Deas, Deborah MD, MPH; Pisano, Etta D. MD; Mainous, Arch G. III PhD; Johnson, Natalie G. MA; Singleton, Myra Haney MEd; Gordon, Leonie MB ChB; Taylor, Wanda; Hazen-Martin, Debra PhD; Burnham, Willette S. PhD; Reves, J.G. MD
African Americans, Latinos, and American Indians are severely underrepresented in the health professions.1 These underrepresented-in-medicine (URM) groups represent only 9% of the nation’s physicians while constituting 25% of the nation’s population. In a state like South Carolina with a large African American population, the incongruence between the racial makeup of the physician workforce and the general population is particularly striking. In 2010, 27.9% of the total South Carolina population was African American, whereas data on medical licenses from 2009 show that only 5.9% ofpracticing nonfederal physicians in South Carolina were African American.2,3
Increasing the diversity of the physician workforce is desirable for a number of reasons. First, increasing minority representation in the physician workforce may be an effective strategy to eliminate or at least decrease health disparities. Considerable evidence indicates that racial, ethnic, and linguistic diversity among health professionals is associated with better access to and quality of care for minority and underserved populations.4,5 Second, a culturally competent workforce will likely be better equipped in dealing with expanding diversity among patient populations. Majority students undoubtedly learn lessons in cultural sensitivity from their minority peers.6 In addition to creating a culturally competent workforce among all physicians, some data suggest that minority patients who have racially concordant physicians are more satisfied and report receiving more preventive services.7,8 Third, a common barrier to the development of new clinical knowledge, particularly for medical problems affecting minority populations, is patients’ reluctance to enroll in clinical research. African American patients describe distrust in the medical community as a prominent barrier to participation in clinical research.9–11 Recommendation by a trusted physician is a key factor in successful recruitment of patients into clinical trials. Consequently, having a diverse physician workforce may help to overcome some of the distrust that minorities may have of medical researchers and the general medical community.
Several medical schools have implemented programs designed to increase diversity in the physician workforce. These programs have primarily focused on admissions policies, increasing the pipeline of potential physicians, and institutional culture.1 Successful programs have tended to focus on several critical elements. They create an institutional culture supportive of diversity among students, staff, and faculty; demonstrate a commitment to diversity throughout the institutional leadership; develop specific admissions policies to promote diversity without establishing quotas; and articulate institutional policies that embrace diversity as a key element for organizational success.
In an effort to develop a more diverse physician workforce, the Medical University of South Carolina (MUSC) College of Medicine (COM) has implemented a variety of initiatives focusing on key elements related to success. This report details our multifaceted strategies and our experience over a 10-year period.
Developing a Diversity Road Map
MUSC, founded in 1824 as the Medical College of South Carolina, is the oldest medical school in the Deep South. Though founded as a private institution, the State of South Carolina assumed ownership of the Medical College of South Carolina in 1913, and in 1969 it became MUSC.12 MUSC has a three-pronged mission, which promotes education, research, and clinical care. Despite MUSC’s educational mission, however, the historical, legal, and political landscapes in South Carolina did not permit the education of minorities until 1965. The first African American male and female graduated from the COM in 1971 and 1973, respectively. Subsequently, enrollment of URM individuals (African Americans, Native Americans, Latinos) at MUSC remained disproportionately low for several decades until Dr. Layton McCurdy, dean of the COM (1990–2001), highlighted the importance of diversity. In 2001, at the end of Dr. McCurdy’s time as dean, there were 49 (10%) URM students within the student body.
A strategic plan for diversity
In 2001, Dr. Jerry Reves was appointed dean of the COM and vice president for medical affairs at MUSC. Shortly after taking his post, he launched a strategic plan,13 which explicitly placed diversity as a necessary strategic aim, and he charged a COM diversity committee with developing an institution-wide diversity plan as a road map to encourage greater diversity in each academic department. The COM plan focused on diversity among faculty, residents, and students with the overarching goals of increasing racial and ethnic diversity to better reflect the general population of South Carolina while continuing to maintain gender diversity, and expanding and enhancing opportunities at all levels within the COM for individuals from all backgrounds.
