Minorities in Medicine:

An Ethnic and Cultural Challenge 

for Physician Training

An Update

COUNCIL ON GRADUATE MEDICAL EDUCATION

Seventeenth Report

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

April 2005

Minorities in Medicine:

An Ethnic and Cultural Challenge 

for Physician Training

An Update

COUNCIL ON GRADUATE MEDICAL EDUCATION

Seventeenth Report

April 2005

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration
SEVENTEENTH REPORT OF COGME ii

The views expressed in this document are solely those of the

Council on Graduate Medical Education and do not

necessarily represent the views of the

Health Resources and Services Administration

nor the U.S. Government.
SEVENTEENTH REPORT OF COGME iii

Table of Contents

The Council on Graduate Medical Education .............................................................................................. vii

Members of the Council on Graduate Medical Education ........................................................................... ix

Executive Summary ........................................................................................................................................... 1

Introduction ................................................................................................................................................. 1

Findings and Recommendations ................................................................................................................ 2

Introduction ........................................................................................................................................................ 7

Implications of Changing Demographics in the U.S. ................................................................................. 7

Health Disparities ....................................................................................................................................... 9 

Influences on Health Disparities ............................................................................................................... 10 

Who Is a URM in Medicine? .................................................................................................................... 11 

Trends in Minority Participation in Medicine .......................................................................................... 11 

Barriers to the Educational Pipeline ......................................................................................................... 12

Implications of Cultural Competence ....................................................................................................... 15 

Assessment of COGME’s Twelfth Report ................................................................................................ 15

Strengthening the Pipeline to Medical School ............................................................................................... 17

Pipeline Programs ..................................................................................................................................... 17

Findings .............................................................................................................................................. 17

1998 Recommendations To Be Attained ............................................................................................ 18

Evaluation Considerations ................................................................................................................. 18

Overcoming Barriers to Increasing URM Medical School 

Applicants ................................................................................................................................................ 18

Findings .............................................................................................................................................. 18

1998 Recommendations To Be Attained ............................................................................................ 20

Evaluation Considerations ................................................................................................................. 20

Social Marketing To Increase URMs in the Pipeline ............................................................................... 20

Findings .............................................................................................................................................. 20

1998 Recommendations To Be Attained ............................................................................................ 21

Evaluation Considerations ................................................................................................................. 21

Strengthening the Pipeline to Medical School: Recommendations .......................................................... 21

Strengthening Upstream Efforts in Medical Training .................................................................................. 23

Admissions ............................................................................................................................................... 23

Findings .............................................................................................................................................. 23

1998 Recommendations To Be Attained ............................................................................................ 24

Evaluation Considerations ................................................................................................................. 24

Medical School Debt and Financial Assistance ........................................................................................ 24

Findings .............................................................................................................................................. 24

1998 Recommendations To Be Attained ............................................................................................ 27

Evaluation Considerations ................................................................................................................. 27
SEVENTEENTH REPORT OF COGME iv

URMs in Specialties ................................................................................................................................. 27

Findings .............................................................................................................................................. 27

1998 Recommendations To Be Attained ............................................................................................ 28

Evaluation Considerations ................................................................................................................. 28

URM Faculty ............................................................................................................................................ 28

Findings .............................................................................................................................................. 28

1998 Recommendations To Be Attained ............................................................................................ 30

Evaluation Considerations ................................................................................................................. 30

Strengthening Upstream Efforts in Medical Training: Recommendations ............................................... 31

Ensuring Cultural Competence in Medicine ................................................................................................. 33

Changing Demographics .......................................................................................................................... 33

Findings .............................................................................................................................................. 33

1998 Recommendations To Be Attained ............................................................................................ 35

Evaluation Considerations ................................................................................................................ 36

Ensuring Cultural Competence in Medicine: Recommendations ............................................................. 37

Bibliography ..................................................................................................................................................... 39

Appendix: A Review of Educational Pipeline Programs and Collaborations ............................................ 49
SEVENTEENTH REPORT OF COGME v

List of Tables

Table 1. Population Estimates for Hispanic and Non-Hispanic Racial/Ethnic 

 Groups and Percentages of Total U.S. Population, 2000 ..................................................8

Table 2. Population Projections for Hispanic and Non-Hispanic Racial/Ethnic Groups 

and Percentages of Total Population, by Decade ..............................................................8

Table 3. Percentages of Families Having Children Under Age 18 Living Below Poverty

 Level, by Race/Ethnicity and Family Type, 2002 ...........................................................10

Table 4. U.S. Census Estimates of U.S. Physicians, by Race/Ethnicity and Gender and 

 Rates per 1,000 Population in Each Group, 2000 ...........................................................11

Table 5. Percentages of Racial/Ethnic Groups Enrolled in U.S. Medical Schools,

 1998-99 Through 2002-2003 Academic Years .............................................................. 12

Table 6. Percentages of Racial/Ethnic Groups Enrolled in U.S. Osteopathic 

 Medical Schools, 1998-1999 Through 2001-2002 Academic Years ............................. 13

Table 7. Percentage of 1992 High School Graduates, by Race Ethnicity, Family Income,

 and Parents’ Highest Education Level ...........................................................................14

Table 8. Debt for Allopathic Medical School Graduates, by Years in Medical

 School, 2001 ...................................................................................................................25

Table 9. Influence of Debt on Specialty Choice for Medical School 

 Graduates, 2001 ..............................................................................................................25

Table 10. Average Debt by Practice Specialty Choice for Medical School Graduates

 Planning To Practice in an Underserved Area, 2001 .....................................................26

Table 11. Percentages of Undergraduates With Student Financial Aid, by Family 

 Income and Type of Aid .................................................................................................27

Table 12. Specialty Plans of URM and Non-URM U.S. Medical School Graduates, 

 2001 ...............................................................................................................................27

Table 13. Number and Percentages of U.S. Medical School Faculty, by 

 Race/Ethnicity, 2002 and 1998 and Percent Change .....................................................29

Table 14. U.S. Osteopathic Medical School Faculty, by Race/Ethnicity, 2001-2002

 and 1998-1999 and Percent Change ..............................................................................30

 
SEVENTEENTH REPORT OF COGME vi
SEVENTEENTH REPORT OF COGME vii

The Council on Graduate Medical Education (COGME) 

was authorized by Congress in 1986 to provide an ongoing 

assessment of physician workforce trends, training issues, 

and financing policies and to recommend appropriate Federal and private-sector efforts to address identified needs. 

The legislation calls for COGME to advise and make recommendations to the Secretary of the Department of Health and 

Human Services (DHHS); the Senate Committee on Health, 

Education, Labor, and Pensions; and the House of Representatives Committee on Commerce. Section 219 of the Department of Labor, Health and Human Services, and Education 

and Related Agencies’ Appropriations Act, 2004, Public Law 

102-394, 106 Stat. 1825, resulted in the Secretary of DHHS 

extending COGME through the end of the fiscal year.

The legislation specifies 17 members for the Council. 

Appointed individuals are to include representatives of practicing primary care physicians, national and specialty physician organizations, international medical graduates, medical 

student and house staff associations, schools of medicine and 

osteopathy, public and private teaching hospitals, health insurers, business, and labor. Federal representation includes 

the Assistant Secretary for Health, DHHS; the Administrator 

of the Centers for Medicare and Medicaid Services, DHHS; 

and the Chief Medical Director of the Veterans Administration.

CHARGE TO THE COUNCIL

The charge to COGME is broader than the name would 

imply. Title VII of the Public Health Service Act, as amended, 

requires COGME to provide advice and recommendations 

to the Secretary of DHHS and Congress on the following 

issues:

1. The supply and distribution of physicians in the 

United States;

2. Current and future shortages or excesses of physicians in medical and surgical specialties and subspecialties;

3. Issues relating to international medical school graduates;

4. Appropriate Federal policies with respect to the matters specified in items 1-3, including policies concerning changes in the financing of undergraduate 

and graduate medical education (GME) programs 

and changes in the types of medical education training in GME programs;

5. Appropriate efforts to be carried out by hospitals, 

schools of medicine, schools of osteopathy, and accrediting bodies with respect to the matters specified 

in items 1-3, including efforts for changes in undergraduate and GME programs; and

6. Deficiencies and needs for improvement in databases concerning the supply and distribution of, and 

postgraduate training programs for, physicians in 

the United States and steps that should be taken to 

eliminate those deficiencies.

In addition, the Council is to encourage entities providing GME to conduct activities to achieve voluntarily the recommendations of the Council specified in item 5.

COGME PUBLICATIONS

Reports

Since its establishment, COGME has submitted the following reports to the Secretary of DHHS and Congress:

• First Report of the Council (1988);

• Second Report: The Financial Status of Teaching 

Hospitals and the Underrepresentation of Minorities 

in Medicine (1990);

• Third Report: Improving Access to Health Care 

Through Physician Workforce Reform: Directions 

for the 21st Century (1992);

• Fourth Report: Recommendations to Improve Access to Health Care Through Physician Workforce 

Reform (1994);

• Fifth Report: Women and Medicine (1995);

• Sixth Report: Managed Health Care: Implications 

for the Physician Workforce and Medical Education 

(1995);

• Seventh Report: Physician Workforce Funding Recommendations for Department of Health and Human Services’ Programs (1995);

• Eighth Report: Patient Care Physician Supply and 

Requirements: Testing COGME Recommendations 

(1996);

• Ninth Report: Graduate Medical Education Consortia: Changing the Governance of Graduate Medical 

The Council on Graduate Medical Education
SEVENTEENTH REPORT OF COGME viii

Education to Achieve Physician Workforce Objectives (1997);

• Tenth Report: Physician Distribution and Health 

Care Challenges in Rural and Inner-City Areas 

(1998); 

• Eleventh Report: International Medical Graduates, 

The Physician Workforce and GME Payment Reform (1998);

• Twelfth Report: Minorities in Medicine (1998);

• Thirteenth Report: Physician Education for a Changing Health Care Environment (1999);

• Fourteenth Report: COGME Physician Workforce 

Policies: Recent Developments and Remaining 

Challenges in Meeting National Goals (1999);

• Fifteenth Report: Financing Graduate Medical Education in a Changing Health Care Environment 

(2000); and

• Sixteenth Report: Physician Workforce Policy 

Guidelines for the United States, 2000-2020 (January 2005).

OTHER COGME PUBLICATIONS

• Scholar in Residence Report: Reform in Medical 

Education and Medical Education in the Ambulatory Setting (1991);

• Process by which International Medical Graduates 

are Licensed to Practice in the United States (September 1995);

• Proceeding of the GME Financing Stakeholders 

Meeting (April 11, 2001) Bethesda, Maryland; 

• Public Response to COGME’s Fifteenth Report 

(September 2001);

• Council on Graduate Medical Education & National 

Advisory Council on Nurse Education and Practice: 

Collaborative Education to Ensure Patient Safety 

(February 2001);

• Council on Graduate Medical Education: What 

is it? What has it done? Where is it going? 

2nd Edition (2001); and

• 2002 Summary Report (2002).

COGME RESOURCE PAPERS

• Preparing Learners for Practice in a Managed Care 

Environment (1997);

• International Medical Graduates: Immigration 

Law and Policy and the U.S. Physician Workforce 

(1998);

• The Effects of the Balanced Budget Act of 1997 on 

Graduate Medical Education (2000);

• Update on the Physician Workforce (2000);

• Evaluation of Specialty Physician Workforce Methodologies (2000); and

• State and Managed Care Support for Graduate 

Medical Education: Innovations and Implications 

for Federal Policy (2004).

 

 For more information on COGME, visit the Council’s 

Web site at:

http://www.cogme.gov or contact:

Council on Graduate Medical Education

5600 Fishers Lane, Room 9A-21

Rockville, MD 20857

Voice: (301) 443-6785

Fax: (301) 443-8890
SEVENTEENTH REPORT OF COGME ix

Members

Chair

Carl J. Getto, M.D.

Senior Vice President Medical Staff Affairs/Associate

 Dean Hospital Affairs

University of Wisconsin Hospital & Clinics

Madison, Wisconsin

Vice Chair

Robert L. Johnson, M.D., Professor of Pediatrics and 

Vice Chair, Department of Pediatrics

New Jersey Medical School

Division of Adolescent and Young Adult Medicine

Newark, New Jersey

Ms. Laurinda L. Calongne

President

Robert Rose Consulting

Baton Rouge, Louisiana

William Ching, Medical Student

New York University School of Medicine

New York, New York

Allen Irwin Hyman, M.D., FCCM

Executive Vice President and Chief of Staff

Columbia-Presbyterian Medical Center

New York, New York

Rebecca M. Minter, M.D.

VAMC Ann Arbor Healthcare System

Surgery Service 

Ann Arbor, Michigan

Lucy Montalvo, M.D., M.P.H.

San Diego, California

Angela D. Nossett, M.D.

Executive Vice President

Committee of Interns and Residents (CIR)

Wilmington Family Health Center

Wilmington, California

Earl J. Reisdorff, M.D.

Director of Medical Education

Ingham Regional Medical Center

Department of Medical Education

Lansing, Michigan

Russell G. Robertson, M.D.

Department of Family and Community Medicine

Medical College of Wisconsin

Milwaukee, Wisconsin

Jerry Alan Royer, M.D., M.B.A.

229 Cascade Falls Drive

Folsom, California

Susan Schooley, M.D.

Chair, Department of Family Practice

Henry Ford Health System

Detroit, Michigan

Humphrey Taylor, Chairman

The Harris Poll, Harris Interactive

New York, New York

Douglas L. Wood, D.O., Ph.D., President

American Association of Colleges

of Osteopathic Medicine

Chevy Chase, Maryland

Statutory Members

Cristina Beato, M.D.

Acting Assistant Secretary for Health

 and Surgeon General

Washington, D.C. 

Mark B. McClellan, M.D., Ph.D.

Administrator, Centers for Medicare and

 Medicaid Services

Department of Health and Human Services

Washington, D.C. 

Robert H. Roswell, M.D.

Undersecretary for Health

Veterans Health Administration

Department of Veterans Affairs

Washington, D.C.

Designee of the Acting Assistant 

Secretary for Health

Howard Zucker, M.D., Deputy Assistant

Secretary for Health 

Department of Health and Human Services

Washington, D.C. 

Members of the Council on Graduate 

Medical Education
SEVENTEENTH REPORT OF COGME x

Designee of the Centers for Medicare and 

Medicaid Services

Tzvi M. Hefter, Director 

Division of Acute Care

Centers for Medicare and Medicaid Services

Baltimore, Maryland 

Designee of the Department of 

Veterans Affairs

Stephanie H. Pincus, M.D., M.B.A.

Chief Academic Affiliations Officer

Department of Veterans Affairs

Washington, D.C. 

Staff, Division of Medicine and Dentistry,

Bureau of Health Professions, HRSA

Department of Health and Human Services

Rockville, Maryland

Tanya Pagán Raggio, M.D., M.P.H.

Executive Secretary, COGME, and

Director, Division of Medicine and Dentistry (DMD)

O’Neal Walker, Ph.D.

Chief, Dental and Special Projects Branch/DMD

Jerald M. Katzoff

Deputy Executive Secretary

C. Howard Davis, Ph.D.

Staff Liaison

Helen K. Lotsikas, M.A.

Staff Liaison

Jaime Nguyen, M.D., M.P.H.

Staff Liaison

Eva M. Stone

Program Analyst and Committee Management Specialist

Anne Patterson

Secretary

Contractor for Report Preparation

Rhonda Ray, Ph.D.

East Stroudsburg University
SEVENTEENTH REPORT OF COGME 1

INTRODUCTION

In 1998, the Council on Graduate Medical Education 

(COGME) published its Twelfth Report, entitled Minorities in Medicine. This report made 21 recommendations for 

achieving two goals: 1) increase the number and proportion 

of underrepresented minorities (URMs) in medicine and 2) 

strengthen cultural competency in physicians. “Underrepresented minorities” refers to African Americans, Native 

Americans, Alaska Natives, Mexican Americans, and Mainland Puerto Ricans—minority groups represented in lower 

proportions in the health professions than in the United States 

(U.S.) population as a whole (1).1 

This report reviews the literature regarding the advancement of these goals since the 1998 COGME recommendations, assesses the progress made through 2003, and 

notes key findings. It also recommends ways to support the 

academic pipeline to facilitate minority entry into medical 

school, strengthen upstream (institutional and policy) efforts 

in medical training, and ensure cultural competence in medicine and medical education.

