Prioritizing Health Disparities in Medical Education to Improve Care

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

The Disparities Solution Center at Massachusetts General Hospital

The Health Extension Rural Offices program at the University of New Mexico

Healthy Youth / Healthy Regions at the University of California Davis

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.

Quality Interactions®
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.

Rural-PRIME
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.

TEACH-MS
A training program at the University of California Davis for residents interested in caring for underserved populations.

Journal Articles

General Reference

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.

Sponsors

Presented by

Academy Friends

Center for the Study of Gene Structure and Function, Hunter College, CUNY

Just Garcia Hill

This meeting is part of our Translational Medicine Initiative, sponsored by the Josiah Macy Jr. Foundation.

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.

Examples of health disparities facing Americans today. (Image courtesy of Claire Pomeroy)

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.

Speakers:
Arthur Kaufman, University of New Mexico
Claire Pomeroy, University of California, Davis

Highlights

• 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.

Combined health and social services spending for OECD countries. While the U.S. spends the most money of any other country on health services, combined spending on health and social services is on par with many other countries. (Image courtesy of Claire Pomeroy)

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.

Social determinants, such as lifestyle choices, contribute significantly to an individual's health but do not receive a significant portion of the healthcare budget. (Image courtesy of Arthur Kaufman)

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.

Speakers:
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

Highlights

• 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.

Physicians' level of comfort with treating patients from various backgrounds. (Image courtesy of Joseph Betancourt)

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.

Self-reported barriers to care in the LGBT community. (Image courtesy of Mitchell Lunn)

Speaker:
Fritz François, New York University School of Medicine

Highlights

• 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.

Various factors that contribute to the epidemiology of colon cancer. (Image courtesy of Fritz François)

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.

Speakers:
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

Highlights

• 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.

According to Nivet, while patient care, education, and research are the main functions of medical schools, the overall mission is health equity. Diversity and inclusion are some of the tools that can be used to achieve health equity. (Image courtesy of Marc Nivet)

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.

Minority students are more likely to practice in underserved areas compared to their Caucasian counterparts. (Image courtesy of Mekbib Gemeda)

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.

The six competencies taught in the Master's program in clinical and translational research at the University of Puerto Rico. (Image courtesy of Estela Estapé)

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.

Moderator:
Joel D. Oppenheim, New York University School of Medicine

Panelists:
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.

According to Pomeroy, a redesigned healthcare system should include new providers, new places of care, and a focus on technology. (Image courtesy of Claire Pomeroy)