Development of a Culturally Competent Health Care Workforce: Strategies for Success

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

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

The University of Arkansas for Medical Sciences is the state’s only academic health center and the only comprehensive teaching facility for the health professions. The mission of UAMS is to improve the health, health care and well-being of Arkansans and of others in the region and nation through education, service, research and patient care. Essential to that mission is the fostering of a culturally competent health care workforce.

The efficacy of healthcare workforce diversity as a pathway to culturally competent care and improved health outcomes has been well documented.1 For underserved and marginalized populations (about 18 percent of Arkansans live at or below the poverty level), the benefits are better access to, and higher quality of, health care. As is the case nationally, many Arkansans living below the poverty line cannot afford health care and are disproportionately affected by multiple health and health care disparities. In the research arena, researchers who are minority are more likely to focus on problems affecting minority and underserved populations, thus accelerating scientific discovery that benefits them.2 In health education programs, such as those at UAMS, when there is greater faculty and student diversity, the educational process is enriched for everyone, thereby resulting in a more culturally competent health care workforce.3

Thus, for an academic health center to set its sights on a more diverse student body and faculty as a way in the long run to improve population health sounds simple and straightforward. However, multiple, interdependent factors are at play. For UAMS, the main foci are the pre-admission process (preparing and recruiting students) and the admissions process (student selection criteria specific to each college). In addition – and often overlooked – is the importance of the retention of minority students, residents, fellows and junior faculty.

Pre-admissions – increasing the pool of qualified applicants

Arkansas is still primarily an agrarian state. Only 19 percent of adults hold a college degree, and 26 percent of children live in poverty (up 22.7 percent in the last decade).4 Underrepresented racial and ethnic minorities are disproportionately represented among those without post-high school education due to the lack or shortage of things middle class families take for granted – books in the home, access to quality pre-K programs, a parent who can serve as a role model and guide for children’s educational advancement, and well-resourced schools and after-school and summer programs – all of which profoundly contribute to success at every point along the academic pipeline that connects Arkansans to UAMS and other institutions of higher learning. As a result, the number of the state’s college graduates in biology, biomedical science or the physical sciences – the majors most often leading to a professional degree in the health sciences – is small, a mere 569 graduates each year on average, according to the Arkansas Department of Higher Education. In addition, whites receive a bachelor’s degree in the biological sciences 2.6 times more often than underrepresented minorities, further contributing to the very small number of minority students who are in a position to pursue a graduate or post-graduate degree.5

How UAMS helps disadvantaged students

There is a chance that many who work at UAMS do not fully appreciate the contribution UAMS makes to the educational advancement of minority and educationally disadvantaged students. For more than 20 years, UAMS has hosted summer enrichment programs; currently more than 300 young persons, kindergarten through college, are taking part. Many eventually enroll at UAMS and graduate as physicians, pharmacists, nurses and other health professionals in service to their home state. Now, these programs – so vital to the development of the state’s health workforce – are imperiled, due to proposed federal budget cuts.

The Center for Diversity Affairs is exploring avenues for alternate funding including a capital campaign so that these programs are preserved – and, hopefully, expanded, so that more students with the talent and desire have the opportunity to pursue a career in health. Everyone who sees the importance of a diverse health care workforce should consider making a donation dedicated to the preservation of these programs, once the campaign launches later this year. And anyone who values greater educational opportunity for disadvantaged Arkansas kids should support state-funded programs all along the educational pipeline, from kindergarten to college.

Recruitment and retention of minority students

Critical to recruiting and retaining minority students is the presence of a “critical mass” of minorities, resulting in the generation of an institutional climate that is inviting, nurturing, supportive and inclusive. Without it, it is difficult to convince minority students or faculty that UAMS is a place in which they will be valued and supported.

Due to the low number of underrepresented minority (URM) students being produced in the academic pipeline, UAMS and many other institutions ask, How do we move forward? How do we produce an environmental climate change?

