PEDIATRICS Vol. 105 No. 1 January 2000, pp. 129-131

AMERICAN ACADEMY OF PEDIATRICS:
Enhancing the Racial and Ethnic Diversity of the Pediatric Workforce

Committee on Pediatric Workforce

	ABSTRACT

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Purpose.  This statement seeks to increase the awareness of the importance of diversity; to encourage the incorporation of principles of cultural competence into all aspects of pediatric education, training, and practice, as exemplified by practitioners, educators, and our national leadership; and finally to identify strategies for implementing this incorporation.

Key Concepts.  The increasing cultural diversity of the population has significant implications for the pediatric workforce and for the provision of pediatric health services. Diversity within the pediatric workforce will enhance the potential for pediatricians to acquire the knowledge and practice skills needed to effectively address the health and wellness needs of children and families. Support from this diversity should be integrated into all aspects of education, including providing quality education for minority students and attracting and retaining minority faculty; and should be sought through collaboration locally, regionally, and nationally with organizations and community leaders.

Anticipated Outcomes.  The Policy Statement recommendations will be used to inform educators, administrators, practitioners, and others in the development of curricula, programs, and initiatives to enhance the diversity of the pediatric workforce and increase the cultural competence of practitioners.

In the United States, the percentage of children from racial and ethnic minority groups* has increased over the past decade and is projected to continue to increase at least for the next 20 years. By the year 2020, approximately 40% of school-aged children are expected to be of non-white racial or ethnic backgrounds. Projections for the year 2025 estimate that the child population will comprise 15.8% blacks, 23.6% Hispanics, 1.1% American Indian/Native Alaskans, 6.9% Asian/Pacific Islanders, and 52.6% whites.¹

The increasing cultural diversity of the population has significant implications for the pediatric workforce and for the provision of pediatric health services. There is a need for a pediatric workforce that is 1) more racially and ethnically diverse, and 2) educated to recognize and address the needs of the increasingly diverse pediatric population. Racial and ethnic diversity among pediatricians enhances opportunities to improve quality of care for these children. Diversity in the pediatric workforce, in pediatric educational systems, and in the leadership of our pediatric organizations promotes the cultural effectiveness of pediatricians.

The health care needs of the pediatric population are influenced by factors relating to culture and ethnicity. Pediatricians must acquire the knowledge and practice skills that will allow them to: recognize and address culture and ethnicity; make valid assessments of clinical findings; and, provide effective patient management. A more diverse student body enhances the medical education process and fosters the development of more culturally effective physicians. Effective education of physicians to address the needs of a culturally diverse pediatric population can best be developed with the active participation of professional colleagues from diverse cultural, racial and ethnic backgrounds serving as teachers, role models, mentors, administrators, and leaders.

	WHY DIVERSITY IS IMPORTANT

The current or projected racial and ethnic mix of pediatricians does not approach the degree of diversity in the pediatric population.² The population of medical students and residents is also characterized by insufficient representation of the racial and ethnic groups. During the next 25 years, the disparities between the racial and ethnic mix of the pediatric population and that of their pediatricians can be expected to widen substantially.

In the United States, compelling evidence exists that persistent, often increasing disparities are apparent in the health status of racial or ethnic minority groups compared with whites.³ For the pediatric population, social, racial, and ethnic barriers may perpetuate these disparities by preventing adequate access to care.^4,5 The race and ethnicity of the physician are also important. Patient and parent satisfaction with care may be higher when the physician is of the same racial or ethnic group as the patient.⁶ Thus, access to and quality of care may be enhanced for children from minority groups with an increase in the racial and ethnic diversity of the pediatric workforce. More data are sorely needed on the relationship between pediatric workforce diversity and satisfaction, access, quality, and outcomes of pediatric care.

	RATIONALE AND STRATEGIES FOR ACHIEVING DIVERSITY

The percentage of underrepresented minorities (URM) as defined by the Association of American Medical Colleges (AAMC)⁷ entering medical school remains at approximately 10%. The highly publicized gains in the number of minority students applying to medical school in the past have significantly eroded in recent years. The national decline in URM applicants to medical school from 1996 to 1997 was 11% compared with a decline of 8% for all other applicants. The number of URM students who entered medical school in 1997 declined to 1770, the lowest since 1991. Since reaching a record high of 2014 in 1994-1995, the URM new entrants have declined from 12.4% to 10.9% (1770) of all entering medical students in 1997-1998. The decline in URM new entrants was not uniform across all US medical schools. Over two-thirds of the decline occurred at schools affected by rulings that prohibited the consideration of race or ethnicity in the admissions process.⁸ The disturbingly low number of minority medical students significantly limits the pool of potential pediatric residents, faculty members, and ultimately practicing pediatricians. The pediatric community should support and undertake concerted, targeted efforts to enhance participation of individuals from diverse racial and ethnic groups as members of the pediatric workforce, using strategies described below. The following 11 concepts are in keeping with the high standards required of students for entry into medical school education programs.

