Marc A. Nivet

Prioritizing health disparities in medical education to improve care

Despite yearly advances in life‐saving and preventive medicine, as well as strategic approaches by governmental and social agencies and groups, significant disparities remain in health, health quality, and access to health care within the United States. The determinants of these disparities include baseline health status, race and ethnicity, culture, gender identity and expression, socioeconomic status, region or geography, sexual orientation, and age. In order to renew the commitment of the medical community to address health disparities, particularly at the medical school level, we must remind ourselves of the roles of doctors and medical schools as the gatekeepers and the value setters for medicine. Within those roles are responsibilities toward the social mission of working to eliminate health disparities. This effort will require partnerships with communities as well as with academic centers to actively develop and to implement diversity and inclusion strategies. Besides improving the diversity of trainees in the pipeline, access to health care can be improved, and awareness can be raised regarding population‐based health inequalities.

Current and Future Status of Diversity in Ophthalmologist Workforce

IMPORTANCE Increasing the level of diversity among ophthalmologists may help reduce disparities in eye care. OBJECTIVE To assess the current and future status of diversity among ophthalmologists in the workforce by sex, race, and ethnicity in the context of the available number of medical students in the United States. DESIGN, SETTING, AND PARTICIPANTS Data from the Association of American Medical Colleges, the American Medical Association, and US Census were used to evaluate the differences and trends in diversity among ophthalmologists, all full-time faculty except ophthalmology, ophthalmology faculty, ophthalmology residents, medical school students, and the US population between 2005 and 2015. For 2014, associations of sex, race, and ethnicity with physician practice locations were assessed. MAIN OUTCOMES AND MEASURES Proportions of ophthalmologists stratified by sex, race, and ethnicity between 2005 and 2015. RESULTS Women and minority groups traditionally underrepresented in medicine (URM)-black, Hispanic, American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander-were underrepresented as practicing ophthalmologists (22.7% and 6%, respectively), ophthalmology faculty (35.1% and 5.7%, respectively), and ophthalmology residents (44.3% and 7.7%, respectively), compared with the US population (50.8% and 30.7%, respectively). During the past decade, there had been a modest increase in the proportion of female practicing ophthalmologists who graduated from US medical schools in 1980 or later (from 23.8% to 27.1%; P < .001); however, no increase in URM ophthalmologists was identified (from 7.2% to 7.2%; P = .90). Residents showed a similar pattern, with an increase in the proportion of female residents (from 35.6% to 44.3%; P = .001) and a slight decrease in the proportion of URM residents (from 8.7% to 7.7%; P = .04). The proportion of URM groups among ophthalmology faculty also slightly decreased during the study period (from 6.2% to 5.7%; P = .01). However, a higher proportion of URM ophthalmologists practiced in medically underserved areas (P < .001). CONCLUSIONS AND RELEVANCE Women and URM groups remain underrepresented in the ophthalmologist workforce despite an available pool of medical students. Given the prevalent racial and ethnic disparities in eye care and an increasingly diverse society, future research and training efforts that increase the level of diversity among medical students and residents seems warranted.

A Diversity 3.0 Update: Are We Moving the Needle Enough?

Five years ago, in a previous Academic Medicine Commentary, the author asserted that the move toward health reform and a more equitable health system required a transformation of more than how we finance, deliver, and evaluate health care. It also required a new role for diversity and inclusion as a solution to our problems, rather than continuing to see it as just another problem to be fixed. In this update, the author assesses the collective progress made by the nations medical schools and teaching hospitals in integrating diversity into their core strategic activities, as well as highlighting areas for continued improvement.The author identifies five new trends in diversity and inclusion within academic medicine: broader definitions of diversity to include lesbian, gay, bisexual, and transgender people and those who have disabilities; elevated roles for diversity leaders in medical school administration; growing use of a holistic approach to evaluating medical school applicants; recognition of diversity and inclusion as a core marker of excellence; and appreciation of the significance of subpopulations within minority and underrepresented groups.More work remains to be done, but institutional initiatives to foster and prioritize diversity and inclusion coupled with national efforts by organizations such as the Association of American Medical Colleges are working to build the capacity of U.S. medical schools and teaching hospitals to move diversity from a peripheral initiative to a core strategy for improving the education of medical students and, ultimately, the care delivered to all of our nations people.

Relocation of Obstetrician–Gynecologists in the United States, 2005–2015

OBJECTIVE To examine recent trends in the relocation of obstetrician-gynecologists (ob-gyns) in the United States. METHODS This longitudinal descriptive study analyzed relocation patterns of ob-gyns between the earliest reference point (2005) and most recently (2015). A physicians county location in a year was compared with his or her location during the previous year. Physician background and county characteristics came from three data resources (Association of American Medical Colleges databases, American Medical Association Physician Masterfile, American Community Survey). A multilevel logistic regression model was used to model factors associated with relocation for the entire period. RESULTS An average of 2,446 (6.5%) of the 37,385 ob-gyns in practice moved per year. Approximately one third (32.1%) relocated (usually once or twice) during the 10 years with more than half (58.2%) remaining within their state. The odds of relocating were higher if the ob-gyns was young, male, black, or an international medical graduate. Relocations were predominantly to counties that were either urban or with a lower percentage of the population in poverty (less than 21.2%). Although the number of ob-gyns and women 18 years or older increased in most states, the population to ob-gyn ratio increased from 3,155 in 2006 to 3,293 in 2015. Net gains from relocations were most apparent in Florida, California, and Washington, whereas net losses were especially apparent in Michigan, Pennsylvania, Ohio, Illinois, and New York. CONCLUSION Approximately one in every three ob-gyns in the United States moved at least once in the past 10 years to counties that were predominantly urban or with less poverty. Observing this trend might contribute to a better understanding about the uneven national distribution of ob-gyns.

