Prioritizing Health Disparities in Medical Education to Improve Care
Posted December 04, 2012
A young single mother in a low income neighborhood who must make five bus transfers to reach her primary care physician; a family in rural New Mexico that lacks access to healthy food; a doctor who, after explaining the importance of taking insulin several times, doesn't understand why a patient's diabetes isn't under control—these are just some scenarios that contribute to health disparities in the United States. On October 2, 2012, medical students, faculty, educators, and administrators convened at the New York Academy of Sciences to discuss how medical schools can reduce health disparities by promoting more diversity in healthcare professions, equipping doctors with tools to serve underrepresented groups, and reaching out to the community. The Prioritizing Health Disparities in Medical Education to Improve Care conference was sponsored by the Josiah Macy Jr. Foundation, the Associated Medical Schools of New York, the New York University School of Medicine, and the New York Academy of Sciences.
Use the tabs above to find a meeting report and multimedia from this event.
Presentations available from:
Joseph R. Betancourt, MD, MPH (Massachusetts General Hospital, The Disparities Solutions Center)
Estela S. Estapé, MT, PhD, DHL (University of Puerto Rico, Medical Sciences Campus)
Fritz François MD, MSc, FACG (New York University School of Medicine)
Mekbib Gemeda, MA (New York University Langone Medical Center)
Arthur Kaufman, MD (University of New Mexico)
Mitchell R. Lunn, MD (Brigham and Women's Hospital, Harvard Medical School)
Fitzhugh Mullan, MD (The George Washington University)
Marc A. Nivet, EdD (Association of American Medical Colleges)
Claire Pomeroy, MD, MBA (University of California, Davis)
Panel Moderator: Joel D. Oppenheim, PhD (New York University School of Medicine)
- 00:011. Introduction
- 01:172. Defining diversity and inclusion
- 03:293. Knowing the knowns
- 10:474. The growth of diversity identities
- 17:305. The past, and repositioning for the future
- 22:556. Why is more diversity desired?
- 23:287. Drivers of health equity
- 25:278. Culture change key to diversity/inclusio
- 00:011. Introduction
- 01:452. The cost of healthcare
- 04:243. Disparities demand change
- 06:344. The growth of diversity identities
- 08:015. Reforming the healthcare system
- 11:576. Healthcare expenditures
- 14:177. The importance of interprofessional teams
- 16:218. Use of innovative technologies
- 20:059. Development of new care venues
- 22:4110. Education of cultural competenc
- 00:011. Introduction
- 08:002. Most important experience with health disparities curriculum
- 10:043. The biggest challenges to incorporating health disparities research into the curriculum
- 22:354. How is research translated to providing care?
- 25:025. Where should we be going with these efforts to change the curriculum in the future?
- 31:566. Audience Q and
Recent Reports on Health Disparities
Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report — United States, 2011. Morbidity and Mortality Weekly Report. Atlanta, GA; January 14, 2011. Vol 60.
U.S. Department of Health and Human Services. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD: National Center for Health Statistics; 2012.
U.S. Department of Health and Human Services. National Healthcare Quality Report. Rockville, MD: Agency for Healthcare Research and Quality; 2012. Publication 12-005.
Organizations Addressing Health Disparities
Building the Next Generation of Academic Physicians Initiative (BNGAP)
An organization dedicated to increasing the awareness of academic medicine among diverse medical students.
Curricula and Training Programs
Post-doctoral Master of Science and Graduate Certificate in Clinical Research, University of Puerto Rico.
An e-learning program providing cultural competency training.
The Fenway Institute
Provides LGBT-related teaching modules.
Gay and Lesbian Medical Association
Provides curricula in LGBT-related subjects.
A five-year MD and master's program at the University of California Davis that trains physicians to improve healthcare delivery in small, isolated communities.
A training program at the University of California Davis for residents interested in caring for underserved populations.
Bawa KS, Balachander G, Raven P. A case for new institutions. Science. 2008;319(5860):136.
Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: ranking the schools. Ann Intern Med. Jun 15;152(12):804-11.
Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002;94(8):666-8.
Nolte E, McKee CM. In amenable mortality — deaths avoidable through health care: progress in the US lags that of three european countries. Health Aff (Millwood). 2012;31(9):2114-22.
Schoen C, Doty MM, Robertson RH, Collins SR. Affordable Care Act reforms could reduce the number of underinsured US adults by 70 percent. Health Aff (Millwood). Sep;30(9):1762-71.
Schroeder SA. Shattuck Lecture. We can do better — improving the health of the American people. N Engl J Med. 2007;357(12):1221-8.
Weissman JS, Betancourt J, Campbell EG, et al. Resident physicians' preparedness to provide cross-cultural care. JAMA. 2005;294(9):1058-67.
Disparities in Colorectal Cancer (Fritz François)
Ashktorab H, Smoot DT, Carethers JM, et al. High incidence of microsatellite instability in colorectal cancer from African Americans. Clin Cancer Res. 2003;9(3):1112-7.
Burt RW. Colon cancer screening. Gastroenterology. 2000;119(3):837-53.
