Ilana S. Mittman

Diversity in Genetic Counseling: Past, Present and Future

Despite decades of efforts to increase ethnic and racial diversity among genetic counselors, African Americans, Hispanics and American Indians, currently constituting almost one-third of Americans, remain only meagerly represented among genetic counselors at a level far under that seen in other health professions. This paper provides the first comprehensive effort to archive published and unpublished initiatives to increase ethnic and racial diversity in the profession. It also provides a review of national data and diversity initiatives in the health workforce in general. The paper reviews diversity initiatives in other health professions and suggests ways to improve recruitment and retention of underrepresented populations into genetic counseling. Increasing the diversity of the genetic counseling workforce stands not only to expand access to genetic services but also to improve the quality of genetic care provided to the American public.

A National Dialogue on Genetics and Minority Issues

This paper summarizes two-day deliberations on issues of genetic services and diverse communities, attended by experts representing genetic consumers, representatives of diverse communities and genetic providers/scientists. The discussions held in round table dialogue sessions focused on the following subjects: Inclusion of ethnic/racial minorities in bio-medical research; ensuring minority access to genetic services; consumer protection in genetic testing and empowering minority communities to take part in genetic research and service provision. The discussions are vividly illustrated by the presentation of numerous quotes obtained from transcripts of the sessions held. The paper concludes with useful recommendations for genetic providers, educators, scientists, and policy makers on the issues of involving diverse communities in the various aspects of the new genetics.

The Diversity Benefit: How Does Diversity Among Health Professionals Address Public Needs?

The Patient Protection and Affordable Care Act (PPACA) signed by President Obama on March 23, 2010, is a far-reaching law intended to improve access to and the quality of health care for Americans. Recognizing the importance of the health workforce to the nation’s health, the Act addresses health workforce and health professions education and training issues through provisions to strengthen the primary care workforce, provide tax relief for health professionals with state loan repayments, establish a national Health Care Workforce Commission, and expand the primary healthcare workforce by increasing and improving low-interest student loans. It is estimated that PPACA would afford access to health care for 32 million more currently uninsured new healthcare consumers, many of which ethnic and racial minorities or members of other vulnerable groups. As the Act is enacted, the nation is experiencing unprecedented demographic change. When the 2010 Census counts are tallied, we may finally grasp the degree of demographic shifts that the nation has undergone in the past decade. Since the 2000 Census, data gleaned from the American Community Survey and demographic models such as the one carried out by the Pew Research Center (Passel and Cohn, U.S. population projections: 2005–2050. Washington, DC: Pew Research Center: Social and Demographic Trends, 2008) predict major population shifts. By 2042, one in two Americans will be an Asian American, Pacific Islander, African American, Hispanic, American Indian, and/or Alaska Native. Since 2000, Hispanics have accounted for over one-half of the population increase in the United States. The number of Asian Americans grew at a larger proportion (9.0%) than any other racial or ethnic group during this same time period. In at least four states (California, Hawaii, Texas, and New Mexico) and the District of Columbia, racial and ethnic “minorities” constitute a majority of the population (U.S. Census Bureau, An older and more diverse nation by midcentury, 2008. http://www.census.gov/Press-Release/www/releases/archives/population/012496.html, Accessed 22 Oct 2008; U.S. Bureau of Census, Hispanic Americans by the number, 2008. http://www.infoplease.com/spot/hhmcensus1.html, Accessed 9 Jan 2010). Moreover, because of reproductive and immigration patterns, minorities are disproportionally represented among the younger population. Today, minorities account for 43% of Americans under 20 years of age, and it is projected that over the next two decades minority students will account for almost 40% of the total college population (Roberts, Minorities often a majority of the population under 20, The New York Times, 2008). Despite the rapid growth of racial and ethnic minority groups in the United States, many are dramatically underrepresented among the nation’s health professionals. The percentage of African American, Hispanic, American Indian, Alaska Native, or Pacific Islander1 in the health professions has grown only modestly at best over the past 30 years. Yet relative to the growth of the minority population in the United States, this rate of increase still leaves the proportion of minority health professionals outstripped by several fold. Hispanics, for example, comprise over 15% of the U.S. population, but only 2% of the registered nurse population, 4.6% of psychologists, and 5.0% of physicians. Similarly, one in eight individuals in the United States is African American, yet less than 1 in 20 dentists or physicians are African American. Minorities are severely underrepresented in academia. During the 2007–2008 academic year, URMs (underrepresented minorities) made up only 7.4% of U.S. medical school faculty, fewer than 7% of undergraduate faculty, less than 10% of baccalaureate and graduate nursing school faculty, 12% of clinical psychology faculty, and 8.6% of dental school faculty (Moreno et al., Using multiple lenses: an examination of the economic and racial/ethnic diversity of college students. In: Univ AoACa, editor. California: The James Irvine Foundation, Claremont Graduate University, 2006; Institute of Medicine, In the nation’s compelling interest: ensuring diversity in the health-care workforce. Washington, DC: Institute of Medicine, 2004; Hall, Clin Psychol Sci Pract 13:258–261, 2006).

Forming State Collaborations to Diversify the Nation's Health Workforce: The Experience of the Sullivan Alliance to Transform the Health Professions

Diversifying the nation’s health professions is essential in order to maintain a vigorous health workforce, able to respond to the needs of all Americans. The inability of the health workforce to keep pace with the changing demographics of the nation is a major cause of the persistent inequities in access to quality health care for ethnic and racial minorities in the U.S. Ethnic and racial minorities have been underrepresented in the genetic counseling profession since its inception, despite vigorous professional initiatives to remedy this situation. Mittman and Downs published a critical review of these initiatives detailing recommendations for change in this journal in 2008. One of their major recommendations was the need to learn from, and join, efforts with other health professions in seeking to increase professional diversity in genetic counseling. This paper reviews new findings on issues impacting health workforce diversity in the nation, presents a case study of a national best practice to diversify the health workforce and illuminates actions that can be taken by the genetic counseling profession. The Sullivan Alliance to Diversify the Health Professions is a culmination of two historic initiatives for addressing the dearth of minority health professionals and is a national catalyst for increasing diversity within the health professions by forging state collaborations among institutions of higher education, health professions schools and other key stakeholders.

Keynote Address: The Need for Greater Racial and Ethnic Diversity in Orthopaedic Surgery

BackgroundAdvances in medicine in the past century have resulted in substantial reductions in morbidity and mortality in the United States. However, despite these improvements, ethnic and racial minorities continue to experience health status and healthcare disparities. There is inadequate national awareness of musculoskeletal health disparities, which results in greater chronic pain and disability for members of ethnic and racial minority groups. The Sullivan Commission concluded in 2004 the inability of the health professions to keep pace with the US population is a greater contributor to health disparities than lack of insurance.Where are we now?While African Americans, Hispanic Americans, and Native Americans constitute more than one-third of the US population, they make up less than 10% of physicians, dentists, and nurses and less than 4% of orthopaedists in the United States.Where do we need to go?Increasing the representation of women and ethnic and racial minorities in orthopaedics will help to increase trust between patients and their providers and will improve the quality of these interactions by enhancing culturally and linguistically appropriate orthopaedic care.How do we get there?Pipeline enrichment programs along the educational spectrum are important in the academic preparation of underrepresented minorities. Collaborations between health professions schools and postsecondary educational institutions will increase awareness about careers in the health professions. Ongoing mentorships and career counseling by orthopaedists should enhance the interest of underrepresented minority students in careers as orthopaedists.