BY: DARLENE SAPORU, PhD
To ensure optimal health care for everyone, the United States needs a diverse, culturally competent physician workforce. Patients tend to feel more affinity toward physicians with whom they share similar racial or ethnic backgrounds, and patients who feel comfortable with their physicians will ask more questions and share more information, leading to more accurate diagnoses and better outcomes.
Nonwhite physicians are more likely to care for patients of their own race or ethnic group, practice in areas that are underserved, and care for patients with Medicaid insurance or no health insurance. In other words, minority physicians play a large role in caring for marginalized/underserved groups and patients of color.
With the passage of the Affordable Care Act, medical schools are called upon to address pervasive racial and ethnic disparities in health outcomes, especially given the increasing diversity of our national demographics. At Loyola University Chicago's Stritch School of Medicine, we believe that physician diversity is central to advancing health care equality and solving complex health-related problems.
Our approach to applicants has evolved in response to recent changes in health care delivery. As medicine moves toward more broad, team-based care, Stritch seeks applicants with the ability to thrive and meaningfully contribute to a health care team with effective interpersonal traits and communication skills. Holistic review processes can help identify applicants that possess intrapersonal and interpersonal attributes in addition to the necessary academic competencies.
Holistic review is a flexible, individualized process that gives balanced consideration to multiple aspects of each applicant and his or her ability to succeed as a medical professional.1 The holistic review framework evaluates candidates by criteria that are institution specific and mission driven. As a Jesuit medical school, Stritch seeks to recruit and enroll students who are in full alignment with our values. We place an emphasis on accomplishments in service, leadership and community engagement. Such accomplishments indicate the potential to become transformative leaders who will promote justice and equity in medicine locally and globally. Our admissions process integrates Jesuit values of self-awareness, humanism and social justice in accordance with the health care mission to treat the human body, mind and spirit.
Stritch places high priority on identifying and selecting applicants whose medical training will make the most of their ability to meet individual as well as societal medical needs. We seek to train physicians who not only are excellent clinicians, but also are aware of social injustice and challenge inequalities by advocating for change.
Developing a cohort of students from diverse backgrounds who bring new perspectives to medicine enhances the learning process and provides a better understanding of how to serve diverse populations. For example, a study conducted at the University of California, Los Angeles found that students who attend medical school with racially and ethnically diverse peers felt better prepared than students at less diverse schools to care for patients from racial and ethnic groups other than their own. They also were more likely to view access to adequate health care as a societal right rather than a privilege.
PIPELINE PROGRAMS
Recruiting a diverse class of students requires targeted interventions and creative programs to identify and capture talent. Stritch implements key pipeline and community outreach programs that enhance educational opportunities for underrepresented and disadvantaged students to enter into sciences and health professional careers. To engage with students earlier in their educational careers, we partner with local high schools in the Maywood area, the Chicago suburb where Stritch is located, through our Health Professions Recruitment and Exposure Program (HPREP). During the six weeks of HPREP, our medical students teach high school students clinical and academic skills, introduce them to health disparities, host panels with minority professionals and also provide them with tools/resources to pursue a career in medicine. HPREP offers financial aid workshops for the parents of our high school students so they can assist their children with applying for college aid.
Our premedical summer enrichment program, ASPIRE — Academic Summer Program Integrating Resource for Excellence — serves as a highly effective tool for recruiting medical school applicants from underrepresented populations who share our concern for their communities. It is one of the few summer programs with an intentional focus on health disparities. While this premedical school program is open to all applicants, Stritch strongly encourages students from disadvantaged or underrepresented minority backgrounds to apply.
ASPIRE is particularly well-suited to prepare and support minority premedical students whose desire to become physicians includes intentions to work in underserved communities. ASPIRE is unique in its mission to provide premedical students with experiences that develop skills and attributes necessary to serve marginalized or disadvantaged communities in addition to fostering academic readiness and solidifying a foundation in the sciences.
The ASPIRE programmatic goals are to:
- Enrich the racial, cultural, ethnic and economic diversity of the Stritch medical student body
- Understand the importance of health equity
- Gain knowledge and skills to improve health for underserved individuals and their communities
- Integrate evidence-based medicine into learning
- Build leadership skills for medical education and health-related community service
During the five-week program, ASPIRE students receive a comprehensive curriculum that integrates science courses, clinical skills, shadowing opportunities, professional development and a community service project. ASPIRE students are required to shadow a primary care physician once a week at four designated clinics in underserved neighborhoods in Chicago. Participants develop and give a capstone presentation that integrates their learning experiences and showcases the knowledge and skills they gained throughout the five weeks. This active learning project requires students to work collaboratively.
ASPIRE serves as our signature recruitment program, and it has been successful in increasing the diversity of both our applicant and matriculant pool. More than 80 percent of ASPIRE participants are accepted to Stritch and other top-ranked medical schools. We matriculate close to half of each ASPIRE cohort into our incoming medical school class.