Increasing the number of URM students who successfully advance through the elementary, secondary, and postsecondary academic pipeline is the first step to enlarge the 

potential number of these students eligible to enter medical 

school. The educational pipeline for URMs, beginning with 

emphasis on reading skills in the early elementary grades and 

continuing through enrollment in medical training, must be 

enhanced to increase the number of URMs in medicine. Barriers to the successful negotiation of that pipeline are being 

addressed, but additional efforts are needed to reduce these 

barriers further. For example, many obstacles to children’s 

educational achievement lie in their personal environment, 

including poverty (3). Further, African American, Hispanic, 

and low-income high school graduates are less likely to be 

academically well prepared for college than other groups (4). 

Overcoming barriers to high school graduation and facilitating educational attainment for URMs must be priorities to increase their high school graduation rates, academic achievement, college admission and graduation, and admission to 

and graduation from medical school. 

Research indicates that the greatest barrier to URM admission to medical school is the low applicant pool of URM 

college graduates resulting from high attrition rates in high 

school and low enrollments in college. Recently, the rate of 

medical school applications for URM college graduates has 

been similar to or even higher than the application rate for 

non-URM college graduates (3). URM college graduates in 

2000-2001 applied to medical school at a rate of 28 per 1,000 

graduates compared to a rate of 25 per 1,000 white college 

graduates applying to medical school that year (5,6).2 To increase the pool of URM medical school applicants, the retention of URM students must be addressed, at both the high 

school and undergraduate levels. 

Increasing the number of URM physicians is an important step for improving health care for minority and underserved populations and, consequently, for decreasing health 

disparities, one of the Nation’s leading health priorities (7). 

Studies have shown that minority patients sometimes receive 

less health care and are less satisfied with their care when 

their physician is of a different race or ethnicity (8-14). Patients who lack proficiency in the English language also have 

less satisfaction with their health care and more difficulty 

in obtaining care than those patients who have no language 

barriers (8,15-17). Studies also show that, compared to nonunderrepresented physicians, URM physicians provide more 

care to minorities, the underserved, the uninsured, those 

insured by Medicaid, and low-income persons (18-20). A 

recent study has suggested that URM physicians may have 

more difficulty getting their patients admitted to hospitals 

and referring them to specialists or for testing (21). These 

studies indicate the need to train more well-qualified URM 

physicians and to address systemic and institutional barriers 

that URM physicians may face. 

The need for additional well-trained physicians representing URM groups is expected to be even more critical 

in the future, as URM populations are projected to grow 

more rapidly than non-URM populations (22). However, 

with the rapid expansion of minority populations and the 

lagging growth of minority physicians in the United States, 

non-URM physicians will continue to provide a large portion 

of health care to racial and ethnic groups different from their 

own. To ensure effective and equitable care for every person, 

all physicians, regardless of their ethnicity or race, should be 

trained to be aware of potential cultural barriers to quality 

health care. The need for increased cultural competence in 

physicians and practice settings has been widely recognized 

in published literature and has been incorporated into medical education accreditation standards and in graduate medical education outcomes (23-40). However, the best means for 

training physicians to be culturally competent continues to 

Executive Summary

1 On June 26, 2003, the Executive Council of the Association of American Medical Colleges (AAMC) approved a new definition for “underrepresented 

minorities”: “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” 

Individual medical schools can use this definition to determine population groups underrepresented in their geographic areas (2).

2

 Rates were computed using the data sources indicated. 
SEVENTEENTH REPORT OF COGME 2

be debated (25). More discussion and research are needed to 

determine the most effective methods of cultural competence 

training and the desired outcomes for that training. 

Promoting diversity among the physician workforce has 

been the goal of numerous organizations. Among the leaders 

in this effort are the Health Resources and Services Administration (HRSA), the Association of American Medical Colleges (AAMC), the Institute of Medicine, the National Medical Association, the National Hispanic Medical Association, 

and the Sullivan Commission on Diversity in the Healthcare 

Workforce. The efforts of these and other organizations have 

called attention to the urgency of diversifying the physician 

workforce and training physicians to be sensitive and effective in serving persons of any race or ethnicity. 

Medical training institutions have also sought to overcome barriers for URMs in medicine and have made strides 

in areas such as retention. Data for URM medical school matriculants beginning their training in 1996 show that 93 percent were either still enrolled or had graduated by their sixth 

year, compared to 92 percent of non-URMs who had graduated within five years (41). Nevertheless, additional strategies and policies are needed to strengthen the enrollment and 

retention of URMs in medical training (42). 

The June 2003 Supreme Court ruling determined that 

race/ethnicity as an admissions criterion can be justified as 

a compelling State interest, and approaches to admissions 

have been much discussed (42-52). Data show that, among 

URM applicants for 2001, 46.0 percent were accepted into 

medical school compared to 50.6 percent of non-URMs. 

African Americans had the lowest acceptance rate, 42.8 percent, compared to 53.4 percent for Mexican Americans, 60.4 

percent for applicants from Mainland Puerto Rico, and 51.0 

percent for Native Americans. African Americans also had 

lower Medical College Admission Test (MCAT) scores than 

other URM groups (53). Effective strategies for improving 

acceptance rates of URMs, especially for African American 

applicants, are needed. 

The continued increase in URM populations without a 

comparable increase in the supply of URM physicians indicates three important strategies for ensuring that URM populations have adequate health care: 1) increasing the number 

of URM students who successfully advance through the elementary, secondary, and post-secondary academic pipeline 

in preparation for entrance into medical school; 2) overcoming policy or systemic barriers at the level of medical training 

institutions, residency programs, licensing boards, specialty 

certification boards, and practice settings; and 3) providing 

effective cultural competence training for U.S. physicians to 

ensure quality health care to people of all cultures. 

Summarized below are key findings regarding achievement of the recommendations in COGME’s 1998 report 

Minorities in Medicine as well as recommendations for continued progress toward increasing the number of URM physicians and strengthening cultural competence in U.S. physicians. 

FINDINGS AND RECOMMENDATIONS

Strengthening the Pipeline to 

Medical School

Findings

1. Numerous K-12, post-secondary, and post-baccalaureate programs exist to enhance the academic preparation of URMs and to promote opportunities for pursuing medical careers (54-79). 

Among these programs are collaborations among 

medical schools, undergraduate and secondary 

schools, and community organizations (80-106).

Although some of these programs have been 

successful in helping to prepare URMs academically for medical school, inconsistent evaluation 

of these programs makes it difficult to compare 

program outcomes. 

2. Lack of persistence in completing high school 

and failure to enroll in and graduate from college are the greatest barriers to URM entry into 

medicine. URMs compose 30 percent of the U.S. 

college-age population, but only 14 percent of 

U.S. college graduates (3).

3. Data from the National Center for Education 

Statistics indicate that “family income” is the 

most influential factor in determining whether a 

high school senior will be “very well qualified” 

for college, based on class rank, grade point average (GPA), and scores on standardized tests 

(3,4,107).

4. Parents’ education and income levels affect academic achievement of children (3,4,107). Disproportionate numbers of URM children live in 

single-parent and low-income households (108), 

factors contributing to lack of success in early 

education, which impacts achievement at all other levels. 

5. For low-income high school graduates who are 

academically well prepared, being from a low-income family has less impact on college enrollment 

than whether students take the college entrance 

examinations and apply to college (4). 
SEVENTEENTH REPORT OF COGME 3

6. Although some programs promote children’s interest, academic achievement, and career choices 

in science and health (109-116), a need exists for 

appropriate organizations to partner with media, 

advertising and marketing firms, and video and 

audio production companies for developing and 

disseminating culturally appropriate messages 

targeted to minority and disadvantaged youth 

to encourage academic persistence and achievement and interest in medical careers.

Recommendations

1. Further efforts are needed to increase the number of URM college graduates to enlarge the pool 

of medical school applicants and URM physicians. 

2. Intense efforts should focus on retention of 

URMs in the educational pipeline from elementary school through secondary school, from entry 

in and graduation from undergraduate school, to 

entry in and graduation from medical school. 

3. Research is needed to understand better the barriers to academic achievement for URMs at all 

educational levels. Such barriers include cultural, linguistic, societal, economic, and systemic.

Effective interventions should be developed and 

implemented to address disproportionately high 

secondary school dropout rates among URMs to 

increase their enrollment in college. 

4. Standards of achievement and outcome measures 

are needed to determine which K-12, post-secondary, and post-baccalaureate programs should 

be considered as models for increasing academic 

achievement of URMs. 

5. More resources are needed to facilitate high 

school guidance counselors to assist URMs in 

taking entrance exams and applying to college 

and to place URMs in college preparatory schools 

and programs.

6. Organizations interested and involved in medical 

training should partner with media, advertising 

and marketing firms, and video and audio production companies to develop and implement effective communication campaigns targeting minority and disadvantaged youth with messages 

that encourage academic achievement, persistence in school, and interest in medicine. 

Strengthening Upstream Efforts in 

Medical Training

Findings

1. The AAMC, the U.S. Department of Education, 

the Institute of Medicine, and published literature have recommended the use of factors other 

than test scores and GPAs in medical school admissions and residency placement decisions (42-

52). However, a lack of evidence exists to indicate 

which non-quantitative factors are being used 

and to what extent such factors are being included in admissions/placement decisions. 

2. Among URM medical school applicants for 2001, 

46.0 percent were accepted into medical school 

compared to 50.6 percent of non-URMs. African 

Americans had the lowest acceptance rate, 42.8 

percent, compared to 53.4 percent for Mexican 

Americans, 60.4 percent for Mainland Puerto 

Ricans, 51.0 percent for Native Americans, 51.7 

percent for whites, 51.1 percent for Asians, and 

49.7 percent for applicants from the Commonwealth of Puerto Rico (53).

3. Research suggests that some residency program 

directors use scores from Step 1 of the United 

States Medical Licensing Exam (USMLE) to determine which applicants to interview for selection (117,118). African American applicants in 

one study were at least three times less likely to be 

interviewed (118). Data indicate that URMs usually score lower than non-URMs on the USMLE 

and other tests (117,119). Use of USMLE scores 

to screen applicants can create barriers for entry 

into some residency programs. 

4. Medical school debt has been increasing annually, reaching an average of $103,855 for U.S. 

graduates of allopathic medical schools in 2002 

(120). 

5. Mean educational debt is generally higher for 

URMs than non-URMs in medical school, although mean debt is almost equal for URMs and 

non-URMs graduating from private medical 

schools (121,122).

6. Among new medical school matriculants in 2001, 

twice as many URMs as non-URMs (30 percent 

vs. 14 percent) indicated that scholarships would 

be used to finance their education. Non-URMs 

were more likely than URMs (17 percent versus 6 
SEVENTEENTH REPORT OF COGME 4

percent) to report that family members or spouses would contribute financially to their medical 

education (123). 

7. Among 2001 medical school graduates, URMs 

were more likely to receive scholarship assistance 

and more scholarship dollars than non-URMs. 

Three quarters of URM medical school graduates in 2001 received scholarship assistance compared to fewer than half of non-URMs. On average, URM medical school graduates received 

$35,000 in scholarships compared to $25,780 for 

non-URMs (124).

8. Twenty-five percent of URM medical school students matriculate in medical school for more than 

4 years, compared to 10 percent of non-URMs 

(125). The greater proportion of URMs than nonURMs who spend more years in medical school 

indicates the likelihood of higher mean debt for 

URMs. 

9. More than two thirds of 2001 URM and non-URM 

graduates of allopathic medical schools indicated 

that debt had no influence on their specialty selection (126). Osteopathic medical students who 

were seniors in 2001-2002 also reported that debt 

level had only a “minor influence” on specialty 

choice (127). 

10. AAMC Graduate Questionnaire data indicate 

that for 2001 allopathic medical school graduates, higher proportions of URMs than nonURMs planned to enter generalist and surgical 

specialties, but higher proportions of non-URMs 

than URMs planned to enter medical specialties. 

About the same proportions of both groups anticipated entry into support specialties (128). 

11. Nearly half of URM medical school graduates in 

2001 compared to 19 percent of non-URM graduates planned to practice in underserved areas 

(128). 

12. Recruiting and retaining minority faculty physicians continue to be important goals, especially 

as evidence indicates that minority faculty are 

more dissatisfied with their careers than non-minority faculty are (129).

13. Seven percent of allopathic medical school faculties were reported as URMs for 2002, an increase of 33 percent since 1998. However, these 

data are inconclusive because race/ethnicity for 

4.1 percent of 2002 faculty and for 6.1 percent of 

1998 faculty was reported as “Other/Unknown”3

(130,131). 

14. In 2001, 3.5 percent of osteopathic medical school 

faculties were reported as URMs, compared to 

3.0 percent in 1998. As for allopathic faculty, race 

was reported as “Other/Unknown” for large proportions of osteopathic medical school faculty: 

4.6 percent for 2001-2002 and 5.4 percent for 

1998-1999 (132).

15. Few programs have been reported that support 

minority medical school students interested in 

pursuing an academic career. One such program 

is the Fellowship Program in Academic Medicine, funded by Bristol-Meyers Squibb (133). 

16. Six Centers of Excellence in Women’s Health 

offer support to help improve minority women 

faculty’s career advancement opportunities. The 

centers recommend evaluation of progress by 

establishing target indicators, institutional support for advancement, retention strategies, and 

increased research of issues related to advancement of minority faculty (134).

Recommendations

1. Desirable outcome measures that include nonquantitative considerations for medical school 

students should be established and used in admissions decisions. 

2. Residency program directors should also consider qualitative as well as quantitative factors when 

deciding which residency candidates to interview 

and select. 

3. Qualitative criteria used in medical school admissions and residency placement decisions should 

be documented and assessed to determine which 

ones are most predictive of successful outcomes. 

4. More research is needed to assess the impact of 

medical school debt on URMs’ decision to apply 

to, matriculate into, and graduate from medical 

school.

5. Assessment of whether increased scholarship assistance rather than loans might encourage more 

URMs to pursue medicine as a career would be 

helpful.

3 “Unknown” indicates that race/ethnicity was not reported. 
SEVENTEENTH REPORT OF COGME 5

6. More research is needed to evaluate obstacles 

or motivations for minority entry into primary 

care or specialty residency programs. Medical 

schools should track medical students’ interest in 

specialties at entry into medical school, at the beginning of the clinical year, and at graduation to 

assess factors that influence choice of specialties 

for both URMs and non-URMs. 

7. Medical schools should develop and implement 

plans for recruiting and retaining minority faculty physicians, including assessing and enhancing the institutional climate for URM faculty. 

8. Minority medical students, residents, and physicians who aspire to serve as faculty should be 

identified and mentored early in their careers. 

9. Interventions should be developed that encourage physicians to practice in underserved areas 

for periods that extend beyond the time commitment of programs requiring service in exchange 

for funding opportunities. 

10. Research is needed to determine optimal conditions and exposure time required for medical 

students to develop and maintain an interest in 

serving in underserved communities.

11. Strategies are needed to assess and reinforce 

the commitment of academic medical centers to 

providing care to underserved populations. This 

commitment should be integral to the academic 

environment and mission and should be fostered 

by means other than funding incentives. 

Ensuring Cultural Competence in 

Medicine 

Findings

1. The need for cultural competence training in 

medical education is widely recognized. This 

training is increasingly available in various venues and methods of educational delivery (23-40). 

Most medical schools report that they have cultural competence instruction incorporated into 

required and elective courses, but few have required courses specifically dedicated to cultural 

competence (135). 

2. Much uncertainty exists regarding the best way 

to teach cultural competence to medical students 

and residents, and problems with some current instructional methods have been reported 

(25,27,28,33,136-142). 