Katkoori VR, Jia X, Shanmugam C, et al. Prognostic significance of p53 codon 72 polymorphism differs with race in colorectal adenocarcinoma. Clin Cancer Res. 2009;15(7):2406-16.
Shavers VL. Racial/ethnic variation in the anatomic subsite location of in situ and invasive cancers of the colon. J Natl Med Assoc. 2007;99(7):733-48.
Soreide K. High-fidelity of five quasimonomorphic mononucleotide repeats to high-frequency microsatellite instability distribution in early-stage adenocarcinoma of the colon. Anticancer Res. 2011;31(3):967-71.
Diversity (Marc Nivet and Makbib Gemeda)
Daley SP, Palermo AG, Nivet M, et al. Diversity in academic medicine no. 6 successful programs in minority faculty development: ingredients of success. Mt Sinai J Med. 2008;75(6):533-51.
Durso SC, Christmas C, Kravet SJ, Parsons G, Wright SM. Implications of academic medicine's failure to recognize clinical excellence. Clin Med Res. 2009;7(4):127-33.
Nivet MA. Commentary: Diversity 3.0 — a necessary systems upgrade. Acad Med. 2011;86(12):1487-9.
Nivet MA, Taylor VS, Butts GC, et al. Diversity in academic medicine no. 1 case for minority faculty development today. Mt Sinai J Med. 2008;75(6):491-8.
Strelnick AH, Lee-Rey E, Nivet M, Soto-Greene ML. Diversity in academic medicine no. 2 history of battles lost and won. Mt Sinai J Med. 2008;75(6):499-503.
Post-doctoral Master's degree in Clinical and Translational Research (Estela Estapé)
Estape E, Laurido LE, Shaheen M, et al. A multi-institutional, multidisciplinary model for developing and teaching translational research in health disparities. Clin Transl Sci. 2011;4(6):434-8.
Estape ES, Segarra B, Baez A, Huertas A, Diaz C, Frontera WR. Shaping a new generation of Hispanic clinical and translational researchers addressing minority health and health disparities. P R Health Sci J. 2011;30(4):167-75.
Social Determinants of Disease (Arthur Kaufman)
Kaufman A, Powell W, Alfero C, et al. Health extension in new Mexico: an academic health center and the social determinants of disease. Ann Fam Med. 2010;8(1):73-81.
Disparities in the LGBT Community (Mitchell Lunn)
Lunn MR, Sanchez JP. Prioritizing health disparities in medical education to improve care. Acad Med. 2011;86(11):1343.
Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011 7;306(9):971-7.
Sanchez NF, Rabatin J, Sanchez JP, Hubbard S, Kalet A. Medical students' ability to care for lesbian, gay, bisexual, and transgendered patients. Fam Med. 2006;38(1):21-7.
Tesar CM, Rovi SL. Survey of curriculum on homosexuality/bisexuality in departments of family medicine. Fam Med. 1998;30(4):283-7.
Wallick MM, Cambre KM, Townsend MH. How the topic of homosexuality is taught at U.S. medical schools. Acad Med. 1992;67(9):601-3.
Wimberly YH, Hogben M, Moore-Ruffin J, Moore SE, Fry-Johnson Y. Sexual history-taking among primary care physicians. J Natl Med Assoc. 2006;98(12):1924-9.
Fritz François, MD, MSc, FACG
Fritz François is an academic gastroenterologist and molecular epidemiologist whose research interests include esophageal disease, H. pylori, and colorectal cancer screening in minority populations. François is the recipient of several national grants including an NIH career development award, a Robert Wood Foundation Clinical Investigator Award, and the American College of Gastroenterology Clinical Research Award. His work has been presented both nationally and internationally and he has received many honors including five American Society for GI Endoscopy Diversity Minority Research awards. He is currently serving as the national chair of the American College of Gastroenterology Minority Affairs Committee and is the associate dean for diversity and academic affairs at the NYU School of Medicine. His recent scholarly publications have focused on risk behavioral risk factors for colorectal cancer among patients and physician knowledge of colorectal cancer screening guidelines.
Mekbib Gemeda, MA
New York University Langone Medical Center
Mekbib Gemeda is the assistant dean for Diversity Affairs and Community Health and the director of the Center for the Health of the African Diaspora at New York University School of Medicine. In these roles, he has been responsible for developing programs and initiatives to increase diversity among students, residents, faculty, and leadership and for developing pipeline programs. He also leads initiatives to expand cultural competency education across the medical center and to integrate a social determinant framework in the core medical school curriculum. Gemeda has over a decade of experience in national and local efforts to reduce health disparities and increase diversity in the biomedical workforce. Before coming to NYU he was involved in developing a robust NIH-supported biomedical research center and a nationally-recognized faculty and graduate student recruitment and retention program at Hunter College of the City University of New York. He was also involved in developing the largest national online network of minorities in science, justgarciahill.org.