The institution-wide diversity plan. The premise for developing a broad goal was to aim toward creating a “critical mass” of URM individuals from which to infuse the benefits of diversity at all levels. A critical mass in this instance refers to having an obvious presence or sufficient number of URM individuals in one place (i.e., medical school, department). In some cases, the existence of a critical mass may suggest that an environment is welcoming, thus enabling recruitment of more URM individuals to that environment.
The diversity committee incrementally implemented the diversity plan and expanded its goals during the process. Since the plan’s inception, the COM has provided the resources for maintaining the diversity plan. The dean and other leaders in the COM made the commitment to take an active role in implementing the plan and leading the development of policies and programs, and to identify and provide resources to improve recruitment, education, retention, professional development, mentoring, and recognition of URM students, residents, and faculty. This dovetails with one of the values listed in the current 2010–2015 MUSC strategic plan: “Seek and welcome students, scholars, and staff regardless of gender, race, age, nationality, religion, or disability, while emphasizing the benefitsof diversity.”14
Specific diversity plans. Two liaisons from the COM diversity committee worked with individual departments to develop department-specific diversity plans. The departmental diversity plans were congruent with the institution-wide plan but tailored to the unique needs of each department. Associate deans for respective areas also developed targeted diversity plans for undergraduate medical education, medical school admissions, and graduate medical education. As an example of how specific diversity plans tailored efforts according to the activities of individual departments or groups, the admissions diversity plan incorporated a more holistic admissions process. First, the admissions committee equally weighs four criteria: the medical school interview, Medical College Admission Test (MCAT) score, grade point average (GPA), and accomplishments (leadership, volunteerism, clinical exposure, and letters of reference). After these four criteria are evaluated, the committee assigns “added value” for certain applicant characteristics with the intention of further diversifying the pool of qualified applicants. Prospective students can earn added value in several areas, such as advanced community service, cultural experiences attending to the needs of underserved and underrepresented populations, sustained work experience, artistic/athletic achievements, overcoming adversity, and rural or inner-city backgrounds. Thus, added value is not limited to research or graduate education performance. We use the added-value process for all applicants regardless of race or ethnicity. The legal counsel at MUSC reviewed and approved the added-value process before implementation.
Charting progress toward diversity goals
The COM diversity committee developed an assessment tool to evaluate progress toward diversity goals. The assessment tool included quantitative and qualitative variables, such as number of URM individuals we recruited, number of grand rounds and seminars related to diversity, number of URM speakers who presented, number of activities related to health care disparities and social determinants of health, and the degree to which departments integrated cultural competency training. Each department completes an assessment annually, and results are analyzed and presented to the deans, department chairs, and faculty. The dean reported on the progress toward diversity goals in his State of the College address and to the Council of Department Chairs annually. On an institutional level, diversity became one of the strategic goals used to evaluate the COM and its departments annually. Further, department chairs undergo annual evaluations related to institutional and individual goals, and the extent to which the goals are met may affect the chair’s incentive. Therefore, all department chairs were required to develop annual diversity goals linked to their end-of-the-year incentives.
Next steps for diversity plans
Dr. Etta Pisano was appointed dean and vice president for medical affairs of MUSC’s COM in 2010, and she endorsed the diversity-related efforts and progress made by the COM. She charged the diversity committee with launching the 2010–2015 COM diversity plan and the departments with developing their individual diversity plans for the same period. The diversity committee expanded the goals of the institution-wide diversity plan to include promotion of racial, ethnic, and gender diversity in leadership positions within the COM; to promote cultural understanding and cultural competency; and to expand and enhance opportunities within the COM at all levels for individuals from all backgrounds. Diversity remained one of the strategic goals for the COM, and diversity goals continued to be included in the annual evaluation of each department chair.
The deans’ institutional and personal commitments to integrate diversity into the culture of the COM embrace diversity as a benefit to the institution, essential to achieving excellence across education, research, and clinical care missions. The systematic development of the COM diversity plan and the requirement of specific departmental plans encode diversity in the culture of our COM.