3. Resources from both public and private agencies have been devoted to developing curricula 

and programs to enhance cultural competence in 

medical school and residency training as well as in 

practices. Publications, Web sites, audio and satellite broadcasts, and training modules are available to help educate practitioners about becoming more culturally competent (24,26,30,31,33-

37,143-159). 

4. Evaluation is considered critical to any program, 

yet little information exists regarding cultural 

competence evaluation outcomes (33,141). 

5. Accreditation standards for both undergraduate and graduate medical education include cultural competency training (38-40). The American 

Board of Medical Specialties and some specialties are also committed to cultural competency 

standards (39,160,161).

6. Although medical licensing boards do not test for 

cultural competence, Step 3 of the USMLE uses 

diverse patients as part of the clinical assessment 

so that examinees must respond to clinical situations that include cultural contexts (162).

7. Continuing medical education (CME) does not 

require education in cultural competency, but a 

few medical schools offer CME training in cultural competence (163-165). 

8. At least three States have pending legislation that 

will mandate that the medical schools in each 

State require at least one course in cultural competency as part of their curricula. Physicians in 

those States must also complete cultural competency training for relicensing. Another State will 

provide for local and State medical societies to 

offer a voluntary cultural competency program 

for physicians (166-169). 

9. Quality standards, including standards for culturally competent care, have been developed for 

use by health plans contracting to provide health 

care services for Medicare and Medicaid patients 

(170-173). The National Committee for Quality Assurance, using the Health Plan Employer 

Data and Information Set (HEDIS®) measures, 

requires managed care organizations to address 

members’ cultural needs, but does not require 

assessment of providers’ cultural competence 

(174). 
SEVENTEENTH REPORT OF COGME 6

10. Although National standards exist, research suggests that State contract language with managed 

care organizations is vague, making standards 

difficult to enforce (175-176). 

11. Although health plans generally do not collect 

data on race and ethnicity of patients, research 

indicates that data acquired from other sources 

can provide a means for health care organizations to evaluate quality of care for patients and 

thus determine disparities in health care of minority patients (177-178). 

Recommendations

1. The varied definitions of cultural competence 

and approaches to cultural competency instruction indicate a need for further research and 

discussion to determine key objectives, desired 

outcomes and competencies, and ways to assess 

progress toward those outcomes in medical education. A National conference should be held at 

which these issues can be more fully addressed.

2. Data are needed to determine whether cultural 

competency training enables medical students, 

residents, and physicians to become more culturally competent and whether that training affects 

patient outcomes.

 

3. The Federation of State Medical Boards should 

encourage individual State licensing boards to 

institute voluntary cultural competency training 

for physicians. 
SEVENTEENTH REPORT OF COGME 7

The Council on Graduate Medical Education (COGME), 

established by Congress in 1986, advises the Secretary of the 

United States (U.S.) Department of Health and Human Services (DHHS), the Senate Committee on Health, Education, 

Labor and Pensions, and the House of Representatives Committee on Commerce. To ensure health care delivery to the 

Nation, the Council makes recommendations regarding the 

supply and distribution of physicians, training issues, and appropriate efforts of public and private sectors, including medical schools, teaching hospitals, and accrediting bodies. The 

diversity of the physician workforce, the training of minority 

physicians, and the contributions made by minority physicians in providing health care to medically underserved areas 

are all-important parts of COGME’s mission. 

Since its inception, COGME has expressed concern that 

minorities are greatly underrepresented in medicine and has 

made recommendations to address the need for a physician 

workforce that reflects the Nation’s diversity. In 1998, COGME issued its Twelfth Report, which made 21 recommendations for increasing underrepresented minorities (URMs) in 

medicine and for enhancing the cultural competence of the 

Nation’s physician workforce. “Underrepresented minorities” refers to African Americans, Native Americans, Alaska 

Natives, Mexican Americans, and Mainland Puerto Ricans—

minority groups represented in lower proportions in the health 

professions than in the U.S. population as a whole (1). 

Despite efforts during the past 3 decades to increase 

minority participation in medicine, some racial and ethnic 

groups remain underrepresented in medical education and 

in medicine, from medical school applicants and faculty 

members to practitioners in some specialties and managed 

care practices. COGME continues to dedicate its efforts to 

increasing URMs in medicine both to enhance equity among 

persons of all cultures and to address one of the Nation’s 

health priorities: reducing health disparities among racial 

and ethnic groups. 

Healthy People 2010, which summarizes the health objectives for the Nation, has targeted the elimination of health 

disparities as one of two overarching National health goals 

(7). Congress, too, has recently introduced the Healthcare 

Equality and Accountability Act to improve the health care 

of minorities. This bill establishes a Center for Cultural and 

Linguistic Competence in Healthcare within DHHS, creates 

a National Working Group on Workforce Diversity to review 

and recommend workforce initiatives, and requires health 

professions schools that receive Federal funding to submit 

information for a National database on race and ethnicity in 

the health professions (179).

Responding to the need to improve the health status of 

minorities, this report reviews the literature since the 1998 

COGME recommendations for increasing the number of 

URM physicians and for promoting cultural competence 

in health care providers. It assesses progress made through 

2003, notes key findings, and recommends ways to support 

the pipeline to medical school, to strengthen upstream efforts 

in medical training, and to ensure cultural competence in 

medicine and medical education. 

IMPLICATIONS OF CHANGING 

DEMOGRAPHICS IN THE U.S.

Racial and ethnic minority populations in the U.S. are 

growing more rapidly than white populations. U.S. Census 

Bureau estimates for 2000 indicate that African Americans, 

American Indians and Alaska Natives, and Hispanics currently represent a quarter of the U.S. population, and Asians 

and Pacific Islanders compose an additional 4 percent. 

Whites make up 69 percent of the Nation’s population (see 

Table 1) (180). However, Census Bureau projections indicate 

that some racial and ethnic minority populations will steadily 

outpace whites in growth (see Table 2). 

By 2010, Hispanics, African Americans, and American 

Indians and Alaska Natives are expected to represent 28 percent of the U.S. population, and Asian Americans and Pacific Islanders will bring that proportion up to almost a third 

of the total U.S. population. By 2050, non-Hispanic whites 

will comprise just over half of the Nation’s populace, and 

Hispanics will represent almost a quarter of the population. 

Every year from now until 2050, the Hispanic ethnic group is 

expected to add the largest number of people to the Nation’s 

population of all racial or ethnic groups. African Americans 

are also expected to increase, but more gradually, to just over 

13 percent of the population. Projections indicate that Asians 

and Pacific Islanders will more than double to almost 9 percent. Native Americans and Alaska Natives are expected to 

remain about the same at just under 1 percent of the U.S. 

population (22).1

The expected increase in minority populations has several implications for the health of the Nation. Estimates for 

2000 indicate that over a third of Hispanics are foreign born, 

suggesting limited language proficiency for a large portion of individuals of Hispanic ethnicity. Similarly, 62 percent of Asian Americans and Pacific Islanders were foreign 

born in 2000, indicating another large population group for 

whom English is a second language (see Table 2) (22). In 

communicating with health care providers, these individuals 

Introduction

1 These expected population trends may be underestimated. The 2000 census shows retrospectively that earlier estimates for 2000 have been underestimated 

by over 6,000,000. New projections based on 2000 census estimates are currently unavailable.
SEVENTEENTH REPORT OF COGME 8

TABLE 1

Population Estimates for Hispanic and Non-Hispanic 

Racial/Ethnic Groups and Percentages 

of Total U.S. Population, 2000 (180)

Population Groups Number Percentage of Total

Total 281,421,906 100.0

Non-Hispanic White 194,552,774 69.1

Non-Hispanic Asian/Pacific 

Islander 10,476,678 3.7

Non-Hispanic African 

American 33,947,837 12.1

Hispanic 35,305,818 12.5

Non-Hispanic Native 

American/Alaska Native 2,068,883 0.7

Non-Hispanic Other 467,770 0.2

Non-Hispanic Multiple Race 4,602,146 1.6

TABLE 2

Population Projections for Hispanic and 

Non-Hispanic Racial/Ethnic Groups and Percentages 

of Total Population, by Decade*

(U.S. Total in Thousands) (22)

Population Group 2000 2010 2020 2030 2040 2050

Total 275,306 299,861 324,926 351,070 377,349 403,686

Non-Hispanic White 71.4 67.3 63.8 60.1 56.3 52.8

Non-Hispanic Asian/

Pacific Islander 3.9 4.8 5.7 6.7 7.8 8.9

 Native Born 37.9 40.5 43.8 46.5 49.3 52.5

 Foreign Born 62.1 59.5 56.2 53.5 50.7 47.5

Non-Hispanic 

African American 12.2 12.5 12.8 13.0 13.1 13.2

Hispanic 11.8 14.6 17.0 19.4 21.9 24.3

 Native Born 64.5 66.5 70.5 73.9 76.9 80.0

 Foreign Born 35.5 33.5 29.5 26.1 23.1 20.0

Non-Hispanic Native 

American/Alaska 

Native 0.7 0.8 0.8 0.8 0.8 0.8

*Projections for percent calculations based on 1990 U.S. Census estimates.
SEVENTEENTH REPORT OF COGME 9

experience language barriers affecting whether they will seek 

care, be properly diagnosed, receive appropriate treatment, 

and be satisfied with their care (8,9,15-17,181,182).

As racial and ethnic minorities increase, a corresponding need exists for increased numbers of minority physicians 

from those groups underrepresented in medicine. Some minorities report more satisfaction with physicians of their own 

race or with those who speak their language, and they select a 

physician of their own race or ethnicity when given a choice 

(8,10,16). Further, differences in health care may result when 

patients and physicians have different races or ethnicities 

(11-15). 

Despite the growing need for more minority physicians, 

for the foreseeable future, physicians from non-URM groups 

will provide care to substantial numbers of patients who differ from them racially or ethnically. 

HEALTH DISPARITIES

To help reduce health disparities among racial and ethnic groups, more URM physicians are needed. An increase 

in racially and ethnically concordant patient-physician relationships can lead to increased health care and better health 

outcomes for underserved and vulnerable populations (18). 

The National Center for Health Statistics (NCHS) reports the following trends regarding health disparities among 

racial and ethnic groups: 

• The gap in the life expectancy between African 

American and white populations has been narrowing, but remains. In 1990, life expectancy at birth 

was 7 years longer for whites than for African 

Americans. By 2000, this difference had narrowed 

to 5.7 years. Preliminary data suggest that the gap 

has further narrowed to 5.5 years for 2001. 

• In 2001, mortality was 31 percent higher for African 

Americans than for white Americans. This gap represents a decrease from 37 percent in 1990. 

• Age-adjusted death rates for 2001 were greater for 

African Americans than for whites by 40 percent for 

stroke, 29 percent for heart disease, 25 percent for 

cancer, and nearly 800 percent for HIV disease. 

• Despite similar mammography screening rates for 

white and African American women, breast cancer 

mortality for African Americans has risen far above 

that for whites. In 2000, breast cancer mortality for 

African American women was 31 percent higher 

than for whites compared to 15 percent higher in 

1990. Preliminary data for 2001 indicate that this 

gap has widened to 34 percent. 

• Rates of death from homicides among both African 

American and Hispanic males ages 15-24 decreased 

by about half from the early 1990s. However, these 

rates remain substantially higher than rates for 

young non-Hispanic white males. 

• Although death rates from HIV disease have declined sharply since 1995 for Hispanic and African 

American males ages 25-44, in 2000, HIV was still 

the second leading cause of death for Hispanic males 

in this age group and the third leading cause for African American males in this age group. HIV death 

rates remained much higher for African American 

and Hispanic males than for non-Hispanic white 

males in this age group. 

• Rates of death from motor vehicle-related injury 

and from suicide for Native American males ages 

15-24 were about 45 percent higher than rates for 

white males in this age group. Despite these disparities, death rates for Native Americans are known to 

be underestimated, so this difference may be even 

greater. 

• Mortality for Asian males was 40 percent lower 

than for white males through the 1990s. In 2000, 

age-adjusted rates for cancer and heart disease for 

Asian males were 38-41 percent lower than rates for 

white males. Death rates for the Asian population 

are known to be underestimated, so this gap may be 

less than reported. 

• Infant mortality rates have declined for all racial and 

ethnic groups, but disparities remain. In 2000, the 

highest infant mortality rate was for infants of nonHispanic African American mothers (13.6 deaths 

per 1,000 live births), and the lowest was for mothers of Chinese origin (3.5 per 1,000 live births). 

• Infant mortality increases as the mother’s education decreases. In 2000, the infant mortality rate for 

mothers having fewer than 12 years of schooling 

was 58 percent higher than that for mothers who had 

13 or more years of education. 

• Early prenatal care (the first trimester of pregnancy) 

increased among all racial and ethnic groups from 

1990-2001 but varied from 69 percent for Native 

American mothers to 90-92 percent for mothers of 

Japanese and Cuban origin. 

• In 2001, Hispanics and Native Americans under age 

65 were more likely to have no health insurance 

than those in other racial and ethnic groups. Persons 

of Mexican origin were most likely to lack health in-
SEVENTEENTH REPORT OF COGME 10

surance (39 percent), whereas non-Hispanic whites 

were least likely to lack insurance (12 percent).

• Among children under age 18, Hispanic children 

were more likely to lack a usual source of health 

care than non-Hispanic African American children 

or non-Hispanic white children (14 percent compared to 7 percent and 4 percent, respectively). 

• Adults ages 18-64 and living below poverty level 

were over twice as likely to have no usual source 

of health care than those living above the poverty 

level (27 percent versus 12 percent). Of those living 

in poverty, Hispanic adults were twice as likely to 

have no usual source of health care as non-Hispanic 

whites or African Americans (44 percent versus 22 

percent and 21 percent, respectively) (183).

INFLUENCES ON HEALTH 

DISPARITIES

The reasons underlying health disparities among racial and ethnic groups are complex and range from access 

to health care to the ease with which physicians treating 

minority patients can admit their patients into hospitals or 

refer patients to specialists or for tests as needed. However, 

as Healthy People 2010 notes, education and income levels 

affect health and influence health disparities. Education and 

income are closely associated and often serve as a proxy for 

one another because education levels closely parallel income 

levels (7). 

Death rates vary by education levels. For 2000, the ageadjusted death rate for 25-64 year olds having fewer than 12 

years of education was nearly three times that for persons 

in the same age group having 13 or more years of education 

(183). More years of education add more years of life. The 

average education level in the U.S. population has been increasing over the past decades and appears to be contributing 

to slight increases in life expectancy. 

Further, as Healthy People 2010 notes, “For women, 

the amount of education achieved is a key determinant of 

the welfare and survival of their children. Higher levels of 

education also may increase the likelihood of obtaining or 

understanding health-related information needed to develop 

health-promoting behaviors and beliefs in prevention” (7).

In addition, those in higher-income brackets experience 

better health than low-income persons. For example, 65-

year-old men having the highest incomes can expect to live 3 

years longer than those with the lowest incomes (7). According to the U.S. Census Bureau, in 2002, 34.6 million or 12.1 

percent of the U.S. population lived in poverty, an increase 

of 11.7 percent from the previous year. More than a third of 

those living in poverty (12.1 million) were children under age 

18 (184). 

Education and income levels differ by race and ethnicity 

as well as by type of household. Table 3 shows the percentage 

of families living below the poverty level. Households with 

married couples have the lowest proportion of poverty for 

all racial and ethnic groups, and female households (no husband present) have the highest proportions of poverty. More 

families with children under age 18 live in poverty than those 

families without children under age 18. Among married couple households, Hispanics experience higher proportions of 

poverty than other groups: 17.7 percent of Hispanic households with children under age 18 live in poverty, compared to 

8.5 percent for African Americans and 4.1 percent for whites. 

