Ensuring a Diverse Physician Workforce: Progress but More to Be Done.

Invited Commentary Ensuring a Diverse PhysicianWorkforce: Progress butMore to BeDone In their study of the diversity of graduate medical education in theUnited States, Deville and colleagues1 call attention yet again to thecontinuedunderrepresentationofwomenandminority groups in medicine compared with the population as a whole. Among the many interesting findings, Iwasmoststruckthatamongall specialties, obstetrics and gynecology had the greatest proportion of women trainees in 2012 (82.4%), the highest percentageofblacktrainees (10.3%),andoneof thehighestpercentages of Hispanic trainees (8.7%). All these percentages reflect substantial increases over the past 3 decades. The proportion of practicing female obstetrician-gynecologists has steadily increased from around 20% in the early 1990s to nearly half by 2010. As a blackwoman and a specialist inmaternal fetalmedicine, I am thankful that growing numbers of physicians from underrepresented minority groups are being trained in women’s health care, a field in which health disparities are importantpublic health issues.Maternalmortality, although low overall in theUnited States, is increasing.2 Blackwomenhave a 3 times greater risk of death in pregnancy than nonHispanicwhitewomen; in addition, blackwomenhavehigher rates of hypertension, obesity, and diabetes mellitus in pregnancy thannon-Hispanicwhites. Black infants aremore likely to die in the first year of life, often because of extremeprematurity. In 2013, 16.3% of live births to black women were preterm (born before 37 weeks gestation) compared with 11.3% of births to Hispanic women and 10.2% of births to nonHispanicwhitewomen.3Racialandethnicdisparitieshavebeen documented inotherobstetricaloutcomes, suchas ratesofprenatal care, cesarean delivery, and vaginal lacerations.4 Althoughnumerous factors specific to thepatient, thehealthcare system, and the societal environment likely account for some of these differences, factors related to physicians have been implicated as well. Providing culturally competent care is as important in obstetrics and gynecology—when women interact with the health care system at one of themost vulnerable times in their lives—as in any other specialty. Not only areminority physicians more likely to work in underserved areas when their training is complete, but the quality of health care maybebetterwhencliniciansandpatients areof the samerace or ethnicity.5,6 The findings also raisequestions,however. For example, it is not clear what makes obstetrics and gynecology so attractive to black and Hispanic trainees. I am unaware of any organizedprogramtoattract studentsor retain traineeswhoareunderrepresented minorities. Data from the Association of AmericanMedical Colleges show that between 1980 and 2012, the number of black women graduates of US medical schools increased 4-fold while the number of black men graduating declined.7Mostof thegains forunderrepresentedminorities in obstetricsandgynecologyare likelyamongblackwomen,partly owing to the highpercentage ofwomenentering the specialty. We lack data on the number of black and Hispanic trainees who complete the 4-year obstetrics and gynecology residency or further subspecialty training in urogynecology, maternal fetal medicine, gynecologic oncology, reproductive endocrinology, and infertility or family planning. These subspecialists account for the majority of researchers and medical school faculty andcare formanyunderservedwomenwith complexmedical needs.Not only are black andHispanic physicians underrepresented among medical school faculty, but they are less likely to be promoted, less likely to hold senior faculty and administrative positions, and less likely to be funded by the National Institutes of Health.8,9 Similarly, the numberofwomen in leadershippositionswithin academic institutions is lowwhen comparedwith the increasing number ofwomen in obstetrics and gynecology and other specialties. It is important to learnwhat factors contributed to the increase innumbers ofwomen, blacks, andHispanics in obstetrics and gynecology and whether those factors could improve representation in other specialties. It is also important, however, for obstetrics and gynecology and other specialties inwhichdiversity is improving tomonitor theirworkforce, the quality of postgraduate training, and the advancement of women, blacks, andHispanics to senior and leadership roles. Progress will stall if women or underrepresented minorities do not advance. Ensuring a diverse physician workforce will require the continuing attention of medical school leadership and health care systems, and interventions to provide opportunities for diverse physicians to join the leadership ranks. Increasing physician diversity is yet another opportunity to improve the quality of care for all of our patients, particularly themost disadvantaged and thosewith a disproportionate burden of disease.