Given the implementation of the Patient Protection and Affordable Care Act and emerging health care workforce and population trends, the Association of American Medical Colleges has predicted a shortage of 91,500 active patient care physicians in the United States by 2020.1 This prediction, combined with persistent health care disparities and changes in population demographics, has created an acute need to increase the number of diverse and culturally competent physicians. The U.S. population is moving closer and closer to the majority–minority shift (which will occur when the majority of people in the United States are nonwhite). In fact, in fall 2014, nonwhite students constituted the majority of students in the U.S. public schools system.2 The Latino population, in particular, which represents the largest and second-fastest-growing nonwhite group in the United States, is predicted to become 30% of the U.S. population by 2050.3 Latinos represent a critical resource of talent that academic health centers (AHCs) should cultivate in their efforts to expand the physician workforce.
In this issue of Academic Medicine, Gloria Sánchez and colleagues4 comment on the shortage of physicians in the United States, asserting that “concern about the impending Latino physician shortage should be even greater, particularly with regard to the provision of health care services in Spanish.” Latino physicians offer unique contributions to the health of the nation and to the health workforce. They are more likely to care for Latino communities, to provide health care to populations that are medically underserved, and to speak Spanish (which facilitates language concordance between patient and provider and, in turn, improved health outcomes for the patient).5 However, over the 30-year period covered by Sánchez and colleagues, there have been only small increases in the number of Latino applicants and enrollees to MD-granting institutions.6 In light of the increasing demand for physicians especially among the Latino population, we assert that expanding the number of Latino physicians involved in clinical practice and in research and policy is a core strategy for addressing Latino health inequity. Aligned with this strategy, AHCs must also integrate education and training to prepare all physicians to provide culturally responsive care to Latino communities.
Is the Physician Workforce, Including Latino Physicians, Sufficient to Address Latino Health Care Needs?
Important nuances in the Latino patient population affect medical education and physician workforce planning. Further Latinos in the United States, including physicians, represent a diverse community. Their ethnicity, beliefs and traditions, language use, migration patterns, and history in relation to the United States all influence their health, access to health care, and the quality of the care they receive. For example, compared with other Latino groups, Puerto Ricans are disproportionately burdened by infant mortality, HIV/AIDS, and low infant birth weight.7
These unique health care needs along with the health disparities related to the Latino community should inspire a sense of urgency for all physicians to enhance their awareness, understanding, knowledge, and skills so as to meet the needs and to reduce inequities. Currently, one in three uninsured individuals in the United States is Latino, and Latinos are less likely than non-Hispanic whites to have a regular primary care provider, which increases the likelihood of poorer health outcomes.8 Furthermore, although Latinos are younger compared with non-Hispanic whites, they are more likely to have obesity and diabetes,8 two chronic conditions placing a significant financial burden on the U.S. health care system. Collectively, these statistics underscore the need for all providers to become better equipped to care for Latino patients.
Sánchez and colleagues’ discussion focuses on the states with the largest (in 2010) populations of Latinos and the distribution of Latino physicians, but it is also important to call attention to other unexpected areas of Latino population growth. States in the South and Midwest—specifically Tennessee, South Carolina, Alabama, Kentucky, and South Dakota—have experienced the most significant growth of Latino populations between 2000 and 2012.9 We call for workforce research on many related topics including the following: health care access and delivery for communities with a high density of Latinos and/or with a burgeoning Latino population; the practice duration of Latino physicians, especially the factors that facilitate or impede providing care in underserved areas; and the facilitators and barriers to including Latino physicians as both primary care providers and specialists.
Ongoing Challenges to and Opportunities for Developing a Latino Physician Workforce
The development of the Latino physician workforce will require a multifactorial approach, recognizing place- and sector-based factors and innovative strategies. Among other possible next steps, we recommend the following solutions, extending the work of Sánchez and colleagues: building the next generation of Latino medical school applicants and matriculants, cultivating Latino medical residents, prioritizing the inclusion of Latinos in the academic medicine workforce, expanding both undergraduate and graduate curricula on Latino health, rebuilding and reframing federally sponsored diversity initiatives, and fostering collaboration between Latino professional organizations and AHCs.