Of female households having children under age 18 present, 

similar proportions for both Hispanic and African Americans 

live below the poverty level: 41.4 percent and 41.3 percent, 

respectively, compared to 26.2 percent for whites and 21.2 

TABLE 3

Percentages of Families Having Children Under Age 18 Living Below Poverty 

Level, by Race/Ethnicity and Family Type, 2002* (108)

Race/Ethnicity and 

Presence of Children 

Under Age 18 

Percentage of All 

Families Below 

Poverty Level

Percentage of 

Married-Couple 

Families Below 

Poverty Level

Percentage of 

Male Households 

(no wife present) 

Below Poverty 

Level

Percentage of 

Female Households 

(no husband 

present) Below 

Poverty Level 

Non-Hispanic White 8.5 4.1 10.4 26.2

African American 27.3 8.5 26.5 41.3

Asian 9.2 7.0 19.0 21.2

Hispanic 24.1 17.7 23.6 41.4

*Percentages are based on total number of families in each group as of March 2003. Data for Native 

Americans are not available.
SEVENTEENTH REPORT OF COGME 11

percent for Asians. Male households (no wife present) having 

children under age 18 experience less poverty than female 

households but more than married-couple households: 26.5 

percent for African Americans, 23.6 percent for Hispanics, 

19.0 percent for Asians, and 10.4 percent for whites (108). 

WHO IS A URM IN MEDICINE?

On June 26, 2003, the Executive Council of the Association of American Medical Colleges (AAMC) approved a new 

definition for “underrepresented minorities”: “‘Underrepresented in medicine’ means those racial and ethnic populations 

that are underrepresented in the medical profession relative to 

their numbers in the general population.” Individual medical 

schools can use this definition to determine which population 

groups are underrepresented in their geographic areas. The 

AAMC will collect data by population groups based on the 

racial and ethnic categories used by the U.S. Census Bureau 

(2). Before the new definition, the term “underrepresented 

minority” referred to African Americans, Native Americans 

(American Indians, Alaska Natives, and Native Hawaiians), 

Mexican Americans, and Mainland Puerto Ricans. The research reported in this document refers to the racial and ethnic groups included in the former definition. 

TRENDS IN MINORITY 

PARTICIPATION IN MEDICINE

According to U.S. Census Bureau estimates of U.S. physicians for 2000, 4.4 percent of physicians are non-Hispanic 

African Americans, 5.1 percent are Hispanic/Latinos, and 

.002 percent are non-Hispanic Native Americans or Alaska 

Natives. Thus, these estimates indicate that fewer than 10 

percent of U.S. physicians are URMs. Non-Hispanic whites 

compose 73.8 percent of physicians, and non-Hispanic 

Asians, Native Hawaiians, and Pacific Islanders make up another 14.9 percent of U.S. physicians (see Table 4) (185).

Rates of physicians per 1,000 population in each group 

reveal that non-Hispanic whites are the most represented 

population group in medicine: 2.66 physicians per 1,000 

population. Hispanic/Latino physicians are available at the 

rate of just over one per 1,000 Hispanic/Latinos. Non-Hispanic African American physicians are available at a rate of 

fewer than one physician per 1,000 persons in that group. 

The rate of non-Hispanic Native American or Alaska Native 

physicians per 1,000 persons in these population groups is 

.57 (see Table 4) (185).

TABLE 4

U.S. Census Estimates of U.S. Physicians, by Race/Ethnicity and 

Gender and Rates per 1,000 Population in Each Group, 2000 (185)

Population Group Male Female Total

Percentage 

of Total U.S. 

Physicians

Rate per 

1,000 

Population*

Total U.S. Physicians 513,923 186,923 700,846 100 2.49

Total Non-Hispanic 488,094 177,101 665,195 94.9 2.70

Non-Hispanic White 392,732 124,306 517,038 73.8 2.66

Non-Hispanic African 

American 18,172 12,741 30,913 4.4 0.91

Non-Hispanic 

American Indian/

Alaska Native 765 406 1,171 .002 0.57

Non-Hispanic Asian/ 

Native Hawaiian/Pacific 

Islander 68,511 35,891 104,159 14.9 9.94

Non-Hispanic Other 848 412 1,260 .002 2.69

Non-Hispanic Multiple 

Race 7,066 3,345 10,411 1.5 2.26

Hispanic/Latino 25,829 9,822 35,651 5.1 1.01

*Rates are based on U.S. Census estimates for Hispanic/Latinos and Non-Hispanic/Latinos by race.
SEVENTEENTH REPORT OF COGME 12

According to the AAMC, after a 6-year decline in applications to U.S. medical schools, applicants for the 2003-2004 

academic year increased by 3.4 percent to a total of almost 

35,000. Included in this increase was a 5 percent increase in 

African American applicants for a total of 2,736, including a 

10 percent increase in female African American applicants 

for a total of 1,904. Hispanic applicants also increased by 

less than 2 percent to 2,483. Despite these gains in number of 

applicants, the number of African Americans and Hispanics 

who matriculated into medical school decreased. A total of 

1,056 African Americans entered medical school for a 6 percent decline, and 1,089 Hispanics matriculated, for a decline 

of almost 4 percent (186). 

The number of medical school applicants peaked in 1996 

at about 47,000, but since then, that number has decreased by 

as many as 4,000 applicants each year. The lowest number of 

applications received was for the 2002-2003 academic year, 

when 33,625 prospective students applied to medical school. 

The decline in male applicants appears to have leveled off 

for 2003-2004, when 17,113 males applied, a slight increase 

over the 17,069 male applicants for 2002-2003 (187). 

Since the 1998-1999 academic year, proportions of allopathic medical students by race and ethnicity have fluctuated 

slightly, but have remained relatively stable for most groups 

(see Table 5). In the 2002-2003 academic year, 7.4 percent of 

medical students were African American; 2.9 percent were 

Mexican and Mainland Puerto Rican; an additional 3.5 percent were from other Hispanic groups; and 0.9 percent were 

Native American. Whites represented 64 percent of medical 

students in 2002-2003, and Asians and Pacific Islanders composed another 20.5 percent. Persons for whom race/ethnicity 

is unreported can affect percentages, and 1.4 percent of medical students in 2002-2003 had no reported race or ethnicity. 

Total numbers of enrolled allopathic medical students fluctuated slightly during the academic years from 1998-1999 

through 2002-2003 from a high to 66,476 in 1998-1999 to a 

low of 65,963 in 2000-2001 (187). 

URMs enroll in osteopathic medical schools at lower 

rates than in allopathic medical schools. However, total enrollment of osteopathic students has been increasing (see 

Table 6). During the 1998-1999 school year, 9,882 students 

(excluding foreign national students) matriculated in osteopathic medical schools, and African Americans, Native 

Americans, and Hispanic students composed 8.7 percent of 

enrollees. The proportion of students from these groups was 

7.8 percent in 2001, a decrease in percentage from 1998, but 

the actual number of URM students remained stable, increasing from 859 to 861. Total enrollment of osteopathic students 

increased by 12 percent to 11,101 students from 1998-1999 

through 2001-2002, accounting for the decline in percentage, 

but not the number of URMs matriculating in osteopathic 

medical schools (188).

BARRIERS TO THE EDUCATIONAL 

PIPELINE 

As a broad measure to increase minorities in medicine, 

COGME’s Twelfth Report recommended strategies and initiatives to enhance the educational pipeline to improve the 

academic preparation of children and adolescents from underrepresented population groups. A recent study published 

in Academic Medicine reinforces the need to ensure that 

TABLE 5

Percentages of Racial/Ethnic Groups 

Enrolled in U.S. Medical Schools,

1998-1999 Through 2002-2003 Academic Years (187)

Race/Ethnicity 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003

Total Enrollment 66,476 66,237 65,963 65,989 66,334

African American 7.7 7.6 7.4 7.2 7.4

Native American 0.9 0.9 0.8 0.8 0.9

Mexican/Mainland 

Puerto Rican

 

3.5 3.3 3.2 3.1 2.9

Other Hispanic 3.1 3.1 3.1 3.2 3.5

White 64.6 64.3 63.9 63.2 64.0

Asian/Pacific 

Islander 19.2 19.6 20.1 19.9 20.5

Unknown 0.1 0.2 0.4 0.5 1.4
SEVENTEENTH REPORT OF COGME 13

URM youth can overcome educational barriers and succeed 

academically. Data show that if URMs stay in the academic 

pipeline, proportions of URM college graduates who apply 

to medical school are similar to or even higher than proportions of white college graduates applying to medical school 

(3). URM college graduates in 2000-2001 applied to medical 

school at a rate of 28 per 1,000 graduates compared to a rate 

of 25 per 1,000 white college graduates applying to medical 

school that year (4,5).2 Increased efforts are needed to ensure 

that children from URM groups can succeed in elementary 

and high school so that they enroll in and graduate from college. Overcoming these early hurdles will facilitate increased 

application and admission to medical school. 

Parental education and parental income affect the academic achievement of students (3,4,107). According to the 

U.S. Department of Education, over half of both Hispanic 

and non-Hispanic African American high school graduates 

in 1992 were from families having incomes under $25,000, 

compared to a third of Asian high school graduates and 21 

percent of white high school graduates (see Table 7). Also, 

for 1992 high school graduates, 15.0 percent of Hispanics 

and 16.9 percent of African Americans had parents who had 

graduated from college, compared to 36.2 percent of whites 

and 48.9 percent of Asians (see Table 7). Data also show that 

high school graduates who are African American or Hispanic 

or who come from low-income families are less likely to be 

academically well prepared for college. Even among those 

who are academically prepared, Hispanic and low-income 

students are less likely to take entrance exams and apply for 

admission to a 4-year college than other groups (4).

 

Parents’ income and education are also associated with 

college enrollment. Data from the U.S. Department of Education show that 49 percent of 1996 high school graduates from 

low-income families enrolled in either 2- or 4-year colleges 

in the same year after graduation, compared to 63 percent of 

students from middle-income families and 78 percent of students from high-income families. These data also indicate that 

89 percent of 1996 high school graduates whose parents had 

completed at least a bachelor’s degree were enrolled in either 

a 2- or 4-year college in the academic year after completing 

high school, compared to 45 percent of high school graduates 

whose parents had not completed high school (107). 

However, for high school graduates who are academically well prepared, being from a low-income family does 

not affect college enrollment as much as whether or not 

low-income students take college entrance examinations and 

apply to college. One study notes, “. . . if low-income students have an academic record and aptitude test scores which 

demonstrate even the minimal qualifications for admission 

to a 4-year institution, if they take a college entrance examination, and if they submit an application for admission, the 

majority of low-income students enroll in post-secondary 

education. . . .” Over 83 percent of academically prepared 

low-income students who took the college entrance exams 

and submitted a college application enrolled in a 4-year college or university (4). 

In addition to affecting academic achievement, as 

Healthy People 2010 notes, low education and income levels 

are associated with poor health outcomes that contribute to 

TABLE 6

Percentages of Racial/Ethnic Groups Enrolled in 

U.S. Osteopathic Medical Schools, 1998-1999 Through 

2001-2002 Academic Years (188)

Race/Ethnicity 1998-1999 1999-2000 2000-2001 2001-2002

Total Enrollment 9,882 10,388 10,817 11,101

African American 4.2 3.8 3.7 3.7

Native American 0.7 0.6 0.7 0.6

Hispanic* 3.7 3.6 3.7 3.7

Non-Hispanic White 76.2 75.6 73.4 72.6

Asian/Pacific Islander 14.2 14.8 16.0 16.4

Other/Unknown 1.0 1.6 2.7 3.25

*Hispanic includes all groups reporting Hispanic origin.

2

Rates were computed using the data sources indicated.
SEVENTEENTH REPORT OF COGME 14

health disparities (7). Disproportionate rates of URM children live in low-income households and single-parent households (184). 

Examining birth rates for 2000 for unmarried women reveals a disproportionate number of births to young mothers 

who are from URM groups. Among Hispanic women ages 

15-17, the birth rate was 51.0 per 1,000 unmarried women in 

this group. The birth rate for African American women ages 

15-17 was 49.9, and the rate for non-Hispanic white women 

ages 15-17 was 13.6. For women ages 18-19, the rate for 

Hispanic unmarried women was 110.6 per 1,000 unmarried 

women in this group; for African American women ages 18-

19, the rate was 116.9; and for non-Hispanic white women 

ages 18-19, the rate was 41.4. In raw numbers, the number 

of births to unmarried non-Hispanic white women ages 15-

17 was 49,964, compared to 42,789 non-Hispanic African 

Americans ages 15-17, and 39,466 Hispanic women (189). 

These disproportionately high numbers of births to young 

unmarried women from groups having relatively low populations indicate large numbers of children whose mothers often 

have interrupted their secondary education and have low incomes. The babies of these young mothers are also at high 

risk for infant mortality (183).

Not only does early parenting create barriers to educational achievement, but the children of young mothers also 

face educational barriers because parental education affects 

educational achievement (3,4,107). Vigorous efforts are 

needed to encourage and facilitate the delay of early childbearing for young women so that they can stay in the education pipeline. More education is beneficial for both young 

women and their children.

 Early parenting for young men as well as young women may also be a factor in early dropout rates and failure to 

complete high school and post-secondary education. Data are 

available by age for only whites and African Americans. For 

2000, the birth rate for African American fathers ages 15-19 

was 40.1 per 1,000 men in this group, compared to 16.8 for 

white fathers ages 15-19. For young fathers ages 20-24, who 

may be bypassing a college education because of parenting 

responsibilities, the rate for African Americans was 133.8, 

compared to 77.6 for whites. These disparities suggest a need 

for further research into young men’s attitudes toward pregnancy prevention, parenting, and the impact of early parenting on their educational achievement (190). 

Further, lack of language proficiency affects education 

levels, especially of Hispanics. A study from the Pew Hispanic Center reports that 33.7 percent of Immigrant Hispanic/

Latino youth fail to complete high school, compared to 14.0 

percent of Native Hispanic/Latino youth. Because the Hispanic population is the fastest-growing minority population, 

this dropout rate raises concern and also suggests reasons 

for the lack of a substantial pool of qualified Hispanic college graduates applying to medical school. The report states, 

“A lack of English-language ability is a prime characteristic 

of Latino dropouts. Almost 40 percent do not speak English 

well. The 14 percent of Hispanic 16-to-19 year olds who 

have poor English language skills have a dropout rate of 59 

percent” (191). In the school system, language barriers may 

be too great for non-English proficient speakers to negotiate successfully and finish high school. Efforts to facilitate 

education of non-English proficient speakers, especially immigrants, will help increase the numbers of Hispanic children 

who stay in school and eventually enroll in post-secondary 

education. 

TABLE 7

Percentage of 1992 High School Graduates, by Race/Ethnicity, 

Family Income, and Parents’ Highest Education Level (4)

Race/Ethnicity

Family Income Parents’ Highest Education Level

Low

(less than 

$25,000)

Middle 

($25,000-

$74,999)

High 

($75,000 

or more)

High 

School 

Graduate 

or Less

Some 

College

College 

Graduate

Asian/Pacific 

Islander 33.5 47.0 19.4 21.9 29.2 48.9

Hispanic 52.0 42.8 5.1 45.8 39.1 15.0

African 

American 53.8 41.5 4.7 35.4 47.6 16.9

White 21.2 61.8 16.9 23.2 40.7 36.2

Source: U.S. Department of Education, National Center for Education Statistics (NCES), 

National Education Longitudinal Study: 1988-1994 (NELS:88), Data Analysis System.
SEVENTEENTH REPORT OF COGME 15

Addressing obstacles to education for URM groups is 

requisite to increase the proportions of these groups that enter medicine. Lack of reading skills and low parental income 

and education levels influence the academic success of young 

children (3,4,107). Ensuring that children read well at an early age can make a positive difference in their later academic 

success. Encouraging and facilitating completion of high 

school for adolescents should be a National priority. Ways to 

reduce barriers for high school graduates to enter and graduate from college, including financial constraints, also need to 

be addressed. Factors that create barriers at any of these educational levels deserve further attention so that obstacles to 

and within the educational pipeline can be removed. Through 

increased education, more qualified URMs will be better prepared to apply to and matriculate in medical school. More 

education among URMs should also facilitate a reduction in 

health disparities as well as increased life expectancy (7). 

