APIAHF Comments to AAMC
Regarding Definition of Underrepresented Minority Option 5
January 17, 2003
Charles Terrell, Ed.D
Vice President
Division of Community and Minority Programs
Association of American Medical Colleges
2450 N Street, N.W., Rm 255
Washington, DC 20037
(202) 828-1125 (fax)
cterrell@aamc.org
Re: Underrepresented Minority (URM) Discussion Document and Alternative Policy Option
Dear Dr. Terrell:
The Asian & Pacific Islander American Health Forum (APIAHF) is a national advocacy organization dedicated to promoting policy, program and research efforts for the improvement of health status of all Asian American and Pacific Islander communities. We have long understood the importance of workforce diversity and have advocated for policies to promote the adequate supply of culturally and linguistically appropriate health providers.
We are writing to address the Alternative Fifth Policy Option, and to supplement arguments made in our previous letter, dated May 15, 2002 (copy attached). Policy Option 5 proposes to replace the current "underrepresented minority" (URM) definition with a new designation, those "underrepresented in medicine". This new designation would include those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population. This option is more dynamic and allows for changes to the definition as demographics change over time. Assuming that this method includes the use of disaggregated racial/ethnic data (for example, Cambodian, Vietnamese, Hawaiian – not just "Asian/Pacific Islander"), we believe that it would provide a more rational basis for designating URM and is consistent with recommendations made in our previous letter.
While we support the basic principle of Policy Option 5, we do, however, have a number of concerns.
REGIONAL FLEXIBILITY
The Discussion Document states,
"Using Option 5, each medical school could target underrepresented groups in its community. These groups could be included in institutional definitions and databases as underrepresented and underserved populations."
The Discussion Document does not indicate that AAMC would maintain a national standard to identify those groups that are underrepresented nationally. This leads one to assume that each medical school would be required to create their own definition of URM by identifying underrepresented groups based on local/regional data.
While we fully support the goal of medical schools to meet the needs of the community in which they are located, we believe there is still a need to maintain a national definition which identifies particular underrepresented groups based on physician to population ratios. This national definition should serve as a uniform standard across medical institutions, to which schools could add groups that are underserved in their communities. The establishment of a national standard will allow the continued influence of URM on other areas of policymaking, benchmarking for diversity programs, eligibility for various fellowship programs and data collection/reporting of race and ethnicity.
Reasons for a National Definition
Capacity - While some medical colleges may have the technical or staff capacity to collect and analyze complex physician and population data by race, others may not. Having accurate and complete data for calculating URM requires a certain amount of expertise and staff time. Medical schools that are unable to invest the time necessary to do this will likely have an inaccurate definition of URM, or even no definition at all.
Availability of Data - Data for smaller populations may not be available at a local or regional level. For example, use of occupational data from the U.S. Census Bureau (which is a sample of the Census population) is unlikely to produce reliable estimates of the number of physicians belonging to the smaller racial or ethnic groups at a local/regional level. Having a national definition of URM will ensure that at least those groups that are recognized to be underrepresented at a national level will be included in the institution’s definition.
Instability of Data for Small Populations – Even in cases where local/regional data is available and accurate, it may not be stable. Imagine an area where there are two Cambodian physicians serving the Cambodian population. Depending on the size of Cambodian community, it is possible that this group would not be considered underrepresented by a medical school if the ratio of physicians to population reaches the URM threshold. However, if these physicians were to leave the area, the medical school’s URM definition would need to be reconsidered to account for the change. While keeping up-to-date information about physicians practicing in an area and revising institutional definitions of URM accordingly is necessary to properly serve communities, in cases of smaller or unstable populations, having a national definition provides more consistency and a more stable basis for designating underserved populations.
Correlation Between Location of Medical School and Location of Practice Basing definitions of URM purely on regional data fails to consider the fact that many students that attend a medical school are not from the same area as the school, and many will not end up serving the community in that area after graduating.
