indian, African),30% Caucasian(Middle Eastern), 10% Asian(East Indian, Pakistani), 20% Latino and no Native Americians”. By attending a school with such a diverse make up you were undoubtably able to learn about other cultures manerisms, beliefs, and customs. I would bet (am geussing) that this has affected (for the better) what kind of doctor you have become. I bet that this occured despite the breadth of experience and seemingly great attitude that you probably took with you to medical school. The impact on a 22 year old white male from small town middle America seems like it would be huge and hugely beneficial. With the overall US med school demographics showing that under represented minorities making up about 15% of the class size, your experience is clearly not what most medical students are getting.
Reason number three is the need for greater minority participation in medical research. With racial differences being identified in the incidence of diseases to differences in drug metabolism, the case for more minorities in medicine and science generally is made stronger. Why do I say this: for the same reasons as cited for the delivery of health care. Minority physicians/scientist are more likely to perform the studies and minority patients are more likely to participate when the studies are being conducted by minority people. The studies showing this are out there. It’s late for me and I am getting tired however.
Further, the disparities persist even once a person is in the healthcare system. The minority patient is less likely to get good care. Some example given in the IOM report are 1) “…whites are 4X more likely to undergo CABG compared to blacks even when date are corrected for age and gender related rates of MI”. 2)“after correcting for pt demographics, comorbidities, therapeutic complications, and hospital characteristics, black patients were 41% less likely to recieve major treatment than the white patient”. The report is full of data some better than others, but as a whole there can be no question of the problem. This is not simply a case where "Disparities in healthcare exist because few physicians want to do what Dr. Blattau does so very well. " I geusss I got a second wind.
Anyhow, these are some of my thoughts on the matter.
| QUOTE (dmaes @ Oct 31 2002, 05:10 AM) |
| Hey Natalie, For once I generally I disagree with you. |
Quite the unusual experience for myself as well
!I've touched on this topic in previous threads. You make excellent points regarding equitable provision of health care, dmaes. For me, it is simply a matter of recruiting the best, most effective medical community that we can.
When my research advisor sat on the admissions committee at Ohio State, he said it made him literally physically ill how random the selections process became, in light of the fact that - by looking at 'numbers' alone - virtually everyone they looked at deserved a place in medical school. So, we are in a position of choosing amongst a pool of highly qualified, academically talented people for a few, select positions. What criteria should we focus on?
I will argue that skimming highest test/grade numbers off the top as your selections process is precisely the wrong thing to do; and that instead having a goal (one goal...) of obtaining adequate cultural and societal representation in your pool is exactly the right thing to do.
When the medical community was overwhelming represented by men, hysterectomies and radical mastectomies were dramatically over performed. Menstrual cramping was 'histrionic personality, with no basis in physiology'; organic medical illness was due to misparenting by the mother. Research on woman's issue was virtually nonexistent. When the medical community was overwhelmingly represented by caucasians (wait...that's today...), minorities were subjected to unethical medical experimentation. Provision of care was unspeakably lopsided.
Like it or not, there is a self selection in medicine for people of privilege. This is true for several reasons. Affluent people know doctors; their kids shadow them in high school. Affluent kids mature in academically supportive environments with unlimited resouces. They do summer research; they enroll in high dollar MCAT preparation courses, and 50K per year Ivy League post bacc programs. For countless reasons that I will not go into, in this country at this time, there is also a self selection in society for caucasians to be represented in affluent communities.
There is no question that, in many situations, with many patients, I am a far more effective physician than many of my counterparts. The reasons have entirely to do with my maturity, my femininity, my understanding of poverty issues, my experiences with substance abuse and broken families, and nothing at all to do with my high grades and high MCAT score.
People from affluent communities have one set of perspectives on life. Some of my most critical perspectives, and those of many of my patients, are not represented there. The most effective, the BEST, provision of medical care in this country occurs when as many people as possible have a face in the field of medicine.
GED2MD,
Your post was absolutely exquisite!
Kim
| QUOTE (GED2MD @ Nov 1 2002, 10:08 AM) |
| There is no question that, in many situations, with many patients, I am a far more effective physician than many of my counterparts. The reasons have entirely to do with my maturity, my femininity, my understanding of poverty issues, my experiences with substance abuse and broken families |
and society still wonders why doctors have a "holier than thou" complex....
| QUOTE (MD/PhD slave @ Nov 1 2002, 07:04 PM) |
|
and society still wonders why doctors have a "holier than thou" complex.... |
Um...are we talking about the same subject? Because I use my own experiences of childhood molestation, substance abuse and neglect to relate to an unwed, alcoholic teenage mother more easily than my prep school colleagues who ridicule and dismiss her, I'm "holier than thou"?
Gee, and all this time I was feeling insecure.
Take it easy ladies and gentleman. I thought this was supposed to be a place for open and reasoned discussion? 
Damon
While I certainly cannot match the eloquence of Natalie or GEDtoMD, I have to agree with a number of their points. Diversity in medicine will not guarantee that these physicians will work with underserved communities, but it will open up a better understanding of these same communities. Because I am currently taking a class regarding women and health, and as a woman, I can really agree with GEDto MD. Just having mroe women in medicine has forced medicine to look at women and their illnesses more seriously, and to include women in research studies (where before all research data obtained from men was assumed to apply to women as well). Also, as an older student among young students, I see a very narrow focus from the younger students. You can tell that they are very bright, but when it comes to real life, they still do not have a clue as to whats going on. As was also pointed out, this would call into question the current method of choosing who will attend medical school. There is more to a person's ability than scores, and while the interview is very important, only those with the highest scores get those interviews. I feel alot of people who would make excellent physicians get passed over in this system.