No Easy Answers in Bioethics Podcast

Medical Workforce Diversity and the Professional Entry Tax: Bogdan-Lovis and Kelly-Blake - Episode 6

February 8, 2018 Libby Bogdan-Lovis photoKaren Kelly-Blake photo

This episode features Libby Bogdan-Lovis, Assistant Director of the Center for Ethics and Humanities in the Life Sciences, and Dr. Karen Kelly-Blake, Assistant Professor in the Center for Ethics and the Department of Medicine at the Michigan State University College of Human Medicine. As leaders of a multi-institutional research team, they were interested in examining strategies and associated rationales for expanding underrepresented minority presence in U.S. undergraduate medical education. In this episode, they provide insight on what their scoping review has revealed, focusing on the notion that underrepresented minorities in medicine are often expected to pursue a service track—an expectation not placed on their white majority peers.

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Today’s guests are Center Assistant Director Libby Bogdan-Lovis and Center Assistant Professor Dr. Karen Kelly-Blake. A multi-institutional research team led by Dr. Kelly-Blake and Libby Bogdan-Lovis was interested in examining strategies and associated rationales for expanding underrepresented minority presence in U.S. undergraduate medical education. To look at trends over time, their research team undertook a scoping review of the 2000-2015 literature to see what the literature might reveal about those efforts. In this episode, Karen and Libby discuss concerns that emerged from the review regarding covert expectations that underrepresented minority physicians are being trained to meet the medical needs of vulnerable populations.

Libby Bogdan-Lovis: Okay, I'm Libby Bogdan-Lovis, I'm the Assistant Director at the Center for Ethics and Humanities in the Life Sciences in the College of Human Medicine at Michigan State University.

Karen Kelly-Blake: I am Karen Kelly-Blake, I'm an Assistant Professor at the Center for Ethics and Department of Medicine, here at Michigan State University.

LBL: And Karen and I have been working on this project for a number of years now, and we have colleagues in other places. Nanibaa’ Garrison and Faith Fletcher, Nicole Smith and Morgann Brafford and Brittany Ajegba all helped us with this project. We are calling it “A Professional Entry Tax: The Covert Costs of Racial and Ethnic Concordance in the Medical Workforce.” And we should probably start out by explaining our observations regarding the notions of identity matching between physicians and patients. There seems to be some general agreement that it's desirable to have a physician workforce that reflects the race/ethnic composition of the patient population, and in fact we agree that that's the right thing to do. Borrowing from the title of a 2001 I.O.M. report—Institute of Medicine report—on diversity in the health professions. But we also wondered what future costs there might be for underrepresented minority [URM] physicians, who are associated with programs and policies that attempt to expand the numbers of underrepresented minorities in medicine. And most especially when the rationale most commonly mentioned in the literature is that the justification is societal benefits, and by that we mean those benefits that might accrue from the extent to which underrepresented minorities in medicine provide care for vulnerable and historically underserved populations.

KKB: So, having that background, we set out to examine the content of literature over a fifteen year period, 2000 to 2015, to see what it might reveal about trends and programmatic strategies used and the associated policy rationales mentioned for increasing underrepresented minorities in medicine. We wanted to focus on that refrain commonly attached to discussions about increasing URMs in medicine that is, that it enhances access for underserved vulnerable populations. There were around ten major reports issued on increasing health care workforce diversity and all mention the societal benefit of service to the underserved. Many pointed to the notion of benefit derived from doctor patient race/ethnic and concordance. In other words when physicians and the patients they care for share some aspects of that identity, visually through appearance or through language or some measure of culture.

LBL: Yeah, and in fact, for benefits it's true. It's been demonstrated repeatedly that underrepresented minorities in medicine do indeed provide medical care for vulnerable populations, to an extent far greater than their well represented peers. But what got our attention is that there's a paradox here. The same 2001 Institute of Medicine report mentioned earlier had a caution that got our attention, and I'm going to quote here. They said, “We must be vigilant against the potentially pernicious effects of creating the expectation that minority physicians are being trained solely to provide health care services to minority patients.”