Jo Wiederhorn, MSW
Jo Wiederhorn earned a Masters of Social Work degree at Rutgers University. She began her career as a public health analyst at the New Jersey Department of Health, where she ultimately became the director of Addiction Treatment and Rehabilitation services. She later held positions at the New York City Health and Hospitals Corporation (HHC) before being recruited to NYU School of Medicine, where she served as chief of staff to the dean. While there, she started the school's Institute for Urban and Global Health and awarded over seventy-five grants to NYU faculty to study the linkage between urban health problems and global health conditions. Wiederhorn is now president and CEO of the Associated Medical Schools of New York (AMSNY) and the New York State Academic Dental Centers (NYSADC).
Sonya Dougal, PhD
The New York Academy of Sciences
Brooke Grindlinger, PhD
The New York Academy of Sciences
Joseph R. Betancourt, MD, MPH
Joseph Betancourt directs the Disparities Solutions Center, which works with healthcare organizations to improve quality of care, address racial and ethnic disparities, and achieve equity. He is director of multicultural education for Massachusetts General Hospital (MGH) and is an expert in cross-cultural care and communication. Betancourt served on several Institute of Medicine committees, including those that produced Unequal Treatment: Confronting Racial/Ethnic Disparities in Health Care and Guidance for a National Health Care Disparities Report.
Estela S. Estapé, MT, PhD, DHL
Estela S. Estapé is a medical technologist with a PhD in pharmacology and toxicology from the Medical Sciences Campus, University of Puerto Rico (MSC-UPR). She completed post-doctoral studies in electrophysiology at the Mount Sinai School of Medicine. During her doctoral studies, she was a fellow of the National Institutes of Health (Heart, Lung and Blood Institute). Estapé was a Veteran's Administration merit review investigator for almost 16 years before becoming dean of the School of Health Professions (SoHP). Her research interests are related to cardiovascular disease and biomarkers. Since 2001, Estapé has been the director of the post-doctoral Master of Science in Clinical Research (MSc) program. She has spearheaded the approval of millions in grant support for clinical research training and education to address health disparities.
Arthur Kaufman, MD
Arthur Kaufman received his MD from the State University of New York, Brooklyn. He served in the U.S. Indian Health Service before joining the Department of Family and Community Medicine at the University of New Mexico, where he has remained throughout his career, providing leadership in teaching, research, and clinical service, and is now a distinguished professor. Kaufman has a passion for creating innovative education and service models to better address community, indigent, rural, and population health needs. He helped initiate the primary care curriculum in New Mexico, which became an international model for change by innovative track in traditional medical schools.
Mitchell R. Lunn, MD
Mitchell R. Lunn is a resident physician in medicine at Brigham and Women's Hospital and a clinical fellow in medicine at Harvard Medical School. A long-time activist in the lesbian, gay, bisexual, and transgender (LGBT) communities, Lunn and co-founded the LGBT Medical Education Research Group at Stanford University School of Medicine, which creates and communicates new knowledge through innovative research, influences health and educational policies, and advocates for LGBT patients and providers. The group's recent seminal study on the current state of LGBT-related content in medical curricula has sparked national discussions. Lunn holds an MD with a concentration in the molecular basis of medicine from Stanford University School of Medicine.
Fitzhugh Mullan, MD
Fitzhugh Mullan is Murdock Head Professor of Medicine and Health Policy at The George Washington University School of Public Health and a professor of pediatrics at The George Washington University School of Medicine. His research and policy work focus on U.S. and international health workforce issues with particular emphasis on capacity building in Africa. He is the principal investigator of the Medical Education Partnership Initiative (MEPI) Coordinating Center, and previously served as principal investigator of the Gates Foundation funded Sub-Saharan African Medical School Study (SAMSS). His U.S. work includes the Kellogg Foundation-funded Beyond Flexner Study and the Medical Education Futures Study. Mullan holds an MD from the University of Chicago Medical School and is board certified in pediatrics. He spent 23 years serving in the U.S. Public Health Service and has written widely for both professional and general audiences on medical and health policy topics. His books include White Coat Clenched Fist: The Political Education of an American Physician, Vital Signs: A Young Doctor's Struggle with Cancer, Plagues and Politics: The Story of the United States Public Health Service, and Big Doctoring in America: Profiles in Primary Care.
Marc A. Nivet, EdD
Marc A. Nivet is chief diversity officer for the Association of American Medical Colleges, where he provides strategic vision and programmatic leadership around diversity and inclusion. Through his advising, lectures, and writing, Nivet works to reframe the narrative around diversity, positioning it as a driver of excellence and highlighting the link between community engagement and health equity. Nivet serves the diversity and academic medicine communities on a variety of boards and commissions.
Claire Pomeroy, MD, MBA
Claire Pomeroy is CEO of the University of California, Davis Health System, vice chancellor for human health sciences, and dean of the University of California, Davis School of Medicine. She leads the education, research, and clinical programs at the School of Medicine and the Betty Irene Moore School of Nursing, as well as the physician practice group and its teaching hospital, U.C. Davis Medical Center. She is chair of the AAMC Council of Deans; serves on the board of directors of the AAHC and California Institute for Regenerative Medicine and on the NIH Advisory Committee on Research on Women's Health; and is a member-at-large representative for the AAAS (medical sciences section).