IMPLICATIONS OF CULTURAL 

COMPETENCE 

The rapidly changing demographic composition of the 

U.S. population and the continued underrepresentation of 

some ethnic and racial groups in medicine compel an examination of the Nation’s future physicians’ competencies. 

Physicians need to be able to communicate with patients effectively and to overcome any barriers to quality health care 

that may result from cultural differences between physicians 

and patients. It is imperative that physicians be aware of how 

their own background and cultural and economic experiences 

have influenced their understanding of patients’ needs. When 

physicians and patients differ in race, ethnicity, language, religion, and values, ensuring equitable and culturally sensitive 

care is challenging but necessary. 

Increasing physician diversity is a desired objective, but 

many physicians who are not underrepresented (e.g., whites 

and Asians) will be providing a large portion of care to racial 

and ethnic groups different from their own. In addition to the 

need to recruit and retain minorities that are underrepresented 

in medicine, cultural competence must be a part of medical 

education and training. 

Cultural competence has many definitions, and most 

agencies or organizations have their own perspective of 

what cultural competence should be (23,24). Although most 

medical schools provide some type of cultural competence 

instruction, training varies in content and in method of educational delivery (25). Some schools require cultural competency training, some have elective courses, and some incorporate cultural issues into course content (33). However, few 

models of effective cultural competency curricula are readily 

available, and evaluation methods are inconsistent (33,142). 

Dissemination of effective cultural competency training is 

needed. This training should measurably illustrate that physicians’ interactions with and treatment of patients take into 

account patients’ cultures, beliefs, values, lifestyles, and family roles. Further, more efforts are needed to evaluate cultural 

competence outcomes and to assess the impact of cultural 

competence on improved patient satisfaction and improved 

health outcomes. 

ASSESSMENT OF COGME’S

TWELFTH REPORT

COGME’s Twelfth Report, Minorities in Medicine, notes 

that the 2 decades before the 1998 report “provided insight 

into the programs and resources required to facilitate minority entry into medicine.” The report made a number of 

recommendations to “strengthen and sustain these efforts, 

and to achieve proportionate minority representation in 

medicine. . . .” 

The continued increase in URM populations, without a 

comparable increase in the supply of URM physicians, indicates three important strategies for ensuring that URM populations have adequate health care: 1) increasing the number 

of URM students who successfully advance through the elementary, secondary, and post-secondary academic pipeline 

in preparation for entrance into medical school; 2) overcoming policy or systemic barriers at the level of medical training 

institutions, residency programs, licensing boards, specialty 

certification boards, and practice settings; and 3) providing 

effective cultural competency training for U.S. physicians to 

ensure quality health care to people of all cultures. 

This report reviews the published literature and other 

sources to assess the progress made on the 1998 recommendations for increasing the numbers of persons from URM 

groups in medicine. The assessment and review include the 

following: 

1. Findings regarding ways to improve the academic 

pipeline leading to medical school; to enhance the 

upstream within medical training institutions, accrediting bodies, and licensing organizations; and to 

ensure cultural competence of U.S. physicians 

2. Assessment of 1998 recommendations not yet attained 

3. Evaluation considerations for future efforts 

4. New recommendations 
SEVENTEENTH REPORT OF COGME 16
SEVENTEENTH REPORT OF COGME 17

PIPELINE PROGRAMS

One of COGME’s recommendations addressed the need 

for “public and private organizations to agree collectively 

upon a Nationwide strategy for duplicating successful models” of pipeline programs to enhance minority representation 

in medicine and to “develop, implement, and evaluate the 

impact of these strategies” as well as widely disseminate and 

publicize successful programs. In another recommendation, 

COGME also stressed the importance of collaborations between and among institutions at various levels of the educational continuum. 

Findings

Numerous pipeline programs have been funded and 

created by public and private organizations to enhance the 

academic preparation of URMs. From K-12 through medical 

school, programs at various stages of the academic process 

have been implemented to help strengthen URM students 

academically and to interest them in medical careers. 

At the National level, “No Child Left Behind,” signed 

into law in 2002 by President Bush, attempts to ensure that all 

students perform successfully in reading and math (54,55). 

Other programs such as the Mathematics and Science Initiative and the Upward Bound Math and Science Program 

are specifically designed to enhance math and science skills 

(56,57). 

The White House has also established several initiatives 

to improve opportunities for URMs to gain a post-secondary education. President Bush signed the Tribal Colleges and 

Universities Initiative in 2002 to support tribal colleges’ access to Federal grants and funding opportunities, to increase 

the colleges’ participation in Federal programs, and to increase awareness of the role these colleges play (58). In 2002, 

the White House also established the “President’s Board of 

Advisors on Historically Black Colleges and Universities” to 

make recommendations to strengthen the capacity of these 

institutions and to ensure that they can compete effectively 

for Federal grants (59). Further, the White House Initiative on 

Education Excellence for Hispanic Americans includes programs to strengthen academic skills and encourage post-secondary education for Hispanic Americans, one third of whom 

fail to graduate from high school (60,61). 

The AAMC’s Project 3000 by 2000 was an important 

step in increasing diversity among physicians by facilitating 

pipeline and upstream programs at all levels (62). Also, private organizations like the Lumina Foundation contribute to 

programs enhancing the education of disadvantaged and minority youth. This foundation awarded almost $10 million in 

grants in 2002 to increase the academic success and college 

access of underprepared, inner-city, and low-income students 

(63). 

U.S. medical schools have developed numerous programs for academic preparation, enrichment, and retention. 

The AAMC’s Minority Medical Education Program, funded 

by the Robert Wood Johnson Foundation, provides intensive 

6-week programs at eleven medical schools. Two thirds of 

the program’s participants are admitted into medical school 

(64). 

Other programs, including numerous post-baccalaureate 

programs or yearlong academic preparation programs, seek 

to prepare URM students for admission and matriculation 

into medical school (65-79) (see Appendix). 

Further, numerous collaborative programs exist across 

educational institutions to enhance the academic preparation 

and representation of URMs. At the Federal level, the Health 

Resources and Services Administration’s (HRSA’s) Health 

Careers Opportunity Program (HCOP) provides assistance to 

disadvantaged students to help them enter and graduate from 

allopathic and osteopathic schools of medicine as well as other health professions programs (80). HRSA’s Centers of Excellence program helps fund Centers of Excellence in health 

professions education for minority students. These Centers 

may have one of four designations: Historically Black Colleges and Universities, Hispanic Centers of Excellence, Native American Centers of Excellence, and “Other” Centers 

of Excellence, which must enroll URMs at rates above the 

National average (81) (see Appendix). 

Many other collaborative programs exist in which medical schools partner with undergraduate, secondary schools, 

and/or community organizations to promote academic 

achievement and interest in medical education (66,82-105) 

(see Appendix). For example, the AAMC’s Health Professions Partnerships Initiative (HPPI), funded by the Robert 

Wood Johnson Foundation and the W.K. Kellogg Foundation, helps increase the participation of URMs in health professions schools by developing educational partnerships and 

early academic intervention programs (32). 

Learning from Others, a recent publication of the 

AAMC, reviews the literature on educational partnerships 

and includes information about HPPI collaborations to demonstrate how organizations can form effective educational 

partnerships (106).

Strengthening the Pipeline to Medical School
SEVENTEENTH REPORT OF COGME 18

1998 Recommendations 

To Be Attained

1. Although the AAMC has published a review of 

literature of educational pipeline partnerships 

(106), no collectively agreed-upon mechanism 

has been established to disseminate model pipeline and upstream programs. Several obstacles to 

such a dissemination strategy exist:

• Reported pipeline/upstream programs 

have varying degrees of success in helping minorities to be admitted and retained in medical school.

• Standards are needed to determine 

which programs should be considered as 

models. 

• Inconsistent methods of evaluating these 

programs make it difficult to compare 

program outcomes. 

Evaluation Considerations

1. Research is needed to understand better the barriers to academic achievement for URMs at all 

educational levels so that interventions can be 

developed and implemented for targeted groups. 

Such barriers include cultural, linguistic, societal, economic, and systemic. 

2. Research should be conducted to determine the 

most effective interventions to achieve academic success for URMs. Programs and curricula 

producing high rates of academically successful URMs should be identified, disseminated as 

models, and replicated at the local level. Such 

programs include those producing reading and 

academic achievement in elementary schools; 

high enrollment, retention, and achievement in 

college preparatory, science, and math courses 

in high school; high enrollment, retention, and 

achievement in undergraduate schools; and admission, retention, and academic success in medical schools. 

3. Data on issues of English proficiency in education need to be collected to increase achievement 

and retention of racial and ethnic minority youth 

who lack English proficiency. 

4. Additional research is needed to show that successful partnerships among educational institutions lead to successful educational practices that 

support the pipeline to medical training. 

5. Objectives for pipeline programs as well as evaluation indicators of success should be established 

to help determine what constitutes a successful 

program at the institutional, regional, State, and/

or National levels. 

OVERCOMING BARRIERS TO 

INCREASING URM MEDICAL 

SCHOOL APPLICANTS

COGME also recommended continued progress toward 

a more representative participation of minorities in medicine, 

including a goal of 4,500 new URM medical school matriculants by the year 2010 and 6,000 by the year 2020. This 

recommendation stressed the need to apply resources and efforts toward “the enormous challenges the Nation will face 

in reaching these objectives.” Further, COGME advised that 

“appropriate targets should be met at every point of the educational pipeline, beginning in middle school.” 

Findings

The goal of 4,500 new URM matriculants by 2010 and 

6,000 by 2020 seems unlikely to be fulfilled, given current 

trends. In 2001, a total of 1,786, or 10.9 percent of first-year 

allopathic medical school matriculants, were identified as 

URMs. An additional 250 students were reported as having 

“Unknown Race/Ethnicity” and/or “Unknown Citizenship.” 

The 2001 total of URM matriculants represents a slight increase over the previous 2 years—1,739 and 1,741, respectively. First-year URM allopathic medical school matriculants peaked in 1994 and 1995 with 2,026 and 2,025 students, 

representing 12.4 percent and 12.5 percent, respectively, of 

new matriculants in those years (192). 

Osteopathic medical schools reported 261 first-year 

URMs in 2001, the highest number since 1997, when 264 

URMs started osteopathic medical training.3

 URMs represented 8.6 percent of total first-year enrollment of osteopathic medical school students in 2001. An additional 81 (2.7 

percent) first-year students in 2001 were classified as “Other 

and Unknown” (other than URMs, white non-Hispanic, and 

Asian/Pacific Islander) (193). 

Consequently, a total of 2,047 medical students identified 

as URMs (less than half the target number) began allopathic 

and osteopathic medical training in 2001. An additional 331 

students had no identified race/ethnicity. 

A total of 7,394 URMs matriculated in allopathic medical schools in 2002, or 11.2 percent of total matriculants for 

3 URM data collected for osteopathic medical students include African Americans, Native Americans, and all students who report an ethnicity of Hispanic origin.
SEVENTEENTH REPORT OF COGME 19

that year. An additional 1,680 students had no reported race/

ethnicity and/or known citizenship. Total URM allopathic 

matriculants peaked in 1997 with a total of 8,254, or 12.3 

percent of total matriculants. The number of enrolled URMs 

has declined since that time, but 2002 also saw the largest 

number on record with no reported race/ethnicity (1,680) 

(194). In 2001, 861 URMs matriculated in osteopathic medical schools, and an additional 361 were of “Other and Unknown” race/ethnicity (188). 

Providing insight into why more URMs are not 

applying to medical school, Richard Cooper’s 2003 study of 

educational trends for the four major U.S. racial and ethnic 

groups—whites, African Americans, Hispanics, and Asians—

indicates that, “for each, the major hurdles to medical school 

are a high school diploma and a bachelor’s degree soon 

thereafter.” Once those hurdles have been surpassed, Cooper 

found, rates of application to medical school are about the 

same for African Americans, Hispanics, and whites (3). URM 

college graduates in 2000-2001 applied to medical school at 

a rate of 28 per 1,000 graduates, compared to a rate of 25 

per 1,000 white college graduates applying to medical school 

that year (5,6).4

 Rates are slightly higher for Asians. In fact, 

higher proportions of Asian college graduates than any other 

group apply to medical school. Although the other groups 

have experienced fluctuations, Hispanics have generally had 

the next highest proportions of college graduates applying to 

medical school (3). 

Even after 1995, after court decisions that challenged affirmative action, rates of acceptance of applicants into medical school did not decline, but the rate of African American 

and Hispanic applicants decreased. Data show that, among 

URM applicants for 2001, 46.0 percent were accepted into 

medical school compared to 50.6 percent of non-URMs. 

African Americans had the lowest acceptance rate, 42.8 percent, compared to 53.4 percent for Mexican Americans, 60.4 

percent for applicants from Mainland Puerto Rico, and 51.0 

percent for Native Americans. African Americans also had 

lower Medical College Admission Test (MCAT) scores than 

other URM groups (53). Although African Americans and 

Hispanics represent 30 percent of the college-age population, 

they compose only 14 percent of medical school applicants, 

largely due to “progressive attrition along the path from grade 

school through college” (3). 

Since the mid-1980’s, Cooper notes, K-12 achievement 

levels have slipped, continuing the achievement gap between 

URMs and whites and Asians. Parental income and parental education affect the academic achievement of students 

(3,4,107). Over half of both Hispanic and African American 

high school graduates in 1992 were from families having 

incomes under $25,000, compared to a third of Asian high 

school graduates and 21 percent of white high school graduates (4). Cooper observes, “Poverty weighs particularly heavily on single-mother families, which account for 43 percent 

of black families and 23 percent of Hispanic families but only 

13 percent of white and Asian families.” Financial limitations contribute to an inability to enroll in college or stay in 

college as well as matriculate into medical school (3). 

For 1992 high school graduates, 15.0 percent of Hispanics and 16.9 percent of non-Hispanic African Americans had 

parents who had graduated from college, compared to 36.2 

percent of whites and 48.9 percent of Asians. According to 

data from the U.S. Department of Education, high school 

graduates who are African American or Hispanic or who are 

low income are less likely to be academically well prepared 

for college than others. Further, even among those who are 

academically prepared, high school graduates who are Hispanic or low income were less likely to take entrance exams 

and apply for admission to a 4-year college (4). 

Research from the U.S. Department of Education also 

shows that fewer African Americans and Hispanic high 

school students than whites and Asians take high-level math 

and science courses. However, students who enrolled in algebra in the eighth grade were more likely to take high-level 

math courses in high school and to apply to a 4-year college 

than students who did not complete algebra as an eighthgrader even if they took a high-level math course in high 

school (195). 

For high school graduates who are academically well 

prepared, being from a low-income family does not affect 

college enrollment as much as whether low-income students 

take the college entrance examinations and apply to college. 

A U.S. Department of Education study notes, “. . . if lowincome students have an academic record and aptitude test 

scores which demonstrate even the minimal qualifications 

for admission to a four-year institution, if they take a college entrance examination, and if they submit an application 

for admission, the majority of low-income students enroll in 

post-secondary education. . . .” Most, over 83 percent, enroll 

in a 4-year college or university (4).

 The ability to persist through college is another factor affecting applicants to medical school. Cooper notes, “Among 

students who enroll full-time in 4-year colleges soon after 

high school, 77 percent of Asians and 67 percent of whites 

were still enrolled or had graduated three years later” compared to 52 percent for African Americans and 53 percent for 

Hispanics. Low-income affects men more than women. Men 

enter college less frequently than women immediately after 

graduating from high school and drop out more frequently 

as well. The ability to persist through college correlates with 

family income and the rigor of the high school curriculum. 

Lower persistence at all levels of rigor characterizes students 

“whose families are low-income, whose high schools served 

4

 Rates were computed using the data sources indicated.
SEVENTEENTH REPORT OF COGME 20

a large percentage of low-income children, or whose parents 

had no education beyond high school” (3). 

Cooper further observes that reading proficiency can determine later academic success. He adds that cultural factors 

influence educational achievement and notes characteristics 

such as a greater number of hours spent watching television 

among African American and Hispanic adolescents compared 

to whites and Asians (3). 

