Graduate Medical Education: The Gateway to Diversity in the Physician Workforce

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MekbibGemedaLandmark reports, including the Sullivan Commission’s “Missing Persons: Minorities in the Health Professions” and the Institute of Medicine’s “Unequal Treatment” and “GME That Meets the Nation’s Health Needs,” have highlighted the need for diversity in the physician workforce in order to address persistent health disparities in the United States. Data from the Association of American Medical Colleges (AAMC) show overwhelming interest by underrepresented minority students as compared with non-minority medical students to practice in underserved communities. Studies on the eventual practice location of underrepresented minority physicians have also demonstrated the link between physician diversity and the care given to underserved patients.

The educational advantage that a diverse group of medical students brings to the training environment has been shown in numerous studies and reports to advance culturally competent medical education.

The Liaison Committee on Medical Education (LCME) issues and mandates the accreditation standards required of all allopathic medical (MD) schools in the U.S. and Canada. The LCME reviews medical schools for accreditation at least once every eight years to evaluate whether appropriate sustained effort and resources are employed toward meeting these standards.

Standards IS-16 and Element 3.3 of the LCME focus on appropriate engagement of medical schools in developing a diverse pool of trainees for healthcare professions in order to meet the needs of a diverse population. The standards read as follows:

IS-16 — An institution that offers a medical education program must have policies and practices to achieve appropriate diversity among its students, faculty, staff, and other members of its academic community, and must engage in ongoing, systematic, and focused efforts to attract and retain students, faculty, staff, and others from demographically diverse backgrounds.

Element 3.3 — A medical school has effective policies and practices in place and engages in ongoing, systematic, and focused recruitment and retention activities to achieve mission-appropriate diversity outcomes among its students, faculty, senior administrative staff, and other relevant members of its academic community. These activities include the use of programs and/or partnerships aimed at achieving diversity among qualified applicants for medical school admission and the evaluation of program and partnership outcomes.

The LCME has also issued standards ED-21 and elements 7.5 and 7.6 to ensure that the medical curriculum prepares students to care for patients of diverse cultural backgrounds, socioeconomic statuses, gender identities, and sexual orientations. The standards read as follows:

ED-21 — The faculty and medical students of a medical education program must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.

7.5 Societal Problems — The faculty of a medical school ensures that the medical curriculum includes instruction in the diagnosis, prevention, appropriate reporting, and treatment of the medical consequences of common societal problems.

7.6 Cultural Competence/Healthcare Disparities/Personal Bias — The faculty of a medical school ensures that the medical curriculum provides opportunities for medical students to learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the healthcare delivery process.

The best practice and accountability model prescribed by the LCME in undergraduate medical education provides a comprehensive standard for cultivating a diverse and well-trained pool of medical students for entry into graduate medical education. Ironically, a parallel standard of practice and accountability has been absent in the accreditation of graduate medical education to ensure a gateway to a diverse physician workforce.

The Accreditation Council for Graduate Medical Education (ACGME) has issued important educational standards that focus on the graduate medical education curriculum to ensure that residents are prepared to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds and to demonstrate sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. However, the accreditation requirements do not provide standards for graduate medical programs — like those developed by the LCME for undergraduate medical education — for engaging in efforts to expand the diversity of residents and fellows. The responsibility of addressing diversity is left to the discretion of individual residency and fellowship programs.

As a school of medicine and health professions established by southeastern Virginia to serve the needs of the community, Eastern Virginia Medical School (EVMS) strives to be the most community-oriented school of medicine and health professions in the nation. To that end, it has established robust pipeline and pathway programs, with local colleges serving large underrepresented minority student populations, including Hampton University and Norfolk State University. The school also integrated service learning and community outreach into its curriculum to
ensure training that meets the needs of the community.

EVMS retains a significant number of its medical students and attracts a diverse pool of trainees into its residency programs, particularly in its primary care programs in family medicine and pediatrics. Of the residents, 19.7 percent of those in pediatrics, 6.4 percent of those in internal medicine, and 31 percent of those in family medicine come from underrepresented minority backgrounds (African American or black, Hispanic or Latino, Native American or Alaska Native, Hawaiian Native or Pacific Islander). EVMS leadership is committed to improving the diversity of the graduate medical education complement and continuing to advance this issue at the national level.

While many institutions and programs such as the ones at EVMS embrace diversity and inclusion as an essential pathway to excellence in medicine, the experience of undergraduate medical education informs us that best practices are best achieved through common guidelines and standards.

The AAMC recently introduced a comprehensive initiative to optimize graduate medical education across three broad areas: investing in future physicians; optimizing the environment for learning, care, and discovery; and preparing the physician and physician scientist for the 21st century. There is growing momentum to adapt best practices from undergraduate medical education to develop standards of practice to advance diversity in graduate medical education. The hope is that the AAMC initiative will accelerate adoption of common standards of practice and accountability on diversity in graduate medical education.●

Mekbib Gemeda is the vice president of diversity and inclusion at Eastern Virginia Medical School, where he leads efforts to address health equity and enhance diversity in the health workforce. He is the founding director of the Center for the Health of the African Diaspora at New York University School of Medicine and has more than a decade of experience working to reduce health disparities and increase diversity in the biomedical workforce in the U.S.