Joel D. Oppenheim, PhD
Joel D. Oppenheim is a professor of microbiology, serves as the senior associate dean for biomedical sciences, and is director of the Sackler Institute of Graduate Biomedical Sciences at NYU School of Medicine. In these positions he oversees all PhD and postdoctoral trainees. He serves on the NYU School of Medicine’s MD and MD/PhD admissions committees and chairs the PhD admissions committee. He is the founder and director of the NYU’s summer undergraduate research and postdoctoral programs.
Oppenheim has served on many national advisory committees (AAAS, AAMC, ASM, Leadership Alliance, NIH, NRC, NSF and UNCF/Merck), grant study sections (NIGMS, NSF, Sloan Foundation), as a reviewer of numerous NRC, NSF, and NAS reports involved with graduate and postgraduate education and the recruitment, pipeline issues, and retention of underrepresented students in graduate programs. He also also serves on the external advisory boards and program review boards of a number of state and national accrediting agencies. Oppenheim has been invited to speaker at over 70 colleges and universities, the NRC, NSF and NIH, as well as at ABRCMS, McNair, SACNAS and UNCF/Merck national meetings, speaking to students and faculty on topics ranging from how to prepare for and apply to graduate and professional schools to career options. He is the founder of the “What Can You Be With a PhD?” symposium, the largest university-based career development program for predoctoral students and postdoctoral fellows in the country. In 2010, Oppenheim was the recipient of the AAAS Life Time Mentoring Award.
Temitope P. Awosogba, MPH
Mount Sinai School of Medicinee-mail
Temitope P. Awosogba is a third-year medical student at the Mount Sinai School of Medicine. As a second-year, she was co-chair of the East Harlem Health Outreach Partnership, Mount Sinai's student-run free clinic. She participates in the interdisciplinary ambulatory care tract, a specialized third year tract for students interested in primary care and chronic care. She holds a MPH from the University of Virginia, focused on the history of urban renewal and removal and its impact on health outcomes in public housing.
F. Garrett Conyers
Harvard Medical School
Garrett Conyers is a second-year student at Harvard Medical School. He is currently a member of the "Race in the Curriculum Working Group" (RICWG), a student group dedicated to eliminating unconscious bias in medicine and promoting the elimination of health disparities through medical education reform. As the current president of the Harvard Black Graduate Student Alliance (HBGSA) and the Harvard Medical School Black Health Organization (BHO), Conyers is also actively overseeing a student-led, university-wide initiative to decrease health disparities in local African-American communities through structural, population-level, and individual community interventions.
Sabrina J. Gard, MPH
New York University School of Medicine
Sabrina J. Gard is a fourth-year medical student at the New York University School of Medicine. She completed her undergraduate education at the Sophie Davis School of Biomedical Education, participating in a 5 year BS/MD program and matriculating as a third-year into New York University School of Medicine. Gard holds an MPH from the University of California–Berkeley, where she worked with the San Francisco Department of Public Health studying health disparities as they relate to HIV infection within the African-American MSM population of San Francisco.
Howa Yeung is a fourth-year medical student at New York University School of Medicine. He recently completed a NIH-funded predoctoral research fellowship in dermato-epidemiology at the University of Pennsylvania. His previous disparities research interests included tobacco cessation treatment access for low-income minorities and the epidemiology of colorectal polyps in ethnically diverse populations.
Jennifer Cable resides in New York City, where she experiments with different methods and outlets to communicate science. She enjoys bringing science to scientists and nonscientists alike. She writes for Nature Structural and Molecular Biology, Bitesize Bio, Under the Microscope, and the Nature New York blog. She received a PhD from the University of North Carolina at Chapel Hill for her research in investigating the structure/function relationship of proteins.
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
An African American born in 2009 can expect to live approximately five years less than a Caucasian born the same year. A young girl is three times less likely to be obese if at least one of her parents has a Bachelor's degree. A patient living in Massachusetts has access to over twice as many physicians as a patient in Mississippi. These are just some of the health disparities identified by the U.S. Department of Health and Human Services and the Centers for Disease Control and Prevention in a 2011 report.
In October, 2012, medical students, faculty, educators, and administrators met at the New York Academy of Sciences to discuss how medical schools and academic institutions can minimize health disparities—differences in health outcomes between groups that often reflect social inequalities—and promote health equality.
The concept of health disparity has evolved over time. As Fitzhugh Mullan of The George Washington University recounted, in the 1960s and during the Civil Rights movement the idea was primarily associated with racism and segregation in medicine; gradually, it has become broader and now encompasses both unequal access to medical care and imbalanced health outcomes for various racial, ethnic, and minority populations. This concept entered academic discourse after it was highlighted in the Institute of Medicine's 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Mullan argued that this report helped to legitimize the concept in the academic world and encouraged professionals from various fields of expertise, such as medicine, education, engineering, and policy, to begin to work together to eliminate disparities.