Financial resources are allocated to diversity efforts from the COM budget. These resources ensure proper staffing and operating budgets to develop essential programs for recruitment, retention, development, and promotion of URM individuals. The diversity office staff includes a senior associate dean for diversity, an associate dean for resident inclusion and diversity education, a manager for recruitment, and a manager for diversity initiatives. Several other individuals throughout the COM are also engaged in diversity-related activities, and some departments designate individuals as key personnel to lead diversity efforts. These leaders ensure that respective aspects of the COM and departmental diversity plans are implemented with regard to students, residents, and faculty. Thus, there is oversight to promote continuous process improvement.
The demonstrated institutional commitment laid the groundwork for development of meaningful diversity programs, such as pipeline programs, cultural competency training, a women scholars program, the dean’s annual diversity colloquium, and leadership training for women and minorities. We describe some examples of these programs below.
Programs and Strategies for Achieving Diversity
Pipeline programs are critical to achieving a diverse health care workforce and must be cultivated consistently over time.5 The COM successfully developed eight pipeline programs over the past 10 years: three for middle and high school students, and five for undergraduate college students. Adequate resources, including proper staffing, well-defined goals and objectives, critical evaluation, and continuous process improvements are essential to the success of a pipeline program.
Equally important as the pipeline programs we created at the COM, the COM has ongoing partnerships with more than 40 colleges and universities, including South Carolina’s historically black colleges and universities, to develop interest in the health professions among URM individuals. The COM admissions office has designated liaisons at each of our partner institutions and maintains frequent contact with the counselors, teachers, and administrators at these schools. The recruitment manager and assistant dean for admissions each make regular visits to these institutions to host informational sessions, recruitment fairs, and individual admissions counseling sessions. The COM admissions office maintains a database of undergraduate students who have expressed interest in a career in medicine, and the students receive career mentoring over an extended period. We invite undergraduate students from our partnership institutions to attend MCAT preparation sessions and mini-medical school programs, which are daylong programs that provide an overview of a typical day for a medical student, such as lectures, small-group discussions, and labs. Interested students also connect with current COM students for campus tours, advice on academic preparation, and volunteer or shadowing experiences. Here, we highlight two unique pipeline programs that exemplify the COM’s novel efforts to encourage diversity.
Post-baccalaureate Reapplication Education Program
The purpose of the Post-baccalaureate Reapplication Education Program (PREP), developed at MUSC in 1992, is to increase the number of URM students and students from underserved areas of South Carolina matriculating in the COM. At the recommendation of the admissions committee, students who are not accepted to medical school but demonstrate the potential and promise to become physicians are invited to apply to PREP. Two to three students are accepted annually.
For two semesters, students complete advanced-level science courses at the College of Charleston, a local state-supported university unaffiliated with MUSC. The COM provides scholarships for tuition and fees for students who are enrolled in PREP. The MUSC Office of Student Diversity also provides an annual stipend to PREP students. On successful completion of the courses (GPA of at least 3.0) and review by the PREP committee, students are admitted to the COM during the fall of the next academic year.
The success, well-being, and professional development of PREP students are essential to the mission of the COM. Throughout their enrollment in the PREP program, the MUSC Office of Academic and Student Affairs and the Center for Academic Excellence (CAE) provide academic support for PREP students to ensure their personal and professional development as future physicians. The assistant dean for student affairs monitors the academic progress of students in consultation with course directors, reviews evaluations and identifies students with marginal performance, and initiates contact with students as necessary to assess problems, identify solutions, and make appropriate referrals to MUSC campus resources.
Students are required to meet weekly with CAE faculty members to develop a plan of study for each course, learn strategies for taking multiple-choice examinations, assess learning styles, andimprove time management. Additionally, tutoring is available for PREP students. Students are assigned tosmall groups to augment their large-lecture instruction. An upper-level student facilitates the weekly small-group sessions for the students.