Building the next generation of Latino medical school applicants and matriculants
Despite broadening the definition of underrepresented racial and ethnic groups in medicine to include not only Latinos who are mainland Puerto Rican, U.S.-born Mexicans, and U.S.-born Cubans but also Latinos who are from any Spanish-speaking country, the growth in the proportion of Latino-identified medical school applicants and matriculants is slow. To illustrate, between 2002 and 2011, the proportion of Latino applicants grew minimally from 7.3% (2,443/33,624) to 7.9% (3,459/43,919), and the proportion of accepted applicants increased slightly from 6.8% (1,193/17,592) to 8.4% (1,701/20,176).6 Data show that this growth in Latino applicants and matriculants has come primarily from individuals identifying as “Other Hispanic.”6 More research is needed to understand the demographic characteristics (e.g., the nativity, gender, socioeconomic status, place of residence, educational experiences) of applicants and matriculants, the changes in their demographics over this same time period, and the impact of these characteristics on institutional climate, culture, and patient care.
A recent study on medical school expansion reported that 38% of 127 medical school respondents (n = 48) reported focusing their efforts on increasing the number of “minority groups currently underrepresented in medicine.”10 However, current numbers do not demonstrate significant outcomes for these efforts. Moreover, despite decades of diversity work, there has yet to be commissioned a summary of evidence-based best practices and recommendations on increasing Latino applicants and matriculants in medicine.11
Scholars and practitioners strongly agree that early intervention is critical to increasing diversity in the sciences and health professions.11,12 Latino children represent an important pool of potential physicians. In 2010, of the Latino population living in the United States, 38.2% were 19 years old and younger (of non-Hispanic whites in the country, 23.3% were in the same age category).13 A key challenge is that the overwhelming majority of racial and ethnic minority students are concentrated in communities living in poverty that are often characterized by underresourced schools.14 According to 2010 U.S. Census data, 26.7% to 28.2% of Latinos live in poverty,15 and, of these, 65.8% live in “poverty areas.”14 Despite the challenges that Latino students may encounter, recent reports show that high school dropout levels among Latinos in 2011 were half what they were in 2000—indicating an increased number of students moving into higher education, and potentially the health professions.16
AHCs have the opportunity to intervene early by working with K–12 educators. AHCs may “grow their own” cadre of Latino physicians by supporting teacher preparation and offering after-school and weekend programs that enhance academic proficiency and/or spark interest in careers in medicine and science. Medical schools also need to begin or increase recruitment at institutions with significant Latino student bodies such as at Hispanic-serving institutions and community colleges.17
Cultivating Latino medical residents
Between 2000 and 2012, the proportion of Latino residents on duty increased from 5.5% to 7.5%; likewise, the proportion of Latinos graduating from U.S. and Canadian Liaison Committee on Medical Education (LCME)-accredited medical schools, U.S. osteopathic schools, and non-U.S. schools also increased.18,19 As with medical student workforce research, there is a need to explore historical trends in the demographics of Latino residents; the effects of the composition of the Latino resident workforce on institutional climate, culture, and patient care; and the evidence-based best practices for increasing Latino residents. Distinct topics of resident workforce research should include both (1) the effects of the increasing number of medical student graduates on Latino applicants matching into primary care versus specialty residencies and on Latino applicants matching into urban versus rural residencies and (2) the factors that impede or facilitate Latino residents choosing to practice in underserved urban or rural areas.
Prioritizing the development of Latinos in the academic medicine workforce
Academicians play a core role in workforce development and in addressing health issues and disparities. They facilitate the recruitment, retention, and promotion of Latino students, residents, and faculty. Additionally, academicians influence the strategic plans of AHCs, including Latino-centered patient, research, educational, and service activities. In 2013, Latinos represented only 3.7% of faculty in MD-granting institutions; in senior leadership, Latinos represented only 3.4% (1,162/33,995) of full professors and only 1.4% (2/141) of medical school deans.20 Moreover, the past 10 years have shown little growth in Latino faculty representation, and recent research has shown that Latino medical students are less inclined than non-Hispanic whites to consider an academic career and that they report distinct challenges.21
Increasing Latinos in the academic medicine workforce is vital to institutional excellence, and AHCs need to support the optimal culture and climate wherein all faculty, including Latino faculty members, can thrive. Latino providers are more likely to speak Spanish,4 which supports institutions’ efforts to provide patient–provider language concordance for Spanish-speaking patients, which in turn contributes to higher patient satisfaction, enhanced patient compliance, better patient outcomes, and even cost savings.22,23 The Latino perspective can help inform cultural competency training programs by providing insight into the community’s cultural beliefs, traditions, migration patterns, family structures, and other factors contributing to health. Latino academicians, given their unique experiences in their communities, will ask different research questions and propose different solutions. Additionally, the younger generations of Latino physicians and researchers desire and benefit from Latino faculty serving as role models and mentors.21,24 Program development and research are needed to increase the presence of Latinos in academia and to assess how their presence strengthens the physician workforce and addresses the health of Latinos and those from other marginalized communities.
