WORKING GROUPS
Working group 3: How to encourage more minorities to choose a career in cardiology
Charles K. Francis, MD, FACC, Chair,
Joseph S. Alpert, MD, FACC,
Luther T. Clark, MD, FACC,
Elizabeth O. Ofili, MBBS, MPH, FACC and
Richard C. Wong, MD
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Introduction and discussion of racial and ethnic disparities in health status, morbidity, and mortality
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The report of this working group focuses on ways to increase the number of cardiovascular specialists who are classified as members of an underrepresented minority (URM). The Association of American Medical Colleges (AAMC) defines URMs as blacks, Mexican Americans, mainland Puerto Ricans, and Native Americans–American Indian, Alaskan Natives, and Native Hawaiians (1). In 2001, according to the American Medical Association, of more than 127,574 total physicians in internal medicine, only 2.72% were black and 3.29% were Hispanic. Of 21,726 cardiovascular physicians, 2% (n = 440) were black, 3.8% (n = 829) were Hispanic, and 12.7% (n = 2,755) were Asian (Fig. 1) (2). In 2002, of 2,223 total trainees in cardiology training programs 3.4% were black and 5.7% were Hispanic, and 29.5% were Asian (3,4).
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Figure 1 Cardiovascular physicians by race/ethnicity (2001–2002). Source: AMA Physician Characteristics and Distribution in the U.S., 2003–2004 edition.
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It is challenging to address a subject as complex as how to significantly enhance career opportunities and influence career choices of URMs in the context of a document that must be concise and, by definition, focus on cardiology workforce. This specific focus is very important for many reasons, including the fact that URM physicians are more likely than other doctors to provide healthcare to minority communities, to practice in medically underserved areas, and to care for patients from their own ethnic or cultural group (5,6). Research has shown that the per capita number of physicians in low-income urban communities is substantially lower than in more affluent communities (7). Black and Hispanic physicians are more likely than non-Hispanic whites to practice in physician shortage areas and to care for more black and Hispanic patients (8). This is just one of many reasons to encourage URMs to aspire to a career in medicine, and to help them achieve this goal.
Major racial and ethnic disparities in health status, morbidity, and mortality have been documented across a wide range of medical conditions. Compared with other Americans, blacks have the highest mortality rates from cardiovascular disease (9). Lack of access to health care, particularly cardiac care, has been shown to be a major contributor to racial and ethnic health disparities in cardiovascular disease (10). The Institute of Medicine's important study "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" (11) documents that ethnic health disparities are prominent throughout the U.S.
Several studies have demonstrated racial and ethnic differences (independent of income, insurance status, and education) in the use of cardiac procedures such as coronary angiography, percutaneous coronary interventions (PCI), and coronary artery bypass graft surgery (CABG) (10,12). For example, blacks are only one-half as likely as whites to be treated with PCI or CABG (13). Of several possible explanations for these disparities in care, one factor is the inadequate number of cardiovascular specialists serving minority communities. This is just one reason—but a very important one—why the nation should seek to increase the number of URM cardiologists.
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Minority medical school acceptances, matriculation, and graduation
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Many factors contribute to the shortage of URM cardiologists, but one of the most significant is the limited size of the pool of qualified applicants. The varied and complex social and economic factors contributing to racial and ethnic disparities in educational opportunities and achievement are beyond the scope of this document. Nevertheless, it is appropriate to outline a few specific suggestions that will help achieve the goal of attracting a greater number of URMs to careers in medicine—and from there—to cardiology.
Strategies to increase the number of URM cardiovascular specialists must consider the long educational path that begins before elementary school and continues through high school, college, medical school, and beyond. There is a definite need to develop more effective programs to improve science proficiency among certain URMs, especially blacks and Hispanics (Fig. 2). Emphasis should also be placed on fundamental skills such as reading comprehension and verbal communication. Consistent efforts must be made to address deficiencies in elementary and high school education and to encourage action at the college level in terms of identifying, advising, and supporting students who have potential to succeed as physicians.
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Figure 2 Percent of U.S. grade 12 students who are proficient in science by race/ethnicity (1996, 2000). Source: Minority Students in Medical Education, Facts and Figures XII is a publication of the Association of American Medical Colleges (AAMC), copyright October 2002. Reprinted with permission of the AAMC.
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As our nation's educators and policymakers consider ways to improve the academic skills of underprivileged and minority students in order to help them achieve their full potential as members of society, it is vitally important that we acknowledge the existence of a significant population of minority students who are already fully capable of becoming excellent physicians. Mentoring of bright high school and college URM students who express interest in pursuing a medical career is vitally important (14). Because racial and ethnic disparities in health status cross social and economic boundaries, there is a need to increase the awareness and attractiveness of medical careers for middle-class URM students as well as those who are economically disadvantaged.
