Family medicine has evolved in many ways since its inception in 1969, especially in terms of the people who are practicing it, but it still needs more diversity to represent the faces of patients.
The specialty has been on the path to a racially diverse workforce over the past few decades. Since family medicine is a discipline where doctors look not just at individual patients, but also at the health of the community, some family physicians see working in their specialty as a way to integrate public health with medicine to curb health inequities.
Maria Harsha Wusu, MD, MSEd, is an example of such a family physician.
Wusu, who is Black and of Japanese descent, chose to practice family medicine to address health in communities of color "which we know in the United States experience health inequities due to structural racism," she said in an interview.
"It's a discipline where you look at the health of the entire family and the community and you really look at the environmental, the political, the historical factors that are influencing the health of the community," explained Wusu, who is currently the director of health equity at Morehouse School of Medicine, Atlanta. Family physicians are not just asking: "Does a patient have hypertension?" but also whether a patient has access to healthy food, green space and other things.
While the field of family medicine is more diverse in the 21st century than it was at its beginning, Wusu, who completed her residency in 2016, still faced challenges to achieving her goal of helping communities of color. These specifically stemmed from a lack of diversity among the people in the places where she studied to become a doctor and family physician.
There were moments when Wusu felt isolated while in medical school and residency, because so few students and faculty members she saw looked like her.
Plus, studies have shown that a racially and ethnically diverse physician workforce is necessary to address health inequities. Research published in 2018 in the Journal of Health Care for the Poor and Underserved, for example, found that underrepresented physicians are more likely to practice in underserved areas than their White peers.
"I went to medical school at a historically White institution, and so there were very few people who identified as what we would say are underrepresented minorities in medicine," Wusu explained. "There are issues with both implicit and explicit racism, which I think could be echoed by colleagues across the country that are additional challenges that I think medical students, particularly students of color, experience during what is an already kind of challenging time of medical school and the rigorous training of residency."
Ada Stewart, MD, FAAFP, president of the American Academy of Family Physicians, echoed Wusu's medical school experience. Stewart, who finished her residency in 2003, said that, out of the 120 students in her graduating medical class, only 10 were Black.
Marginalized groups are still underrepresented in residences. According to data compiled by the Association of American Medical Colleges, only 9.3% of Black people, 10% of Latino, and 0.3% of Native Hawaiian or other Pacific Islanders are residents in family medicine residency programs in 2019-2020. Meanwhile, White residents make up 50.8% of the residency program.
"We really need to do all that we can to increase diversity within our medical schools and residencies," Stewart said.
In regards to gender, there has been an increasing number of women in the family medicine specialty. A 2021 study found that the proportion of female physicians in family medicine has grown from 33.9% 2010 to 41.9% in 2020.
"There's still room for growth and we have to change the system and those structures that created these problems," noted Stewart.
The Social Responsibility of Family Medicine
The family medicine specialty was born during an era of protest of social change, alongside the Civil Rights Movement, the peace movement, and counterculture protests. In April 1966, 3 years before American Boards approved family practice as a new specialty; the National Commission on Community Health stated that every person should have a personal physician who is the "central point for the integration and continuity of all medical services to his patient." They also said such physicians should be aware of the "many and varied social, emotional and environmental factors that influence the health of his patient and family."
While the diversity of family medicine specialty has significantly increased since its beginnings, it continues to lag behind the general U.S. population. A 2018 study published in the Journal of the American Board of Family Medicine, which aggregated data from 1987 to 2017, found that the proportion of Black and Latino board certified family physicians increased from 1.3% to 7.8% and 2.3% to 9.1%, respectively, in 30 years.
A 2014 study included 2 decades worth of data from the U.S. Census and the Association of American Medical Colleges to examine trends in racial and ethnic composition among family medicine residents. The U.S. population increased from 9% to 17% for Latinos, 11.7% to 12.2% for Blacks/African Americans, and 0.87% to 0.89% for Native Americans from 1990 to 2012. Meanwhile, minority representation in family residencies increased 4.9% to 9.4% for Hispanics/Latinos, from 4.2% to 7.9% for Blacks/African Americans, and from 0.7% to 0.9% for Native Americans.