Expanding both undergraduate and graduate curricula on Latino health
The National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care23—along with calls by the Institutes of Medicine, the LCME, and the Accreditation Council for Graduate Medical Education (ACGME) for enhanced cultural competency training—provide an opportunity to take inventory of existing educational modules and develop and evaluate new ones on Latino health. Courses entitled “Medical Spanish” have emerged on many campuses; however, greater research is needed to understand what level of language acquisition and proficiency translates into improved patient–physician communication. Additionally, greater research is needed on best practices in training faculty to deliver Spanish-language content. A community-based participatory approach to teaching health and health disparities is one important educational framework to consider.25
Interprofessional education and collaborative practice also offer promise. All trainees should train in teams that include a diverse group of health professionals who effectively work together to leverage team members’ skills, including language ability, so as to meet patient needs.26 Interpreters play a vital role in improving communications between the provider and patient. Training that includes working with an interpreter is critical for all physicians working in Latino communities.
A novel idea to broaden opportunities for medical students to learn about Latino health is to transform community health centers, especially those that provide care to a large percentage of Latino populations, into teaching health centers. This model has been applied in the education and training of physician assistants, nurse practitioners, and family medicine residents.27,28 Additionally, retired Latino health professionals and promotoras (i.e., community lay health workers) can be recruited to instruct medical students and residents.29
Rebuilding and reframing federally sponsored diversity initiatives
In the past 40 years the U.S. federal government first broadened diversity-related funding to initiate 34 Centers of Excellence (COEs) and 74 Health Careers Opportunity Programs (HCOPs), but then reduced funding to support only 4 COEs and 4 HCOPs. Now, diversity leaders must work tirelessly to procure institutional and state buy-in to maintain the remaining COEs and HCOPs.30 Before COEs and HCOPs are completely lost, the medical and medical education communities must take a thorough inventory of these entities—and then publish their best practices and lessons learned. Only by sharing and applying such information can diversity efforts be rebuilt and reframed to achieve greater success in the next 30 years. Additionally, funding should be allocated to support Centers for Workforce Diversity that can critically evaluate diversity-related programming and activities.
Fostering collaboration between Latino professional organizations and AHCs
The recognition of unmet Latino health care needs, of obstacles to Latino diversity and inclusion in the physician and academic pipelines, and of feelings of isolation and marginalization among Latinos at many AHCs has led over the past 20 years to the creation of three national Hispanic-identified medical organizations: the Latino Medical Student Association (LMSA), the National Hispanic Medical Association (NHMA), and the Hispanic-Serving Health Professions Schools (HSHPS). Collectively, these organizations, which represent the interests of over 50,000 Latinos in the medical pipeline and 37 Hispanic-serving institutions, are working to unify and train Latinos and others to serve as a catalyst in addressing Latino health issues. As these organizations have considerable access to large segments of the Latino medical workforce, they are well suited to inform research (through, for example, the HSHPS professional development workshop entitled “Using Data Systems to Improve Hispanic Health Outcomes”), to advocate policy (through the work of the LMSA’s National Policy Section), and to offer community education (through the NHMA’s Obesity and Diabetes Initiative) that address Latino health–related issues and disparities. Further, these organizations can serve as a resource for AHCs in identifying current or future talent (through, for example, the NHMA Leadership Fellowship Program), in informing strategy to develop more inclusive environments, in meeting regulatory standards (e.g., CLAS, LCME, and ACGME standards), in providing networking and mentoring opportunities for matriculants and faculty (through the HSHPS Student Mentorship Program for Hispanic Health Research), and in influencing education and training curricula on Latino health. These organizations can solicit philanthropic contributions toward a Latino health agenda through the dissemination of white papers and policy statements. Further, these organizations may help effect policies that address Latino health through their influence on state-based medical organizations such as the California Medical Association and the Washington State Medical Association. Continued and enhanced federal, state, and foundation funding can enable these organizations to develop, implement, and, most important, evaluate the outcomes and impact of their activities.
The number of Latinos is rapidly growing—nearly one in three individuals in the United States will be Latino by 20503—thus, there is an urgent need for U.S. AHCs to proactively meet the needs of this population. Research on the outcomes of and best practices among our Latino physician pipeline programs is overdue. Hispanic-identified organizations, leaders, and health professionals must be engaged to inspire and recommend institutional innovation and excellence. Sánchez and colleagues call attention to the shortage of Latino physicians that has persisted for 30 years. We call on our colleagues to build the next generation of the Latino physician workforce and to develop the skills and knowledge of all health care professionals to address Latino health care and disparities.
Acknowledgments: The authors would like to thank Amanda L. Hernández, president of the Latino Medical Student Association, for her thoughts on building the Latino medical pipeline.
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