This study examined methods of recruiting and retaining minority house staff at US residency training programs. A 28-item questionnaire was mailed to pediatric chief residents at 78 US training programs with more than 35 residents. The response rate was 74%. Programs were characterized by patient populations served, number of ethnic/racial minority house staff and faculty, and the presence of minority house staff support systems within the institution. In this largely urban sample, minority recruitment and retention was reported as an explicit priority by 40% of pediatric chief residents. The majority (71%) reported that their house staff recruitment committees had no explicitly defined recruitment goals regarding minority house staff. Seventyseven percent reported that within their departments, recruitment efforts toward minorities were no different than for nonminorities. Overall, few minority house staff and minority faculty were identified in the responding institutions. The most frequently reported intra-institutional support systems for minority house staff included individual pairing with faculty advisors from the same minority group (29%), an affirmative-action office located at the institution (8%), and the existence of a minority faculty support group (4%). These results indicate that pediatric chief residents may not be fully aware of the specific challenges related to the recruitment and retention of minority physicians, and most house staff recruitment committees do not have explicit goals in this regard. (J Natl Med Assoc. 1999;91:459-465.)
Key words: residency programs minorities pediatrics
Achieving racial, ethnic, and cultural diversity in the health-care setting and having a physician workforce whose membership reflects the composition of the populations served remains an explicit goal for many medical educators and their institutions.1-6 Medical schools and their faculties have worked on both short- and long-term strategies to prepare, recruit, and retain members of underrepresented minority groups such as blacks, Mexican Americans, mainland Puerto Ricans, and Native Americans in the medical profession.1,7-13 Distinguished medical school leaders have called on medical educators to continue working on comprehensive efforts directed at achieving diversity in the medical profession, and the issue is framed as an obligation rather than a choice.2,4
In the past, professional associations, governmental agencies, and private foundations have launched a number of high-profile initiatives to focus attention and stimulate action toward the expansion of minority opportunities in medicine.14 For example, in 1991, the Association of American Medical Colleges' (AAMC) launched Project 3000 by 2000 to address the problem of minority underrepresentation in US medical schools.15 The project fosters working partnerships between medical schools and high schools and colleges to improve academic preparation of entering students. The AAMC also formed Health Professionals for Diversity, a coalition of more than 51 medical, health, and education organizations. Health Professionals for Diversity helps ensure that health profession schools continue to have freedom to consider race, ethnicity, and gender in selecting students to create a diverse, technically and culturally competent health-care workforce.16
From a governmental perspective, the Office of Disadvantaged Assistance's Health Careers Opportunity Program (HCOP) of the US Department of Health and Human Services (DHHS) seeks to increase the number of health professionals from disadvantaged backgrounds, including physicians. The Health Careers Opportunity Program meets expanding health-care needs of underserved populations via programs that enhance academic skills and provide support to individuals who desire to work in health care.17
Private foundations also have supported programs that promote diversity among medical school applicants, trainees, and graduates. Several foundations have partnered with AAMC to promote these programs. For example, the Robert Wood Johnson Foundation along with the WK Kellogg Foundation support the Health Professions Partnership Initiative, which seeks to build on the Project 3000 by 2000 iniative.18 The Robert Wood Johnson Foundation supports other initiatives including the Minority Scholar's Program directed at the development of academic physicians from underrepresented minority groups. Additionally, the Josiah Macy Foundation supports Ventures in Education, which identifies qualified underrepresented minority 10th and 11th grade students interested in careers in medicine. This initiative links minority students with participating medical schools, establishes special academic programs as students progress through secondary school and college, and guarantees early acceptance for selected students to medical schools.19
Although multiple initiatives, such as those described, have helped build diversity in undergraduate medical education, the progress has not been steady. Despite a call for national dialogue on diversity and the release of a blue ribbon commission report on the topic, the nation's sentiment appears to be shifting away from traditional policies designed to target the inequities faced by minorities in general.20 The rhetoric in recent political campaigns and court judgments that have limited previously successful efforts to promote diversity are evidence of this trend.45,20 The backlash against affirmative action appears similar to other such backlashes against social programs directed at the economically and educationally disadvantaged members of our society.21-23
The pattern of minority enrollment in medical school, which mirrors national trends, has been categorized into three phases.1 The first is the social activism phase in which minority enrollment of 3% in 1968 went up to 10% in 1974. Second is the stagnation phase where from 1974 to 1989, the percentage stayed approximately the same while the proportion of minorities in the general population increased faster than medical school enrollment. The third phase is marked by the 1991 launching of Project 3000 by 2000. In 1990, there were 1470 underrepresented minority medical school enrollees; this number increased by 30% to an all-time high of 2000 in 1994. Over the past several years, the number of minority students enrolling in medical school has declined, making the 3000 target unlikely. In 1996, minorities comprised 21% of the population but comprised <12% of medical school matriculants.6 The 1997 trend was not encouraging as there was an 8% decrease in the number of all US medical school applicants and a 14% decline in the number of minorities.6
Trends in related literature suggest looking at underrepresented minorities aggregate performance and demographics.24-27 In addition, targeted programs that promote the preparation, recruitment, and retention of qualified medical trainees have been evaluated and document individuals who go on to contribute to the profession and the people it serves.1,15 A unifying principle in many programs has been the creation of specific supports that encourage a diverse group of trainees to gain the skills necessary to achieve competence in the field of medicine.
