Historically, racial and ethnic minorities have experienced higher rates of chronic disease, obesity, and premature death.1 African American patients in particular have among the worst health outcomes, experiencing higher rates of hypertension and stroke, and African American men have the lowest life expectancy of any demographic group, living on average 4.5 fewer years than White men.2 This health inequity persists today, and the health equity divide has been made even more obvious with the impact of the COVID-19 pandemic, where minority populations shoulder a disproportionate burden of COVID-19 cases, hospitalizations, and deaths.3
A number of factors have been found to contribute to these health disparities, one of which is the need for greater ethnic and racial diversity among physicians1,4 such that the population served may more closely resemble the medical providers. The current racial/ethnic makeup of the physician workforce does not reflect the diversity in the US general population.5 Indeed, 5.8% of practicing physicians in 2018 identified themselves as Hispanic and 5% identified as Black or African American. These proportions are an underrepresentation of the national makeup of the United States, since according to the US Census Bureau, in 2019 Hispanics/Latinx were an estimated 18.3% and African Americans an estimated 13.4% of the population.6 Lack of diversity and maldistribution of medical personnel appear related; 47.6% of Underrepresented Minorities medical school graduates reported that they plan to provide care to underserved populations compared with 19.3% of all other graduates.7 Physicians who are Underrepresented in Medicine (UIM) are more likely to serve poor, uninsured, and vulnerable populations.8 In addition, research suggests that sharing a racial or cultural background with one's doctor helps promote communication and trust.9
More than 80% of African American physicians in the United States were trained at a historically Black medical school.10 Even with this output on the part of the Historically Black Colleges and Universities (HCBUs), the number of UIM physicians continues to lag. The American Medical Association recently prioritized health equity and outlined a strategic framework toward realizing the goals of achieving optimal health for all, one of which is to increase health workforce diversity and cultural awareness/competency.11 Inasmuch as HCBUs have contributed to this need, in order to meet the demand, an increase in enrollment at other medical schools would be helpful. The University of Pennsylvania Train-in-Place OEM Residency, in existence since 1999,12 while successful at training physicians making a mid-career change to Occupational and Environmental Medicine (OEM), had been less successful at enrolling UIM residents. To meet this challenge, program leadership determined to be intentional about increasing the UIM applicant pool from which to draw, in an attempt to potentially increase enrollment such that the residents and graduates may more closely resemble that of the general US worker population, whom residents would be called upon to serve. Program leadership recognized the need and strategized to address this need.12
This was a before-after study. An Inclusion and Diversity Committee (IDC) was formed in 2008, which consisted of the program director (PD), as well as past and current residents, including all UIM residents and graduates. The main goal was to recruit and develop UIM residents, as well as create a welcoming curriculum. Meeting at least twice each year, strategies to recruit UIM residents included development and distribution of descriptive brochures and posters13 at select national and regional meetings such as the Student National Medical Association and the Hispanic Medical Association. Targeted advertising was conducted, such as advertisements placed in the Journal for Minority Medical Students, in which an article describing the field of OEM was also published.14 Residents and graduates supervised advertised 1-day observerships for residents and medical students. Residents and UIM graduates presented at and reached out personally to UIM residents and medical students at local, regional, and national meetings to generate interest in the field in general and the program in particular. There was also informal outreach to UIM residents and medical students by committee members, including contacting MPH programs in an effort to inform candidates of both the specialty and the program.
UIM graduates were available to mentor residents and often the PD/associate PD connected UIM residents with UIM graduates during the application process, and this relationship continued throughout the residency and beyond. To nurture relationships formed and foster new ones, an annual reception for faculty, graduates, and residents was held at the National Occupational Health Conference starting in 2012. Here UIM residents connected in person with UIM and other graduates in an inclusive environment. The program faculty were also diverse and remained consistently so over the decades before and after the intervention. Curriculum development to address equity and diversity constructs was prioritized where cultural competence and unconscious bias were intentionally included in the formal curriculum.
Residents who self-identified as Black, Hispanic, or American Indian were included in this analysis. Race and ethnicity data were abstracted from the residency application forms. The residents were assigned according to year they graduated from the program.
Human participant compliance statement: This study and report did not include human participants.
Twenty residents self-identified as UIM of which 17 of 135 (13%) self-identified as Black, 3 of 135 (2%) self-identified as Hispanic White, and none as Native American. Eleven identified as male and 9 identified as female. During the first decade of the program (1999-2008), 4 (4/65; 6%) UIM residents were trained. After the establishment of the IDC in 2008, the number of UIM residents increased to 23% in the subsequent decade (2009-2020). Indeed, during the latter 5 years, 27% of the residents were UIM residents (Table 1).
TABLE 1 -
Number of Resident Physicians Underrepresented in Medicine Before and After Creation of the Inclusion and Diversity Committee (1999-2020)
||Number UIM/Total Residents (%)
|Jul 1999-Jun 2008
||9-y period pre-IDC
|Jul 2008-Jun 2020
||12-y period post-IDC
|Jul 2008-Jun 2014
||First 6-y period post-IDC
|Jul 2014-Jun 2020
||Second 6-y period post-IDC
Abbreviations: IDC, Inclusion and Diversity Committee; UIM, Underrepresented in Medicine.
