It’s a well-known fact that women do better with female doctors, and minorities do better with doctors that look like them, but both demographics are underrepresented in surgical medicine. The reasons are complex, but the requirement is obvious: we need more men and women from minority backgrounds to aspire to the medical professions in general, and more specifically to be surgeons. Parents need to encourage our middle-schoolers to choose a medical career (starting early is better), and then the mentoring and support that helps with studies and personal development can bring about success. Dr. Melvyn Harrington describes the active network of support that exists to facilitate inclusive participation in medical training, and the part his organization plays. With Eileen Bodie.
Episode 61: America Needs More Minority Doctors & Nurses: Why & How.
Featuring Dr. Melvyn Harrington.
It’s a well-known fact that women do better with female doctors, and minorities do better with doctors that look like them, but both demographics are underrepresented in surgical medicine. The reasons are complex, but the requirement is obvious: we need more men and women from minority backgrounds to aspire to the medical professions in general, and more specifically to be surgeons. Parents need to encourage our middle-schoolers to choose a medical career (starting early is better), and then the mentoring and support that helps with studies and personal development can bring about success. Dr. Melvyn Harrington describes the active network of support that exists to facilitate inclusive participation in medical training, and the part his organization plays. With Eileen Bodie. Posted on August 26, 2020.
Eileen: Welcome to the Health Disparities Podcast, a program of the Movement is Life Caucus. We have conversations about health disparities with people who are working to eliminate them. I’m Eileen Bodie. I’ve been a member of the Caucus for 10 years, and I’m delighted to be hosting today’s conversation with Dr. Melvyn Harrington. Dr. Harrington is a Professor of Orthopedic Surgery and Residency Program Director at Baylor College of Medicine in Houston, and a longtime collaborator in equity, diversity, and inclusion aspects of medicine in the Movement is Life Caucus. Good morning, Dr. Harrington.
Dr. Harrington: Good morning.
Eileen: Diversity and inclusion have been very, very important issues for you. Can you tell me what you’re doing with them at Baylor College of Medicine?
Dr. Harrington: Well, at Baylor in my role as Residency Program Director, I’m working to try to get as diverse a group of residents going into orthopedic surgery as possible. I also through working with our Office of Diversity and Inclusion work on improving diversity across the board throughout the entire institution.
Eileen: Why is diversity in medicine an important issue?
Dr. Harrington: Well, I think it’s been well-documented and shown that patients respond best and have better outcomes with concordant physician, race, and gender. And our medical population at the present time does not reflect our population in terms of diversity and gender equity.
Eileen: What are the statistics of that? What is the differential?
Dr. Harrington: Well, I know in orthopedics, we are number one in terms of being the least diverse medical specialty. It’s one of our big issues. Whereas 50% of the medical school classes are currently women, in orthopedics, our residency programs, we only have around 13 to 14% of women residents. And this has been unchanged for many, many years. For underrepresented minorities, the data is much lower where we are only about 4 to 5% in our residents.
Eileen: 4 to 5%, that’s pretty low. Why is that? Why are the percentages so low?
Dr. Harrington: It’s a good question. We’ve been working on it for quite some time. I think there may be two different issues in terms of the issues for women, particularly going into orthopedics versus underrepresented minorities. For women, there are plenty of women to choose from to go into orthopedics in the med school class. We have to figure out why are they choosing to go into other specialties rather than orthopedic surgery. For underrepresented minorities, there’s much more of a pipeline issue where there are just not enough underrepresented minority students in the medical school class to choose from. Then that small number is being divided up among all of the various medical specialties.
Eileen: Does that filter back to college in terms of the number of minorities going on from college to medical school?
Dr. Harrington: I think it probably goes all the way back to middle school.
Eileen: Well, can you explain that? That’s an interesting concept.
