Adi Talwar

On a recent Thursday, Dr. Carla Boutin-Foster at her office as Associate Dean at SUNY Downstate Medical Center.

She remembers when her fifth grade teacher said, “You are going to college.” When her biology teacher at August Martin High School in Queens tapped her and her best friend for a Saturday Science Technology Entry program (STEP) program in Manhattan at City College. When, in a Cornell summer program during her college years, she had an opportunity to speak with medical students, do biomedical research, and watch doctors and nurses at work. Her early childhood spent in Haiti, where her father earned an engineering degree; he did not know how a bright student might navigate the barriers faced by an immigrant in our city. She needed guidance. She received it at school.

Now Carla Boutin-Foster is a physician, and Associate Dean for the SUNY Downstate Office of Diversity Education and Research in Brooklyn. And as a woman of color, she is a rarity in the medical field.

Rare, but not alone. The words of Dr. Diana Torres-Burgos’s guidance counselor at Junior High School 52 in Inwood have stayed with her. “If this is where you want to go,” she says of a career in medicine, “it will be difficult. But you will find some people want to help you and it will work.” Looking back, she says, “Basically, I just had desire. Lots of people said I couldn’t do it and that is what motivated me to say, ‘Yes, I can.'” She is now Advisor for Hispanic Health for the National Hispanic Health Foundation and the NYC Network chairperson of the National Hispanic Medical Association.

“I did not do this on my own. I had a lot of people who were helpful,” Torres-Burgos continued. “My own experience shows me that if you have people who are really interested and want to help students who have the aspiration, it will work out. But it is very difficult if you don’t have the guidance and the role models.”

Solid research in the medical literature demonstrates that the United States desperately needs more people of color in medicine and advanced health fields.

According to the American Association of Medical Colleges, 7.1 percent of current medical students are Black; 6.4 percent, Latino, and 0.2 percent American Indian or Alaska Native.  In contrast, according to the U.S. Department of the Census, 13.4 percent of the U.S. population is Black, 18.1 percent Latino, and 1.3 percent American Indian or Alaska Native. Interestingly, the number of medical students identifying as “multiple race/ethnicity” is greater than that identifying as either Black or Latino.

Studies show physician diversity leads to better patient outcomes in primary care. As George Strait, Assistant Commissioner for Public Affairs at the Food and Drug Administration, has said, “Diversity in health care is not about fair representation – it is about saving lives.”

DOE makes some effort

Many factors go into creating a diverse physician workforce. A diverse teaching corps in medical schools is important. Helping students get into—and pay for—college and medical school is also critical.

“The clinician workforce is not as diverse as the patient populations. And the ethnicity of the workforce is an area that needs attention,” Eliseo J. Pérez-Stable, director of the National Institute on Minority Health and Health Disparities (NIMHD), explained.  “It is very important that the pipelines to medical school and other health professional schools are created earlier and enhanced.”

But the making of a doctor starts well before college: in college guidance work, to let students and families know that financial assistance is available and that schools are looking for Black and Latino candidates; in high school classrooms, where science and math programs are key; in elementary and middle school when some set their sights on the healthcare fields; and even in the way much younger children are told about the opportunities that exist. Black and Latino students have to be able to see themselves as doctors before they can study to become one.

The New York City Department of Education says it has “32 Career and Technical Education health care programs across 22 schools,” training students for such positions as Certified Nurse Aide, Certified Medical Administrative Assistant, Certified Clinical Medical Assistant, Certified Pharmacy Technician, and the like. Meanwhile, according to a DOE website, the CTE (Career and Technical Education) Healthcare Commission is “comprised of 27 schools and 42 programs across all five boroughs.”

Training students for these lower-level (and lower-salary) healthcare professions is important. But so is identifying particularly gifted students, in these programs and in other programs, with the potential to go on to more responsible, better paid positions as physicians, advanced-practice nurses, registered nurses (RNs), social workers, psychologists, public health experts, and researchers.

Currently, good programs exist to help gifted city students of color enter the more responsible realms of the healthcare workforce. But observers say they are too far and too few between.

Since 1994 the Arthur Ashe Institute of Urban Health in Brooklyn has served hundreds of high-school students from Brooklyn partner schools. Students learn about anatomy and physiology; get hands-on lab experience; gain study and presentation skills – all while targeting students’ self-confidence and showing them they possess the potential to succeed, says Marilyn Fraser, a doctor and the institute’s CEO.

In addition, the institute runs workshops on navigating college and college finances. “Traditionally in college these bright students of color are weeded out during the first year because of financial burdens.” Fraser, who is also a research associate professor at SUNY Downstate Medical Center and co-Director of the Brooklyn Health Disparities Center, says. The need to work to meet expenses diminishes study time, a burden students with more financial support do not bear. Further, for many students, “inability to navigate the system” and “lack of confidence” have their greatest impact during the first year of college.