KKB: So, I'm going to push back a little bit with Libby, because Libby and I have had this conversation before. She likes to use language “well represented peers” which means absolutely nothing to me.
[Laughter]
So what we're talking about are underrepresented minorities, how we're defining that, and we're talking about their white medical student counterparts. That's who we're talking about. The challenge is that underrepresented minorities in medicines are being targeted to serve underserved populations in a way their white peers are not being targeted.

LBL: And in fact, that's one of the reasons we chose to look at African-American and Latino and Native American—American Indian—populations, including Alaskan Natives.

KKB: Correct. So, the concern that we have is that underrepresented minorities in medicine might be viewed as instruments to address failings in our health care system. In such a circumscribed rescue role for the U.S. health care system, URMs then would have delimited professional futures through policies, loan payback programs, and the subtle incentives of positive feedback rewards. URMs essentially would be guided into what in our research we call quote unquote “service” tracks to address the broader societal need to expand care and access for vulnerable populations. What got our attention is that this expectation is in fact quite common, and we found an increase in mention of that particular rationale over a fifteen-year period. The repetition in the discourse in itself might independently amplify the expectation and reinforce strategies. And if I might add before Libby joins further is that we also see the same sort of service track cropping up in admissions decisions, that depending on what university you're applying to, whatever they decide is their mission. If their mission is to provide care to the underserved, which is a very noble laudable mission. If part of that admissions process is to then sort of mainstream pipeline students into those particular tracks as a way for them to achieve admission I think that also is an issue.

LBL: So is it common that admissions look for that commitment?

KKB: I think right now with admissions the idea is to use a holistic approach and part of that holistic approach is to consider people who are coming in from disadvantaged backgrounds, however you want to define that. Socioeconomic, sexual orientation, race, ethnic, rural-urban designation. All those things come into play through a holistic process. I think one of my concerns is whether or not that holistic process amplifies the notion that those people who come from the disadvantaged background are then targeted to physicians’ specialties to focus on serving underserved. It goes to primary care, internal medicine. And those are great specialties, but it should be the choice of the individual, and their future careers should not be delimited in any way by making that choice.

LBL: And tracking them into those specialties means not opening up their future possibilities to others. I guess to illustrate, it seemed to us that well-intended policies and programs might paradoxically be placing sort of an entry tax on underrepresented minorities into the medical profession. And in the long run unfairly curtailing their medical professional possible futures, that those individuals have more restricted options.

KKB: And I was thinking about this earlier, and I should say for the record that Libby really has been the driving force behind this research and she's been doing a fabulous job.

LBL: Thank you.

KKB: This idea of an entry tax, and I was thinking is the tax just, this idea that it's by chance because of the chance of your birth. That just by the chance of your birth you're born with a particular disadvantage. So, you decide that as you’re growing up you want to become a physician, and because of that disadvantage it's seen that if you want to be a physician then maybe you also want to serve the people in your own community. And for many people that is true, they do want to give back. They have this very noble, very deeply held idea that they should give back. But what about those people who don't hold those same sorts of plans and ideas and notions, but maybe feel constrained that they have to present themselves in certain ways in order to get that prize which is entrance into medical school.

LBL: Yeah absolutely.

KKB: So, one might argue that this sort of tracking simply provides another avenue to enhance medical workforce diversity, and that in and of itself another avenue is fair and just to those individuals taking advantage of such a pathway. But that argument would be ignoring the downstream impact on those individuals’ professional future. Devoting their career to service has relatively less remuneration than pursuing high status well-paying residencies and subspecialties. Equally it also requires that they turn away from careers in medical research and medical education.

LBL: Yeah, I agree. And medical education… I remember seeing an article that suggest that medical education, really there's a tension between viewing it as a social good and viewing the education piece as an avenue for people to advance themselves in a particular career. So, it's a social good I guess in educating and training physicians to meet society's healthcare needs, but it's also that recognized professional avenue to advance your own lot in life. To pursue a relatively satisfying career because it's well paying, it includes opportunities for advancement, and through our research we feel that URMs should be afforded those professional perks just the same as their well represented peers, of majority white peers.

KKB: So, I think one of the questions we can answer for our audience is why do we feel that this research is valuable in today's world. So, we hope it will heighten awareness and open up discussion about the hidden expectations placed on underrepresented minorities in medical education. Expectations that are not placed on their white majority peers.