Increasing the number of qualified African American and 

Hispanic applicants to medical school will require efforts at 

many levels. Unless educators address the academic achievement and retention of URM students, both at the high school 

and undergraduate levels, the pool of URM medical school 

applicants will not increase. Further, programs such as “A 

Better Chance,” which targets talented URMs for enrollment 

in college preparatory schools, are needed to enhance academic opportunities for minority youth (105). 

1998 Recommendations 

To Be Attained

1. Based on current trends, the goals of 4,500 new 

matriculants by 2010 and 6,000 by 2020 are not 

achievable in the near future. 

2. Appropriate targets for URM educational attainment at every point of the educational pipeline 

need to be set and met. 

Evaluation Considerations

1. Efforts need to focus on retaining URMs in the 

educational pipeline all the way through medical 

school and on intervening in processes that undermine retention and academic achievement. 

2. To understand why URMs are not entering medical schools in the numbers previously anticipated, 

the processes, obstacles, motivators, and facilitators for individuals going through the educational pipeline need to be better understood and 

addressed. Interventions are needed to address 

factors that prevent URMs from completing high 

school and entering and graduating from college. 

Dropping out of the educational pipeline is the 

greatest barrier to URMs’ entry into medicine. 

Education and income levels of parents affect 

academic achievement of their children. Disproportionate numbers of URM children live in 

single-parent and/or low-income households, a 

factor contributing to lack of success in early education and influencing achievement at all other 

levels. 

3. Standards of achievement and outcome measures 

are needed for evaluation of K-12, post-secondary, and post-baccalaureate programs that seek 

to increase academic achievement of URMs. 

4. Research is needed to determine reasons academically prepared URMs may fail to take entrance exams and apply to college. 

SOCIAL MARKETING TO INCREASE 

URMs IN THE PIPELINE

COGME’s 1998 report recommended the development 

of partnerships among National and local media, advertising agencies, and video production companies to create and 

implement innovative, culturally appropriate campaigns to 

promote science and health careers for minority and disadvantaged children.

Findings

Some innovative campaigns have been established to 

encourage science and health careers for minority and disadvantaged children: 

• Kids into Health Careers is a program sponsored 

by DHHS’s HRSA to encourage grant recipients 

to work with school systems to promote health and 

science. The program’s objective is to “(1) encourage and inform minority and disadvantaged teenage 

students of educational and career opportunities in 

health professions; and (2) assist minority and disadvantaged students in planning and preparing for post 

secondary education in the health care professions.” 

The Kids into Health Careers’ Web site includes visual aids and talking points to assist volunteers. The 

program disseminates four basic messages: 

 Jobs are available in health care. 

 Qualifying for them is achievable.

 Financial assistance is available.

 Many minority and disadvantaged people 

lack health care (109).

• Another HRSA campaign is the Health Careers 

Adopt-A-School Program, which encourages partnerships between schools and businesses to enhance 

students’ academic performance and career awareness. The program provides support for school 

partners to initiate activities that motivate students, 

enhance their academic success, build one-on-one 

relationships, encourage students to adopt safer and 

healthier lifestyles, and foster career goals in science, technology, and health. Suggested projects include serving as speakers, mentors, or tutors; host-
SEVENTEENTH REPORT OF COGME 21

ing career fairs; sponsoring awards for academic 

improvement; providing financial assistance to 

cultural events; donating school supplies and equipment; recognizing outstanding teachers; and providing “mini-grants” for teachers (110). 

• The American Medical Association’s (AMA’s) Minority Affairs Consortium sponsors the AMA Doctors Back to School program, which encourages 

physicians, residents, and fellows to serve as models 

and mentors to children from URM groups. Health 

providers interact with children in schools and community organizations and share their history and 

practices to promote interest in health careers and 

to emphasize that pursuit of a medical career is a 

worthwhile and attainable goal (111).

• The Association of American Medical Colleges 

sponsors an annual “Minority Student Medical Career Awareness Workshop and Recruitment Fair,” 

during which high school and college students are 

provided information and encouragement to pursue 

careers in medicine (112). 

• The Society for Advancement of Chicanos and 

Native Americans in Science (SACNAS) has initiated a number of activities for minority children 

to encourage interest and achievement in science. 

Among these activities is the SACNAS Biography 

Project, which makes available the life stories of 

minority scientists, mathematicians, and engineers 

so that students can see their own potential in these 

individuals’ careers. The K-12 Education program 

supports educators with teacher workshops that 

“have grown into a National effort to support superior pre-college education in the sciences for Native 

American/Alaska Natives, Chicano/Latino, African 

American and Pacific Island students.” SACNAS 

receives support from a number of sources, including the Indian Health Service and the National Institutes of Medicine (113). 

• The University of Washington’s Making Connections, Making Choices program has a Brain Power 

Van that visits schools so that students learn more 

about neuroscience through the van’s personnel and 

exhibits. The program also provides a speaker’s bureau so that researchers can engage students’ interest in science. These programs are part of a larger 

program to promote science education (114).

• The National Native American Youth Initiative is 

a weeklong event in Washington, D.C., for Native 

American students ages 16-18. A cooperative agreement between the Office of Minority Health and the 

Association of American Indian Physicians funds 

this intense academic enrichment program that seeks 

to motivate Native American students to stay in the 

academic pipeline and pursue a health professions 

career. Students learn the program material through 

lectures, field trips, and tutorials and are presented 

with an overview of health sciences and biomedical 

research (115).

• The American Association for the Advancement 

of Science joined with the Nation’s largest African 

American sorority, Delta Sigma Theta, and the Delta Research and Education Foundation, to produce 

an innovative radio program that targeted minority 

youth to encourage them to aspire to science careers. 

Funded by the National Science Foundation, the 

program, called Delta SEE Connection, conducted 

radio interviews with scientists and engineers to 

introduce children to the scientists as role models 

(116). 

1998 Recommendations 

To Be Attained

 

1. Although some programs promote children’s 

career choices in science and health, partnerships with media, advertising and marketing firms, and video and audio production companies are needed to help develop 

and disseminate culturally appropriate messages targeted to minority and disadvantaged 

children. 

Evaluation Considerations

1. Research should be conducted on target audiences to determine whether medical and other 

health professions messages are sufficiently culturally specific, whether they are being received 

by sufficient numbers of the target audiences, 

whether they are having the desired effect, and 

whether the channels and media being used are 

the most effective for the target audiences. 

STRENGTHENING THE 

PIPELINE TO MEDICAL SCHOOL:

RECOMMENDATIONS

1. Further efforts are needed to increase the number of URM college graduates to enlarge the pool 

of medical school applicants and URM physicians. 

2. Intense efforts should focus on retention of 

URMs in the educational pipeline from elementary school through secondary school, from entry 

in and graduation from undergraduate school, to 

entry in and graduation from medical school. 
SEVENTEENTH REPORT OF COGME 22

3. Research is needed to understand better the barriers to academic achievement for URMs at all 

educational levels. Such barriers include cultural, linguistic, societal, economic, and systemic.

Effective interventions should be developed and 

implemented to address disproportionately high 

secondary school dropout rates among URMs to 

increase their enrollment in college. 

4. Standards of achievement and outcome measures 

are needed to determine which K-12, post-secondary, and post-baccalaureate programs should 

be considered as models for increasing academic 

achievement of URMs. 

5. More resources are needed to facilitate high 

school guidance counselors to assist URMs in 

taking entrance exams and applying to college 

and to place URMs in college preparatory schools 

and programs.

6. Organizations interested and involved in medical 

training should partner with media, advertising 

and marketing firms, and video and audio production companies to develop and implement effective communication campaigns targeting minority and disadvantaged youth with messages 

that encourage academic achievement, persistence in school, and interest in medicine. 
SEVENTEENTH REPORT OF COGME 23

Many of COGME’s recommendations addressed ways 

for medical training institutions, accrediting bodies, and licensing boards to overcome systemic and policy barriers to 

entry into medicine and to facilitate URM matriculation and 

graduation from medical school and entry into residency programs and specialties. 

Medical training institutions have sought to overcome 

barriers for URMs in medicine and have made strides in areas 

such as retention. Data for URM medical school matriculants 

beginning their training in 1996 show that 93 percent were 

either still enrolled or had graduated by their sixth year, compared to 92 percent of non-URMs who had graduated within 

5 years (41). Nevertheless, as a recent Institute of Medicine 

report discusses, additional strategies and policies are needed 

to strengthen the enrollment and retention of URMs in medical training (42). 

ADMISSIONS

One of COGME’s 1998 recommendations addressed 

the need to examine the role of standardized test scores and 

grade point averages (GPAs) in medical school admissions 

and residency placement. The recommendation also indicated the need to develop criteria for determining desirable 

characteristics in medical students to use in admissions and 

placement decisions. 

Findings

Despite controversy regarding the fairness of affirmative action programs (196), considerable published literature 

stresses the need for medical education programs to use factors other than standardized test scores and GPAs as criteria 

for admission. The desirability and benefits of a diverse classroom, as well as the inequities of K-12 education, have been 

cited as reasons to support affirmative action (44,197,198).

In June 2003, the U.S. Supreme Court ruled that race 

could be used as a factor in admissions decisions, thus ruling 

in favor of the continued use of affirmative action policies. 

As the Supreme Court decision affirmed and as research supports, a diverse medical school student body can be considered a compelling State interest: minorities serve minority 

and underserved communities at higher rates than non-minorities do; a diverse student body helps increase sensitivity 

of non-minority medical students to diverse populations; and 

more minority physicians help ensure the health care of minority populations (43).

After the 2003 Supreme Court decision, the AAMC 

produced guidelines to help medical schools assess their admissions policies. These guidelines ask that medical schools 

consider the extent to which diversity is a “compelling interest” for the school, ways that the school can “demonstrate 

diversity as a compelling interest,” and the framework of the 

“school’s narrowly tailored policies” (43). 

Among the recommendations in the AAMC guidelines is 

the need to find “workable race-neutral policies” rather than 

race-conscious policies. Use of qualitative or non-quantitative factors in admissions decisions is one such race-neutral 

policy (43). An important race-neutral reason to include nonquantitative factors in admissions policies is that medical 

school graduates are increasingly expected to have qualitative 

competencies (45). For example, the Accreditation Council 

on Graduate Medical Education (ACGME) emphasizes medical education outcomes of communication skills and professionalism, which include ethics, cultural competence, and a 

committed and responsible relationship to patients and the 

profession (40). 

Use of such factors as GPAs and MCAT scores as the 

main admissions criteria results in less diverse medical students or residents. URMs have traditionally not performed 

as well on quantitative measures as non-URMs (46). Also, 

use of Step 1 scores from the United States Medical Licensing Exam (USMLE) to decide which residency applicants to 

interview, a practice of some residency program directors, 

results in a lower number of minority residents in those programs (118). 

As one author observes, quantitative measures, such as 

MCAT scores, do not necessarily predict who will become 

the best physicians (48). The MCAT was developed in 1928 

and has been revised four times since then. These revisions 

“demonstrate that the definition of aptitude for medical education reflects the profession’s social mores and values of the 

time” (199). 

Nevertheless, research suggests that quantitative measures are correlated with certain aspects of academic success. 

One study indicates that scores on the COMLEX exam taken 

by osteopathic medical students correlated with GPAs as well 

as performance in medical school coursework (200). Yet another study notes that URMs at one medical school answered 

more exam questions incorrectly in basic science courses 

than non-URMs did. The author adds that the attrition rate 

for these URM medical students was four times that for nonunderrepresented groups (201). 

Debate continues about which factors other than GPAs 

and test scores should be incorporated into medical school 

admissions or residency placement. One article notes that 

Strengthening Upstream Efforts in 

Medical Training
SEVENTEENTH REPORT OF COGME 24

“we know that quantitative factors are not good predictors of 

success, but we don’t know which qualitative ones are better” (46). 

An alternative way to rethink admissions is to examine 

methods of stratifying population groups. For example, one 

study advocates use of socioeconomic and disadvantaged status rather than race or gender as the criterion (49). The University of Massachusetts Medical School uses criteria such as 

oral and written communication skills, community service, 

and extracurricular activities (47). The AAMC’s Expanded 

Minority Admissions Exercise suggests such factors as “leadership,” “determination and motivation,” “social interest,” 

and “maturity and coping capability” (50). 

The U.S. Department of Education also encourages innovation in admissions criteria for institutions striving to diversify their student body. Some examples of such innovative 

programs include use of socioeconomic status as a preference, 

recruitment of students from schools not usually considered 

to be “feeder schools,” “skills development” programs and 

partnerships to improve academic performance of students 

at traditionally low-performing schools, and admission plans 

created for top-ranking high school students. The U.S. Department of Education report on race-neutral approaches 

stresses that until race-neutral criteria are fully implemented 

and evaluated, the extent of their success remains unknown 

(52). 

Among URM medical school applicants for 2001, 46.0 

percent were accepted into medical school, compared to 50.6 

percent of non-URMs. African Americans had the lowest 

acceptance rate, 42.8 percent, compared to 53.4 percent for 

Mexican Americans, 60.4 percent for applicants from Mainland Puerto Rico, 51.0 percent for Native Americans, 51.7 

percent for whites, 51.1 percent for Asians, and 49.7 percent 

for applicants from the Commonwealth of Puerto Rico (53). 

1998 Recommendations 

To Be Attained

 

1. Criteria are needed for determining alternative 

characteristics desirable inmedical students other 

than those characteristics revealed by quantitative 

measures.

 

Evaluation Considerations

1. A need exists for documented assessment of various non-quantitative admissions criteria to indicate those most predictive of successful outcomes. 

Measures could be developed to capture qualitative or non-quantitative factors being used in 

medical school admissions/residency placement 

decisions. For example, data on first-year medical school matriculants might indicate the proportion of students who have health care experience or those who majored in disciplines other 

than biological sciences. Selected non-quantitative criteria could then be reported Nationally 

along with quantitative measures such as average MCAT scores. 

2. Desirable outcome measures should be examined 

and perhaps redefined to incorporate non-quantitative or qualitative considerations. “Success” 

is generally defined in terms of quantitative measures such as proportions of students who pass 

coursework or board exams or those who perform well on Step 1 of the USMLE. If a desired 

outcome is a caring physician, then criteria indicating that outcome should be included in admissions/residency placement decisions. 

MEDICAL SCHOOL DEBT AND 

FINANCIAL ASSISTANCE

COGME recommended assessing the impact of rising 

medical student debt on the entry of minorities into medicine; 

determining the influence of debt on career choice, including 

choice of practice location; and ensuring the availability of 

financial assistance to URMs across educational levels, including medical school.

Findings

Both the AAMC and the American Association of Colleges of Osteopathic Medicine (AACOM) collect debt information through surveys of medical school graduates (AAMC) or 

seniors (AACOM). Medical school debt has been increasing 

annually, reaching an average of $103,855 for U.S. graduates 

of allopathic medical schools in 2002 and $131,200 (including undergraduate debt) for osteopathic medical seniors in 

2001-2002 (120,202). The reality of rising medical school 

costs may deter students from ever applying to or matriculating in medical school. 

Mean educational debt is generally higher for URMs 

than for non-URMs in public allopathic medical schools 

(203). However, mean debt is almost equal for URMs and 

non-URMs who graduate from private medical schools (122). 

Medical school students, especially URMs, accumulate more 

debt the more years they spend in medical school. For nonURMs, debt fluctuates according to the number of years in 

medical school but is consistently lower than debt for URMs. 

One quarter of URM medical school students matriculate in 

medical school for more than 4 years, compared to a tenth of 

non-URMs (204). The greater proportion of URMs than nonURMs who spend more years in medical school increases 

the likelihood of higher debt levels and higher mean debt for 

URMs as a group (see Table 8). 

Despite the increase in debt, data from the 2001 graduates indicate that debt was not a factor in choice of specialty 
SEVENTEENTH REPORT OF COGME 25

for 66.3 percent of URMs and for 69.8 percent of non-URMs. 

