School of Medicine Office of Diversity and Multicultural Affairs

1. School of Medicine Office of Diversity and Multicultural Affairs Rafael Ortega, MD

2. Objectives: • Explain the Mission and Vision of the Office of Diversity • Describe the evolution of Diversity at BU School of Medicine • Emphasize the importance of Diversity in education and health care • Discuss how you can help us achieve our goals

3. INTERRELATED OBJECTIVES Health Care Disparities Underrepresented in Medicine Diversity and Multicultural Affairs

5. Larry Chin Doug Hughes Samantha Kaplan Alex Norbash Rafael Ortega http://www.bumc.bu.edu/oma/

6. Monitors and promotes diversity at BUSM and BUMC including statistics on students, faculty and trainees. • Reports on diversity issues to the Dean and Executive Committee. • Collaborates with Departments in BUSM to identify and achieve diversity goals. • Works with OSA to monitor progress of students. • Mentors students, faculty and trainees. • Provides support for medical student cultural and ethnic groups on campus. • Explores new funding and grant support for diversity efforts. • Manages EMSSP including recruitment, retention and academic preparation and assessment of students. Maintains collaboration with partner colleges and universities and seeks opportunities to expand affiliations. • Monitors and promotes diversity at BUSM and BUMC including statistics on students, faculty and trainees. • Reports on diversity issues to the Dean and Executive Committee. • Collaborates with Departments in BUSM to identify and achieve diversity goals. • Works with OSA to monitor progress of students. • Mentors students, faculty and trainees. • Provides support for medical student cultural and ethnic groups on campus. • Explores new funding and grant support for diversity efforts. • Manages EMSSP including recruitment, retention and academic preparation and assessment of students. Maintains collaboration with partner colleges and universities and seeks opportunities to expand affiliations. Office of Diversity and Multicultural Affairs

7. Healthcare Equality Index 2010

8. Mission The Boston University School of Medicine Office of Diversity and Multicultural Affairs serves as the Dean’s proponent for diversity and cultural competence among students faculty and staff. The Office of Diversity will accomplish this mission through collaboration with all departments to develop model recruitment and retention strategies and for curriculum and faculty development. The Boston University School of Medicine Office of Diversity and Multicultural Affairs serves as the Dean’s proponent for diversity and cultural competence among students faculty and staff. The Office of Diversity will accomplish this mission through collaboration with all departments to develop model recruitment and retention strategies and for curriculum and faculty development. Vision Boston University School of Medicine will lead medical schools in diversity of faculty, students, staff and trainees, by development of innovative programs that educate, recruit and retain a multicultural constituency. We will create a culture and climate that demonstrates BUSM belief that diversity adds value to intellectual development, academic discourse, patient care and research. We believe that diversity is essential to the development of future leaders in healthcare and research to serve our community, nation and world. Boston University School of Medicine will lead medical schools in diversity of faculty, students, staff and trainees, by development of innovative programs that educate, recruit and retain a multicultural constituency. We will create a culture and climate that demonstrates BUSM belief that diversity adds value to intellectual development, academic discourse, patient care and research. We believe that diversity is essential to the development of future leaders in healthcare and research to serve our community, nation and world.

9. The Expanding Definition of Diversity Race Ethnicity Gender Sexual Orientation Gender Identity Socio-economic Status Immigration Status Age Disabilities Religious Beliefs Political Beliefs Military Service Marital Status Same Sex Marriage Children Nationality Educational Attainment Language Health Care Disparities Interracial Marriage Intercultural Marriage Urban vs. Rural

10. AMERICAN ASSOCIATION OF PHYSICIANS FOR INDIAN ORIGIN (AAPI) • ASIAN PACIFIC AMERICAN MEDICAL STUDENT ASSOCIATION (APAMSA) • CHRISTIAN MEDICAL DENTAL ASSOCIATION (CMDA) • IRANIAN HEALTH CARE STUDENTS ASSOCIATION • MAIMONIDES SOCIETY • MEDICAL GAY AND LESBIAN ORGANIZATION (MedGLO) • MEDICAL STUDENTS FOR CHOICE (MSFC) • PHYSICIAN FOR HUMAN RIGHTS (PHR) • SOUTH ASIAN MEDICAL STUDENT ASSOCIATION (SAMSA) • STUDENT NATIONAL MEDICAL ASSOCIATION (SNMA) • OTHER Examples of Diversity Organizations on Campus

