December 17, 2014

The Health Care Workforce, Academic Health Centers and the Community

By Billy Thomas, MD, MPH
UAMS Vice Chancellor for Diversity and Inclusion
Professor, College of Medicine

Billy Thomas, MD, MPH UAMS Vice Chancellor for  Diversity and Inclusion Professor, College of Medicine

Billy Thomas, MD, MPH
UAMS Vice Chancellor for
Diversity and Inclusion
Professor, College of Medicine

This issue marks the second year anniversary of Diversitas. Our hope is that we have been able to address not only some of the more pressing health and health care issues of the state and nation but also many of the social and environmental factors that in many cases are responsible for the lack of good health.

As we examine our current health care system a major problem has been the lack of a diverse and inclusive health care workforce.  The overall benefits are multiple with the ultimate outcome being improved individual and population health. This is one of the goals of Title VII programs started in the mid-seventies to increase admission and graduation of students from groups underrepresented in medicine. Unfortunately progress has been slow.  In medicine approximately 8,454 (about 17.6% of the applicant pool) are applicants from groups underrepresented in medicine (1). In all disciplines, the number of minority and disadvantaged students matriculating through academic health centers (AHC) has remained relatively flat with no significant increases over the past two decades. So naturally we at UAMS, like many other institutions, spend a great deal of time trying to identify the causes and possible remedies for such low numbers. As you can imagine, there are no quick solutions.

The road to acceptance and matriculation through any health professions school can be divided into three stages – the pre-admissions process (that includes completion of post-secondary education), the admission process, and matriculation. Interventions to increase the likelihood of success can be made at any of these three stages. The stage that is most often addressed (and perhaps most perplexing) is the pre-admission process, which takes into account all the years leading up to and through post-secondary education and ultimately defines the annual cohort of applicants to the various AHCs. The size and quality of the applicant pool is directly dependent on multiple factors at the undergraduate level, as well as the entire K-16 academic pipeline.  The AHCs are dependent on the private and public post-secondary educational institutions to produce well prepared science, technology, engineering and math (STEM) students.

So how do we increase an applicant pool that is directly dependent on the US K-16 educational system?  First we must realize that the system has been stagnant for the past two decades so it is unlikely that a single event or a series of events will change this outcome.

Focusing on the K-16 educational pipeline and supplementary programs such as those funded by Title VII dollars is a reasonable and to some degree effective approach to diversifying the health care workforce. However, in Arkansas the pool of qualified STEM candidates – across all racial and ethnic groups – remains limited. The state high school graduation rates are high, with 82.7% of individuals over age 25 earning a diploma. However, only 19.7% of Arkansans over 25 have a bachelor’s degree, compared to 28% nationally, (2) with graduation rates in the STEM areas being much smaller (only 10-11% of all graduates) (3).

It is clear that efforts focused on the K-16 pipeline have not brought the results hoped for. Across the board the number of available URM applicants to AHCs remains unacceptably low. Lately, relevant research has begun to emphasize much more upstream determinants of educational success – extending to the social, ecological, and biological systems that play a major role very early on – perhaps even prior to and during pregnancy – and throughout life in determining our overall cognition, learning behavior, intellectual ability, critical thinking and in the end our overall health.

Very recently a very good friend of mine sent me the link to an article (4) that presented an ecobiodevelomental framework (an interplay between our social structure, ecology and biology), for human development that illustrated that prenatal, early childhood and environmental influences may play a more defining and lasting role in health and wellbeing – including cognitive capacity – than previously believed. Researchers have applied the term “toxic stress” to the effects of persistent adverse life circumstances – such as racism and poverty – that may leave an indelible signature on the genetic predispositions that affect an individual’s emerging brain architecture and long-term health (4). Now there is evidence that “toxic stress” is more than a construct to help explain the health effects of chronic hardship, but actually touches on something much deeper. From a developmental standpoint this has a pronounced effect on those areas of the developing fetal brain that primarily function in our critical thinking, behavioral responses, cognition, linguistics, and ability to respond to stressful situations. This research is still in its infancy and much is unknown, including the potential for reversing such effects.

The study suggested that many diseases should be viewed as developmental disorders that begin early in life and that persistent health disparities associated with poverty, discrimination or maltreatment could be reduced by the alleviation of toxic stress in childhood. But, more intriguing was the profound effect of toxic stress on both the newborn and the mother prior to, during and after pregnancy. In addition there is evidence that this effect may extend into subsequent generations.

There is evidence showing that interventions within the ecological system – environment – can result in a reduction of the effect of these toxic stresses, suggesting that a sound investment that reduces environmental adversity will most likely strengthen the foundation for physical and mental health.

These new insights may help explain why interventions focused on the K-16 pipeline have not fully produced a diverse cohort of  AHC applicants. Disturbingly, these findings indicate that this is an extremely complex issue that is a problem for society at large – and AHCscommitted to diversifying the healthcare workforce. Perhaps a broader and more complex approach may be required to relieve or avert many of the underlying stressors (environmental, socioeconomic) that are so chronic and common in underserved neighborhoods. Geographically many AHC are in close proximity to such communities. AHC’s must reach out to surrounding communities, establish a real physical presence and develop partnerships that will result in very early interventions that may reduce environmental stressors. In the process, this has the potential for sparing upcoming generations from alterations in genetic expression that in many cases result in functional deficits and poor health. Many minority and disadvantaged students from these neighborhoods may as a result lag in learning behavior and critical thinking and in the end overall health.

We must reach out. Distance is not an issue in what is a long-term investment that we must be willing to make; otherwise our goal of diversifying the health care workforce may not be realized.

  1. AAMC: 2013 Applicants to U.S. Medical Schools, 2006-2013
  2. United States Census Bureau. Quick Facts. 2012.
  3. Arkansas Department of Higher Education: Report on STEM Graduation and Enrollment Trends, April 2013.
  4. Jack P. Shonkoff, Andrew S. Garner, THE COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON EARLY CHILDHOOD, ADOPTION, AND DEPENDENT CARE, AND SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Benjamin S. Siegel, Mary I. Dobbins, Marian F. Earls, Andrew S. Garner, Laura McGuinn, John Pascoe and David L. Wood Pediatrics 2012; 129; e232; originally published online December 26, 2011; US Department of Commerce.
  5. Shonkoff JP. Building a new biodevelopmental framework to guide the future of early childhood policy. Child Dev. 2010;81(1):357–367