New York, New York! What Can This Great, Diverse City Teach Us About Health Care?
Diversity--Looking in the Right Places:
Harlem Hospital Center's Approach to
Decreasing Oral Health Disparities

Dr. John M. Palmer in front of one of Harlem Hospital Center's historic art treasures. The mosaic mural in the background was completed in 1969 by the world-renowned artistCharles Alston and is entitled "Man Emerging in Brotherhood."

"Experience has taught us that, in order tot promote the potential for compliance, culturally competent care must include explaining the treatment plan in lanuage the patient can understand."
Dr. Lawrence Bailey

By John M.Palmer, PhD
Executive Director,
Harlem Hospital Center
Renaissance Health Care Network

James R. King, DDS
Director of Dentistry;
Chief and Program Director
Oral and Maxillofacial Surgery
Harlem Hospital Center

Lawrence Bailey, DDS, MPH
Director of Dentistry
Renaissance Health Care Network

Sylvia L. White, MPA
Chief of Staff
Harlem Hospital Center

Nicole A. Beason, JD
Director, Public Affairs
Harlem Hospital Center

The issue of a lack of diversity among our nation's healthcare professionals has been gaining traction in recent years. Racial and ethnic minorities comprise 25% of the population of the United States, but only 9% of the country's physicians and 2% of the country's dentists. Latinos comprise 15% of the population, but only 4% of physicians and 4% of the country's dentists. In 2004, the Sullivan Commission, led by former US Secretary of Health and Human Services, Dr. Louis W. Sullivan, summarized the situation as follows: "The problem is that the health care workforce does not adequately represent the population it is designed to serve, nationally or locally. This is true whether we are talking about physicians, nurses, physician assistants, dentists, dental hygienists, or pharmacists."

What Difference Does Diversity Make in the HealthCare Environment?

That same year, The Institute of Medicine report, "In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce," made the case that when communication and language barriers are minimized and providers and patients share similar racial and ethnic characteristics, the result is improved patient satisfaction, increased access to care, and better compliance with treatment plans.

The report showed that minority patients experience greater satisfaction and feel greater trust when their healthcare provider shares their background and life experience. These feelings increase compliance with treatment, which leads to improved treatment outcomes. Moreover, access to care for minority patients was shown to expand in proportion to the number of physicians and dentists of color who are willing to be located in and to treat minority patients living in federally defined medical manpower shortage areas.

Understanding the Role of Cultural Biases and Ethnic Mores in Health Care

In a large acute care public hospital, cultural proficiency and understanding of ethnic mores can mean the difference between a patient who receives adequate health care versus a patient who receives no care or whose illness is misdiagnosed.

Cultural biases and ethnic mores greatly influence our beliefs and values about illness, disease, and disability. They shape how we classify the seriousness of a health condition and help us explain why some illnesses exist. They also establish boundaries for our relationships with providers, and influence the types of healers and practitioners we consult.

As our nation grows more diverse, all the evidence indicates that any serious attempt to reduce racial and ethnic disparities in health outcomes must focus on minimizing barriers to care, providing culturally proficient and ethnically sensitive health care, and ameliorating the severe shortage of minorities in the health professions. But can diversity be achieved?

The Harlem Hospital Center - Columbia University Model

The model developed by the Harlem Hospital Center Department of Dentistry demonstrates that the answer is "yes."

Harlem Hospital Center is a member of the New York City Health and Hospitals Corporation and the Generations+/Northern Manhattan Health Network. The center has a clinical affiliation with Columbia University's College of Physicians and Surgeons, which enables it to deliver a consistently high level of health services to the community. Harlem Hospital Center is a Level I Trauma Center capable of treating patients with multiple illnesses. Last year, this 286-bed hospital provided nearly 300,000 outpatient visits, 76,000 emergency department visits, and had over 13,000 inpatient admissions.

Increasing the number of minority dentists has been a priority for the Harlem Hospital Center Department of Dentistry for over 20 years. In the late 1980s, in response to an increased need for a more diverse workforce, the Department's former director, Dr. James E. McIntosh, in partnership with former Dean of the Columbia University College of Dental Medicine, Dr. Allan J. Formicola, established the Minority Dental Specialty Program to train minority specialists who would return to Harlem Hospital Center and/or serve in communities where oral health disparities are most prevalent. Dr. McIntosh and Dr. Formicola had the foresight and wisdom to know that this collaboration would create a win-win-win situation for the community, the Hospital, and the dental school, while simultaneously addressing a severely unmet oral health need.

The program proved to be a huge success, benefiting all stakeholders. It produced three periodontists, six prosthodontists, two orthodontists, three pediatric dentists, five endodontists, and two Master's in Public Health professionals. All maintain their practices either in Harlem or other medical manpower shortage areas.

The Department of Dentistry's model confirms what many of us have known all along: Diversity can be achieved, when you look for qualified candidates in the right places and use effective models. Drs. McIntosh and Formicola used mutual education goals and objectives to create synergy between Harlem Hospital Center and Columbia University College of Dental Medicine. This partnership created a career ladder for minority students to gain access to training programs that continue to be extremely difficult for them to enter because of ongoing socioeconomic factors. Serving as mentors to young dentists, they stressed the need for increased training of qualified minorities in dental postgraduate and specialty training programs.

Dr. McIntosh also initiated successful recruitment strategies, such as visiting the campuses of historically black colleges, establishing volunteer opportunities for dental students, and implementing the highly sought-after Summer Dental Student Externship Program. These volunteer activities afforded dental students opportunities to learn and gain valuable clinical experience in a community health-care setting, as well as exposure to the practice of general dentistry and oral surgery.

Collaborations were also established with two of the most prominent historically black colleges in the United States: Howard University and Meharry Medical College. Both institutions proved to be a rich resource for recruiting gifted and talented students of color. This collaboration continues to support the diversity goals of the Department of Dentistry.

If We Build It, They Will Come

The first step in creating meaningful change is to understand that change is possible. We have seen that an increase in the numbers of minority dentists, physicians, and nurses is possible when academic institutions partner with healthcare providers to explore various options, including reaching out to schools with a pool of minority students and implementing strategies for identifying talented students.

An effective diversity program also needs to include career ladder programs beginning in high schools, progressing through junior colleges, and proceeding into continuing education programs designed to develop stronger pipelines into the health professions. Successful diversity initiatives also need federal, state, and local leaders and health agencies to review educational funding models and determine their impact on the future of healthcare delivery based on changes in national demographics. In addition, commitments must be made to increase Medicaid reimbursement, Graduate Medical Education, tuition reimbursement, loan forgiveness, and expanded scholarship opportunities, as well as to devise incentives for professionals to practice in medically-underserved areas.

Finally, the expansion of public-private collaborations must be encouraged if we are to seriously address health professional disparities. Only through the identification and training of culturally competent professionals will we make it possible for the students of today to develop into talented providers of tomorrow.