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Falling Short in America: Increasing Diversity in the Health Profession
Falling Short in America: Increasing Diversity in the Health ProfessionKeynote Address at the Association of Black Cardiologists 30th AnniversaryNovember 6, 2004, New Orleans, LAThank you for this very generous introduction. Let me begin by telling you how honored I am to be delivering the keynote address at the Association of Black Cardiologists’ 30th Anniversary. I have enormous respect for ABC, its leadership in the identification of disparities in cardiovascular health, and its advocacy in developing innovative outreach programs for multi-cultural and multi-ethnic constituents.Based on the earlier introduction of me as a physician scientist, you must be wondering -- why is he talking on the subject of diversity and health disparities? You are right to wonder. In fact, I asked myself that question. And I asked Elizabeth Ofili that very same question when she invited me to speak. She was quite insistent that I speak on this subject. My credentials, or lack thereof, would suggest that I am not sufficiently qualified to speak on the subject of disparities. I have no track record in this area. I have done no research on this subject, nor have I developed major educational and clinical programs in this area. Perhaps I may qualify based on my efforts with Paul Farmer in addressing global health inequity through the creation of the Division of Social Medicine and Health Inequalities at Brigham and Women’s Hospital when I was chair of medicine, and through my current role in leading Duke’s initiative in global health. Perhaps my own experience as a minority in this country and as an individual with a diverse background may qualify me to share with you some common perspectives. I think it is time for me to introduce myself again: I am Victor Dzau and I was born in Shanghai. My family of five lived as refugees in a small room. I come from a diverse religious background. Growing up in postwar China and then in Hong Kong, I witnessed dramatic economic disparities and the impact of TB and malnutrition in the poor populations. In fact, I lost several members of my family to the devastating effects of tuberculosis. As Paul Farmer wrote in his book The Pathology of Power, health inequalities are directly linked to economic inequalities. Beyond these common experiences, what else do we have in common? I know that we have a shared desire and a strong commitment to do something about the problems of diversity and health disparities. I have had a longstanding interest in inequalities in health among different racial, ethnic, and cultural populations, and since I moved to Durham, NC, I have developed a deep interest in these problems disproportionately affecting African Americans. This evening, I am going to share with you my thoughts about strategies to improve diversity in the delivery of health care and diversity in the training of physicians and future leaders. Here I am an amateur. I also want to share a little of Duke’s history, Duke today, and lessons learned. Martin Luther King Jr. stated, “Of all the forms of inequality, injustice in health is the most inhuman.” It is well documented that health disparities occur in the United States and globally, negatively affecting people of color and of poor economic status. Cardiovascular disease ranks as the No.1 killer of African Americans The basis of this health inequality is primarily socioeconomic. High poverty and unemployment rates contribute to the substantial ethnic and racial disparities in health status and health outcomes. Consequently, minority populations experience limited access to primary care, especially in rural areas. The problem is further aggravated by communication barriers and a lack of trust between the minority populations and health care providers who are predominantly white. Practicing evidence-based medicine on the minority patient can be particularly challenging since there is inadequate research data on minorities due to a failure of funding agencies to provide resources routinely to study this issue. One of the major problems contributing to disparities is the lack of diversity among the care providers. A report of the Sullivan Commission on Diversity in the Healthcare Workforce, Missing Persons: Minorities in the Health Professions (In 2003 the W.K. Kellogg Foundation issued a grant to the Duke University School of Medicine to plan and Convene the Commission), stated that: “Today’s physicians, nurses, and dentists have too little resemblance to the diverse population they serve, leaving many Americans feeling excluded by a system that seems distant and uncaring. In future years, our health professionals will have even less resemblance to the general population if minority enrollments in schools of medicine, dentistry, and nursing continue to decline and if health professions education remains mired in the past and -- despite some improvements -- inherently unequal and increasingly isolated from the demographic realities of mainstream America. Failure to reverse these trends could place the health of at least one-third of the nation's citizens at risk.” Together, African Americans, Hispanic Americans, and American Indians make up more than 25 percent of the U.S. population approaching 300 million, but they only make up 9 percent of the nation’s nurses, 6 percent of the nation’s physicians, and 5 percent of the nation’s dentists. There are less than 1,500 Hispanic and African American board-certified cardiovascular specialists (less than 7 percent of the U.S. pool). Minorities make up only 4.2 percent of medical school faculties. This problem results in a shortage of minority leaders at high levels in institutions who are in the position to influence and change the work and training environment. It has been proposed that an effective way of reversing the trend is through education and training -- in the case of health care, by developing a critical mass of physicians and providers of color who can provide empathic care to minority patients and a critical mass of leaders who can influence and shape the experience and diversity of our future physicians and leaders. The problem we face today is substantial. There is a lack of programming at the earliest stages of educational development to foster academic skills for science and math. There remain significant entry barriers for qualified African Americans, especially to medical schools. The problem is in part due to the lack of quality, focused pre-med counseling for underrepresented minorities and to the fact that admission committees are still relatively homogeneous (i.e. mostly white male) and use criteria are not favorable to minorities. Similar issues face cardiovascular training. It is estimated that there are 75 African American cardiologists in training, yielding 25 graduates per year. To increase the number by 50 percent in five years, it will require 50 to matriculate each year. That will mean a 100 percent increase in admissions to cardiology training programs. StrategiesIn order for us to realize our passion for change, there must be a strong and widespread movement to tackle the inequalities and barriers. For medical schools and health systems, their roles are to change the environment, culture, and attitudes of the workplace, and to increase diversity of its employees, trainees, faculty, and most importantly, of its leaders. To be successful, it is imperative that commitment must be made at the highest level. Diversity happens when