AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. June 2003, Volume 5, Number 6.

Policy Forum

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Diversity and the Road to the "Land of Best Care"

The author discusses why the U.S. needs ethnically diverse medical professionals in order to stay competitive in the global economy.

Lonnie R. Bristow, MD

How to achieve the goal of best care for every American? Consider these facts: in the year 2000 African Americans comprised 12.9 percent of the US population but only 2.5 percent of our nation's physicians, and only 7.7 percent of the pool of applicants to medical school. Some groups fared even worse. While Mexican Americans, for example, made up 7.3 percent of the US population, they comprised only 1.9 percent of the medical school applicant pool. The US Census Bureau projects that by 2050, more than 40 percent of the US population will be people of color. At present, the burdens of illness and their attendant costs fall disproportionately on those populations that have minority status in the United States and that are likewise underrepresented throughout the health professions. This is more than pure coincidence.

How does increasing the diversity of US health professionals figure into the equation of best care for all Americans? This question spans the entire spectrum of all health professionals, not just physicians. The short answer—diversity amongst the caregivers is not only the right thing to do; it's also very much the smart thing to do. America is fighting to maintain its leadership position in a global economy. To compete effectively, we will need optimal health for our workforce. Those burdens of illness, injury, and disability, with their attendant costs, must be reduced to the barest minimum possible for all Americans, if we are to achieve and maintain maximum productivity for our nation.

In its 2001 report, Crossing the Quality Chasm, the Committee on Quality of Health Care at the National Academy of Sciences' Institute of Medicine declared that our nation should adopt 6 aims for health care for all Americans. I think of them as being the readily measurable parameters of quality; in effect, they are the dimensions of true quality. The care Americans receive should be safe, effective, patient-centered, timely, efficient, and equitable. The centerpiece is the patient-centered dimension. Too often health care focuses on the needs of the hospital, the caregivers themselves, the intermediary payers, or some corporate entity or part of the government. Patient-centered means the care should be designed and produced to meet the needs and wishes of the patient, not only those needs dictated by science but also those emanating from the unique cultural perspective of that person. Every American should have access to culturally competent care if that care is to be truly patient-centered.

Achieving the long sought goal of best care for every American, unarguably, makes good moral sense. Having a healthy national workforce also sharpens our competitive edge, but what role does diversity play? It can be said that diversity is an essential element but not sufficient by itself, to achieve cultural responsiveness in any medical interaction. Significant increases of diversity in the medical and health care professions would demonstrate that there's more than just talk in our claim to respect the richness and contribution of all cultures. It's difficult to make the case that we value all cultures if, de facto, the dominant "majority" monolithically excludes others from the full range of opportunity America has to offer.

Perhaps more important than what the dominant culture offers all others is what those cultures contribute to our mutual goal: best care for every American. For diversity to make its maximal contribution, however, it must embrace the opportunity for exploration, and exploitation in a creative way, of some of the cultural differences that a diverse group of individuals brings to the table. There is often more than one way to attack a problem. I strongly believe that people of different ethnic and cultural backgrounds often bring different problem-solving skills and techniques to a given problem. Having several creative ideas can often prove better than a monolithic approach. The whole really is greater than the sum of its parts--but only if it is allowed to function interdependently as a true whole, rather than simply a collection of parts.

Diversity and creative thinking

The business sector seems to reflect the benefits of a diverse workforce. A 1998 survey of over 1000 managers and executives of American companies by the American Management Association (whose member companies make up about 25 percent of the American workforce), showed that where the senior management of a corporation had great "heterogeneity" (referring to a mix of genders, ethnic backgrounds, and ages), there was a consistent correlation with superior corporate performance, as compared to corporations in the same industry group which had traditional "homogeneity." Such companies are evidently more productive and more creative, which translates into better bottom lines for their stockholders. Logic cries out that the same circumstances should apply well in health care. Different problem-solving skills should lead to more creative thinking about clinical and research problems, patient satisfaction, and cost containment. Everybody benefits from this type of problem solving, not simply minority groups.

Diversity, then, is an essential component for culturally responsive care, which, in turn, is vital to achieving best care for all Americans. Achieving greater diversity in all health profession education is truly the smart thing to do.

Lonnie R. Bristow, MD, is an internist from San Pablo, California, and served as president of the AMA in 1995-96. He is now a medical consultant, spending most of his time engaged in public health issues. He served on the Institute of Medicine committee which produced the report on medical errors, To Err Is Human. Currently he chairs an IOM committee, which is developing a report, Strategies for Increasing the Diversity of the US Health Care Workforce, due out in early 2004.

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