Since the program’s inception, 51 students have enrolled in the PREP program and 46 have successfully completed the course of study and entered MUSC COM. Three students are currently enrolled in the PREP program, and 5 students did not successfully complete the program.
Of the 46 PREP graduates, 29 have graduated from MUSC, 14 are current medical students, and 3 withdrew from the university. Of the 3 students who withdrew from medical school, 1 later received a doctor of nursing degree, 1 is pursuing a graduate degree in a science field, and another plans to pursue a health-related field of study.
The 26 PREP graduates selected the following residency medical areas: internal medicine (9), family medicine (4), obstetrics–gynecology (3), preliminary surgery (3), surgery (2), pediatrics (2), medicine–pediatrics (1), and anesthesiology (1). One has delayed residency training. Eighteen (62%) of these graduates chose a primary care residency, which is noteworthy in contrast to 62/155 (40%) selecting primary care (defined as internal medicine, family medicine, pediatrics, or medicine–pediatrics) in the 2012 graduating class overall. URM students from our PREP program have contributed disproportionately to filling a critical needs area in medicine by choosing primary care. This further underscores the value of the PREP program.
A Gentleman and a Scholar
Most African American male COM students cite the welcoming environment, the academic and social support system, retention rate, and graduation rate as factors for choosing MUSC.15 Motivated by their experience at MUSC and the desire to give back, the African American males attending the COM in 2006 founded “A Gentleman and a Scholar,” a mentoring program for high school and college African American males with an interest in the health professions. The mentoring program includes one-on-one meetings between mentors and mentees, monthly on-campus workshops and seminars, and development of test-taking skills, study skills, resume writing, and professional decorum. Each COM African American male medical student serves as mentor to one to three mentees. The program’s philosophy is to accept all applicants if they are motivated to fully participate. Forty-nine students have enrolled to date. Of these, 1 student was admitted to podiatry school, 16 high school graduates are currently enrolled in college, and 1 student was admitted to MUSC COM. The remainder of the students are current participants in the program. In 2009, the Gentleman and a Scholar program was featured in the AAMC Reporter16 as an example of a unique pipeline program.
As seen in Figure 1, there were 56 (11%) URM students within the student body at MUSC in 2002, just after Dr. Reves’ strategic diversity planning. Within a four-year period, we saw an overall increase in the total student body, and the number of URM students rose to 94 (17%). Although growth remained unchanged for several years, by fall 2012, the number of URM students increased to 119 (21%). Compared with national data for URM students at peer institutions,17 MUSC demonstrates leadership in medical student diversity. In 2006, the COM matriculated 10 African American males in one class, a number five times greater than the national average of African American males matriculating in a single class at non–historically black medical schools.18 For four consecutive years, 2006 through 2010, at least 10 African American males matriculated each year in the COM. Among the 2010 MUSC medical student matriculants, 49% and 43% cited student diversity and faculty diversity, respectively, as very positive/positive factors for choosing MUSC.19
Today, the retention rate for all MUSC medical students is 98%, and the United States Licensing and Medical Exam Step 1 and Step 2 scores are at the national average.
Recruitment and retention plan
We consider recruitment and retention to be simultaneous processes, both necessary for positive diversity outcomes. The recruitment process begins long before the official application. Communication is an essential component; therefore, the admissions office maintains regular communications with our pipeline programs as well as with college and university partners. Once an applicant is accepted, we provide a student ambassador from the COM to communicate information about the COM and to answer questions regarding the academic and social environment. All accepted students regardless of URM status are assigned a COM student ambassador.
Prior to matriculation, we provide a peer mentor of the same race/ethnicity for new URM students to assist with the transition to medical school. Additionally, all new students, including URM students, participate in the COM peer-mentoring team program, which consists of small teams of first-year students mentored by two second-year medical students. The peer-mentoring teams meet several times during the year to discuss useful resources, “pearls” for succeeding in medical school, and other first-year student issues. These COM teams exist longitudinally throughout the four years of medical school. The associate dean purposefully assigns students to ensure that groups are diverse (age, gender, race/ethnicity, geographic location, etc.).
