Addressing the Healthcare Diversity Gap

Healthcare organizations have a growing responsibility to improve diversity, equity and inclusion (DEI) efforts not only for their employees, but also to better serve the patients and families within their communities. While diversity is broadly defined as the inclusion of varied attributes or characteristics, within the medical community, diversity often refers to the inclusion of healthcare professionals, trainees, educators, researchers and patients of varied race, ethnicity, gender, disability, social class, socioeconomic status, sexual orientation, gender identity, primary spoken language and geographic region. As in other sectors, the root issues surrounding DEI in healthcare are multilayered and complex, and there is no one solution to the myriad challenges ahead for organizations hoping to grow and evolve.

Understanding the Demographics

According to the Association of Medical Colleges, only about 36 percent of active physicians are female; 5 percent of physicians identify as Black or African-American (despite making up 13 percent of the U.S. population) and fewer than 6 percent of physicians identify as Hispanic (even though Hispanics make up about 19 percent of the U.S. population). When contrasting that with the fact that 28 percent of physicians and surgeons in the U.S. are immigrants, with doctors from India and China making up the largest groups, the key takeaway is that those from minority groups who have been historically oppressed in the U.S. have less representation in healthcare professions than immigrants of color.¹

While discrimination, limited job offers and uneven promotion opportunities continue to be among the factors holding back DEI efforts in healthcare, four studies published within the first months of 2022 shed new light on some of the other leading factors. The first is a lack of diversity in academics. While the number of women represented in healthcare education has increased significantly over the past few years, the presence of Black men in the field has decreased dramatically, according to a finding from a recent study published in The New England Journal of Medicine.² “Even with advances, we are nowhere near representative parity,” says Sophia Kamran, MD, a professor of medicine at Harvard Medical School.

To conduct her study, Dr. Kamran analyzed the gender, race and ethnicity of faculty at the nation’s leading medical schools between 1977 and 2019. In an interview with the Harvard Gazette, Dr. Kamran noted that the findings from her study show the continued need for medical schools and medical programs to increase efforts to recruit underrepresented populations into the field and to help those students develop not just into doctors and researchers but also into academic leaders.3 “This is an area in desperate need of study because we need to reverse these trends in order to address the lack of Black leadership at all levels of academic medicine,” Dr. Kamran said. “I didn’t have many mentors, teachers or role models in clinical medicine from a similar background as mine to help guide me. The U.S. population is going to continue getting more diverse as time goes on. We’re sounding the alarm because we are clearly falling behind.”

DEI Issues in Academic Research

Studies show that white men still tend to hold a majority of teaching roles in healthcare academics, and according to a study published in the Journal of Racial and Ethnic Health Disparities, many lead authors of medical studies published in two leading medical journals (Journal of the American Medical Association and The New England Journal of Medicine) were white men.⁴

The study also found that less than 7 percent of the primary authors leading the research in these premier medical journals were Black and less than 4 percent were Hispanic. It’s important to note that this was the first study to provide concrete numbers for true representation among senior or primary authors on studies — the role normally filled by the person who serves as the figurehead for the research and who will benefit from it most in terms of publicity, academic tenure and leading industry job offers.

Assessing the Cost of Healthcare Education

The cost of healthcare education is another significant factor when it comes to racial inequities. According to a study published in JAMA Network Open, most students enrolling in medical schools, regardless of race, come from affluent backgrounds.⁵ The study analyzed data from nearly 45,000 students who had recently enrolled in medical school and delved into the ethnicity of those candidates and the amount of money each student reported their parents earned annually. The findings show most of these students came from the nation’s top 5 percent of wealthiest families.

When you consider that the Association of American Medical Colleges estimates that four years of medical school can cost between $250,000 and $330,000, it’s easy to see how these types of wealth disparities can impact not just where these doctors choose to practice and in what they choose to specialize, but also the very way in which they interact with and relate to their patients.

To begin addressing this issue, medical schools will need to consider outreach efforts in lower-income communities of color while also offering more scholarship programs to offset the prohibitive cost of a medical education.

Imbalances in Clinical Trials

Although not directly related to the gender, race or ethnicity of medical providers, clinical trials that are used to help observe risk factors for illness and are essential in the development of everything from pharmaceuticals to vaccines have also been a pain point when it comes to diversity and representation. Despite ongoing efforts at inclusion, people of color and ethnic populations are still poorly represented in these efforts, even though they are at a disproportionate risk for certain diseases. This disparity reduces the amount of data available and can limit physicians’ knowledge of how to best treat diverse populations.