Efforts to promote diversity in graduate medical education such as residency training are less than desired. The American Medical Association's (AMA) Advisory Committee on Minority Physicians wants to expand the AMA's effectiveness in addressing issues important to minority physicians. One of the five specific missions of the Advisory Committee is the monitoring of medical school and graduate medical education policies to ensure that additional barriers are not created for minorities.28 The American Academy of Pediatrics (AAP) Task Force on Minority Children's Access to Pediatric Care addressed a number of issues related to the unique needs of minority children and the perspectives of minority pediatricians.29 The AAP Task Force identified the paucity of minority pediatricians and called for action at many levels to prioritize the recruitment of minority group members into medicine and specifically into pediatrics.
Given the concerns for increasing the number of minority physicians in the profession, this study examined the institutional approaches that pediatric residency training programs take with regard to minority house staff recruitment and retention as reported by pediatric chief residents.
MATERIALS AND METHODS
A 28-item questionnaire addressing multiple aspects of the residency program concerned with minority recruitment and retention was developed. Information sought included the metropolitan status of the patients served by the training program, the number of minority faculty and house staff, chief residents' understanding of minority recruitment policies, support structures in place at the institution, and opinions related to specific minority recruitment issues.
The sample for the survey consisted of pediatric chief residents from 78 nonmilitary pediatric training programs listed as having 335 residents in the AMA's Graduate Medical Education Directory. The questionnaire was pilot tested, revised, and mailed to the 78 programs in the fall of 1991. Nonresponders received a second copy six weeks later. Those who did not respond to the second mailing received phone calls one month after the second survey was mailed. Those who did not respond to the second and third mailing received phone follow-up through the summer of 1992.
Questionnaires were included in the analysis if at least 50% of questions were answered. Questions with responses that should add up to 100% were included in the analysis provided their sum was between 90% and 110%. Responses were entered into MicroStat II version 2.0 (Ecosoft Inc, Indianapolis, IN) and analyzed using descriptive statistical methods. The results are descriptive in nature using primarily medians with ranges owing to the nonparametric character of the responses and frequencies of response noted as percentages. Responses to open-ended questions were transcribed and categorized by content. The analysis is descriptive in nature because of the small sample size and the hypothesis-generating nature of the work.
The response rate was 74% (n=58). Tables 1 and 2 summarize characteristics dealing with the size of the residency program and the racial/ethnic mix of patients, house staff, and faculty.
Table 3 summarizes the perceptions of chief residents about minority house staff recruitment and retention as an explicit priority within this program. Seven percent of chief residents indicated that their house staff selection committee had specifically defined minority house staff recruitment goals, 71% indicated that their house staff selection committee did not have such goals, and 22% were not sure (n=58). Of the four programs that had explicit goals, two stated that the goals were met for the prior year, one stated that they were not met, and one was unsure.
Chief residents were asked to describe follow-up with minority house staff applicants who did not select their program. Nineteen percent reported that no follow-up was done, 21% were not sure if followup occurred, 10% indicated that follow-up did not reveal any patterns, and 3% indicated that follow-up helped identify reasons/patterns.
When asked how they would approach a minority medical student who voiced an interest in pediatrics as a career (n=57), 67% of responding chief residents indicated they would encourage the choice, while 18% were not sure. Sixty-five percent of respondents indicated they would attempt to recruit the medical student to their program, with 18% not sure. Seventy-two percent of chief residents indicated that they do not treat minority medical students differently than they do nonminority medical students, with 7% not sure.
Responses to similar questions related to the formal efforts of their pediatrics department toward minority medical students who voiced an interest in pediatrics revealed that 46% of chief residents thought the department would encourage the choice of pediatrics as a career choice, while 11% were not sure. Forty-seven percent thought the department would attempt to recruit the medical student, with 11% not sure. Seventy-seven percent of chief residents thought that the efforts of the department of pediatrics toward recruitment of minority students did not differ from the department's efforts toward nonminority student recruitment. Questions related to the minority recruitment efforts of pediatric chief residents and their departments elicited text responses that were categorized into three areas: 1) explicit special recruitment attempts toward minority applicants, 2) neutral on race/ethnicity, and 3) emphatic about making no special attempts because of minority status.
Ninety-four percent of chief residents (n=56) indicated that it was not difficult to retain minority house staff within their program. Additionally, 76% of respondents reported that no specific person was identified to handle minority affairs, while 19% were not sure.