All URM students participate in the Mentoring Assures Medical School Success program, which consists of monthly roundtable luncheons with the associate dean for diversity, associate dean for diversity education, assistant dean for student affairs, and executive director of student programs. These roundtable luncheons include dialogue related to accessing resources, study skills, and managing personal and professional issues. All students regardless of URM status are expected to use the CAE, which provides assessment of learning styles, development of study skills and test-taking skills, and supplemental instruction (individual and group). Across the COM, we make an effort to destigmatize the need to seek mental health services, and we encourage students to use the services at Counseling and Psychological Services.
As shown in Figure 2, there were 16 (3%) URM residents at MUSC in 2003. All clinical departments have incorporated recruitment of URM residency candidates into their individual diversity plans. In 2006, the overall number of URM residents increased more than twice from the baseline rate, rising to 36 (7%). The implementation of the “Second Look Visit” program was influential in attracting candidates, especially URM individuals. Residency candidates were invited to return to MUSC for a “second look” after their initial interview, during which time the candidates had an opportunity to meet with current residents and faculty at MUSC. This program targeted residency candidates regardless of URM status. The Second Look Visit program also included an informal reception, which created an environment for the candidates to ask current residents and faculty about the environment at MUSC and other issues of concern. The number of URM residents reached an all-time high of 61 (10%) by 2008 and fell slightly to 54 (9%) by 2010. Over the past 10 years, with the exception of dermatology and orthopedic surgery, all departments have enrolled URM residents in their programs. Although we are able to encourage applicants’ continued interest in our residencies through programs such as the Second Look Visit, the National Resident Matching Program prohibits both applicants and programs from making prior commitments regarding how each will be ranked.20
URM residents, along with the associate dean for resident inclusion, have formed the McClennan–Banks Residents Networking and Mentoring Society. The society provides an avenue for URM residents to engage in networking with faculty and other residents, obtain a mentor, participate in community outreach and recruitment efforts, and develop an interest in academic medicine. It provides a venue for URM residents to interact across specialties and to serve as ambassadors to departments for recruiting new resident physicians.
Recruitment of URM faculty is integral to developing diversity throughout the institution. A diverse faculty aids in the recruitment of all students and residents, plays a key role in their education and training, and fosters an environment conducive to advancement and development. URM and non-URM students alike learn firsthand from diverse individuals with diverse perspectives. These faculty–student interactions serve to incorporate the roles of culture and social determinants of health care delivery, address misperceptions and stereotypes, and build relationships.
As shown in Figure 3, there were 35 (4%) URM faculty members in 2003, and 52 (6%) by 2005. The faculty ambassador program, developed in 2003, assigns a current URM faculty to meet with faculty recruits from various departments during the interview process, and appears to have been a positive recruitment strategy for faculty. Faculty ambassadors share with the recruits their experiences at MUSC, aspects of the environment, characteristics of the community, and avenues for social enrichment for the family. Despite faculty attrition and an overall increase in number of faculty, the COM has maintained 66 (6%) minority faculty as of fall 2011.
During the fall of 2011, Dean Pisano formalized a faculty mentoring process in the COM. Each department developed a mentoring plan and identified a mentoring champion as a liaison to the Dean’s Office. Junior faculty members are paired with senior faculty for academic and professional development. In 2011, Dean Pisano also appointed five part-time associate deans of faculty affairs to serve the faculty. Together, these associate deans are available 40 hours per week to faculty. The group of associate deans is purposefully diverse (gender, age, specialty, race, basic/clinical science) to ensure that most faculty members are able to find an associate dean appropriate for her or his needs. The faculty affairs deans are able to identify resources and match faculty to those resources on the basis of their needs. This demonstrates to all faculty, especially URM faculty, that the dean is sensitive to diverse faculty needs.
To address the goal of promoting racial, ethnic, and gender diversity in leadership positions, department leaders are actively devising plans to develop individuals who show promise for leadership positions. Additionally, the Dean’s Office provides funds to individuals who have successfully competed for admission into regional and national leadership programs. The faculty affairs group has developed a leadership school on campus and implemented it during spring 2012. The COM associate dean for diversity monitors the academic promotion and leadership process for faculty and reports to the dean annually about progress toward faculty diversity goals.