institutional leaders support diversity. To change the profile of the physician workforce, fundamental changes must be made in the admission process and the training experience. The issue of debt burden must be addressed especially for the minority students who are more likely to be financially disadvantaged. The issue of funding additional positions in cardiology training programs must be addressed. In the recent past, many institutions have declared their commitment to diversity. Many initiatives have been undertaken to increase the number of underrepresented minorities among the workforce, faculty, fellows, residents, and students. Although some progress has been made, the outcome is generally disappointing. At Duke, diversity has become an imperative. Through leadership commitment and direct involvement, we can now see fundamental changes in Duke’s culture. Duke has come a long way! It was a very different institution only a few decades ago. It was a white institution -- the plantation, as the black employees called it. What happened? How did the transformation occur? Can we learn from Duke’s experience? Duke and Durham HistoriesDuke University and its medical center, like others, have a troublesome history that still resonates with us today. The history is based on the very sad and devastating reality of racism and segregation in the country, especially in the South. Durham County had three hospitals: Duke Hospital, Watts Hospital, and Lincoln Hospital. Duke Hospital was a tertiary care hospital. Watts Hospital was the community white hospital. Lincoln Hospital served the minority population. Physicians at Lincoln Hospital did not have privileges at Duke or Watts hospitals. In the early ‘50s, the backlog of patients for the only black surgical ward (Nott Ward) at Duke was so large, Surgery Chair Dr. Hart established a satellite service under one of the younger faculty members, Dr. William Shingleton, at Lincoln Hospital. As late as 1964, segregation was still being maintained at Duke University Hospital. There were two sets of bathrooms, two sets of water fountains, and separate morgues. Eventually the bathrooms and water fountains were merged, but the waiting rooms remained segregated. Current Duke employees and their children remember this segregation, which is part of our institutional memory. The first appointment of a black faculty member did not occur until 1970 when Dr. Eugene Stead appointed Dr. Charles Johnson. Dr. Charles Curry became the first black resident at Duke in 1963. Duke was one of the last two medical schools in the South to admit a black student. The first black medical student graduated in 1973! Duke TodayToday, I walk the halls of Duke and run into people of color who serve in senior leadership positions. I walk into a waiting area and see people reflecting diversity not only in race and culture, but in gender, education, and socioeconomic background, waiting to be seen by a health care worker of color. Duke University is located in Durham County (central North Carolina) with a population of 234,000, with 51 percent white, 40 percent black, and 8 percent Hispanic. Duke University Health System employees number 32,087, with 31 percent minorities:
A Multicultural Resource Center (MRC) was established to oversee and provide resources for:
Dr. Goldschmidt recruited Dr. Rosey Gilliam to Duke as chief of adult electrophysiology, and he has been a magnet for URM applicants. Duke is fortunate to have Dr. Augustus Grant, president of the American Heart Association, as a professor of medicine in cardiology. Without changing its high admission standards for fellowship and medical school, Duke has been able to ensure that 25 percent of its medical students and 25 percent of its cardiology fellows are African Americans. Currently, Duke is planning a collaborative fellowship training program with Morehouse College and the Association of Black Cardiologists. The program will conduct joint training of cardiology residents (fellows) by Duke and Morehouse, using existing approved training slots of the Duke Fellowship Program. University Leadership for DiversityDuke’s progress in its recent history can be traced to the arrival in the early 1990s of President Emeritus Nan Keohane, who identified diversity as one of her first major initiatives. Because of this leadership imperative, the following changes were made:
Duke University Health System Leadership for DiversityTo make diversity an organizational imperative, similar to other imperatives like financial stability or compliance, the Duke University Health System Diversity Leadership Group was established. Serving on this committee are the CEOs of all three DUHS hospitals, who not only attend the meetings, but are expected to implement strategies for increasing diversity. Their focus is to ensure that productivity is not only measured by efficiency and quality of services performed, but to:
The Diversity Leadership Group (DLG) developed inventory data collection methods for tracking and measuring hiring practices and “best methods” drawn from the health system which will be implemented consistently. Balanced scorecards are to include specific diversity goals and measures advancing a data-driven method of holding leaders accountable for accomplishing these goals and measures. DLG and the Office of Institutional Equity provide support and guidance in the creation of diverse applicant pools. Data are reported semiannually to senior leaders. In addition, a process was initiated to assess and validate performance to enhance business with women and minority vendors by:
Lessons Learned: What Can One Learn from Duke’s Progress?Institutions and their leadership must be committed to addressing the problems of health disparities and the training of African American physicians and employees to become the future providers and leaders. To do so you must:
What is Duke Doing Now? Providing Global Health in Your Own Backyard
Despite the success at Duke, the health status of Durham citizens is still quite poor. This is an embarrassment since Duke is the primary provider of care to Durham County. The success in diversity must be complemented with a major effort in improving health care and removing disparities. We should be ready to tackle this problem now.
My first priority at Duke was to increase awareness of the need to address health inequities. I have been particularly championing the development of a global health initiative at Duke. Global health is not about geography -- global health is everywhere. I assembled a multidisciplinary group of senior leaders to define major needs in Durham, provide a work plan for a defined project, determine strategies for implementation, and determine associated budget costs. In Closing
Duke Medicine will continue to recruit diverse medical students for training as our future leaders at Duke and around the world Duke is developing pipeline partnerships with local public school systems. As Martin Luther King Jr. said on March 14, 1964, “Evidence indicates that diversity is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better educational experiences.” At Duke, we have come a long way, but there is much yet to be done. We must celebrate our success and recognize our failings. We must share our experience with others and hope to have a national and global impact through communication, education, and experimentation. Most importantly, we must keep pushing to do what is right “The time is always right to do what is right” -- Martin Luther King |
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