The CDA – and the Chancellor’s Minority Recruitment and Retention Committee – have recommended strategies that may help UAMS work smarter with the limited applicant pool. Chancellor Dan Rahn and Vice Chancellor Jeanne Heard are supportive, and the CDA and the colleges are already taking steps to work together. A few of these strategies are

  • A review of current admissions processes so that disadvantaged students of promise are not excluded. Other academic health centers have benefited from a truly holistic admissions process; we can learn from their example.
  • Greater investment in student support services, such as mentoring, tutoring, wellness, and “an early warning system” to identify and help students in academic distress. This fall, the Office of Educational Development is stepping up its services to students, and the CDA is launching a mentoring program, the first year of which will be a pilot program targeting  minority students in the College of Medicine with plans for inclusion of all students in all colleges.
  • Development of a post-baccalaureate program for those aspiring to enter the College of Medicine. Perhaps our most promising pool of academically talented URM applicants is made up of those who applied but just missed making the cut for admission. It makes sense to invest institutional resources in their development. Plans for a UAMS post-bac program – a proven strategy at many other medical schools for increasing diversity – are on the table.

Minority faculty development – a “grow your own” approach to diversity

Growing your own is not a new concept, but it has never been truer. A pool of potential minority faculty for UAMS already exists, and we must not let the opportunity slip away. A lack of minority faculty creates an environment that is both uninviting and, in many cases, a deterrent to recruiting and retaining minority students and faculty.6

Before minority faculty become faculty, they are students. If there are only 3,140 minority medical students graduating each year in the U.S., and the number is relatively flat, then how do we approach the problem from the perspective of improving population health? Simply shifting students from state to state will not improve national health. Each institution and state must be aware of and avoid the “zero sum effect.” If minority students and faculty are disproportionately distributed between states and institutions, the overall health of the nation suffers. An ideal goal is an equal distribution of minority health care workers in each state in accordance with each state’s demographics, moving towards population parity, improving access and quality of health care, and a reduction in health disparities.

In all colleges, strengthening programs that nurture the development of students, residents, and postgraduate fellows from diverse backgrounds will result in a gradual increase in the number of minority faculty. Retention efforts must be direct and focused.

The newly revitalized Minority Faculty Development Caucus (see article in this issue), a grassroots effort by junior minority faculty, deserves the active support of UAMS administrators and faculty. Elemental to that happening will be policy changes in how the colleges reward faculty who take time to be involved in diversity-promoting activities, which could be in the form of increased funding, formal recognition, or changes in promotion and tenure policies.

Each institution and state must move toward self-sufficiency as it deals with the challenges associated with the provision of health care to an increasingly diverse population. What has been touched on here are some of the efforts unfolding at UAMS. Cultural competency extends well beyond the race, ethnic background or gender of a health care provider, but rather is a gestalt of knowledge, skills, and attitudes that every health care provider – regardless of training or degrees after one’s name – should aspire to attain. To that end, UAMS is in the midst of a myriad of initiatives – revamping curricula, training for providers, programs to better engage patients in the health care system – to help us all become more culturally sensitive and aware. 

1. Cooper LA, Roter DL. Patient-Provider Communication: The Effect of Race and Ethnicity on Processes and Outcomes of Healthcare, 2003, In Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine: Washington, D.C., National Academies Press.

2. Cohen J. The Consequences of Premature Abandonment of Affirmative Action in Medical School Admissions. JAMA. 2003; 289(9):1143-1149 (doi:10.1001/jama.289.9.1143.)

3.  Health care disparities have causes originating in the organization of the health care system, patient-provider interactions, and patient characteristics. Perhaps the most malleable are those associated with interactions. (Is the provider able to communicate effectively with the patient? Does the provider share some past experiences with the patient? Does the provider possess the necessary degree of understanding, humanism and empathy needed to provide equitable quality care? It has been show that racially concordant provider-patient relationships improve quality of care, increased patient involvement in the care plan, increased patient adherence, and result in a positive patient perception of care. Most researchers feel that in the long run this will reduce health care disparities and improve population health. Unequal Treatment, IOM.

4. Arkansas Advocates for Children and Families. 2012 Arkansas Poverty Update.

5. African-Americans, Native Americans, Mexican Americans, and mainland Puerto Ricans make up 30% of U.S. population but less than 8% of practicing physicians and less than 7.4% of medical school faculty, 8.6% of dental school faculty, < 10% nursing school faulty (AAMC, Facts and Figures). In 2011, URMs made up 9.8% of first-year UAMS COM students.

6.  Nationally, the number of full-time minority faculty members in higher education is 14.9%. In contrast, non-Hispanic whites comprise 81.7% of full-time faculty. The bulk of minority faculty is at the assistant professor or instructor level, where they make up 17.8% and 16.9%, respectively. Harvey WB, Anderson, EL. Minorities in Higher Education 21st Annual Status Report: 2003-2004. Washington D.C.: American Council on Education; 2005.