Dr. Harrington: There’s data to show that I think third grade is where they say for a lot of minority students the determination of where they go in terms of completing school and ultimate achievement. And trying to get students through middle school and high school, and then getting them through high school, out of high school, and into college is the challenge. The numbers, the pipeline just keeps getting smaller and smaller for underrepresented minorities. So, we take the students who make it out of high school and go to college, and then they get divided up into the various majors and areas and the small number that end up in medicine, and then the even smaller number that ends up looking at various subspecialties.
Eileen: What is needed to bring diversity to orthopedics?
Dr. Harrington: I think we need to for women, again, figure out what we can do as a specialty to make it more friendly to get women to consider it. There’s a lot of traditional biases because it is such a male-dominated specialty and to show that women can do it and it’s a great opportunity and a great specialty for everyone. And I think for underrepresented minorities it’s dealing with the pipeline issues and getting more underrepresented minorities into medical school and then exposing them early to the subspecialties, such as orthopedics and other competitive specialties to go in. There’s a big push for underrepresented minorities to go into primary care where they are certainly needed, but we also need them in academic orthopedic surgery, which I do.
Eileen: This is a very interesting idea. You said, biases, what kind of biases are there for women?
Dr. Harrington: Well, a lot of these stem from way back in all of the surgical specialties and a lot of it is the lifestyle. You know, residency is right when most folks are making life changes, and getting married, having children and things like that. It can be challenging. The work hours are long. The perception is that the surgical fields are longer and harder than some of the non-surgical fields. You can debate whether that’s totally true or not. In orthopedic surgery, there’s the myth that you have to be big and strong. There are a lot of former athletes in orthopedics and there’s definitely biases saying that oh, women aren’t strong enough to reduce fractures and actually do the work, but that’s really false.
Eileen: Can you give me some examples of organizations bringing diversity into medicine?
Dr. Harrington: One of the great organizations that I actually have been working with since its inception within orthopedics is Nth Dimensions. It’s a program designed to get women and underrepresented minorities who are already in medical school, early exposure to orthopedics, and to really help them learn how to play the game and get them into orthopedic surgery, to be competitive applicants for residency.
Eileen: Nth Dimensions. What exactly did they do? I mean, how do they bring diversity into orthopedics?
Dr. Harrington: So, the main project that we work on is our orthopedic summer internship, where we have students apply for a summer internship between their first and second year of medical school. We ship them somewhere across the country to work with a mentor for a couple of months. During that time, they get a clinical exposure to orthopedics, whether it’s in the clinic or the operating room. They also do a research project that then is presented each year as a poster at the National Medical Association Meeting.
Eileen: Placing them with a mentor, does that prove to be successful?
Dr. Harrington: So far, it has been quite successful. The match rate for Nth Dimension students in recent years has been nearly 90% who have applied for orthopedics have gone into it now. Of course, not all of the students who we pick after their first year decide to ultimately go into orthopedic surgery, but they end up benefiting from the process and do well in other fields also.
Eileen: That’s good to hear. I know that one thing you’re really concerned about is changing perhaps this concept of Step 1 with the National Board of Medical Examiners exam. Can you explain why you’re concerned about that?
Dr. Harrington: So, there is a recent change, I believe it’s on February 12th, the National Board of Medical Examiners decided to change the scoring reports for the Step 1 Board Exam from a three-digit numerical score to a strictly pass-fail scoring system. And just as a bit of background the National Board of Medical Examiners has a three-part test for medical licensing. Basically, the goal of the exam is to determine if the examinee has achieved the basic medical knowledge to be a licensed physician. And it is what’s used by state licensed boards to grant a license.
So, in theory, it should be a pass-fail test that do you know enough medicine to be a licensed physician. However, with the three digits score over the years, that became something that has been used as a stratification tool for resident selection. The Step 1 exam is taken typically traditionally after the second year of medical school. So, we as program directors and residency programs have used that as an indicator and a screening tool for selecting resident applicants, even though it was not originally designed for that. So, we use that similar to SAT scores and CAT scores and other standardized tests.
Eileen: Why does that create a problem for minority residents?
