By Francis G. Lu, M.D.

While politicians debate the need for affirmative action programs, recent developments in medicine have reaffirmed the critical importance of cultural diversity and cultural competence in providing medical care for underserved ethnic minorities.

Taken as a whole, these developments underscore the importance of not only maintaining affirmative action, but also redoubling efforts already under way by organizations such as APA, the Association of American Medical Colleges (AAMC), and the American Psychological Association to broaden cultural diversity and improve cultural competence among practitioners and faculty members. Although these terms describe characteristics of persons beyond that of ethnicity (that is, race, language, gender, age, country of origin, sexual orientation, religious/spiritual beliefs, social class, and physical disability), I will focus on underserved ethnic populations, faculties, and practitioners.

Recent data from the AAMC and American Psychological Association demonstrate a vast underrepresentation of blacks, Hispanics, and Native Americans among the faculties of U.S. medical schools, departments of psychiatry, and graduate departments of psychology. For example, while blacks constitute 12.7 percent of the U.S. population, they represent only 2.5 percent of the medical school faculty, 3.5 percent of the psychiatry faculty, and 4.0 percent of the psychology faculty. Although Hispanics make up 8.9 percent of the population, their respective percentages are 2.9, 3.5, and 2.0. Especially underrepresented are Mexican Americans_while 6 percent of the population, they constitute a meager .3 percent of medical school faculty and .45 percent of psychiatry faculty. While .75 percent of the population is American Indian/Native Alaskan, they constitute only .1 percent of medical school faculty and .14 percent of psychiatry faculty.

An equally significant level of ethnic underrepresentation exists at the practitioner level for all three fields. For example, only 4 percent of physicians are black and only 5 percent of physicians are Hispanic.

Studies published in the May 17, 1995, issue of the Journal of the American Medical Association and the May 16, 1996, issue of the New England Journal of Medicine examined the relationship between physician ethnicity and care of ethnic minority patients and indicated the need to increase the number of physicians from ethnic minority populations.

The first study showed, "Racial and ethnic minorities are more likely to receive care from nonwhite physicians. Low-income patients, Medicaid recipients, and the uninsured are more likely to receive care from nonwhite physicians. Individuals who receive care from nonwhite physicians are more likely to be in worse health, receive care in an emergency department, and be hospitalized."

The second study concluded, "Black and Hispanic physicians have a unique and important role in caring for poor, black, and Hispanic patients in California. Dismantling affirmative-action programs, as is currently proposed, may threaten health care for both poor people and members of minority groups."

Furthermore, the AAMC survey of 1995 medical school graduates showed that 41.4 percent of blacks and 30 percent of other underrepresented minorities planned to practice in a socioeconomically deprived area. In contrast, only 10 percent of "other Hispanics," Asians, and whites planned to practice in these areas.

To increase minority representation in medical school enrollment, the AAMC in 1990 embarked on "Project 3000 by 2000" designed to double the number of matriculants of underrepresented minority groups from 1,500 to 3,000 by the year 2000. Gains realized during the period from 1990 to 1995 include a 37 percent increase in matriculants and a 62 percent increase in applicants from underrepresented minorities. If this effort succeeds, it will also improve representation among medical school and psychiatric faculties in the long run.

APA has also supported efforts to develop minority psychiatric faculty through two federally funded programs: the APA/Center for Mental Health Services Fellowship Program and the APA/National Institute of Mental Health Program for Minority Research Training in Psychiatry. As a minority faculty member in psychiatry for 19 years, I know how critically important these two programs have been for the field.

Recognizing that all practitioners regardless of their ethnicity will need to be competent in assessing and treating culturally diverse populations, the concept of "cultural competence" has become an increasingly visible part of training program requirements and practice guidelines.

The Accreditation Council for Graduate Medical Education's new "Requirements for Residency Training in Psychiatry" (effective January 1, 1995) include, for example, changes that provide more specificity about the content of instruction regarding the U.S.'s diverse cultures: "Instruction should include such issues as sex, race, ethnicity, religion/spirituality, and sexual orientation," according to the revised requirements.

Furthermore, DSM-IV includes an "Outline for Cultural Formulation" to address potential difficulties in using the manual in a multicultural environment.

Proper care of medically underserved ethnic minorities, who by the year 2000 will constitute 25 percent of the U.S. population, requires support and encouragement.

If we turn our backs on the care of these people by actions such as abolishing affirmative action, we do so at our collective peril of added financial costs, a widening gap in health status between segments of the population, and an increasing moral burden.

Dr. Lu is a clinical professor of psychiatry at the University of California, San Francisco, Medical School and codirector of the Cultural Competence and Diversity Program at San Francisco General Hospital.

(Psychiatric News, November 1, 1996)