Examining Success and Lessons Learned
MUSC COM has made a strong institutional commitment to developing a diverse physician workforce, and this commitment has yielded several positive outcomes. Progress has come from steadfast leadership throughout the COM, committed students assisting with recruitment and retention, concentrated mentoring initiatives, and support from an increasing number of minorities on campus (the critical mass effect). The commitment from the deans since the first strategic plan for diversity in 2002 has been essential, but is not sufficient for success. The department chairs, faculty, and students have embraced the cultural change necessary for success. The approach has been comprehensive, multifaceted, and strategic from pipeline programs to faculty development.
One hallmark of the plan was to increase diversity as a means to enrich the learning environment for all and, specifically, to improve the quality of medical education by introducing greater student diversity. In all that we have done, the purpose was to broaden the background and experience of students, residents, and faculty rather than to reach preconceived numerical goals. We found that incremental progress toward strategic goals was the best way to effect the necessary cultural change. Although the programs we describe have grown out of the unique culture and circumstances at MUSC, other institutions may find our experiences helpful in developing diversity initiatives to suit their specific needs.
The PREP program is a unique pipeline program because it is a collaborative effort between MUSC and a local unaffiliated undergraduate university, the College of Charleston. This novel relationship was necessary for MUSC because MUSC is a health sciences university and does not have an undergraduate applicant pool as do most universities with both undergraduate and medical schools. A second important feature of the program is MUSC’s financial investment of paying the tuition for students in the PREP program. MUSC has a significant interest in PREP students’ success and transition to medical school. The program has been successful in preparing students for medical school and has proven to be a source of future primary care physicians, contributing to MUSC’s commitment to graduate an increasing number of primary care physicians who will meet growing primary care needs. The PREP program could serve as a model for medical schools like MUSC that are not affiliated with an undergraduate university, as well as for universities that do have undergraduate schools but wish to pursue innovative pipeline partnerships.
Our experience addressing the challenges we faced may also be of use to others implementing a strategic diversity plan. An essential component of a successful diversity plan is having unwavering commitment from the dean as well as committed stakeholders (students, residents, and faculty) who are involved in strategic planning and implementation of diversity goals. It is also important to select a diversity committee composed of individuals who demonstrate recognition of the value of diversity for the entire institution. Doing so can help avoid delays in initiating the process. Once a committed, qualified group of individuals has identified a strategic plan, we have found that clear—and clearly communicated—timelines for specific components of the plan are crucial to move the process along. As we mentioned above, the COM made a financial commitment to diversity, funding initiatives and sponsoring PREP students as an investment in the future of diversity at MUSC. Without institutional support, financial and otherwise, a strategic plan cannot succeed. Further, from the beginning, we made every effort to integrate diversity plans and programs into the overall mission of our institution. Taking a piecemeal approach can result in a “silo” effect, making diversity an important issue only for certain groups or departments. In the end, a more diverse environment is more attractive to all individuals, especially URMs. Developing diversity benefits the entire institution, not just URM stakeholders.
Diversity in the health care workforce is compelling because it improves access to care21 and patient satisfaction,22,23 develops cultural competence,24 and enhances the educational experience.25 Increasing diversity of the physician workforce has undoubtedly added value to MUSC as a whole. Among the benefits are the use of “collective wisdom” in strategic planning, the expansion of health disparities research, a broader vision through use of various talents, an enhanced learning environment, the integration of diversity throughout the curriculum, the education of physicians to serve diverse populations, and the expansion of thought leaders. We offer the MUSC COM’s strategic initiatives and experiences with increasing diversity in the health care workforce as a model for other academic health centers.
Acknowledgments: The authors wish to acknowledge the College of Medicine diversity committee, department chairs, faculty, students, and staff for their efforts to promote diversity at the Medical University of South Carolina and to implement the college’s diversity plan.
Other disclosures: None.
Ethical approval: Not applicable.