12. Latino 15% Black 12% MD Physicians by Race and Ethnicity AAMC Data

13. URM House Officers in BMC Residency Programs 21% 17% 12% 14% 12% 11% 8% TOTAL: 632

14. Number of URM House Officers in BMC Residency Programs

15. Percentage of URM House Officers in BMC Residency Programs 15% 17% 21% 8% 25% 44% 38% 0% 50%

16. 2010 BUSM Total Full Time Faculty: 1,191

17. 2010 BUSM Total Medical Students: 728

18. 2010 BUSM Total Medical Students: 728 10% 0.4% 10% 80%

19. 2010 BUSM Full Time Gender Faculty Distribution by Rank

20. 2010 BUSM Full Time URM Faculty Distribution by Rank

21. http://www.bu.edu/apfd/recruitment/fsm/ Searching for Excellence & Diversity: A Guide for Search Committee Chairs, a guide developed by the Women in Science & Engineering Leadership Institute (WISELI) at the University of Wisconsin Madison

22. Common Arguments and Comments • “I am in favor of diversity, but I don’t want to sacrifice quality.” • “We have to focus on hiring the ‘best.’” • “We are so focused on diversity that white males have no chance” • “There are no women or minorities in our field.” • “There are few available, they are in high demand – we can’t compete.” • “Minority candidates would not want to come to our campus.” http://www.bu.edu/apfd/recruitment/fsm/

23. November 18, 1993

24. U.S. Foreign Born Population / Top Ten Total: 33 million Data from 2000 U.S. Census and 2004 Yearbook of Immigrant Statistics (projected for 2010)

25. December, 2008

26. The Effect of Race and Ethnicity on Patient-Physician Communication (adapted from Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine. 2004 Institutional Resources Direct Services (Interpreters, Linguistic Competency in Health Education Materials) Cultural Homophilly (Using Staff of Similar Background, Understanding Folk Remedies and Traditional Healers) Institutional Accommodation (Clinic Location, Hours of Operation, Cultural Competency and Training) Expectations Bias Stereotypes Expectations Bias Stereotypes PATIENT – PROVIDER COMMUNICATION PATIENT Ethnicity Gender Age Social Class Literacy Health Status PHYSICIAN Ethnicity Gender Age Social Class PATIENT – PROVIDER COMMUNICATION PATIENT – PROVIDER COMMUNICATION PATIENT -PROVIDER COMMUNICATION PATIENT – PROVIDER COMMUNICATION Patient evaluations and judgments / Physician cognitions and decision-making Outcomes, Satisfaction, Adherence, Functional Status, Quality of Life

27. What Caught My Attention? Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia Todd K H et al. JAMA 1993;269(12):1537-1539 “Hispanics with isolated long bone fractures are twice as likely as non-Hispanic whites to receive no pain medication in the UCLA Emergency Medicine Center.” The Effect of Ethnicity on Physician Estimates of Pain Severity in Patients with Isolated Extremity Trauma Todd K H et al. JAMA 1994;271(12):925-928 “Physician ability to assess pain severity does not differ for Hispanic and non-Hispanic white patients.”

28. The Language Barrier and PCA Bernardo Ng et al: The effect of ethnicity on prescriptions for patient-controlled analgesia for post-operative pain. Pain 66 (1996)9-12 • Whites received significantly more analgesics than Hispanics after limb fractures. • Blacks also received less analgesia than did whites. • Language was not the reason. • The self-administered narcotics (PCA), including self- • administered and self-administered plus infusion, were not • significantly different across the ethnic groups.

29. Am J Anesthesiology 1999;26(9):429-432

30. Obstetrical Analgesia

31. Anesthesiology and Disparity

32. Relevant Today? Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency DepartmentsPletcher et al. JAMA. 2008;299(1):70-78.

33. Percentage of Emergency Department Pain-Related Visits at Which an Opioid Was Prescribed, White vs. Non-White % Adapted from: Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency DepartmentsPletcher et al. JAMA 2008;299:70-78.

34. Reason and Countermeasures COUNTERMEASURES • Physicians & nurses underestimate & undertreat pain • Different verbal & physical expression of pain • Lack of understanding of different ethnic groups • Anecdotal information • Stereotypes • Portrayal of various ethnic groups by the media • Patients react differently based on physician’s ethnicity • Subtle prejudice Pain Intensity Scales PCA Cultural Competency Evidence-Based Medicine Avoid oversimplification Beware of Hollywood Situational Awareness Self Awareness

35. Recommended Reading National Academies Press 2003

36. Disparities in health – differences between two or more population groups in health outcomes and in the prevalence, incidence, or burden of disease, disability, injury, or death. • Disparities in health care – differences between two or more population groups in health care access, coverage, and quality of care, including differences in preventive, diagnostic, and treatment services. Disparities in Health & Health Care: Definitions