It is useful to summarize recent URM trends with respect to medical school applications, medical school enrollment, medical school graduation, internal medicine residency training, and specialization in cardiovascular disease. This information should help academic institutions, professional organizations, and other entities develop policies, procedures, and practices to increase the size of the URM cardiology workforce. The number of U.S. medical school applicants peaked at 46,965 in 1996 to 1997, when there were 5,157 URM applicants. Medical school acceptance rates vary among different racial and ethnic groups. They also fluctuate for the general categories of URMs and non-URMs. (Fig. 3) (1). In general, enrollment of URMs continues to be low (Fig. 4) (1) compared with their representation in the population. One striking exception in the past two decades has been the steady increase in the percentage of matriculants who are Asian (Fig. 5) (1).
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Figure 3 Acceptance rates for underrepresented minorities (URM) and non-URM applicants to medical school, 1974–2001. Source: Minority Students in Medical Education, Facts and Figures XII is a publication of the Association of American Medical Colleges (AAMC), copyright October 2002. Reprinted with permission of the AAMC.
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Figure 4 Race/ethnicity of 2001 matriculants to medical school. Source: Minority Students in Medical Education, Facts and Figures XII is a publication of the Association of American Medical Colleges (AAMC), copyright October 2002. Reprinted with permission of the AAMC.
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Figure 5 Medical school matriculants, 1980–2000 (expressed as a percentage of 1980 matriculants). Source: Minority Students in Medical Education, Facts and Figures XII is a publication of the Association of American Medical Colleges (AAMC), copyright October 2002. Reprinted with permission of the AAMC.
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Between 1990 and 1996, the number of black applicants increased by 56%, with a record number of 3,527 applicants in 1996 (Fig. 6) (1). Beginning in 1997, anti-affirmative action ballot initiatives and court decisions in California (15) and Texas (16) resulted in laws that prohibited the use of race and ethnicity in decisions regarding admissions to public educational institutions. These major legal events had an immediate and lingering effect on minority medical education throughout the nation, because California and Texas are the states that produce the largest number of URM medical students (1).
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Figure 6 Black applicants to medical school, 1974–2001. Source: Minority Students in Medical Education, Facts and Figures XII is a publication of the Association of American Medical Colleges (AAMC), copyright October 2002. Reprinted with permission of the AAMC.
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Diversity among medical school faculty, medical students, residents, and fellows contributes to "cultural competency" that eventually will help all physicians relate more effectively to patients from a wide range of ethnic, racial, and socioeconomic backgrounds. Although there has been an increase in the racial and ethnic diversity of medical school faculties between 1980 and 2001, URM faculty still only account for 4.2% of the total (Fig. 7) (1). Racial and ethnic disparities also exist in academic rank. Fewer than 10% of URMs are full professors. This may reflect, in part, the fact that URM faculty are less likely to be involved in research and less likely to receive research awards from the National Institutes of Health (NIH), especially RO1 grants (17).
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Figure 7 Distribution of U.S. medical school faculty by race/ethnicity, 1980–2001. Source: Minority Students in Medical Education, Facts and Figures XII is a publication of the Association of American Medical Colleges (AAMC), copyright October 2002. Reprinted with permission of the AAMC.
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Because of their small numbers in many medical schools, URM faculty frequently find themselves overextended. There is a growing and unmet need for mentors and preceptors, regardless of race or ethnicity, who can connect on a personal level with students of diverse backgrounds. Full-time and part-time medical school faculty members play a vital role in helping students make informed career choices. They serve as role models and help shape students' impressions of potential career paths from an academic research-oriented position to private practice as a primary care physician or specialist. Medical student career choices are also affected by attitudes and actions of their peers as well as residents and fellows in various specialties and subspecialties. The attitudes and interests of students and residents are also influenced by the quality of teaching, level of professionalism, and commitment to excellence in patient care they observe among attending physicians and others.
The output of new cardiologists is a function of the number of medical students that choose an internal medicine residency and, subsequently, a cardiology fellowship. The significant role of international medical graduates (IMGs) in this equation is discussed by Working Group 4. The number of URMs choosing to train in internal medicine is low compared with their representation in the U.S. population. This is important because the career path to cardiology begins with a residency in general internal medicine. The situation is aggravated by a recent trend that reflects declining interest in primary care specialties including general internal medicine (18).
Casual comments or strongly voiced opinions about certain specialty choices in terms of income potential, career satisfaction, and work–life balance can discourage medical students from considering certain specialties. It is true that the current practice environment is stressed because of rising requirements with respect to documentation, exorbitant medical liability costs, and increasing workloads—all in the face of declining reimbursement in most specialties. Despite these challenges most physicians enjoy what they do and value their unique role in caring for patients. It is important to remember that we can emphasize the negative aspects of being a physician in the 21st century, or we can focus on the extraordinary difference that we, as cardiologists, can make in the lives of millions of persons with cardiovascular disease.