Recommendations
AAMC should use national data to develop a list of groups that are underrepresented in medicine on a national level.
This national definition should serve as a floor, upon which medical colleges can augment based on local needs and local data.
AAMC should encourage medical schools to collect and use local/regional data, and provide technical assistance and other support.
DISAGGREGATION
It is imperative that, regardless of whether URM is calculated using local data or national data, heterogeneity of the "Asian American and Pacific Islander" (AAPI) group be taken into account. The AAPI category encompasses almost fifty subgroups, more than a hundred different languages and dialects, diverse cultural backgrounds, and unique immigration experiences. Many of these groups suffer from high rates of poverty and low rates of education, yet are not now considered "under-represented minorities". Failure to view AAPIs as separate and distinct communities has resulted in an inaccurate reflection of whether the provider needs of these communities are being met.
Recommendations
AAMC should use information about AAPI sub-populations (disaggregated data) to develop a national definition of URM.
AAMC should encourage and support the use of AAPI sub-population data for use by medical schools in supplementing their institutional definitions of URM.
AAMC should monitor and revise their existing databases as necessary in order to capture critical race/ethnicity information, and to seek out other sources of data to supplement it.
ADDITIONAL CONSIDERATIONS
While race and ethnicity are critical factors in creating a diverse health workforce, we believe it is also necessary to consider other factors in meeting the needs of the overall population.
Language Skills
Studies of limited-English proficient populations in health care settings reveal many disparities in quality of care. The lack of language services results in an impaired exchange of information, loss of language cues that may aid in diagnosis, incomplete patient education, lack of informed consent, less access to services and thus a lower level of preventative care. According to the 1990 Census, approximately 24.2% of AAPIs live in linguistically isolated households, in which none of the individuals aged 14 years or older speaks English very well compared to 2.8% in non-AAPI households. This percentage is much higher for some AAPI subgroups: 60% of Hmong, 55% of Cambodians, 52% of Laotians, 42% of Vietnamese, 35% of Koreans, and 35% of Chinese. Workforce diversity policies that explicitly target language ability are critical for meeting the needs of limited English proficient patients.
Primary vs. Specialty Care
The supply of primary care physicians is particularly important to meeting the needs of the growing AAPI populations. Through additional analysis of the 1990 Census data, APIAHF has found that AAPI physicians are more likely than the overall physician population to work in hospital settings and less likely to work in medical offices. This finding validates the notion that although there may be an "over-representative" supply of physicians from certain AAPI subgroup, there is likely still a shortage of these providers in primary care settings.
RESEARCH AGENDA
APIAHF supports efforts to establish a research agenda to substantiate URM policy. In particular, research into other factors that will create a diverse physician workforce, such as those listed above, will eventually result in a more accurate and effective policy for meeting the needs of a diverse population. In addition, continuous efforts to reevaluate the URM policy will be necessary to reflect the demographic changes of the population and the physician workforce.
APIAHF would like to commend the AAMC for its commitment to an open process and consideration of these and other public comments. We would also like to offer any assistance we can provide to support AAMC’s efforts in collecting, tracking or analyzing data about various racial and ethnic populations, or in providing technical assistance to medical institutions. The Asian and Pacific Islander Center for Census Information and Services (ACCIS) was established by APIAHF to meet the census data needs of organizations interested in identifying, defining, targeting, and serving AAPIs throughout the United States. APIAHF was officially designated in 1992 by the U.S. Census Bureau as a national Census Information Center. The CIC program was established to serve organizations by providing better access to census data, offering technical support, and providing products that meet census data needs.
If you would like to discuss any of our comments or opportunities for collaboration, please do not hesitate to call Jan Liu, Policy Analyst at 415-954-9952.
Sincerely,
Ho L. Tran, M.D., MPH
President and CEO
Encl. May 15, 2002 Letter from APIAHF to AAMC Regarding Definition of Underrepresented Minority (URM)