Dr. Harrington: Well, one of the concerns with the numerical score is that number one, the test was not designed to really stratify medical knowledge. So, it’s not been validated for that purpose. We used it because it is one universal measure that we can use to compare students across the board from different medical schools. The challenge has been that over the years students are applying to more and more residencies and it has become extremely competitive and students are really focused only on Step 1 exam. They’re neglecting the other general med school education. One of the big concerns was resident wellness and the stressing out over a single high stakes exam. And, also, students were basing their career choices based on that exam. If they didn’t do extremely well on the exam, then they’re not felt to be a candidate for some of the more competitive specialties.
Eileen: I can see where that would be a major issue for minority students.
Dr. Harrington: And it’s been a challenge with minority students, traditionally having slightly lower scores on the exam and not getting looked at for more competitive residency programs. So, one of the theoretical benefits of a pass-fail system is that we don’t have to worry about that, and students will get reviewed where they may not have otherwise gotten reviewed. So, I think that’s a potential benefit. I would encourage those of us who are reviewing applications to do a more holistic review, which is what is being pushed by the AAMC and other organizations to try to improve diversity and get a broader range of candidates. So, I think in theory, that is a great option.
Putting on my program director’s hat, it makes things more difficult because for example, we have six spaces in our orthopedic residency program. We get over 800 applications for that spot. There are around 960 applicants going into orthopedic surgery. So, almost all of the applicants apply to over 90 programs on average. So, the challenge is trying to weed that 800 down to a reasonable number to invite, to interview, and to make our selections. While holistic interviewing is wonderful, that’s a difficult thing to do for 900 applications and so, that’s where the board scores became the stratification tool. So, we residency directors at lots of programs would pick a number and it was usually a very high number as a cutoff. If you were above the cutoff, then your application would get reviewed but if you were below the cutoff, regardless of whatever the rest of your application looked like you may not have a chance at matching in your desired specialty because your application may not get looked at.
Eileen: Do you think it would be important for medical schools and with a residency to make it, I wouldn’t say a law, but a policy that one of the residents is African American or a minority, and that one of the residents of the six is a woman? Is that realistic?
Dr. Harrington: I don’t think people would go for having mandatory quotas. Everybody always says we want the best applicants and from wherever they’re from and whatever that is. The challenge is that the best quality applicants have been conflated with board scores, which has been repeatedly disproven. Really, I think the main data that Step 1 numerical scores have shown is that you’re a good test taker if you get a good score. There’s some data that links a marginal score to being able to pass your orthopedic surgery boards, but that’s really about it. It doesn’t reflect on what type of a resident or what type of physician you’re going to be.
Eileen: I was just going to bring that up. Just because you have great board scores doesn’t necessarily mean you’re going to be a humanitarian or an empathetic surgeon.
Dr. Harrington: A lot of us program directors’ joke that in addition to having a minimum board’s cutoff, we probably should also have a maximum.
Eileen: Well, I think that there has to be a certain amount of judgment that goes into bringing the six residents on because to have 900 applicants and only being able to accept six. What are your criteria other than board scores for including them in your residency program?
Dr. Harrington: We look at the grades that they achieve in medical school. We look at the Dean’s letter, each of the med students gets a letter from the Dean that assesses their overall performance in medical school, and that sort of stratifies where their rank falls in the class. We look at their letters of recommendation that they get from people they have worked with, usually physicians in that specialty. Then we look at research and other extracurricular activities. We look for evidence of leadership, volunteerism, and things like that.
And so, every program is different in terms of what they look at. Some may emphasize research more than others. There are some that emphasize board scores and they want you in the 99 plus percentile, and that’s who they look at. So, everything is variable from program to program and I think probably even from reviewer to reviewer.
Eileen: Have you ever been in a situation where you thought this resident would be an absolutely wonderful surgeon, but he or she did not have the board scores to make the cut?