What can medical schools, in particular, do to address health disparities? To answer this, we must first define the role of medical schools. At the simplest level, a medical school exists to train future physicians. However, as the speakers described, that responsibility encompasses more than just teaching students about the newest treatments for disease. As Mullan asserted, in choosing who has the opportunity to become a physician and what to teach, medical schools are inherently selecting for and determining which values will prevail in the medical field. Most medical schools have a mission statement that includes a reference to the "three-legged" stool of medical education: patient care, education, and research. Claire Pomeroy, dean of the School of Medicine at the University of California, Davis, asserted that academic medical centers also have a responsibility to ensure that healthcare and services are available to everyone. To achieve this, she and others stressed the need to add a fourth leg—social mission—to address health disparities.
If medical schools are to accept the responsibility of addressing health disparities, how should they do so? How can social mission be incorporated as a primary goal? According to Mullan, a commitment to social mission would include mainstreaming diversity, assessing graduates' goals and career development, advancing access to care, and raising awareness of health disparities. Two main strategies were discussed throughout the conference, which can broadly be described as "reaching out" to the community to align university resources with community needs and "reaching in" to promote diversity within the university and to increase the participation of underrepresented minorities within the medical field.
Several new initiatives aiming to transform medical school curricula to include a stronger focus on health disparities equip students to better serve an increasingly diverse patient population and encourage them to "reach out" to communities. Arthur Kaufman from the University of New Mexico described the need for medical schools to address social determinants of health, such as education, lifestyle, and access to affordable housing and transportation, and underlined efforts to do so at the University of New Mexico. Joseph Betancourt from Massachusetts General Hospital and the Disparities Solutions Center emphasized the importance of cultural-competence training, highlighting Harvard Medical School's initiative to equip students and physicians with tools to care for a diverse population. Mitchell Lunn from Brigham and Women's Hospital and Harvard Medical School followed up with specific steps medical schools can take to ensure that physicians are prepared to care for lesbian, gay, bisexual, and transgender (LGBT) patients. Claire Pomeroy from the University of California, Davis described initiatives at the university to address social determinants of health and to provide cultural-competence training. Finally, Fritz François from New York University School of Medicine provided an overview of the school's curricula, highlighting how molecular epidemiology is being used to address health disparities.
Others spoke about how medical schools must "reach in" to support a diverse workforce. Marc Nivet from the Association of American Medical Colleges underscored how diversity within the student body, the faculty, and the workforce is essential to eliminating health disparities, while Claire Pomeroy highlighted programs at the University of California, Davis to promote diversity and inter-professional teams. Mekbib Gemeda from New York University Langone Medical Center described the challenges involved in maintaining underrepresented minorities in academic medicine, and Estela Estapé from the University of Puerto Rico, Medical Sciences Campus discussed a new postdoctoral Master's degree program in clinical and translational research that provides training in health disparities and works to increase the number of Hispanics and women in the field.
Arthur Kaufman, University of New Mexico
Claire Pomeroy, University of California, Davis
- Social determinants, such as lifestyle, education, and economic status, have a significant influence on health, but social services do not receive adequate resources to address these factors.
- The problems and concerns identified by communities may not align with the primary goals of medical research institutions.
- Medical schools have an obligation to reduce health disparities by addressing social determinants of health in the community and to align research efforts with community concerns.
Reaching out: addressing social determinants of health
Many people will agree that the U.S. healthcare system needs improvement. Although the U.S. spends more money than any other developed country on healthcare, it still ranks near the bottom in several key health outcomes. In a 2009 report by the Organization of Economic Cooperation and Development (OECD), the U.S. ranked 31 out of 34 in infant mortality rates; 19 out of 34 in life expectancy for men; and 26 out of 34 in life expectancy for women. However, Claire Pomeroy, dean of the School of Medicine at the University of California, Davis, argued that the U.S. healthcare system does not need more money to improve health outcomes. Instead, Pomeroy recommended that healthcare funds be reallocated to address the social causes of disease, as this would put U.S. spending on social services on par with several other OECD countries.
Both Pomeroy and Arthur Kaufman of the University of New Mexico illustrated how the current allocation of the national healthcare budget is skewed towards healthcare services like disease screening and treatment but largely ignores the social causes of disease, which are estimated to contribute to approximately 40% of an individual's health. These include lifestyle factors like diet, activity, and substance use, and social factors like education. Despite the key role social determinants play in health, social services receive only 1% of the national health budget. To put this in perspective, approximately 90% of the national health budget goes to health services, which contribute to approximately 10% of an individual's health, according to Pomeroy. Even the best screening and treatment programs, however, cannot compensate for decades of poor nutrition, low employment, poor education, high stress, and other social determinants of health. To address health disparities, therefore, medical schools must address social determinants of health by learning what the needs of the local community are and by encouraging students and trainees to address those needs.
In addition to explaining the need to change healthcare spending and resource allocation, Pomeroy described five approaches that would promote the establishment of a new healthcare system: address social determinants of health; build inter-professional teams; employ innovative technologies; create new venues for care; and focus on cultural competence. These approaches were touched on by all the speakers and emerged as key to efforts to prepare the healthcare system for 21st century challenges.