The average debt for these URM respondents was $97,664 

and for non-URMs, $89,582 (see Table 9 above) (126).

 

Similar proportions of both URMs (16.1 percent) and 

non-URMs (16.8 percent) indicate that debt had a “minor 

influence” on their choice of specialty. The average debt for 

these respondents was $113, 494 for URMs and $100,480 for 

non-URMs, 16 percent and 12 percent higher, respectively, 

than debt for those graduates who reported that debt was not 

a factor in specialty choice. 

Almost 12 percent of URMs said that debt was a “moderate influence” on their specialty choice, and these physicians had an average debt of $123,600. About 9 percent of 

non-URMs reported that debt was a moderate influence, and 

the average debt for this group was similar to that of URMs, 

$122,861.5 

Only 5.9 percent of URMs and 4.5 percent of non-URMs 

indicated that debt was a “strong influence” on their choice 

of specialty, and this group had the highest debt of all. URMs 

for whom debt was a “strong influence” had an average debt 

of $119,006, and non-URMs in this group had a higher mean 

debt of $125,265 (126). 

The AAMC also reports the amount of debt by practice specialty and anticipated practice location. The amount 

of educational debt for graduates planning to practice in an 

underserved area was similar to the debt for those who did 

not plan to practice in an underserved area: $102,163 versus 

$103,394 for URMs and $99,532 versus $97,628 for nonURMs (205). 

For 2001 graduates planning to practice in an underserved area, those planning to serve in a primary care specialty had the lowest average debt (see Table 10) (205). 

Data from the AAMC 2001 Graduate Questionnaire indicate 

that almost half of non-URMs and 39.2 percent of URMs 

planning to practice in underserved areas selected primary 

care specialties. Over a quarter of URMs and 17.4 percent 

of non-URMs intending to practice in an underserved area 

TABLE 8

Debt for Allopathic Medical School 

Graduates, by Years 

in Medical School, 2001 (204)

Years in Medical 

School URMs Non-URMs

Four $100,000 $99,000

Five $117,000 $102,000

Six $132,000 $97,000

Source: AAMC 2001 Graduate Questionnaire. 

TABLE 9

Influence of Debt on Specialty Choice for 

Medical School Graduates, 2001 (126)

Degree of 

Influence

URM

Average Debt

Percentage 

of 

Respondents

Non-URM 

Average

Debt

Percentage 

of 

Respondents

None $97,664 66.3 $89,582 69.8

Minor $113,494 16.1 $100,480 16.8

Moderate $123,600 11.7 $122,861 8.9

Strong $119,006 5.9 $125,265 4.5

Source: AAMC 2001 Graduate Questionnaire.

5

 Data collected from Facts and Figures, AAMC. Lois Colburn. May 11, 2004. 
SEVENTEENTH REPORT OF COGME 26

selected surgical specialties (206). Of those graduates planning to locate in an underserved area, support specialties had 

the highest average debt, $121,692 for URMs and $108,914 

for non-URMs (205). Similar proportions of both URMs and 

non-URMs (just under 16 percent) who anticipated locating 

in underserved areas chose support specialties (206).

Like allopathic medical students, osteopathic medical 

students also experience high debt levels. Seniors in 2001-

2002 had an average debt of $131,200, a 2 percent increase 

from 2000-2001, when the average debt for graduating seniors was $128,700.6

 Nevertheless, this debt increase was 

moderate compared to the prior year when mean debt was 

$121,000. Thus, during a 2-year period, debt for senior osteopathic medical students increased by $10,000, or 8 percent (190). For senior URMs in 2001-2002, debt averaged 

$135,400, which represents a decrease from $138,400 the 

previous year; for whites, the mean debt was $135,700, an 

increase from $130,300, and for Asians, $107,800, a decrease 

from $114,000 the previous year (207). 

Information regarding factors influencing specialty 

choice reveals that debt level had very little influence on 

the choice of specialty for 2001-2002 osteopathic medical 

school seniors, regardless of race or ethnicity and regardless 

of whether they were planning to practice in a primary care 

specialty or a non-primary care specialty. The most important factor listed by senior osteopathic medical students planning primary care specialties was a preference for working 

with a “person or patient more than techniques,” followed 

closely by “intellectual content of the specialty.” Lifestyle 

ranked third and was an especially high priority for URMs 

and Asians who were planning to practice in primary care 

specialties. For seniors planning to practice in non-primary 

care specialties, “intellectual content” most influenced specialty choice, followed by “skills [and] abilities” required of 

the specialty (127). 

According to the AAMC, almost three quarters of 2001 

URM allopathic medical school graduates and slightly fewer 

than half of 2001 non-URM graduates received scholarship 

assistance while in medical school. URM graduates received 

an average of almost $35,000 in scholarships, compared to 

$25,780 for non-URMs. For 2001 graduates attending private 

medical schools, URMs received an average of $6,000 more 

in scholarships than non-URMs, and for 2001 public school 

graduates, URMs received an average of $7,000 more than 

non-URMs (124).

Although similar proportions of new allopathic medical 

school matriculants (60 percent) indicate that their medical 

education will be financed through loans, 30 percent of URMs 

stated that scholarships will help pay for their education compared to 14 percent of non-URMs. Seventeen percent of nonURMs indicated that family or spouses will help finance their 

education compared to 6 percent of URMs (123).

Among osteopathic medical school seniors, 42.3 percent 

of URMs received scholarships, and the average scholarship 

amount was $38,600. Among whites, 34.7 percent received 

scholarships at an average of $39,500, and 20.3 percent of 

Asians received scholarships at an average of $38,000 (208).

According to available survey estimates from the U.S. 

Department of Education for the 1999-2000 school year, 

URM undergraduates received more aid of any type, more 

Federal assistance, and more grants than non-URMs (209). 

In addition, URM master’s and doctoral students, as well as 

URM first professional degree students, received more financial assistance in dollars than non-URM students (210). 

Further, data collected for 1995-1996 indicate that the 

percentage of undergraduates who received financial aid was 

inversely proportional to family income (see Table 11). SevTABLE 10

Average Debt by Practice Specialty Choice for 

Medical School Graduates Planning To Practice in 

an Underserved Area, 2001 (205,206)

Specialty Choice

URM Non-URM

Average

Debt

Percentage of 

Respondents

Average

Debt

Percentage of 

Respondents

Primary Care $97,296 39.2 $95,907 48.8

Medical $100,567 19.1 $101,313 18.2

Surgical $98,241 25.8 $100,646 17.4

Support $121,692 15.9 $108,914 15.6

Source: AAMC 2001 Graduate Questionnaire.

6

 These figures include undergraduate debt. 
SEVENTEENTH REPORT OF COGME 27

enty percent of students whose families had incomes below 

$20,000 in 1994 received financial aid, 66 percent of which 

included grants. In contrast, 28 percent of students whose 

family income was at least $100,000 received financial aid, 

17 percent of which included grants (107). 

1998 Recommendations 

To Be Attained

1. More research is needed to determine the impact 

of medical school debt on URMs’ decisions to apply to or matriculate into medical school. 

Evaluation Considerations 

1. Current mechanisms for evaluating the impact 

of debt on URMs may not fully capture important considerations. Data are needed to assess 

the impact of potential indebtedness on selecting medical school as a career option in the first 

place. Assessing students who possess the requisite academic credentials but who elect other career options may be helpful. 

2. Research to assess whether increased scholarship assistance rather than loans might encourage more URMs to elect to pursue medicine as a 

career would be useful.

URMs IN SPECIALTIES

COGME’s recommendations also included a need to 

identify and eliminate barriers to URM entry into medical 

and surgical specialties. COGME encouraged medical and 

surgical specialty organizations and societies to assist in ensuring that URMs have the same flexibility in selecting specialties that non-URMs have. 

Findings

The AAMC collects data by specialties for medical 

school graduates, and the AACOM collects specialty data for 

osteopathic medical school graduates (128,211). AAMC data 

from the 2001 Graduate Questionnaire reveal that, although 

a higher percentage of URMs than non-URMs graduating in 

2001 planned to pursue generalist or surgical specialties, a 

greater proportion of non-URMs than URMs planned to pursue medical specialties. Proportions choosing support specialties were similar for both groups (see Table 12) (128). 

TABLE 11

Percentages of Undergraduates With Student Financial Aid,

by Family Income and Type of Aid (107)

Family Income (in 1994) Any Aid* Grants Loans

Less than $20,000 70 66 35

$20,000-$39,900 60 51 38

$40,000-$59,900 47 30 32

$60,000-$79,900 43 25 27

$80,000-$99,900 38 20 23

$100,000 or more 28 17 13

*Includes grants, loans, and other types of aid such as work-study.

Source: NCES, 1995-1996 National Postsecondary Student Aid Study (NPSAS:96).

TABLE 12

Specialty Plans of URM and Non-URM 

U.S. Medical School Graduates, 2001 (128)

Type of Specialty Percentage of URMs Percentage of Non-URMs

Generalist 27.0 24.8

Medical 21.4 25.5

Surgical 29.2 26.2

Support 22.4 23.5

Source: AAMC. 2001 Graduate Questionnaire.
SEVENTEENTH REPORT OF COGME 28

Potential barriers to minority entry into some specialties 

include board exam information and feedback procedures. 

The USMLE provides standardized feedback to examinees, 

including strengths and weaknesses, particularly important 

for those who fail the exam, yet feedback to examinees from 

specialty board exams is inconsistent or nonexistent. Similarly, specialty boards have inconsistent levels of information 

regarding preparation for board certification exams (212). 

Minorities and older examinees in one study were more likely to fail certification exams, and passing rates are correlated 

with performance in medical and residency training (213). 

Inadequate information regarding preparation for board exams, as well as feedback upon failure of these exams, can 

create obstacles for examinees seeking to become certified 

in some specialties. Also, a need for more academic support 

in medical training for both minorities and older students is 

indicated. 

Further, research suggests that some residency program 

directors use scores from Step 1 of the USMLE to determine 

which applicants will be interviewed for selection. Depending on the threshold of scores used to select interviewees, 

African American applicants in one study were three to six 

times less likely to be interviewed by these programs (118). 

The use of USMLE scores to screen applicants for residencies can create obstacles for minority entry into some residency programs. Also, some residency program directors use 

the selectivity of applicants’ medical schools to help narrow 

applicant pools, another factor that may result in fewer minorities in those residencies (47). 

The results of the American College of Surgeons’ annual 

survey of residents enrolled in surgical graduate medical education each year for 1994-1995 and 1995-1996 indicate that 

few minorities reported entry into surgical specialties in those 

years. Of the 5,541 residents who were surgical specialists in 

1994-1995, 301 (.05 percent) reported that they were African American and 218 (.04 percent) reported that they were 

Hispanic. In 1995-1996, 305 (.06 percent) of 5,397 surgical 

residents were African American, and 226 (.04 percent) were 

Hispanic. The report noted that “although recruitment of the 

most highly qualified US and Canadian medical school graduates has been a source of pride to the profession,” a strong 

need exists to increase diversity of surgical residents (214).

However, a recent study of efforts to recruit students into 

surgical residencies at the Robert Wood Johnson Medical 

School was extremely successful in increasing the number 

of students who pursued surgical residencies and who were 

matched into those residencies. The proportion of students 

accepted into surgical residencies increased from 18 percent 

during 1993-1997 to 22 percent from 1999-2003. By 2003, 

the proportion of graduating seniors matched into surgical 

residencies increased to 26 percent. Over a quarter of those 

matched into surgical residencies were URMs, and 19 percent spoke English as a second language. Further, the quality 

of students accepted into surgical residencies remained high 

(215). 

1998 Recommendations 

To Be Attained

1. A need continues for research into obstacles and 

motivations for minority entry into residencies or 

specialties. 

Evaluation Considerations

1. Tracking interest in specialties at entry into medical school, at the beginning of the clinical year, 

and at graduation would be helpful to examine 

factors influencing specialty choices for both 

URMs and non-URMs. A multivariate analysis 

can help determine relative influence of various 

factors. 

2. Tracking barriers to and motivators for entering 

specialties would be helpful to examine factors 

influencing specialty choices for both URMs and 

non-URMs. 

3. Residency program directors should be encouraged to use factors other than exam scores or selectivity of medical schools in selecting applicants 

for interviews. 

URM FACULTY

One of COGME’s recommendations addressed the need 

to increase proportions of URM medical school faculty to 10 

percent of total faculty. The recommendation also suggested 

that “every academic medical center should have in place 

specific programs and a dedicated budget for identifying and 

supporting underrepresented minority students with an interest in academic medicine.”

Findings

According to the AAMC Faculty Roster in 2002, 6.9 

percent of allopathic medical school faculty reported that 

they were URMs. In 1998, 5.9 percent of faculty was URMs. 

However, these data should be viewed cautiously because of 

the large proportion of faculty for whom race/ethnicity was 

reported as “Other/Unknown”: 4.1 percent in 2002 and 6.1 

percent in 1998 (130,131).

The number of reported allopathic medical school faculty increased from 87,230 in 1998 to 98,802 in 2002. Numbers 

of faculty increased for all identified racial/ethnic groups except for Native Americans, who decreased from 123 to 105. 

The proportion of white faculty members decreased from 

78.3 percent to 76.9 percent, whereas the proportion of Asian 

faculty members increased from 9.6 percent in 1998 to 11.5 

percent in 2002 (see Table 13) (130,131).
SEVENTEENTH REPORT OF COGME 29

Data reported for osteopathic medical school faculty for 

2001 indicate that 3.5 percent were URMs compared to 3.0 

percent in 1998. As for allopathic faculty, large proportions 

of osteopathic medical school faculty were reported as “Other/Unknown”: 4.6 percent for 2001 and 5.4 percent for 1998. 

From 1998-2001, total faculty members in osteopathic medical schools decreased 1 percent from 2,586 to 2,561. The reported total of African American faculty decreased from 46 

to 43, and the number of white faculty decreased from 2,253 

to 2,204 (see Table 14) (132). 

However, as researchers at a recent conference at Dartmouth University note, increasing numbers of URM faculty 

only partly solves the problem of increasing diversity among 

faculty. A more important issue is the need for exchanging 

ideas and experiences and for examining tenure criteria, 

which have been largely determined by tenured faculty, the 

majority of whom continue to be white and male. Minority 

faculty is expected to carry out traditional demands of research and also to advocate for diversity and to represent 

minorities. Academic institutions should examine the climate 

of their institutions to determine whether they truly provide 

opportunities for minority faculty members to share power 

with their non-minority colleagues (216). 

Research indicates that minority faculty should be recruited and mentored early in their careers, but few programs 

have been reported that focus on supporting URM students 

interested in academic medicine. However, one such program 

is the Fellowship Program in Academic Medicine, supported since 1990 by $5 million grants from the Bristol-Myers 

Squibb Company. This program seeks to increase minority 

physician representation among medical school faculty and 

in biomedical research. The Fellows are selected from second-year, third-year, or fourth-year minority medical students 

who are nominated by medical school deans. These candidates are reviewed and selected by a committee of medical 

school faculty and biomedical researchers. The Fellows propose and conduct research during an 8- to 12-week period, 

during which they work closely with a faculty mentor (133). 

The Minority Medical Faculty Development Program, 

established by the Robert Wood Johnson Foundation, offers 

4-year postdoctoral research fellowships to minority physicians. The program seeks to increase minority faculty who 

progress successfully through the ranks of academic medicine by supporting research opportunities. As many as 12 

Fellows are appointed with an annual stipend of $65,000 plus 

an additional $26,350 to support research expenses. The Fellows work with faculty mentors as well as National Advisory 

Committee mentors and attend an annual meeting where research presentations and career development workshops are 

conducted (217,218). 

