In a workshop organized by NICHD and the AAP in January 2004, we addressed and discussed issues related to a Hispanic perspective in Training and Retaining of underrepresented minority physician scientists in the United States. A review of the literature related to training of underrepresented minority physicians in the United States (US) was performed, giving emphasis to those related to the Hispanic population. Success and failure in training and retention of Hispanic physician scientists and trainees was examined. An underrepresentation of Hispanic minorities in medical research workforce was found. This fact has recently resulted in efforts to increase their recruitment and there is a mandate by the National Institute of Health (NIH) for their inclusion. The Hispanic population in the US has increased rapidly, with diversity among the Hispanics in their personal and professional behavior. Significant disparities in health, health risk factors and access to health care manifested by an increased burden of illness and death have been documented. There in an undersupply of academic Hispanic neonatologist. Factors such as availability of academic employment, limited research funding in pediatrics, managed care and large debt burden of the US medical graduates interfere with recruitment of Hispanic trainees and academic physician scientist. Possible solutions, including recognition research awards, revision of NIH policies in awarding funds for neonatology, establishing strategies to improve minorities' acceptance, participation in research and increase accrual of Hispanic population in clinical trials should be given priority.
In a workshop organized by the National Institute of Child Health and Development (NICHD) and the American Academy of Pediatrics (AAP) in January 2004, the participants were requested to address and discuss issues related to training and retaining of under-represented minority physician scientists in the United States – a Hispanic perspective.
Underrepresentation of racial/ethnic minorities in medical research
It is a well-known fact that there is an under representation of racial/ethnic minorities in medical research. This fact has recently resulted in efforts to increase their recruitment and in a mandate for their inclusion by the National Institutes of Health (NIH)1. It is evident that there is a need to determine how history, attitudes, cultural beliefs, social issues and behavior of established investigators affect minority enrollment and participation in academic institutions.2
There are many issues that affect Hispanics, both in their professional behavior and in their personal life. One of these is the issue of diversity, as Hispanics may be Mexican, Puerto Rican, Cuban, South or Central American or of other Spanish culture or origin, regardless of race. This diversity is complicated by the issue of different languages, religions and cultural beliefs. The perception of benefits and values of research among Hispanics is markedly different from that of the Anglo-Saxon. Hispanics do not trust easily their superiors, co-workers and strangers.
Impact on recruitment of minority physician scientists
Although not well appreciated, in many instances, minority researchers are highly effective because they can work successfully within the community in the recruitment of research participation and establishing strong bonds with community-based organizations. In other instances, they constitute strong, visible and accessible islands within academic institutions that have little representation of minorities in research3. Hispanics have a distinct cultural empathy among themselves, which provides a bridge constructed of shared values, language, culture, attitudes and traditions. Their capacity to establish bonds with community-based organizations that they know well is an effective tool to increase credibility in accessing minority populations. In many occasions, minority investigators function effectively as mentors for young students, thereby helping to increase the number of future minority investigators. By role modeling and mentoring, they are probably the best tool to increase the number of minority researchers.
NIH policy on inclusion of women and minorities in clinical research
It occurs in response to ethical principles of justice and to the importance of balancing research burdens and benefits. The United States has one of the most ethnically diverse populations in the world. A third of the current US population belongs to minority groups and this proportion is expected to increase steadily, so that by the early part of the 21st century these groups are likely to make up more than half of the US population. Information gathered from minority groups will be essential for the implementation of health and education policies and intervention.4
The 2002 Census demonstrated that more than one in eight people in the United States were of Hispanic origin (12.5%) and that 20% or more live in the southwestern states (Figure 1). In contrast, Hispanic/Latinos comprise only 3.4% of medical school enrollees. This makes it difficult to have an adequate pool of candidates to recruit and train pediatric scientists.5
Health disparities in the Hispanic population
The Hispanic population is affected by many factors that have effect in their individual survival and deserved happiness. It is evident that there is a crisis in minority health, manifested by the continuing disparity in the burden of illness and death experienced by minorities, as compared to the entire United State population.
There are great disparities in access to health care. Hispanics are the least likely to have health insurance as 34% are uninsured whereas only 11.6% of white non-Hispanics lack health insurance. This limitation has a significant impact on the health status and quality of life in the Hispanic population.
There is also a significant disparity in risk factors.6 The incidence of diabetes (10.2%) is higher among Hispanic than among Caucasian. Obesity is also a high-risk health factor in Hispanics. When the infant mortality was examined in 2001,7 significant disparities were found in the US. The National Average Infant Mortality rate was 6.8/1000 live birth as compared with 5.8% in Hispanics and 7.8/1000 live birth in US Puerto Ricans.
Infant mortality rate was higher in the Puerto Rican population, both in the mainland and in the island of Puerto Rico. This problem in health care requires new approaches by the Maternal and Infants Care Programs.
There are other important health disparities. Human immunodeficiency virus among African Americans and Hispanics accounts for 75% of all adult AIDS cases, although they only comprise 25% of the population. Puerto Rican mothers have a higher risk to have babies with neural tube defects than Caucasian mothers. Health status has a striking impact on morbidity and mortality rates in Hispanics specially those related to cardiovascular diseases.