1. Working with community and educational leaders and boards of education to develop programs to foster the interests of minority elementary and secondary school students in mathematics and the sciences. Such a strategy enhances the likelihood that minority students will receive the education necessary for college entry and encourages students to consider careers in medicine.
2. Developing flexible student, resident, faculty selection processes that value service-oriented extracurricular activities, cross-cultural sensitivity, and communication skills.
3. Developing educational interventions specifically tailored to address the educational gaps frequently experienced by minority students.
4. Establishing programs and systems to support the special psychosocial needs of minority students and residents.
5. Actively supporting minority residents, fellows, and junior faculty to encourage their participation in curriculum development and to foster their professional advancement.
6. Assessing and addressing the specific professional needs of minority faculty and cultivating and supporting their roles as mentors and role models for students, residents, and colleagues.
7. Assuring that minority faculty members, who participate in activities related to advocacy for cultural diversity, are provided with appropriate recognition for those activities.
8. Assuring that minority faculty members have adequate protected time to facilitate traditional activities leading to academic advancement and promotion.
9. Using the resources available at other medical organizations including the National Medical Association, the Association of American Medical Colleges and the American Medical Association, to identify existing programs and initiatives that address culturally effective health care.
10. Working with local, regional, and national organizations and with community physicians to recruit appropriate individuals who can serve as additional resources as role models, mentors, and collaborators in curriculum development.
11. Enlisting specific input, at all programmatic levels, from residents, fellows, and faculty to identify factors perceived to have an impact on the potential for advancement of racial and ethnic diversity within the pediatric workforce.

Given the rapidly changing racial and ethnic profile of children in the United States, the issues in this statement need to be priorities for the pediatric community. The American Academy of Pediatrics supports and promotes actions for developing and maintaining a multicultural, diverse pediatric workforce that responds to the health care needs of children.

The American Academy of Pediatrics provides the following recommendations to the pediatric community:

1. The strengthening of primary and secondary education systems needs to be supported to help ensure quality education for minority students. The attractiveness of careers in pediatrics needs to be promoted at these levels.
2. Ongoing tracking of career plans and paths of talented minority youth should be a priority for the pediatric community.
3. Affirmative action initiatives need to be supported to recruit, select, and retain minority medical students, residents, faculty, and practicing pediatricians.
4. Formal curricular goals, objectives, and evaluation tools for medical students, residents, and fellows should be developed that foster cultural effectiveness and should be incorporated into medical school, residency, and continuing medical education.
5. Minority residents, fellows, and faculty should be actively supported to foster their professional development and advancement.
6. Implementation of the 11 strategies described in this policy statement.

COMMITTEE ON PEDIATRIC WORKFORCE
Jeffrey J. Stoddard, MD, FAAP, Chairperson
Michael R. Anderson, MD, FAAP
Carol D. Berkowitz, MD, FAAP
Carmelita Britton, MD, FAAP, Principal Author
Robert Nordgren, MD, MPH, FAAP
Richard J. Pan, MD, MPH, FAAP
Debra Ralston Sowell, MD, FAAP
Jerold C. Woodhead, MD, FAAP

RETIRED
Elena Fuentes-Afflick, MD, FAAP
Stephen Keith, MD, FAAP
Kathleen Nelson, MD, FAAP

LIAISONS
Walter Tunnessen, MD, FAAP
 American Board of Pediatrics
Frances J. Dunston, MD, MPH, FAAP
 National Medical Association

STAFF CONSULTANT
Mary Ruth Back

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

^* It is recognized that the meanings of the terms race and ethnicity are overlapping and defined by the context in which they are used. In the context of this statement, our purpose is to be culturally inclusive rather than specific. Racial categories used by the US Census and others have varied widely, and the terms race and ethnicity are often used interchangeably. This statement points to the need to deal with cultural context in addition to racial identity.

As established in the January 1999 statement of the AAP Committee on Pediatric Workforce, culturally effective health care refers to the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of cultural distinctions. Such understanding should take into account the beliefs, values, actions customs, and unique health care needs of the distinct population groups. Providers will thus enhance interpersonal and communication skills, thereby strengthening the physician-patient relationship and maximizing the health status of patients. The American Medical Association considers "cultural competence" and "culturally effective health care" as synonymous terms, but has retained the use of the term "cultural competence" because of its widespread use and acceptance. Culturally effective health care is related to cultural competence and cultural sensitivity. However, whereas cultural competence and cultural sensitivity refer to the provider's attributes, the term culturally effective health care refers to the interaction between provider and patient. Thus, culturally effective health care is based on cultural sensitivity and cultural competence, but also goes beyond these concepts in describing the dynamic relationship between provider and patient. To promote the provision of culturally effective health care to pediatric patients, the Academy recognizes the need to develop education and training materials and courses.

The AAMC definition includes African-American, Mexican American/Mainland Puerto Rican, and Native American in the category of underrepresented minority groups.

	ABBREVIATIONS

URM, underrepresented minorities; AAMC, Association of American Medical Colleges.

	REFERENCES

Top Abstract References

1. Statistical Abstract of the United States: 1997. 117th ed. Washington, DC: US Government Printing Office; 1997:20-27
2. AAMC Survey of USMG pediatrician graduates 1983-89, and AMA Masterfile Data, 1996
3. Council on Graduate Medical Education. The health status of minority populations. In: Minorities in Medicine. Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration. May 1998:7-13
4. Blum BD, Blank S Children's services in an era of budget deficits, Am J Dis Child 1991; 145:575 [Abstract/Free Full Text]
5. American Academy of Pediatrics. Report of the Task Force on Minority Children's Access to Pediatric Care. Elk Grove Village, IL: American Academy of Pediatrics; 1994:16
6. Gray B, Stoddard JJ Patient-physician pairing: does racial and ethnic congruity influence selection of a regular physician? J Community Health. 1997; 22:247-259 [CrossRef][Medline]
7. Report of the Association of American Medical Colleges Task Force to the Inter-Association Committee of Expanding Educational Opportunities in Medicine for Blacks and Other Minority Students. Washington, DC: Association of American Medical Colleges; 1970
8. Minority Medical Students in Medical Education: Facts and XI. Washington, DC: Association of American Medical Colleges; 1998