Pomeroy gave specific examples of several efforts at the University of California, Davis to address social determinants of health. For example, to help improve the nutrition of local school children, medical residents partnered with members of the community to redesign school cafeteria menus. Medical students also engaged with elementary and high school students and elderly populations in the community to educate them on health issues.
Kaufman described how the University of New Mexico has changed its curriculum to work with the community and address social determinants of health. The medical school now requires that all students be trained in public health. This training enables students to view health not just from the perspective of their individual patients but from a population-wide perspective. In this way, they can take action to address some of the factors, such as access to care, that affect their patient population.
In addition to receiving training in public health, students actively work with the community to address social factors affecting health. Because one of the most significant contributors to health is education, students speak at local schools to introduce students to healthcare professions and to stress the importance of education in general. To address inadequate nutrition among community members, students help to set up food pantries and help communities to grow their own food. Students and residents also work with community health workers at clinics the university has set up around the state, which provide access to healthy food, transportation, and housing. These experiences enable students to witness first-hand how social interventions can affect a patient's health.
Kaufman argued that medical schools have a responsibility to reach out to the community, to determine its needs, and to assess how university resources can meet them. Compare the top priorities identified by county health planning councils in New Mexico—substance abuse, teen pregnancy, obesity, access to care, violence, and diabetes—to the university's top research priorities—cancer, cardiovascular disease, brain and behavior, and infectious disease and immunity: there is very little overlap. To address this disconnect, the University of New Mexico has stationed fulltime agents in health extension rural offices (HEROs) to better align community needs with the resources of the university. For example, the HEROs identified a lack of medical coding skills among some rural doctors, which resulted in hospitals losing significant amounts of money, so the University of New Mexico set up a coding program to address this need. Other communities risked losing local pharmacies because of a lack of pharmacy technicians before HEROs set up a remote pharmacy system in collaboration with the College of Pharmacy to ensure that medications could be dispensed locally. The HEROs program decentralizes the university's activities, enabling it to benefit local communities throughout the state.
Joseph Betancourt, Massachusetts General Hospital, The Disparities Solutions Center
Claire Pomeroy, University of California, Davis
Mitchell Lunn, Brigham and Women's Hospital, Harvard Medical School
- Racial and ethnic minorities often receive a different quality of care, even when factors such as socioeconomic status are considered.
- Due to the increasing diversity of the patient population, doctors will need new tools and skills to effectively care for patients from different backgrounds and cultures.
- Programs that provide culture-competency training for physicians have the potential to reduce health disparities.
Reaching out: providing culturally-competent education
A 2002 Institute of Medicine report revealed that patients receive different quality of care based on race, ethnicity, and language, even when factors such as socioeconomic status and education are considered. For example, an African American patient with end-stage renal disease is significantly less likely to be put on a renal transplant list than a Caucasian patient with the same disease; minority patients are less likely to receive an equivalent amount of pain medication for an identical injury; and African American patients presenting with chest pain are significantly less likely to be referred to angioplasty or cardiac bypass surgery.
Part of the reason for these disparities is a lack of effective communication and trust between physicians and patients. Good communication ensures that care is delivered effectively and promotes positive outcomes by encouraging patients to, for example, take medications properly and share concerns or problems with physicians. Most medical schools focus on training physicians in the best and most current treatment methods but often provide very little training in effective communication. It can be especially difficult for physicians to communicate with and relate to patients who come from a different background from their own. With the number of newly insured patients expected to increase by over 30 million when the Patient Protection and Affordable Care Act takes full effect in 2014, the majority comprising underrepresented minorities, and the increasingly diverse patient population in general, it will become even more important to equip physicians to provide quality care to diverse populations.
How comfortable are physicians in treating patients from backgrounds that are different from their own? In a study by Joseph Betancourt from Massachusetts General Hospital and the Disparities Solutions Center, 97% of residents reported that it is "moderately" or "very important" "to consider the patient's culture when providing care." However, only 20%–25% of residents felt prepared to care for patients who are from different cultural backgrounds; who hold views on healthcare that are at odds with Western medicine; who distrust the U.S. healthcare system; who do not speak English as a first language; or whose religious beliefs may impact treatment. One way to prepare physicians to treat a diverse patient population is to provide cultural-competence training. According to Pomeroy, cultural competence entails appreciating different perspectives of health and disease, using appropriate and respectful language, and being able to integrate cultural beliefs with traditional medical approaches.
Although residents in Betancourt's study agreed that providing cross-cultural care is important, and reported that failing to do so can lead to longer visits, patient non-compliance, and unnecessary procedures, they identified time constraints as a significant barrier to providing such care.