Chief residents were asked to identify all support systems offered to house staff from ethnic minorities (n=51; some respondents gave more than one response so the percentages do not total 100%). Twenty-nine percent of respondents paired house staff with faculty advisors from similar ethnic minority groups, 8% identified an office of affirmative action located in their hospital, 4% indicated the existence of a minority faculty support group, 51% percent circled 'none of the above,' and 8% selected other and wrote in comments such as 'no need to-nobody has had problems,' 'informal network via Assistant Dean,' and 'community minority groups.' Respondents wrote unsolicited comments that indicated divergent sentiments such as:
Everyone is treated equally; no group has only support system not made available to any individual.
Truthfully, we don't do enough at all levels to encourage minority students to: 1) go to college, 2) be doctors, 3) be pediatricians, or 4) be pediatricians here. I think we need to work on increasing the pool of qualified candidates on all levels rather than individual institutions all competing for the same few candidates and as above help them feel they have advocates and role models once they got here.
Thirty-five percent of chief residents believed that the number of minority house staff in comparison to other pediatric programs at their own institution was low. In comparison with other pediatric programs, 27% thought the number was average, while 24% were not sure (n=55). In a similar comparison, 47% believed the number of minority faculty was low compared with other pediatric programs, 25% believed the number was average, and 21% were not sure (n=55).
Finally, Table 4 lists the responses to the Likerttype questions asked of the chief residents.
The survey results represent responses from relatively large pediatric programs serving predominantly urban populations with more than two-thirds of the programs treating urban patients in both the inpatient and outpatient setting. At the time of the study, few programs had minority faculty members or minority house staff. This finding is consistent with national trends indicating few minorities either in training or in leadership positions. The small number of minority physicians is problematic since minority physicians have few mentors from their own racial, ethnic, or cultural group, and young minority professionals can benefit from such role models.30 Additionally, diversity in the training environment may make the training experience culturally rich, although not all see the value in promoting diversity within the workplace and training environment.31,32
More than one-half of the chief residents surveyed did not view minority recruitment as an explicit priority for themselves. Chief residents also did not perceive minority recruitment a priority for the leadership of their department, including the program director and members of the house staff selection committee. More than two-thirds of chief residents were unaware of specific minority recruitment goals for house staff, and nearly one-half did not respond when asked if follow-up occurred with minority candidates who did not choose their program. The other respondents indicated uncertainty as to whether follow-up had occurred. The aggregate responses indicate a lack of awareness on the part of the chief resident toward recruitment of minority house staff to a given program.
A positive finding was that nearly two-thirds of chief residents reported that they would encourage the choice of their program and would attempt to recruit an interested minority applicant. However, more than two-thirds indicated they would make no special recruitment efforts for minorities over and above those made for nonminority candidates. Because life experience of minority house staff may differ from that of majority house staff, additional recruitment and retention efforts may be indicated. The additional efforts directed at achieving greater inclusion for minorities in medicine may serve to demonstrate an understanding of differences within the program and create a supportive, nurturing environment for minority house staff applicants.
Recent years have seen several drives designed to undermine affirmative action, and the effect with regard to medical school enrollment by minorities has been remarkable. The AAMC reported that minority students' entrance into medical school declined from 1994 to 1997 by 12%.33 By the end of 1997, minorities accounted for only 11% of the national total of matriculating medical students, while demographic representation of minorities in the US population was approximately 21%.33
Unfortunately, the AAMC's '3000 by 2000' plan seems destined to remain unfulfilled, as minority representation at all levels, from faculty to medical school applications and acceptances, is decreasing. The findings of this study reflect this.
Achieving true diversity in the medical profession is a goal that will require action from both institutions and the individuals within them. Chief resident physicians in every specialty are in a pivotal position to recruit and support underrepresented minorities in medicine. As individuals involved with both medical training and hospital hierarchy, chief residents are also in a unique position to put the meaning of affirmative action into play. It is concerning that, in this study, pediatric chief residents were generally neutral to the idea of active recruitment of underrepresented minorities.
While there was a nearly universal perception among responding chief residents that recruiting minority applicants would not be difficult, there was a negative sentiment toward affirmative action efforts as a vehicle to increase the number of minorities in pediatrics. The situation may be worse today than when this study was done in 1992, when members of underrepresented minorities in medical training were increasing. Today, the number of underrepresented minorities in medicine are now declining, and a comprehensive survey performed now may be more revealing of current sentiments. Overall, the themes expressed in 1992 seemed to presage the general societal trend against the use of affirmative action as a means of increasing racial and ethnic diversity in all fields, including medicine.
Pediatric chief residents may not be fully aware of the specific challenges related to the recruitment and retention of minority physicians. Furthermore, most house staff recruitment committees do not have explicit goals in this regard.
We thank Dr Sean Lincoln for suggestions made during the revision of the article and Bernadette Toner for her help with the manuscript's preparation.
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From the University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA, and the University of South Florida, Tampa, FL. Requests for reprints should be addressed to Dr Angelo P Giardino, Children's Hospital of Philadelphia, 9th Fl, Main Bldg, 3400 Civic Clr Blvd, Philadelphia, PA 19104.