LBL: Yeah. And there's another, I mean, there are lot of concerns related to our research. A related concern is that other factors might explain the high level of service to vulnerable populations. There is certainly a possibility of institutional racism that might restrict underrepresented minorities’ practice locale. Where can they hang a shingle and have a practice. And it might not be economically or socially tenable for an underrepresented minority physician to set up practice in a white populated community. Another concern is that the notion of concordance could perversely be turned around I guess, to suggest that white patients should be able to see a white doctor and work against underrepresented minority diversity expansion in the workforce.

KKB: And finally there is an admitted risk to drawing attention to the issue. There are those who might say, “Hey, first let us in the door before you go mucking around with these fairness concerns.” But we argue that the societal need to provide care for underserved vulnerable populations is a responsibility, perhaps a burden, that should be equally shared by all in the medical profession. And not have that responsibility shifted to underrepresented minorities in medicine.

LBL: I guess our listening audience might wonder what got us interested in this, and I would credit one particular student who said to his peers, “You know I know when I get selected to show up for some kind of big event where I'm standing in front of the audience. I know what they want me to say, what they want me to say-” and I guess Karen you alluded to this earlier, like with admissions students knowing what's expected of them, “They want me to say that I want to become a physician so that I can go back and take care of my own.” He said that, “In fact I come from a really, really difficult background. I sometimes call it the hood in South Florida.” And he said, “I don't want to go back and have a profession, and have my profession there, and to practice my profession there. I want to go to a city, I want to raise a family in comfortable circumstances, and that wouldn't be back where I was raised, and yet I know that's really not what they want to hear from me.”

KKB: So that sounds like a very enlightened, self-aware student-

LBL: He was, and brave.

KKB: Yes, and brave. To understand what the expectations are, but to say that's not what I want for my own professional life. So, what are our goals for this research? We have embarked really on a preliminary analysis really of what's happening in the literature. I think we've talked about this that maybe some of our future goals is to try to see what current data is available at our own institution here at Michigan State University, College of Human Medicine. I think ideally the idea is to seek and hopefully gain funding to perhaps expand for a statewide assessment. And probably the long-term goal and vision is to really be able to do some sort of nationwide survey, to see what really is happening across the United States. And I think what you've mentioned before is really to maybe try to be able to do a comparison between what's happening internationally and in the U.S., you may want to expand on that Libby.

LBL: Yeah, I think it would be very interesting to open up the conversation to see what other countries are doing to address these issues. As I mentioned to you Karen, when I was in London I was struck by the amazing diversity of their medical workforce, it's phenomenal. I'd like to know if they pay attention to these issues and where they come into play, and if so, how.

KKB: And it might be interesting too, and I don't know if I'm digressing here. But considering your past experience in the UK and this idea that they actually start their students early on within this whole sort of medical school adventure. Can you speak to that at all?

LBL: Yeah so, the students go through a very intensive high school equivalent, high school education, and then take their exams and apply for medical school at that point. So, they come out much younger. They’re done when they're about twenty-six or twenty-seven and entering into the medical workforce at that point.

KKB: So that might be something interesting for us to think about as we're continuing our work. How those sorts of models compare to the model of medical education here in the U.S. What, how do those models impact these sorts of discussions about increasing diversity in the medical workforce?

LBL: The other thing I would like to look at if there were some way to incorporate this is the aspect of intersectional identity. That the professional identity is one of many identities. And there might be sexual orientation, gender issues, locale, whether or not there's a whole issue of foreign born medical practitioners. Who, you know, might by the status accrued with being a physician and perhaps the status they had in the country they were born in, be a higher level than the way they are treated once they get into the United States. So that's another complexity of intersectionality that I think would be really interesting to explore.

KKB: So, it sounds like there are a lot of areas that we can research and really add to this particular research. A lot of ways we can, not necessarily diverge, but how we can really complement what we've already been doing.

LBL: I think so. Yeah, it's opened up a lot of doors, which is what we had hoped to get accomplished with the scoping review.

KKB: So, do we have any final words for the audience?

LBL: I think that’s it.

KKB: Alright, well thank you all very much.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.