Undersupply of academic Hispanic neonatologists
Examination of the participation of racial or cultural groups in the delivery of health care in the USA shows that only 6% of male and 4% of female physicians are Hispanics/Latinos, as shown in Figure 2. There is a serious undersupply of pediatrician scientists in the US.8 Therefore, there is a diminished pool of pediatricians who may pursue a career as academic neonatologists. The need to increase the number of minority pediatricians and neonatologists to provide health care is supported by the observation that minority physicians are more likely to provide services to minorities. There are several reasons to explain the existing situation. There is better pay in the private practice, as compared to academic medicine, so newly trained neonatologists will prefer to go to private practice because of a higher income. In addition, during their training, they are exposed to a diminished academic faculty morale and higher academic faculty dissatisfaction, which have an important negative impact on the recruitment of neonatology trainees.
Other factors that affect recruitment of Hispanics trainees include those related to manage care, which has interfered with the use of funds for education and research, as well as in the availability of populations for training and longitudinal studies in health care.
Another important factor is the huge debt burden of the US medical graduates.9 The average US medical school graduate debt for students graduating in 2003 rose 5.4% from the previous year. Fifty-eight percent had incurred a debt of $100 000, whereas 25.4% faced debt of $150 000 or more. This fact interferes in the decision process to pursue an academic career.
The faculty of academic institutions has an important role in the recruitment of pediatricians and neonatologists. For this reason, it is important to revise faculty issues and their impact on attracting new pediatricians and neonatologists for training.
When we examine the race/ethnicity of the faculty of US medical schools, we find that less than 7% of minority faculty hold appointments in basic science departments in non-minority medical schools and minority professors constitute less than 10 and 40% of minority faculty are women.
Minority faculty account for only 3.5% of US medical schools' faculty. Therefore, the faculty of the existing medical schools have at present a limited role in attracting minorities for academic work and research.
At the same time it is important to examine the burdens affecting the faculty. At present, there is a greater competition for research funding, and research support for pediatric faculty is limited. Only 5.3% of the NIH budget is assigned to the Departments of Pediatrics, and NIH grants remain concentrated in a limited number of departments. As a result, trainee exposure to pediatrician investigators is limited.
Stabilization in the number of academic faculty positions has resulted in difficulty for recruitment of additional young faculty. This situation is affected by a larger number of women entering pediatrics, with a desire to reduce their time commitment during childbearing years, causing a reduction in the work force.
In many instances, job satisfaction, security and financial solvency of the academic institutions are not adequate, creating additional difficulties.
All these factors have caused an increased pressure upon the faculty to generate professional income by the medical schools administration, establishing a greater administrative and clinical burden.
Actions to improve recruitment and training of Hispanic physician scientists
The problems affecting education and training of neonatology researchers in general, and among minority groups, such as Hispanics, in particular, are complex, multifactorial and difficult to solve with any simple formula.10 Possible actions that may help to find solutions to the problem are as follows:
To revise salaries of academic neonatologists and offer economic incentives and recognition rewards for research.
To revise NIH policies in awarding funds for neonatology and junior investigators especially for Hispanics and other minority groups.
To revise the neonatology fellowship training aiming to reduce time spent in the sub specialist training if the fellow chooses academic medicine career.
To establish strategies to improve minority's acceptance and participation in research.
To establish campaigns to increase accrual of Hispanic population to clinical trials. These campaigns should also target the primary physicians in their communities.
Goal for the 21st century
In conclusion, promoting ethnic, racial and gender diversity in clinical research will help address existing gaps in social justice and health disparities, while attaining higher representation of our multicultural, multiethnic, heterogeneous society, in areas as diverse as health, education, safety, quality of life and employment.
In conclusion, a goal for the 21st century is to promote ethnic, racial and gender diversity in clinical research. This will help address existing gaps in social justice and health disparities, while attaining higher representation of our multicultural, multiethnic, heterogeneous society in areas as diverse as heath, education, safety, quality of life and employment.
This work was presented in the NICHD-AAP Workshop on Research in Neonatology in January 2004.
Shavers VL, Lynch CF, Burmese LF . Knowledge of the Tuskegee study and its impact on the willingness to participate in medical research studies. J Nat Med Assoc 2000; 92(12): 563–572.
Population Reference Bureau, 2000 Census.
FOPE II Pediatric Sub Specialists of Future Workgroup, Final Report.
The Future of Pediatrics Education II Neonatology: Supplement, p 1233.
HHS Fact Sheet, Eliminating Minority Health Disparity, US Department of Health and Human Services, 2000.
American Academy of Pediatrics, Division of Health Policy Research, Periodic Survey of Fellows #43, 2000.
http://www.tulane.edu/~finaid [revised: April 7, 2000].
Wilfred Y, Fujimoto MD . Community involvement and minority participation in clinical research, journal.diabetes.org/diabetesspectrum/98v11n3/pg161.
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