TABLE 2 -
Percentage of African American and Hispanic Graduates From US Medical Schools by Yeara
From Association of American Medical Colleges.16–18
The targeted multifaceted strategic approach to increase enrollment of UIM physicians was successful. Creating a diversity committee with defined strategic goals, as well as implementing mechanisms to meet these goals, was important to the success. Being intentional resulted in the training program's ability to graduate OEM physicians who were more reflective of the general population of the United States, which is important toward addressing national health care disparities. The IDC formulated plans each year, which iteratively changed year by year depending on the ideas of new committee members, the personnel, and the opportunities at hand. Starting out with only having 6% of the graduating physicians being UIM during the initial 9 years of the program, this percentage quadrupled over the subsequent 12-year period to 23%. Although this still falls short of the UIMs in the general US population, it is above the national average for UIM residents in US medical graduate education programs.6
The program was supported by Health System leadership whose commitment to inclusion and diversity created a supportive environment for these initiatives. Indeed, in 2011, the University of Pennsylvania President and Provost released an Action Plan for Faculty Diversity and Excellence, which led to a campus-wide effort to optimize diversity at Penn, redefining it as a critical pillar of an eminent institution. In addition, the Dean of the School of Medicine led a strategic planning process toward strengthening faculty diversity and inclusion. An Alliance of Minority Physicians (AMP) was also formed in 2011, with one of the goals being community outreach. Our residents and faculty were able to join AMP recruitment events. The program continues to attract a diverse group of applicants, which is important toward addressing national health care disparities. Our faculty are also diverse, and our curriculum formally teaches cultural competency and diversity topics as we work toward building a physician workforce to meet the needs of the nation's workers.15
The temporal relationship between the IDC creation and the increase in UIM residents in the program suggest an association between the intervention and the increase. However, given that this is an observational before-after evaluation of an intervention and not an experimental evaluation, it is not possible to determine cause and effect. However, the percentage of UIM medical school graduates over the past couple decades has remained low and quite stagnant, with no significant increase in the percentage of African American medical school graduates since 2000. Although there has been some fluctuation in the percentage of Hispanic graduates, ranging from 3.7% to 8.5%, there is no linear increase (Table 2). The more significant increase in UIM residents since the IDC was introduced was seen in this study was for African American residents. As such one is hard-pressed to attribute the increase in UIM residents to an increase in a pipeline of medical student graduates. This intervention managed to move the needle without a wider UIM medical graduate pipeline.
In addition, there has been no increased publicity of OEM programs or increased support of OEM programs. Furthermore, there were no other contributing factors going on at the same time such as independent outreach activities from other NGO, government, or private sector entities that could be identified. However, there were no temporal trends that we are able to identify that could account for an increase in the number of UIM residents in this training program. As such, it is possible that the IDC intervention led to the laudable increase in UIM. Certainly, this is a before-after study and cannot say anything about causation.
Implications for Policy & Practice
- Targeted intentional strategic interventions can lead to increased enrollment of UIM residents.
- Providing an inclusive environment for UIM residents through intentional mentoring and culturally sensitive curriculum may increase retention and assist in successful recruiting.
- Leadership commitment to inclusion and diversity and support of such programs can contribute to the success of attracting diverse applicants.
1. Weinstein J, Geller A, Neguddsie Y, Baciu A. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2016.
2. Arias E, Heron M, Xu JQ. United States Life Tables, 2014. Vol 67. Hyattsville, MD: National Center for Health Statistics; 2017. NCHS Rep No. 4.
3. Bambino D, Shah A, Doubeni C, Sia I, Wieland M. The disproportionate impact of COVID-19 on racial and ethnic minorities in the Un-ited States. Clin Infect Dis. 2020:ciaa815. doi:10.1093/cid/ciaa815.
4. Torres N. Research: Having a Black doctor led Black men to receive more-effective care. Harvard Business Review. August 10, 2018:2–6.
5. Nunez-Smith M, Ciarleglio MM, Sandoval-Schaefer T, et al. Institutional variation in the promotion of racial/ethnic minority faculty at US medical schools. Am J Public Health. 2012;102(5):852–858.
6. Association of American Medical Colleges. Diversity in medicine: facts and figures 2019, Executive summary. https://www.aamc.org/system/files/2019-12/19-222-Executive%20Summary-FINAL-120919.pdf
. Published 2019. Accessed November 13, 2020.
7. Association of American Medical College. Interactive report. Section II current status of the US physician workforce comments 2014. https://www.aamcdiversityfactsandfigures.org/section-ii-current-status-of-us-physician-workforce/index.html
. Accessed April 15, 2016.
8. Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995;273(19):1515–1520.
9. Singhal A, Tien Y, Hsia RY. Racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. PLoS One. 2016;11(8):e0159224.
10. Association of American Medical Colleges. At a glance: Black and African American physicians in the workforce. https://www.aamc.org/news-insights/glance-black-and-african-american-physicians-workforce
. Published February 20, 2017. Accessed September 14, 2020.
11. American Medical Association. Press release: AMA outlines ambitious approach toward health equity. https://www.ama-assn.org/press-center/press-releases/ama-outlines-ambitious-approach-toward-health-equity
. Published June 13, 2018. Accessed September 14, 2020.
12. Green McKenzie J, Emmett E. Characteristics and outcomes of an innovative Train-in-Place Residency program. J Grad Med Educ. 2017;9(5):634–639.
13. Green-McKenzie J, Drummond J. Strategies to increase underrepresented minorities in Occupational and Environmental Medicine training programs. Presented at the Third National Leadership Summit—Eliminating Racial and Ethnic Disparities in Health: A Blueprint for Change; March 3, 2009; Rockville, MD.
14. Green-McKenzie J. Occupational and Environmental Medicine: a veritable choice. J Minor Med Students. 2003;15(3):35–38.
15. Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services; Institute of Medicine; Eden J, Berwick D, Wilensky G, eds. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: National Academies Press; 2014.
16. Association of American Medical Colleges. Diversity in medicine: AAMC facts and figures 2008. https://www.aamc.org/media/7581/download
. Accessed November 13, 2020.
17. Association of American Medical Colleges. Diversity in medicine: AAMC facts and figures 2016. https://www.aamcdiversityfactsandfigures2016.org/report-section/section-3
. Accessed November 13, 2020.