To address these concerns, the U.S. Food and Drug Administration (FDA) recently issued new guidelines that include increased public outreach campaigns, educational materials and new collaborations and partnerships — all designed to help enroll diverse populations within future studies, which could increase clinical trial diversity and broaden the type and amount of information healthcare providers will have for treating diverse populations. “The U.S. population has become increasingly diverse, and ensuring meaningful representation of racial and ethnic minorities in clinical trials for regulated medical products is fundamental to public health,” said FDA Commissioner Robert M. Califf in a news release announcing the change in guidelines. “Going forward, achieving greater diversity will be a key focus throughout the FDA to facilitate the development of better treatments and better ways to fight diseases that often disproportionately impact diverse communities.”⁷

Counting the Human Cost of Healthcare Inequity

People from underrepresented communities also face challenges in receiving equitable healthcare, often when it is needed most. The COVID-19 pandemic spotlighted these existing healthcare issues by disproportionally impacting communities of color. Pacific Islander, Latino, Indigenous and Black Americans all have a COVID-19 death rate of double or more than that of white and Asian Americans. And, these statistics create an urgent call to action for health administrators to prioritize cultural competency. “Our nation’s health disparities increasingly fall along economic and racial lines,” says Kysha Harriell, PhD, LAT, ATC, who co-teaches the Cultural Competence in Healthcare course at the University of St. Augustine for Health Sciences.¹ Dr. Harriell defines cultural competence in healthcare as “a set of behaviors, knowledge and skills that help administrators and practitioners respond to cultural issues relating to patients.” She explains that “These skills will help create culturally competent administrators who are skilled at collaborating with a diverse team of colleagues and ensuring respectful and equal treatment of all patients.”

A Look at Real World Examples

For many, the concept of healthcare inequity can still feel ambiguous until looking at actual case studies. Consider the case of Lamar Johnson, a 33-year-old African American patient deemed a “frequent flyer” (a term used to describe those who keep coming to the hospital for the same reason, often assumed to be drug seekers) by the nurses and doctors in the emergency department. Each time he came in complaining of extreme headaches, he was given pain medication and sent home. On his last admission, he was admitted to the ICU, where Courtney, a nurse, had just begun working. When she heard him described as a frequent flyer, she asked another nurse why he was thought to be a drug seeker. “He has nothing else better to do; I’m not sure why he thinks we can supply his drug habits,” she was told. Although Courtney says her instincts told her something else was going on, she saw his tattoos, observed his rough demeanor and went along with what everyone else was saying. While she was wheeling him to get a CT scan, Johnson herniated and died. It turned out that he had a rare form of meningitis. If the staff had not stereotyped him as a drug seeker, perhaps his life could have been saved.⁹

Also consider the case of Hilda Gomez, a Spanish-speaking patient who came into a clinic three days in a row to complain of abdominal pain. The first two times, the staff used her young, bilingual daughter to translate and treated her for the stomach ache she described. The staff didn’t understand why she kept returning with the same problem until on her third visit, the nurse located a Spanish-speaking interpreter. It turned out that Gomez needed treatment for a sexually transmitted disease, but was too embarrassed to talk about her sexual activity with her daughter as interpreter.⁹

These cases help illustrate how much additional training is needed to address healthcare and nonhealthcare policies that have a disproportionate impact on the health of diverse communities. “When staff are in situations with people from different cultural backgrounds, they need to have the awareness and tools to respond and provide respectful, competent care,” says Dr. Harriell.¹

The Role of Community Health Partnerships

When it comes to building healthcare policies and processes, industry and organizational leaders are encouraged to put on what Julie Smithwick, the director for the Center for Community Health Alignment, calls health equity glasses. “It’s like going to a 3D movie, and you have to proactively put on the glasses in order for the picture on the screen to come in with full effect,” she explained. “When designing health systems and processes, leaders need their health equity glasses to see the full effect of how that policy will play out and affect traditionally marginalized communities.”¹⁰

In the effort to address the inequities in healthcare, community health workers have emerged as key players. These nonclinical professionals are responsible for supporting patients, addressing patients’ social needs and driving care coordination. By employing layperson community health workers for these duties, healthcare organizations can utilize their resources more efficiently while still ensuring patients receive comprehensive care. According to Anthony Davis, a veteran and community health worker at the Crescenz VA Medical Center, using his own experiences helps him relate to patients and support their individual needs.¹¹ “We do things that doctors, nurses and social workers don’t,” Davis said. “I noticed a lot of my patients had post traumatic stress disorder and were socially isolated. I took my time with them and got them to come out each week to social activities like movies or bowling. We even planted an urban garden. After these efforts, you can see the difference in their health.”

Experts agree it is those shared experiences that make community health workers so successful. Separate research published by JAMA Oncology showed that nonclinical healthcare professionals are essential for filling in care gaps and can expand care to patients who otherwise would go without: “Unlike physicians and nursing staff, [community workers] are not limited by the traditional model of clinic-based care. They engage patients during clinical encounters with healthcare professionals and between appointments through frequent telephone communication.”¹²

As healthcare continues to zero in on DEI issues, it’s clear individuals and organizations will need to embrace those so-called “health equity glasses” and pursue a collaborative approach to achieve meaningful change. “We’re only used to using the lenses that we’re given, and we’re not able to use an equity lens until we really understand it,” Smithwick concluded. “In order to understand it, we have to partner with people who have been there, who have lived it and who have really delved into this stuff. You can find folks who are willing to partner with you in that way and help you see it through a different lens, and that’s a really big step.”¹⁰