Furthermore, 13.4% of the U.S. population is Black and 18.5% of the population is Latino, while only 7.8% of family medicine residents in 2019 were Black and 9.1% of family medicine residents were Latino, according to a recent study published in Family Medicine.
Recruiting a Diverse Physician Workforce
The AAFP has launched a few initiatives to increase diversity within the specialty. In 2017, the AAFP established the Center for Diversity and Health Equity, a center to address social determinants of health. The EveryONE Project, an initiative that's part of the AAFP's center, offers members education and resources to promote workforce diversity. Some of those resources include "The Ladder Program," an initiative founded by an AAFP member which involves monthly meetings and events for students as young as 9 years old to introduce them to medicine at a young age.
"You can't see what you don't see," noted Stewart, who is the first Black, female president of the AAFP, and the fourth woman in the role. "I really have seen how important it is to be a mentor and to be out there so that individuals who look like me can see that they too can become a family physician and be that member of their community."
In addition to The Ladder Program, some other resources aimed at increasing diversity among family physicians include Tour for Diversity in Medicine and the Doctors Back to School Program.
The Tour for Diversity in Medicine involves a team of physicians, other clinicians and students hosting events nationwide for minority students to help them see a path to medicine and other health professions. Meanwhile, the AAFP's Doctors Back to School Program involves family physicians visiting children at schools, clubs, community organizations, and other places to raise childhood awareness of family medicine and help them see their own potential in health care careers.
Stewart said these programs have been successful in increasing underrepresented groups.
"We are trying to see how best to measure their success," the AAFP president said. "Looking at the high numbers of individuals who chose the specialty of family medicine last year is what I would deem a success."
Wusu also believes outreach to children in elementary schools is important when it comes to increasing diversity in the family medicine specialty.
One organization that's proving such outreach is the Student National Medical Association, a branch of the National Medical Association, which is a professional organization of Black physicians. This group's initiative, the Health Professions Recruitment Exposure Programs, exposes teens to science-related activities while introducing them to careers in health professions. Another SMNA program, called Youth Science Enrichment Program, targets elementary and junior high school students.
Wusu led a 2019 project that focused on creating a more diverse family medicine residency program by developing and implementing a strategic plan for diversity recruitment, which involved increasing outreach to marginalized groups and revising interviews to minimize bias. In a paper published on the results of the initiative, Wusu and coauthors noted that, between 2014 and 2017, the total number of underrepresented minority applicants to the Boston Medical Center Family Medicine Residency Program increased by 80%. Before the intervention, the percentage of applicants who were part of an underrepresented group ranged from 0% to 20%. During the intervention, that range jumped to 25% to 50%, according to the paper.
While Wusu considers these programs to be beneficial for the specialty, she doesn't believe they should be done in isolation. There should also be efforts to tackle lack of opportunities and structural racism.
"With any inequity, you have to address it on multiple levels," Wusu explained. "It's great that there has been recognition for a need for diversity in family medicine, but my hope is that the call for equity would reach beyond that."
Fostering an Inclusive Environment
While family medicine has come a long way with regards to increasing the amount of underrepresented groups in its specialty, Stephen Richmond, MD, MPH, believes there also needs to be a focus on the infrastructure of support to help retain these physicians.
"The problem of diversity within family medicine and largely in other specialties cannot be summed up simply as a matter of poor representation. We must do be better to understand the lived experience of physicians of color, in particular Black physicians, once they arrive in the medical professional environment. Doing so will help institutions to provide that infrastructure of support – including antiracism policies and practices – that will enhance wellness and representation," said Richmond, clinical assistant professor of medicine in the division of primary care and population health at Stanford (Calif.) University.
Wusu also suggested establishing an explicitly antiracist environment. This can be done in multiple ways, including by holding programs that acknowledge the impact of structural racism on both the patients, medical students and faculty, and by educating staff about the history of racism, she said.
Stewart and Wusu think the specialty has improved in its representation of minorities, but that it has a "long way to go."
"I think family medicine is really one of the more inclusive specialties. I mean, it has higher numbers of Black and Brown residents and physicians than other specialties," Wusu said. "We still have a very long way to go to be at numbers that match the general population. But I think, in that way, family medicine is a place where a lot of Black and Brown physicians can find a home."
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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Cite this: FM Diversity Has Increased, but More Physicians of Color Needed - Medscape - Jul 22, 2021.