Betancourt argued that supplementing traditional curricula with cultural-competence training would improve healthcare quality, address health disparities, and promote health equity. He emphasized the need to garner "buy-in" by convincing trainees that taking a culturally-sensitive approach need not increase time spent with patients and can actually make care more efficient. Quality Interactions, an e-learning program used by Harvard and other medical schools and hospitals around the country, teaches clinicians the impact of cultural competence in clinical care through case-based examples and provides strategies to assess how culture affects a patient's approach to health and treatment. At the University of California, Davis several programs are available to give medical students an opportunity to gain experience treating minority populations: the TEACH-MS program, which provides training for medical students working in underserved urban areas; a summer institute on race and health that focuses on migrant workers; and the Academy for Cultural Competence and Diversity Education, which develops curricula and programs in cultural competency.
Mitchell Lunn from Brigham and Women's Hospital and Harvard Medical School focused on the need for additional training on the issues of the LGBT community to address health disparities in these patients. LGBT patients are at increased risk for overweight, several chronic diseases, and substance abuse; however, this group may encounter barriers to receiving needed care as a result of fear that medical service will be refused or that they will experience discrimination based on sexual orientation and identity. Studies by Lunn and others have shown that medical students receive very little background or training on LGBT health-related issues. When such training is provided, it is often in the form of lectures and includes very little clinical exposure to the LGBT community. While many schools were found to teach students about topics such as sexual orientation, HIV, and gender identity, few focused on more primary care-focused LGBT-related topics such as transitioning, body image, sex reassignment surgery, and chronic diseases. Lunn stressed the need for better tools and training to ensure that physicians understand the unique health issues encountered by this community, which do not only involve sexual health, and to help them develop specific, effective communication skills. To provide these tools, medical schools do not need to reinvent their curricula; LGBT-related health topics can be incorporated into current lectures. Several organizations, such as the Fenway Institute, the Association of American Medical Colleges (AAMC), and the Gay and Lesbian Medical Association (GLMA) have developed materials geared towards LGBT-related topics that educators can utilize to address these needs.
Fritz François, New York University School of Medicine
- New efforts are being made to help medical students apply what they learn in the classroom to the bench and to the bedside.
- Providing students with opportunities to take ownership of learning can foster valuable skills, such as the ability to assess an array of contributors to health and disease.
- Introducing concepts in molecular epidemiology is one avenue to teach students about health disparities.
Reaching out: using molecular epidemiology to address health disparities
To illustrate another curriculum change medical schools can make to address health disparities, Fritz François from New York University School of Medicine gave an overview NYU's C21 curriculum. The curriculum uses a patient-centered, disease-focused model to help students connect the dots from the classroom to the bench to the bedside. Its goals are to emphasize cultural competency, diversity, and global health. François demonstrated how focusing on molecular epidemiology, which studies how genetic risk factors relate to disease across various populations, can be a useful teaching approach. Using colorectal cancer (CRC) as a case study, François showed how students are encouraged to tie in various topics and concepts as they progress through medical training.
Before students are provided with any background knowledge of CRC, they are tasked with approaching patients about CRC screening. By presenting students with scenarios and cases first, François encourages students to take time to determine what information is needed to address a problem—to take ownership of their learning opportunities. After learning more about CRC, students are introduced to the racial and gender disparities in CRC and then asked to connect lessons from anatomy, population health, genetics, and cancer biology to develop hypotheses about the causes of these differences and how clinicians can address them. Teaching clinicians, for example, that genetic factors make African Americans more likely to develop lesions on the right side of the colon and that such lesions are unlikely to be detected by certain methods, prepares them to deliver more effective care, targeted to address likely outcomes in a specific population. Making connections between genetic factors, health outcomes, and medical practice teaches students to draw on lessons from genetics and other disciplines in their everyday practice of medicine.
The NYU curriculum aims to teach students to ask "Why?"—to tie all contributing factors together when making decisions about diagnosis and treatment. This type of problem-solving approach, which encourages students to question the causes of disease and health disparities, has led to several student-led research projects on topics such as the association between CRC and body mass index and the effect of genetic polymorphisms on the position of lesions in the colon. François hopes this skill will endure as a new generation of students graduate to become practicing physicians. A problem-solving approach like this is essential when addressing health disparities that endure despite advances in our medical knowledge.
Marc A. Nivet, Association of American Medical Colleges
Mekbib Gemeda, New York University Langone Medical Center
Estela S. Estapé, University of Puerto Rico, Medical Sciences Campus
Claire Pomeroy, University of California, Davis
- Universities must embrace a culture that not only seeks diversity but also finds ways to draw upon its members' different experiences and skills.
- Medical schools can take steps to increase the number of minority students choosing a career in academic medicine and medical research.
Reaching in: promoting diversity in healthcare professions
In addition to demonstrating how medical schools can "reach out" to address health disparities, speakers also discussed how medical schools can "reach in" by promoting diversity within their institutions and the medical workforce. However, as Marc A. Nivet of the Association of American Medical Colleges (AAMC) explained, diversity itself is not enough. Universities must also foster a culture that values diversity and harnesses the differences between people. Nivet described how the concept of diversity has evolved over time.