Dr. Harrington: Yes, we’ve had that. There are plenty of physicians out there who may not have done so well on the boards and may not have matched the first time they applied and ultimately get in and become outstanding physicians. So, we know that the board scores, they’re one piece of the pie and one piece of the assessment process. I think the majority of us used cutoffs just to limit our numbers and limit our time in reviewing.
Eileen: That makes sense. Do you think that increasing diversity in the orthopedic industry would help reduce healthcare disparities?
Dr. Harrington: I think so. The studies again show that underrepresented minority physicians are more likely to practice in neighborhoods and areas that have more minorities. So it’s access to care issues. And I think in terms of quality of care and outcomes and patients feeling comfortable with their physicians and having physicians who can practice more culturally competent care is critical.
Eileen: Considering the future of bundled payments and considering the limitations on healthcare insurance, there are a lot of orthopedic surgeons that are not accepting Medi-Cal, Medicaid or even Medicare. Do you think having a more diverse orthopedic surgeon industry would improve access to care for a lot of people who have limited insurance options?
Dr. Harrington: That’s a tough one. Because having more minority surgeons certainly may improve access, but the challenge also comes down to sort of a business proposition. These days very few orthopedic surgeons are going out into solo practice and more are joining hospital systems and are becoming employees. So, a lot of those decisions are not necessarily made at the individual practitioner level anymore. It’s sort of, “I work for this hospital system and these are the insurances that we take.” So that’s a challenge.
Then also on the private side, it’s a business decision to be able to have appropriate reimbursement, just to be able to keep your doors open. So, those are all the challenges, particularly when it comes to payments and payment systems, whether it’s Medicare, Medicaid, or private insurance.
I think one of the other issues with some of the bundled care that can potentially impact health or worsen health disparities are the potential penalties for complications in bundled care. So, if you’re practicing at a county hospital or with an underserved population, you’re expected to have the same outcomes as someone practicing with an all well-insured group that doesn’t have all of the other social issues that can affect your outcomes.
Eileen: Safety net hospitals are disappearing in the United States due to low reimbursements and that is impacting the minority people, both in the African American community and in the Latino community. What can the orthopedic industry do to perhaps salvage these safety net hospitals? Is there anything that can be done?
Dr. Harrington: From an orthopedic side, that’s a challenge. Our department covers our county hospital and one of the challenges that we’ve had in the past is, there’s a great need for orthopedic procedures done in our county in the uninsured, underinsured population, but depending upon the county’s budget, they are not always interested in doing the more elective surgeries. They’re barely able to cover the life-threatening emergency procedures. So, when we have a patient who may just need a knee arthroscopy, or a carpal tunnel release, something that’s critical and may be necessary to keep that person able to work or just to be functional in society, that’s definitely a needed operation, but it’s elective, and whether or not they have funding to be able to do enough of those procedures has been a challenge for some of my colleagues.
Eileen: What’s wrong with our healthcare system right now? I know that’s a really big question.
Dr. Harrington: It’s a political question, depending on your point of view. I think the push for universal healthcare, I think it would be wonderful if everyone had some basic healthcare. Now getting into the details of what’s covered, what’s not covered, and who pays for what becomes the big challenge. When you factor in all of the different interests, whether it’s from the medical healthcare side or the insurance side, or anything else that’s where the devil’s in the details and the difficulties that come in.
Eileen: Do you think by increasing minority surgeons and minority healthcare professionals that will help improve some of the issues in the healthcare system?
Dr. Harrington: I think if nothing else, it would help give us a stronger voice to advocate for our minority and underserved patients.
Eileen: Thank you very much for your comments today. We really appreciate your time.
Dr. Harrington: Thank you.
Eileen: And thank you to our listeners for joining us for this episode of the Health Disparities Podcast. We hope you found it interesting. Please remember to subscribe on iTunes, or you can sign up on our website to receive notifications of future episodes. I’m Eileen Bodie, and on behalf of the Movement is Life Caucus, I thank you for your time.
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