Monday, July 21, 2014

Nurturing the next generation of diverse family physicians

Since joining my current practice two years ago, I've noticed that I care for a disproportionate number of immigrants of Chinese and other Asian descent compared to my colleagues. Although both of my parents were born in Taiwan, I don't speak Mandarin or have special expertise on medical conditions common in Asian Americans. Nonetheless, Asian patients seem more comfortable with me anyway. Similarly, U.S. health workforce analyses show that underrepresented minority physicians (Black, Latino, and Native American) are more likely to provide primary care to medically underserved populations.

A recent Robert Graham Center Policy One-Pager examined the racial diversity of family medicine resident physicians from 1990 through 2012. It compared the proportion of residents of a particular race with the proportion of the U.S. population of the same race. The White and Native American resident to population ratio was close to 1:1, but Blacks and Latinos were present in family medicine residency programs at only 50 to 75 percent of their proportions in the population. (Asian residents have always been overrepresented compared to the population, with a current ratio of 5.1 to 1.) The good news is that family physicians are diversifying; the bad news is that Black and Latino physicians still have a long way to go to "catch up" to their numbers in the population. This means that many Blacks and Latinos will receive primary care from physicians of different races, which isn't automatically a bad thing. But it begs the question of why this situation exists in the first place.

Too many Black and Latino Americans grow up in desperately poor and crime-ridden neighborhoods with substandard public schools, and for decades resources have been poured into programs designed to give these students opportunities for educational success, from Head Start to Fairfax, Virginia's Young Scholars. It's still a rough and treacherous road, as Ron Suskind illustrated in the bestseller A Hope in the Unseen, about Cedric Jennings, an African American from Washington, DC who overcame a heartbreaking upbringing (his father was repeatedly incarcerated for dealing drugs and he and his mother were evicted from multiple homes for falling behind on rent payments) and dysfunctional schools to be admitted to Brown University. But if communities can give these kids enough K-12 support to get them accepted to four-year colleges, then a good number of them should go on to become doctors, right?

It's not that simple. In the New York Times Magazine article "Who Gets to Graduate?," Paul Tough delved deeply into the problem of college dropouts at the University of Texas at Austin, a respected public university that offers automatic admission to any Texas resident who graduates in the top 7 percent of his or her high school class. He followed Vanessa Brewer, an African American woman raised in a single-parent home who aspired to become a nurse anesthetist. Vanessa experienced a crisis of confidence after failing her first statistics test, and wondered: "Am I supposed to be here? Am I good enough?" Wrote Tough:

There are thousands of students like Vanessa at the University of Texas, and millions like her throughout the country — high-achieving students from low-income families who want desperately to earn a four-year degree but who run into trouble along the way. Many are derailed before they ever set foot on a campus, tripped up by complicated financial-aid forms or held back by the powerful tug of family obligations. ... Many are overwhelmed by expenses or take on too many loans. And some do what Vanessa was on the verge of doing: They get to a good college and encounter what should be a minor obstacle, and they freak out. They don’t want to ask for help, or they don’t know how. Things spiral, and before they know it, they’re back at home, resentful, demoralized and in debt.

The bottom line on national statistics on college graduation rates is that "rich kids graduate; poor and working-class kids don't." And surprisingly, graduation rates have little relationship to natural ability and much more to do with confidence, rooted in one's socioeconomic background.

A case in point: I failed my first anatomy exam in medical school. It felt terrible to see my score near the bottom of the class, but as the son of a pharmacist and a computer scientist with two Master's degrees, and the grandson of a neurologist and related to a long line of doctors, I pulled myself together and eventually earned a passing grade. Had this sort of setback happened to a student who was the first in his family to finish college, it could easily have led to that student leaving medical school entirely.

A U.T. program called the University Leadership Network (ULN) not only confirmed that a lack of confidence related to humble upbringing puts students at the highest risk of dropping out, but successfully tested an brief online intervention that measurably improved their odds of completing at least 12 credits during their first semester and staying on track to graduate in four years. Tough summarized ULN's straightforward strategy: "Select the students who are least likely to do well, but in all your communications with them, convey the idea that you have selected them for this special program not because you fear they will fail, but because you are confident they can succeed." The payoff for replicating this program at universities across the nation, Tough suggested, could be immense:

Beyond the economic opportunities for the students themselves, there is the broader cost of letting so many promising students drop out, of losing so much valuable human capital. ... Most well-off students now do very well in college, and most middle- and low-income students struggle to complete a degree. ... These two trends are clearly intertwined. And it is hard to imagine that the nation can regain its global competitiveness, or improve its level of economic mobility, without reversing them. ... A big part of the solution lies at colleges like the University of Texas at Austin, selective but not superelite, that are able to take large numbers of highly motivated working-class teenagers and give them the tools they need to become successful professionals. The U.T. experiment reminds us that that process isn’t easy; it never has been. But it also reminds us that it is possible.

Becoming a family physician isn't easy. But America's need for the next generation of diverse family physicians has never been greater, and Tough's article has convinced me that nurturing them is possible.