Racial and Ethnic Differences Between Obstetrician-Gynecologists and Other Adult Medical Specialists.

OBJECTIVE: To compare racial and ethnic differences between obstetrician–gynecologists (ob-gyns) and other large groups of adult medical specialists who provide the predominant care of women. Whether physician diversity influences their practice locations in underserved areas was also sought. METHODS: This cross-sectional study reports an analysis of U.S. national data about racial and ethnic characteristics, gender, and specialty (obstetrics and gynecology, general internal medicine, family medicine, emergency medicine) of 190,379 physicians who came from three resources (Association of American Medical Colleges Student Records System, Association of American Medical Colleges Minority Physicians Database, American Medical Association Physician Masterfile). Underserved locations were identified as being rural, having 20% or more of the population living in poverty or being federally designated as areas of professional shortages or underserved populations. Bivariate measures of associations were performed to study the association between physician race and ethnicity and their practice location. RESULTS: Female physicians in all specialties were more likely than males to be nonwhite, and ob-gyns were most likely to be female (61.9%). Compared with other studied specialists, ob-gyns had the highest proportion of underrepresented minorities (combined, 18.4%), especially black (11.1%) and Hispanic (6.7%) physicians. Underrepresented minority ob-gyns were more likely than white or Asians to practice in federally funded underserved areas or where poverty levels were high. Native Americans, Alaska Natives, and Pacific Islanders were the ob-gyn group with the highest proportion practicing in rural areas. CONCLUSION: Compared with other adult medical specialists, ob-gyns have a relatively high proportion of black and Hispanic physicians. A higher proportion of underrepresented minority ob-gyns practiced at medically underserved areas.

A Diversity and Inclusion Framework for Medical Education

director, Advancing Holistic Review Initiative, Association of American Medical Colleges Relevance • Diversity in organizations can lead to increased innovation and less biased decision making; it has a positive effect on key business indicators.1 Thus, diversity is essential for academic medicine. • For the true benefits of diversity to be realized, diversity must be at the core (not the periphery) of academic medicine.2 • Creating a culture and climate that values diversity and inclusion will help support this shift.3,4 • While academic medicine is making significant progress in advancing diversity and inclusion, there remains the need for a comprehensive assessment of climate and culture.5 • The Association of American Medical Colleges (AAMC) developed the Diversity 3.0 framework to provide academic health centers with a guide to assess their culture and climate in order to promote a culture of inclusion. • A comprehensive, inclusive assessment of organizational culture and climate allows for evidence-based interventions that will improve and enhance medical education. A Diversity and Inclusion Framework for Medical Education Marc A. Nivet, EdD, MBA, chief diversity officer, Laura Castillo-Page, PhD, senior director, Diversity Policy and Programs and Organizational Capacity Building Portfolio, and Sarah Schoolcraft Conrad, MS, director, Advancing Holistic Review Initiative, Association of American Medical Colleges

Placement of US Medical School Graduates Into Graduate Medical Education, 2005 Through 2015

Placement of US Medical School Graduates Into Graduate Medical Education, 2005 Through 2015 Medical school enrollment has increased in the United States during the past decade1; however, growth in graduate medical education (GME) positions has been slower, raising concerns about whether graduates will be able to obtain the GME necessary to qualify to practice medicine.2 Particular concerns have been raised about graduates from minority groups traditionally underrepresented in medicine.3 We evaluated graduates of all US MD-granting medical schools from 2005 through 2015 to determine whether they entered GME training in the United States, with particular assessment of minority graduates.

Workforce diversity and community-responsive health-care institutions.

While the levers for the social determinants of health reside largely outside institutional walls, this does not absolve health professional schools from exercising their influence to improve the communities in which they are located. Fulfilling this charge will require a departure from conventional thinking, particularly when it comes to educating future health professionals. We describe efforts within medical education to transform recruitment, admissions, and classroom environments to emphasize diversity and inclusion. The aim is to cultivate a workforce with the perspectives, aptitudes, and skills needed to fuel community-responsive health-care institutions.

Commentary: who will help the United States attain the goal of health equity?

A research report in this issue of Academic Medicine by Peek and colleagues describes how physician organizations are mounting different initiatives targeted at reducing health disparities. The study emphasizes how these organizations are attempting to promote health equity through policies and programs focused on education, clinical care, research, and advocacy. They found that 68% of surveyed organizations have at least one initiative targeting health disparities.This commentary acknowledges the positive trend uncovered by Peek and colleagues which characterizes the engagement level of national physician organizations on this critical issue, and suggests four ways to enhance future efforts. First, health equity should be linked to overall quality of care and emerging initiatives aimed at transforming the delivery of health care. Second, the effect of such efforts can be magnified by evaluating what works and sharing best practices. Third, interventions must be targeted at institutions as well as individual physicians. Finally, it should be emphasized that the driving rationale for physicians to strive for health equity is the ethical imperative to promote justice in health care.

The Racial and Ethnic Composition and Distribution of Primary Care Physicians

Abstract:Racial and ethnic minority physicians are more likely to practice primary care and serve in underserved communities. However, there are micro-practice patterns within primary care specialties that are not well understood. To examine the differences among primary care physician practice locations by specialty and race/ethnicity, a retrospective study was conducted on U.S. medical graduates who were direct patient care physicians in 2012. The group-specific contributions to primary care accessibility were decomposed by individual group of minorities underrepresented in medicine (URM). Results confirm significant differences not only in their distribution across underserved areas but also in their racial/ethnic composition by primary care specialties, with internist most diverse and family physicians least diverse. However, stratified analysis shows that within each primary care subspecialty, URM physicians were more likely to practice in underserved areas than their White peers regardless of specific specialties.