37. Other Examples of Disparities Among Some Minorities • Higher rates of death from cancer. • Less screening and treatment for cardiac risk factors. • Less childhood immunizations. • Less immunizations for influenza • Higher incidence of AIDS in Black and Latino children • Less preventative careindividuals with disabilities • Poorer health in ruralresidents Source: US Department of Health and Human Services

38. Relevant Today? Keyword “Disparity” A Recipe for Medical Schools to Produce Primary Care Physicians N Engl J Med 2011; 364:496-497February 10, 2011 Leveling the Field — Ensuring Equity through National Health Care Reform N Engl J Med 2009; 361:2401-2403December 17, 2009 Payment Reform and the Mission of Academic Medical Centers N Engl J Med 2010; 363:1784-1786November 4, 2010 Eliminating Healthcare Disparities in America: Beyond the IOM Report N Engl J Med 358:1081, March 6, 2008 Assessing Race, Ethnicity, and Gender in Health N Engl J Med 356:1279, March 22, 2007 Dissecting Racial and Ethnic Differences N Engl J Med 354:408, January 26, 2006 Editorial Racial Trends in the Use of Major Procedures among the Elderly N Engl J Med 353:683, August 18, 2005 Health Care in America — Still Too Separate, Not Yet Equal N Engl J Med 351:603, August 5, 2004 Racial Disparities — The Need for Research and Action N Engl J Med 349:1379, October 2, 2003 Racial Disparities in Clinical Trials N Engl J Med 346:1400, May 2, 2002

39. Examples of Reasons for Disparities (in many racial and ethnic groups, the poor, and less educated patients) • Less education -- more likely to have report poor communication with their physicians. • More problems with some aspects of the patient-provider relationships. • Lower income patients report more difficult patient-provider relationships. • Less access to health care information, including information on prescription drugs. Source: US Department of Health and Human Services

40. Access to health care Quality of care Insurance coverage Genetics Personal behavior Disparities in Health & Health Care Interrelated Factors

41. Cross Cultural Education: A Requirement

42. “Diversity is Essential for Promoting Excellence in Education and Health Care” • Diversity: • challenges assumptions • broadens perspectives • enhances socialization • triggers intellectual and cognitive gains • improves treatment of individuals from different backgrounds • Minority physicians are more likely to treat minority patients, and more likely to practice in underserved communities. • Diversity in the health professions workforce is key to eliminating health care disparities. • TheU.S. is still producing too few racial and ethnic minority physicians to • assure quality health care for all. • Diversity: • challenges assumptions • broadens perspectives • enhances socialization • triggers intellectual and cognitive gains • improves treatment of individuals from different backgrounds • Minority physicians are more likely to treat minority patients, and more likely to practice in underserved communities. • Diversity in the health professions workforce is key to eliminating health care disparities. • TheU.S. is still producing too few racial and ethnic minority physicians to • assure quality health care for all.

43. FUNCTIONS AND STRUCTURE OF A MEDICAL SCHOOL Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree (Standard IS 16) “An institution that offers a medical education program must have policies and practices to achieve appropriate diversity among its students, faculty, staff, and other members of its academic community, and must engage in ongoing, systematic, and focused efforts to attract and retain students, faculty, staff, and others from demographically diverse backgrounds.” LCME

44. Teach basic principles of culturally competent health care. • Recognize health care disparities and develop of solutions to such burdens. • Meet the health care needs of medically underserved populations. • Development of core professional attributes (e.g., altruism, social accountability) needed to provide effective care in a multi-dimensionally diverse society. LCME

45. Students’ assumptions are challenged • Perspectives are broadened • Greater socialization acrossracial and ethnic groups • Demonstrated intellectual and cognitive benefits • Improved ability to treat all patients • More likely to treat racial and ethnic minorities How Does Diversity Influence Education? Health Resources and Services Administration, Bureau of Health Professions. The Rationale for Diversity in the Health Professions: A Review of the Evidence. Rockville, MD: U.S. Dept. of Health and Human Services; 2006.

46. Published in 2008: Meeting the HealthCare Needs of Diverse Populations • Published in 2010: Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals • Will evaluate compliance with the Patient-Centered Communication standards: beginning January 1, 2011 Joint Commission

47. Joint Commission Cultural competence requires organizations and their personnel to do the following: • value diversity • assess themselves • manage the dynamics of difference • acquire and institutionalize cultural knowledge • adapt to diversity and the cultural contexts of individuals and communities served

48. 2008 http://www.jointcommission.org/assets/1/6/HLCOneSizeFinal.pdf

49. 2010 http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

50. NIH Institute created by the passage of the Minority Health and Health Disparities Research and Education Act of 2000 • NIH has made health disparities a priority • Enhance minority health disparities research • Increase underrepresented minority students and students from health disparity groups with an interest in careers in biomedical research. National Center on Minority Health and Health Disparities