ASPIRE has helped us to identify and attract a spectrum of talented underrepresented minority students to our educational community, and they have served as leaders in implementing community outreach programs that now are incorporated fully within our elective curriculum.
This curricular integration is important, because while student body diversity by traditional metrics — race, ethnicity, gender — is critical, we feel it also is important to implement curricular emphasis on cultural competence. We cannot assume that individuals of diverse backgrounds indirectly (or magically) imbue themselves and their classmates with core tenets of cultural humility, interpersonal competencies and social determinants of health.
In other words, diversity is not an end to itself, but, rather, a means for graduating physicians who are equipped to provide compassionate care to people from all walks of life. To ensure that Stritch medical students understand the structural and cultural barriers to health equity, we embed these themes throughout courses across the curriculum.
CULTURAL COMPETENCE IN THE CURRICULUM
Our curriculum is designed to help develop community leaders and physician advocates who think collaboratively to meet the needs of those who are underserved. With Stritch School of Medicine resources such as the Neiswanger Institute for Bioethics and Health Policy and the Center for Global and Community Health, students have access to faculty who are passionate about service and who have helped create key components of the medical school curriculum that are directly relevant to cultural competency and treating a diverse patient population.
Stritch students are required to take a 12-hour mini course on the relationship of the business of medicine to medical professionalism and justice. In addition, approximately 20 percent of students take an elective on social justice and race.
These two curricular components have very different aims. The social justice elective considers the subjective experience of race and culture and aims at developing empathy and sensitivity toward the experiences of patients of color. Recognizing the impact of race, poverty and social inequalities on health outcomes is key for building a foundation of cultural competence. Here, students and faculty use a current narrative to explore the experience of persons in underserved minority populations, particularly African-Americans or Latinos, with the thematic culture alternating with iterations of the course.
A book such as My Beloved World by U.S. Supreme Court Justice Sonia Sotomayor, or The Warmth of Other Suns by Isabel Wilkerson, provides an opportunity for frank discussion among the students and instructors concerning race and privilege within medical education and the larger society. By relating to the authors or explaining in what ways their experiences differ, students are able to educate each other into the meaning that race and culture have within their social sphere. These discussions can be uncomfortable, but they inspire a much deeper appreciation of differing perspectives.
In addition, the students participate in a service learning experience at one of Chicago's two Cristo Rey Network high schools.2 Medical students either partner with one of the high school teachers to enrich lesson plans in their curriculum or offer a break-out session on a topic of their choosing at a half-day conference at each school on health and the health profession. Through this direct engagement with high school students and teachers, medical students directly learn about the cultures represented and also "give back" by being a potential role model.
The required curriculum helps students understand the economic and policy underpinnings of health and health care injustice and the duty of the medical profession to be advocates for structural change. It provides students with a basic overview of health care financing and the trade-offs between margin and mission that health care facilities and physicians must make because of systemic inadequacies.
This curriculum is integrated into the third-year clinical skills course and begins with such microeconomic issues as how physicians bill and get paid. It explores the various forms of health insurance in the United States and the health consequences of being uninsured. It also considers who is left uninsured after full implementation of the ACA.
Clinicians guide the students through common scenarios they encounter in treating these patient populations. The sessions culminate in presentations by health care executives who discuss hospital and clinic strategies for serving uninsured populations.
The partnership between students, faculty and the community provides the mechanism to thoughtfully develop and integrate cultural issues and experiences into the curriculum.
SERVICE LEARNING
Our Center for Global and Community Health honors program also supports a service-learning framework for future health care providers who aspire to advance health equity. The program aims to help students develop and implement population-based health promotion projects, access community resources, engage with community leaders and understand the rewards and challenges of providing health care in an under-resourced setting. Students in this program are required to attend career and topic seminars that bring in voices from practitioners in the field to discuss experiences with domestic health disparities and challenges facing care for underserved populations. In addition, students are required to complete a 14-week field experience.
Diversity is a critical component of our mission to train physicians who are transformative leaders and agents of change in our communities. The benefits of diversity are produced through carefully structured policies and programs designed to embed equity, cultural competence and inclusion throughout all aspects of our learning environment. Through policies such as holistic review, outreach programs like ASPIRE and the integration of health disparities in our curriculum, Stritch School of Medicine is committed to enhancing the diversity of the physician workforce. We continually seek to evaluate and improve our programs to meet the needs of our students and to ensure they are prepared to practice medicine in a global society.
DARLENE SAPORU is assistant dean for diversity and inclusion, Loyola University, Stritch School of Medicine, Maywood, Illinois.
NOTES
- Amy N. Addams et al., Roadmap to Diversity: Integrating Holistic Review Practices Into Medical School Admission Processes (Washington, D.C.: Association of American Medical Colleges, 2010). https://members.aamc.org/eweb/upload/Roadmap%20to%20Diversity%20Integrating%20Holistic%20Review.pdf.
- Cristo Rey high schools are Jesuit and Catholic schools that enroll only low-income urban youth and blend four years of work experience with rigorous academics. See Cristo Rey Network, www.cristoreynetwork.org/page.cfm?p=356.