ISSUE
     
New York, New York! What Can This Great, Diverse City Teach Us About Health Care?
Why Dentistry Needs to Contain Multitudes
 


Howard Bailit, DMD, PhD Professor Emeritus, Department of Community Medicine University of Connecticut School of Medicine




New York's Little Italy during the feast of San Gennaro.




Figure I The Percentage of Underrepresented Students in U.S. Dental Schools, 1984 to 2007




Times Square, crossroads of the world, in all its digital, animated glory.




By Howard Bailit, DMD, PhD
Professor Emeritus,
Department of Community Medicine
University of Connecticut School of Medicine

In his epic poem, "Song of Myself," the great 19th century American poet Walt Whitman celebrated the genius of American democracy in general, and New York City's uniqueness in particular, with the words, "I am large, I contain multitudes." For Whitman, America's strength is a direct result of its success in constructing a pluralistic, all-embracing, all-inclusive American identity.

Whitman's vision of national greatness through diversity is even more relevant today. All health-care professions face serious public policy challenges related to large disparities in access to health care and a lack of practitioner diversity.

According to the Association of American Medical Colleges (AAMC) and the American Dental Education Association (ADEA), underrepresented minorities are defined as "those racial and ethnic populations that are underrepresented in the healthcare professions relative to their numbers in the general population." The three groups that are generally considered underrepresented are African Americans, Hispanics, and Native Americans.

With respect to dentistry, only 5.2 percent of practicing dentists are from underrepresented minority communities: African American (2.2%), Hispanic (2.8%), or Native American (0.2%). In contrast, these three populations now constitute about 28 percent of the US population, and by 2050 they are expected to make up 42 percent of the population. Are the healthcare professions in general, and dentistry in particular, prepared to care for this population?

The Access Issue
The heart of the matter is that the United States is becoming a more diverse country, and dentistry and the other health professions need a work force that reflects this diversity.

There are compelling arguments for this view, beginning with the appeal to social justice, which says that since few minority students were accepted into majority dental schools over the past 200 years, this is an opportunity to make up for past discrimination.

There is also a case to be made for greater diversity as a means of improving the educational experience for all students. There is substantial evidence that a "critical mass" of minority students in the class enables non-minority students to gain a greater understanding of and appreciation for access disparities and the importance of cultural issues in providing health care. In support of the argument that culturally competent graduates are better prepared to meet the health needs of the American people, it's worth noting a relatively recent decision of the Supreme Court.

In 2003, the issue of giving any ethnic or racial group preference for positions in universities and professional schools reached the Supreme Court in a landmark case involving the University of Michigan Law School (Grutter v. Bollinger, 539 U.S. 306, 2003). The court concluded that the educational benefits of racial diversity - improving teaching and learning and enhancing civic values - were substantial and supported appropriately designed and implemented race-conscious admissions policies.

But perhaps the most compelling reason for a diverse student body is that access to care and diversity go hand-in-hand. Simply put, minority physicians and dentists are much more likely to care for minority patients than non-minority clinicians. Also, minority patients report higher satisfaction and better communication with clinicians of the same ethnic and language background - a greater "comfort level" - which increases the likelihood that minority patients will seek needed care and follow the advice of their doctor.

What New York City Can Teach Us About Health Care
New York is now, as it has been since the 1850s, a multicultural city, a global city, and the archetypal city for our nation and world. Indeed, New York City is a laboratory for exploring human potential, and its history demonstrates that the more varied the cultures, the more exciting and successful the outcome.

And just as New York's diversity lures people with its vitality and the promise of a better life, so will a more diverse workforce strengthen our nation's healthcare system, making it more relevant and responsive to the needs of society.

Strengthening Dentistry Through Diversity: The Path Forward

If we accept the idea that diversity is essential to dentistry's ability to thrive, the question becomes: What must we do to achieve it? To find the answer, let's look at diversity in dental education.

Figure I shows the trend in the percentage of underrepresented minorities in US dental schools. The percentage of underrepresented minority students increased slightly from almost 10 percent in 1984 to almost 12 percent in 2007.

But these percentages are misleading. Two dental schools, Howard University and Meharry Medical College, account for a large percentage of African-American dental students. If these two schools are omitted, only 9.6 percent of dental students in majority schools are from underrepresented minority populations.

Because of changes taking place in the larger environment, dental schools face a number of challenges in recruiting more underrepresented minority students. First, underrepresented minority recruitment programs are relatively expensive, and most dental schools are experiencing significant reductions in federal and state funds. To make up for these losses, most schools have raised tuition, leading to large increases in student debt and, in turn, to fewer students from lower-income families.

Second, the number and quality of applicants has increased substantially in the past 20 years, making it much more competitive to get into dental school; and third, most schools have relatively few underrepresented minority students or faculty and may not have a supportive internal environment for students of color.

To meet these challenges, dental schools need to have a clear mission statement that values diversity; formalizes a commitment to recruit minority students and faculty; and pledges to establish and support effective core recruitment programs.

Successes

In terms of specific schools, Baylor University School of Dentistry has done an outstanding job in recruiting minority students. Close to 40 percent of Baylor's entering class is made up of minority students. Other dental schools with exemplary minority recruitment records include the University of Michigan, University of Illinois-Chicago, the University of California at Los Angeles, and New York University. The records of these schools demonstrate that successful underrepresented minority recruitment programs require administrative leadership, supportive faculty, adequate resources, and effective management of core recruitment programs.

Although progress toward increasing diversity in dentistry has been slow, there is now a national effort underway to create a more diverse pool of applicants and dental school students. Importantly, this effort has the full support of the dental academic and practice communities. Moreover, America has never been more diverse, vibrant, and well positioned to take on this challenge. For all these reasons, I think it is fair to say that the prospects for a profession that looks increasingly like America have never been better.