For all of the institutions involved in developing a more diverse healthcare workforce, a central problem is that many kids of color may not consider themselves capable of going into the more advanced health fields. “We need to find ways to empower them,” Torres-Burgos says. “We need the Department of Education to expose students to careers early in their school lives – that is, elementary and middle school, for by high school some kids loose that drive. And we need the community and parents to be supportive,”

There is an important role here for an array of healthcare institutions. There should be a greater number of partnerships between city schools and institution that bost highly-trained healthcare practitioners and researchers, Boutin-Foster says: “Graduate schools need to reach out to high schools.” Some do: Currently, the SUNY Downstate Medical Center has an ongoing partnership with Erasmus Hall High School in Brooklyn.

The State University of New York’s (SUNY’s) Prodigy Program has sponsored similar partnerships. The Prodigy Program website says the program is working to “align campuses with their respective K-12 communities to assist underrepresented students graduate from high school, to provide access to higher educational opportunities and to help them have a successful college experience leading to graduation.”

Asked if the DOE has shown willingness to join in stronger relationships with organizations with a track record in after-school, weekend and summer programs, Fraser expresses a little frustration about ensuring “that programs that address increasing minority representation in the health professions get on the DOE’s radar.”

Developing dreams

Many kids may not consider themselves capable of going into the more advanced health fields, and we need to find ways to empower them, Torres-Burgos saya. “We need the Department of Education to expose students to careers early in their school lives – that is, elementary and middle school, for by high school some kids loose that drive. And we need the community and parents to be supportive,” Dr. Boutin-Foster adds. “Waiting for college is too late if you want to address the barriers.”

“Getting into schools to speak with students about careers in healthcare can be quite a challenge,” AHEC’s Mitchell says in relation to their Summer Health Internship Program (SHIP).  “It often requires several emails, letters and phone calls to access a principal, assistant principal, or guidance counselor. This creates barriers for the students.” Competent health professionals, whether working or retired or semiretired, should have ready access to assembly programs and classroom presentations.

One opportunity for reaching out to students and parents would be at the DOE’s annual citywide Career and Technical Education Fair, which already includes a gender equity panel, “Bright Futures: Girls in CTE.” As women have been underrepresented in jobs in these fields, this panel is in place to inform female students and their parents about opportunities. The DOE did not respond when asked if there is a similar panel for people of color or plans to arrange for such a panel in future Fairs.

But the career fair is just one opportunity. Schools could bring retired and semiretired doctors and additional health professionals in to talk about careers. “Even people who are retired may well feel an obligation to keep the professions strong for the next generation and consistent with the mission to care for people,” says Virna Little, a physician who directs the Center for Innovation in Mental Health (CIMH) at CUNY’s School of Public Health.   “A lot of retired people might be willing to talk with students in schools if asked, but might not be proactive and do something on their own.  So, it would be good to have a way to connect with retired professionals who would be willing to engage with students.”

Some students lack a true grasp what people in the health fields actually do or whether what they do is helpful. Such information is useful in terms of careers, but is absolutely essential for enabling a person to efficiently access healthcare services. In speaking with students in schools in the Bronx, Little has found, for example, that some middle school students apparently think “maybe the work of social workers is to take apart families.”

Beyond schools

Not that the city is solely to blame. The National Institutes of Health, the state and private foundations are not providing sufficient support for existing programs.
Mary J. Mitchell, executive director of the Manhattan-Staten Island Area Health Education Center (AHEC), says each year she receives 200 applications for their summer internships but has only 30 slots.  “Many qualified students are not accepted because of insufficient funding.”

Summer internships in hospitals and community health centers, such as those offered by AHEC, constitute “one of the most effective pathways to increase diversity in the healthcare professions,” AHEC’s Mitchell says.

Yet, while years ago summer programs provided students with a stipend, now at most students are given enough to cover carfare and small miscellaneous expenses, according to Maxine Golub, Senior Vice President of The Institute for Family Health in Manhattan and Director at AHEC. “Stipends are important. Kids from poor neighborhoods have to work during the summer. Without stipends we are unable to reach some of the kids most in need of being reached.”

The problem of inadequate funds and stipends is widespread. Lynn Holden, the president of Mentoring in Medicine and a professor in the department of emergency medicine at the Albert Einstein College of Medicine, explains that many of their students receive no money at all while they actually hire and pay some of their college students to do various tasks, as a way of providing them with some money.

AHEC’s Mitchell says that because of insufficient funding, 2018 was the first time AHEC was able to offer “absolutely no stipends.” As a consequence, “portions of the future health care work force of our city and our country are probably working at McDonald’s rather than preparing to train to save lives.”

In sum, how is our city, and our country, doing in encouraging greater participation in the more advanced areas of healthcare by people of color? “We really haven’t moved much further along than 20 or 25 years ago,” Torres-Burgos’s says. “It is really very sad.”

Fraser concurs. “More could be done. So much more could be – and should be – done,” she says,