This working group believes it is vitally important that more URM medical students choose the career path that we have followed. We recognize that a decrease in the number of URM cardiologists would be especially problematic for poor and underserved patients because they already carry a disproportionate burden of cardiovascular disease, especially hypertension, coronary heart disease, heart failure, and stroke (19). Numerous reports have documented the limited access to primary and specialty care in most low-income, rural, inner city, and minority communities. The tendency for new physicians, whether URMs or not, to choose to practice in more affluent urban or suburban locations, rather than inner city or rural environments, has contributed to a mal-distribution of practitioners. Ironically, the nation's growing shortage of cardiologists is creating more opportunities for new cardiology graduates (including URM and IMGs) to practice in locations that are perceived to be highly desirable from various standpoints. Thus, the shortage of cardiologists will likely have a detrimental effect on the poor and minority patients' access to specialty care—the very kind of care that has been shown to enhance outcomes in the types of cardiovascular diseases that affect minority and underserved populations disproportionately.
Increasing the number and proportion of URM cardiologists will require designing and implementing more effective strategies at all levels of the educational continuum. There are many reasons to devote more financial and intellectual resources to confront this challenging problem. Cardiologists have embraced the importance of risk-factor modification as a powerful tool to reduce the burden of cardiovascular disease in our society. If we hope to reduce the disproportionate burden of cardiovascular disease that affects the poor and underserved, both our nation and our profession must work together to make it possible for more black, Hispanic, and other URMs to enter medicine and become cardiovascular specialists.
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Recommendations
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- The medical profession should support local and national efforts to enhance the educational opportunities for minority students so there is a larger pool of qualified URM applicants to medical school—the first formal stop on the career path to cardiology.
- Academic medical centers should work hard to create and maintain an atmosphere that values diversity and, reflecting the focus of our working group, an environment that actively supports and encourages URM students, postgraduate trainees, and faculty members.
- Academic and practitioner cardiologists should actively encourage URM medical students and internal medicine residents to consider a career in cardiology.
- Internal medicine training program directors and cardiology training program directors should make an active effort to recruit, matriculate, and graduate increased numbers of URMs.
- The ACC, together with the Association of Black Cardiologists (ABC), the American Heart Association (AHA), and the Association of Professors of Cardiology (APC), and the cardiology training program directors, should collaborate in the development and implementation of curricula on racial and ethnic disparities in cardiovascular disease status, outcomes, morbidity, and mortality.
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Working Group 3 References
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- Minority Students in Medical Education, Facts and Figures XII. Association of American Medical Colleges. 2002. Available at: http://www.aamc.org/publications/medicalschoolapplicants.pdf. Accessed January 31, 2004
- Smart DR. Physician Characteristics and Distribution in the U.S. 2004. Chicago, IL: American Medical Association, 2003
- Brotherton SE, Simon FA, Etzel SIUS. graduate medical education, 2001–2002: changing dynamics. JAMA. 2002;288:1073–1078[Abstract/Free Full Text]
- Brotherton SE, Rockey PH, Etzel SIUS. graduate medical education, 2002–2003. JAMA. 2003;290:1197–1202[Abstract/Free Full Text]
- Cantor JC, Miles EL, Baker LC, Barker DC. Physician service to the underserved: implications for affirmative action in medical education. Inquiry. 1996;33:167–180[Medline]
- Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995;273:1515–1520[Abstract]
- Kindig DA, Movassaghi H. The adequacy of physician supply in small rural counties. Health Aff (Millwood). 1989;8:63–76[Medline]
- Komaromy M, Grumbach K, Drake M, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305–1310[Abstract/Free Full Text]
- Heart Disease and Stroke Statistics—2004 Update. American Heart Association. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3018163. Accessed February 19, 2004
- Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence. Summary Report. Henry J. Kaiser Family Foundation and the American College of Cardiology Foundation, 2002
- Unequal Treatment: Confronting Racial and Ethnic Disparities in Health. Washington, DC: The National Academies Press, 2004
- National Healthcare Disparities Report 2003. Agency for Healthcare Research and Quality. Available at: http://www.qualitytools.ahrq.gov/disparitiesreport/download_report.aspx. Accessed January 31, 2004
- Mayberry RM, Mili F, Ofili E. Racial and ethnic differences in access to medical care. Med Care Res Rev. 2000;57(Suppl 1):108–145[Abstract/Free Full Text]
- American Medical Student Association. Study Group on Minority Medical Education: Findings From Literature Search and Anecdotal Data. Final Report. September 20, 1996. Health Resources and Services Administration, U.S. Department of Health and Human Services
- California Constitution. Article I, Paragraph 31. 2003
- Hopwood v. Texas. 78 F3d 932 (5th Cir). 1996. 116 SCt 2581. Cert denied
- Fang D, Moy E, Colburn L, Hurley J. Racial and ethnic disparities in faculty promotion in academic medicine. JAMA. 2000;284:1085–1092[Abstract/Free Full Text]
- Greene, J. Primary Care Matches Down Again: Fourth Year of Decline Worries Some. American Medical News. Available at: http://www.ama-assn.org/amednews/2001/04/09prse0409.htm. Accessed April 9, 2001
- Barondess JA. Specialization and the physician workforce: drivers and determinants. JAMA. 2000;284:1299–1301[Free Full Text]
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