Originally, diversity was about social justice: promoting both fairness and access for women and racial minorities. This mindset often assumes that diversity is counterproductive to excellence, and that in order to achieve diversity, universities must sacrifice some level of excellence. Nivet feels that most universities have moved past this mindset and now view diversity as a means to promote cultural competence: diversity and excellence are important, yet separate, goals. Nivet argued that universities must adopt a more evolved viewpoint of diversity that considers diversity as essential to excellence and brings diversity to the core of their mission.
How can diversity promote excellence? As Nivet explains, a diverse medical workforce will increase access to high-quality health service, advance cultural competence—something both Betancourt and Lunn described as important for addressing disparities—and broaden the medical research agenda. Furthermore, Nivet argued, universities can no longer afford to sit back and wait for diverse students and faculty to find them; instead, universities must actively recruit and attract candidates from various backgrounds and create an environment that not only fosters diversity but also ensures that such individuals thrive.
If universities accept that diversity is an important component in the achievement of excellence and accept a mandate to reduce health disparities, what can be done to attract underrepresented minorities into medical and research professions? Mekbib Gemeda from New York University Langone Medical Center and Estela S. Estapé from the University of Puerto Rico, Medical Sciences Campus discussed strategies and programs that aim to do just that. Gemeda focused on the shortage of underrepresented minorities employed in academic medicine as university faculty and researchers. Historically, minorities have not been encouraged to enter academic medicine or to engage in scholarly research but rather to serve in underserved communities. Even today, minority students are more likely to lose interest in academic medicine during medical school training and to serve in underserved communities after receiving their degree. Gemeda argued that these students do not realize that community service and academic medicine are not mutually exclusive. To encourage diversity within academic medicine, Gemeda contended, students need to experience how research and academic institutions can work hand-in-hand with communities. To do so, Gemeda advocated integrating health disparities into curricula, focusing on the social determinants of health, and engaging students in community-based education and research.
Estapé described a new postdoctoral Master's degree program in clinical and translational research that she is spearheading at the University of Puerto Rico. The program is founded on a multidisciplinary approach with a strong focus on mentoring; students are matched, based on their interests, with investigators in the U.S. and England and conduct primary clinical research. While developing the program, Estapé and her colleagues worked with a multidisciplinary team to develop a new online course, Health Disparities: A Translational Research Approach, to equip students with the background information and training needed to alleviate health disparities. Other new courses on scientific communication and biomedical informatics were also developed based on gaps Estapé and her colleagues identified. The program aims to develop six competencies that Estapé feels are necessary to effectively address health disparities.
Addressing health disparities requires bringing professionals together from across disciplines and across distances to create teams with complementary skill sets. The students in Estapé's program come from diverse backgrounds—from medical doctors in multiple disciplines to professionals in dental medicine, allied health, pharmacy, public health, and basic research. The program has a roughly equal number of men and women. By training Hispanics and including a high percentage of women, the postdoctoral program is promoting a diverse scientific workforce and increasing the representation of women in research.
Pomeroy further highlighted the importance of diversity in addressing health disparities. Changing the healthcare system cannot be achieved by healthcare professionals alone; it will require collaboration with educators, policy makers, urban planners, and other experts. Institutions must transcend traditional boundaries. As an example, Pomeroy described how the University of California, Davis has combined its School of Medicine, School of Nursing, and public health programs to create the Schools of Health Division, which has a single set of core values. This structure enables students to learn and train inter-professionally so that they will be equipped to practice in this manner.
Joel D. Oppenheim, New York University School of Medicine
Temitope P. Awosogba, Mount Sinai School of Medicine
F. Garrett Conyers, Harvard Medical School
Sabrina J. Gard, New York University School of Medicine
Howa Yeung, New York University School of Medicine
After hearing from the experts, a panel of medical students weighed in on their experiences addressing health disparities. The panel, moderated by Joel Oppenheim of New York University School of Medicine, consisted of Temitope Awosogba from Mount Sinai School of Medicine, Garrett Conyers from Harvard Medical School, Sabrina Gard from New York University School of Medicine, and Howa Yeung from New York University School of Medicine.
The students unanimously agreed that the manner in which health disparities are taught is just as important as the material itself. Disparities should not be taught as a series of facts to be memorized but as a topic that is relevant to the student. Several of the students on the panel have been involved in modifying the curriculum at their university to change the way disparities are taught. For example, Conyers works with faculty members and the administration at Harvard University to address curriculum change, and Yeung was part of a student-led effort to change the Health Medicine and Society course at the Sophie Davis School of Biomedical Education to make the material more case- and problem-based, using relevant local public health data. Yeung also cited a student-led effort by the LGBT People in Medicine Club at NYU, which collaborated with the Office of Diversity Affairs in creating a certificate course in LGBT health.
The students also recognized the difficulties involved in making health disparities a priority in medical education and the need to garner "buy-in" from students, faculty, and the administration. Faculty and administrators may be reluctant to prioritize health disparities because research in this area is sometimes viewed as a soft science and the topics discussed, such as race, gender, sexuality, and socioeconomic class, may make students uncomfortable. Despite these challenges, the students agreed that they have a responsibility to share their enthusiasm about health disparities and to help educate their classmates on solutions that address them.