TABLE 13

Number and Percentages of U.S. Medical School Faculty, 

by Race/Ethnicity, 2002 and 1998 and 

Percent Change (130,131)

Race/Ethnicity

2002 1998 Percent 

Total Percent* Total Percent* Change

Native American 105 0.1 123 0.1 –15

African American 2,964 3.0 2,348 2.7 +26

Mexican American 535 0.5 350 0.4 +53

Puerto Rican 915 0.9 703 0.3 +30

Other Hispanic 2,328 0.2 1,636 1.9 +42

Total URM Faculty 6,847 6.9 5,160 5.9 +33

White 76,025 76.9 68,294 78.3 +11

Asian 11,408 11.5 8,412 9.6 +36

Multiple Races 430 0.4 430 0.5 0

Other/Unknown 4,092 4.1 5,364 6.1 –24

Total 98,802 100.0 87,230 100.0 +13

*Percentages do not equal 100 because of rounding.

Sources: AAMC Faculty Roster, December 31, 2002; AAMC Faculty Roster, 

December 31, 1998. 
SEVENTEENTH REPORT OF COGME 30

Female minorities often have unique obstacles to advancing as faculty members in medical education. To address 

barriers for minority faculty women, six National Centers of 

Excellence in Women’s Health use the following strategies to 

support female minority faculty:

• Funding

• Awards

• Leadership symposiums

• Mentoring programs

• Faculty development workshops

The Centers also offer assistance in the promotions process and in targeted retention and recruitment initiatives and 

have formed a committee addressing female minority faculty 

concerns. They stress the need to establish and track diversity indicators, provide institutional support as faculty move 

through the promotion process, commit to institutional strategies to recruit and retain minority faculty, and conduct research on ways to overcome barriers to advancement (134). 

One study indicates that URM medical school faculty 

are more dissatisfied with their careers than non-URM faculty are (129). Increased efforts are needed to ensure that the 

institutional climate of medical training institutions fosters 

career growth and satisfaction for URM faculty. 

 

1998 Recommendations 

To Be Attained

1. More complete reporting of faculty by race/ethnicity is needed to determine progress made in 

increasing URM faculty. Race/ethnicity for a 

large percentage of faculty is reported as “Other/

Unknown.” 

2. Recruiting and retaining minority physicians 

as medical school faculty continue to be important goals, especially as evidence indicates that 

minority faculty are more dissatisfied with their 

careers than non-minority faculty.

Evaluation Considerations

1. Programs like the Centers of Excellence in Women’s Health or the Fellowship Program in Academic Medicine can provide valuable “lessons 

learned” for institutions attempting to enhance 

opportunities for minority medical school faculty. Collecting and reviewing data on the outcomes of such programs (e.g., numbers recruited, 

numbers retained, and satisfaction) are essential 

for developing new initiatives or refining ongoing 

ones. 

TABLE 14

U.S. Osteopathic Medical School Faculty,* by Race/Ethnicity, 

2001-2002 and 1998-1999 and Percent Change (132)

Race/Ethnicity

2001-2002 1998-1999 Percent 

Total Percent Total Percent Change

Native American/

Alaska Native 8 0.3 6 0.2 +33 

African American 43 1.7 46 1.8 –7

Hispanic 38 1.5 26 1.0 +46

Total URM Faculty 89 3.5 78 3.0 +14

White 2,204 86.1 2,253 87.1 –2

Asian 134 5.2 116 4.5 +16

Multiple Races 15 0.6 † † †

Other/Unknown 119 4.6 139 5.4 –14

Total 2,561 100.0 2,586 100.0 –1

*Full- and part-time, all ranks. 

†

Data are not available.

Source: AACOM, Annual Osteopathic Medical School Questionnaire,

2001-2002 and 1998-1999 Academic Years.
SEVENTEENTH REPORT OF COGME 31

2. Separating the category “Other” from “Unknown” race/ethnicity of faculty for reporting 

purposes might provide a better representation 

of the proportion of faculty who are minorities 

and would indicate more accurately the proportion of faculty who fail to report their race. 

3. Establishing and tracking diversity indicators for 

minority faculty recruitment, tenure, and promotion would help foster commitment to having 

a diverse faculty and would also help document 

obstacles for minority faculty that should be addressed. 

STRENGTHENING UPSTREAM 

EFFORTS IN MEDICAL TRAINING:

RECOMMENDATIONS

1. Desirable outcome measures that include nonquantitative considerations should be established 

for medical school students and then used in admissions decisions. 

2. Residency program directors should also consider qualitative as well as quantitative factors when 

deciding which residency candidates to interview 

and select. 

3. Use of qualitative criteria in medical school admissions and residency placement decisions 

should be documented and assessed to determine 

which ones are most predictive of successful outcomes. 

4. More research is needed to assess the impact of 

medical school debt on URMs’ decision to apply 

to, matriculate in, and graduate from medical 

school.

5. Assessment of whether increased scholarship assistance rather than loans might encourage more 

URMs to pursue medicine as a career would be 

helpful.

6. More research is needed to evaluate obstacles 

or motivations for minority entry into primary 

care or specialty residency programs. Medical 

schools should track medical students’ interest in 

specialties at entry into medical school, at the beginning of the clinical year, and at graduation to 

assess factors that influence choice of specialties 

for both URMs and non-URMs. 

7. Medical schools should develop and implement 

plans for recruiting and retaining minority faculty physicians, including assessing and enhancing 

the institutional climate for URM faculty. Indicators and targets for recruitment, tenure, and promotion of minority faculty should be established 

and tracked. 

8. Minority medical students, residents, and physicians who aspire to serve as faculty should be 

identified and mentored early in their careers. 

9. Interventions should be developed that encourage physicians to practice in underserved areas 

for periods that extend beyond the time commitment of programs requiring service in exchange 

for funding opportunities. 

10. Research is needed to determine optimal conditions and exposure time required for medical 

students to develop and maintain an interest in 

serving in underserved communities.

11. Strategies are needed to assess and reinforce the 

commitment of academic medical centers to provision of care to underserved populations. This 

commitment should be integral to the academic 

environment and mission and should be fostered 

by means other than funding incentives. 
SEVENTEENTH REPORT OF COGME 32
SEVENTEENTH REPORT OF COGME 33

Ensuring Cultural Competence in Medicine 

CHANGING DEMOGRAPHICS

In its 1998 report, COGME noted that, given the 

changing demographics of the U.S., physicians will care for 

increasingly diverse populations. Because the diversity of the 

physician workforce is not keeping pace with the diversity 

of the Nation, physicians need to have competencies that 

promote high-quality care of culturally, racially, and ethnically 

diverse populations. COGME also made recommendations 

addressing ways to ensure cultural competence in physicians, 

including the need to arrive at a consensus regarding the 

definition of cultural competency in medicine; to develop, 

implement, and assess cultural competency training; and to 

incorporate cultural competency in accrediting standards for 

medical academic institutions, licensing board criteria, and 

quality standards for managed care. 

Findings

Although no formal panel has been convened to reach 

a consensus definition of cultural competence, much discussion has occurred during recent years regarding what cultural 

competence is or should be. Indeed, based on the complexity and variety of perspectives of cultural competence, the 

possibility of reaching a single consensus seems unlikely. As 

the National Center for Cultural Competence at Georgetown 

University States, “many definitions of cultural competence 

are emerging in the literature yet none is accepted as the ‘gold 

standard’” (23). Further, Lisa Tedesco, in an essay published 

in The Right Thing to Do, The Smart Thing to Do, states that a 

consensus on definitions of cultural competence is “a distant 

goal” (219). Cindy Brach and Irene Fraser with the Agency 

for Healthcare Research and Quality (AHRQ) also state, 

“Every organization and author define cultural competency 

somewhat differently” (24). 

Nevertheless, some definitions of cultural competence 

have emerged. The most common definition used is one developed by T.L Cross and associates in a 1989 report (220). 

DHHS’s Office of Minority Health (OMH), in its National 

Standards for Culturally and Linguistically Appropriate Services in Health Care, borrows Cross’s concept of “cultural 

and linguistic competence”: “a set of congruent behaviors, 

attitudes, and policies that come together in a system, agency, 

or among professionals [and] that enables effective work in 

cross-cultural situations” (26). 

 

Other definitions include one from the National Center 

for Cultural Competence, which defines cultural competence 

as effective provision of services to individuals within a 

larger family, community, and cultural milieu. This organization stresses the need for physicians to understand their own 

culture, to acknowledge a “patient’s different culture, value 

systems, beliefs, and behaviors,” to be aware that “cultural 

difference is not synonymous with cultural inferiority,” and 

to learn about patients’ culture in order to provide optimal 

health care (23). 

Despite the lack of uniformity in definitions of cultural 

competence, the desirability of cultural competency training in medical education is recognized, and this training is 

increasingly available in various courses and educational 

delivery methods (23-40). However, the limitations of some 

methods of incorporating cultural competence into medical 

training curricula are also apparent. As Michael Whitcomb, 

Editor of Academic Medicine, states, “it is not yet clear how 

best to teach students how to begin acquiring the knowledge, 

skills, and attitudes they need” to develop relationships with 

culturally diverse patients (25). 

The various perspectives expressed in the published 

literature affirm that approaches to teaching and assessing 

cultural sensitivity, cultural awareness, and other key issues 

involved in being “culturally competent” are in a pioneering 

stage. Much discussion in the literature revolves around the 

best means to change attitudes and the best way to measure 

those changes, both in the medical school environment and in 

practice settings (27-29,136-142,221-224).

Since the 1998 COGME report, private and public organizations have sponsored numerous initiatives to develop and 

implement curricula and programs promoting cultural competency. A brief summary of cultural competence initiatives 

include many developed or sponsored by HRSA: 

• The Provider’s Guide to Quality and Culture, an 

electronic resource that includes a self-assessment, 

cultural competence information and pointers, information about patient-provider relationships, audio clips of providers’ perspectives, and resources 

(143). 

• The Cancer Diagnostic Guide, which addresses 

culturally competent approaches to cancer prevention and treatment and assists providers in effective 

cross-cultural communication (225).

• The Minority AIDS Initiative, which provides funding for organizations to help fight AIDS. Funded 

programs incorporate cultural competent activities 

(225).

• Be Safe, a cultural competence guide for African 

Americans, which provides information about the 

management and treatment of African American patients with HIV/AIDS (225).
SEVENTEENTH REPORT OF COGME 34

• “Cultural Workshops for Providers” to meet specific 

needs of the AIDS Education and Training Centers 

(225).

• A 2003 Satellite Broadcast, entitled “Cross-Cultural 

Communication in Health Care: Building Organizational Capacity,” which focuses on language services in health care and provides a six-step model 

for planning and managing these services (144).

• Indicators of Cultural Competence in Health Care 

Delivery Organizations: An Organizational Cultural Competence Assessment Profile, which offers a 

systematic approach to cultural competence in community-oriented organizations (145).

• A review of literature that examines information to 

help assess cultural competence in health care delivery settings (146).

• A cultural competency program that seeks to promote cultural competence and demonstrate its effectiveness in increasing health care access and decreasing health disparities (147).

• “Cultural Competence Workshops and Technical 

Assistance” (148).

• A 2002 conference, entitled “Bridging Cultures & 

Enhancing Managed Care,” at which presentations 

were made addressing provision of cultural and linguistic competence in managed care (149-153).

• A “Cultural Competence Works” competition for 

HRSA grantees that have successfully made cultural 

competence an integral part of their organizations 

(154).

The AHRQ has also produced reports on cultural competence: Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model, 

Reducing Disparities through Culturally Competent Health 

Care: An Analysis of the Business Case and, recently, the National Healthcare Disparities Report (24,155,156).

In addition to Federal efforts, private organizations have 

launched numerous cultural competence initiatives: 

• An online cultural competence-training module at 

the National Center for Cultural Competence at 

Georgetown University (157).

• The California Endowment’s report Principles and 

Recommended Standards for Cultural Competence 

Education of Health Care Professionals, which includes standards for content, methods, and evaluation of cultural competency training (30).

• The Committee on the Health Professions Education Summit’s report, which advocates five basic 

competencies in health professions education (31).

• The AAMC’s “Tool for Assessing Cultural Competency Training,” which is being developed to help 

medical schools assess their cultural competency 

curricula (32).

• The Commonwealth Fund’s report Cultural Competence in Health Care: Emerging Frameworks and 

Practical Approaches, which helps health care organizations improve health care by overcoming cultural barriers (33).

• The AMA’s Cultural Competence Compendium, a 

compilation of efforts, tools, presentations, reports, 

and articles promoting cultural competence (34).

• The American Association of Health Plans’ 

(AAHP’s) 2003 audio conference entitled “The Case 

for Cultural Competencies in Health Care” (35).

• Kaiser Permanente’s A Provider’s Handbook on 

Culturally Competent Care: African American 

Population and A Provider’s Handbook on Culturally Competent Care: Latino Population and training modules entitled “Introduction to Diversity,” 

“Culturally Competent Care: Cultural Awareness,” 

“Culturally Competent Care: Cultural Knowledge,” 

and “Culturally Competent Care: Cultural Skills” 

(36,37,158).

• An initiative launched in 2002 by the National 

Medical Association, the AMA, and other specialty 

groups to educate physicians about health care disparities, particularly for heart disease (159).

Information from the Liaison Committee on Medical 

Education, Part II of the Annual Medical School Questionnaire, reveals that almost all U.S. medical schools provide 

required and/or elective training in cultural competency or 

topics related to cultural competency. Of the 125 academic 

health centers reporting for 2000-2001, however, only three 

required a separate course in cultural diversity, 112 incorporated cultural diversity as part of a required course, 21 offered 

an elective course in cultural diversity, and 43 included cultural diversity as part of elective coursework (135). Studies 

also indicate that some residency programs are incorporating 

training that promotes cultural competence in residents (227-

229). Further, continuing medical education (CME) courses 

in cultural competence are emerging (164,165).

Much progress has been made toward including cultural 

competence in accreditation standards for both undergraduate and graduate medical education. The Licensing Committee on Medical Education (LCME) has explicit accreditation 
SEVENTEENTH REPORT OF COGME 35

standards that include cultural competency for medical education (38). Also, the ACGME has developed an Outcomes 

Project that stresses six areas of competency for residents, 

one of which, “Professionalism,” includes demonstrating 

“sensitivity and responsiveness to patients’ culture, age, gender, and disabilities” (39,40). The American Board of Medical Specialties supports these outcomes, and some specialty 

organizations have adopted guidelines that include cultural 

competency training (160,161). 

Although licensing boards do not test for cultural competence, Step 3 of the USMLE uses diverse patients as part 

of the clinical assessment so that examinees must respond to 

clinical situations that include cultural contexts (162). The 

Accreditation Council for Continuing Medical Education 

does not require specific competencies (163). 

New York has pending legislation that mandates that the 

medical schools in the State require at least one course in cultural competency and that physicians must complete cultural 

competency training for relicensure (166). New Jersey has 

pending legislation that requires cultural competency training 

for physicians to be licensed or relicensed (167). California 

and Illinois have bills pending that provide for State medical 

societies to offer voluntary cultural competency programs for 

physicians (168,169). 

Although some managed care plans have developed 

strategies for increasing minority physician representation 

and culturally competent care in their practices, continued 

efforts to increase minority physician representation in managed care are needed. 

Kaiser Permanente has established a National Diversity Department, but this large managed care organization 

acknowledges difficulty in recruiting minority physicians 

(230). To facilitate cultural competence in its organization, 

Kaiser Permanente has created its own Institute for Culturally Competent Care and has Centers of Excellence for African Americans, for Latinos, and for linguistic services. This 

health plan also has received an AAHP grant for Innovation 

in Quality Improvement (35). 

As managed care increasingly provides health care for 

large portions of the U.S. population, much effort has been 

made to develop, implement, and assess cultural competence 

strategies and to evaluate cultural competence in managed 

care organizations. The Centers for Medicare and Medicaid 

Services (CMS) commissioned the AHRQ to develop guidelines to provide assistance to managed care plans: “Oral, 

Linguistic, and Culturally Competent Services” and “Providing Oral Linguistic Services” (171-172). In addition, CMS 

has established and updated its Quality Improvement System 

for Managed Care Standards and Guidelines (173). 

Further, the George Washington University Center for 

Health Services Research and Policy, in consultation with 

HRSA and Resources for Cross Cultural Health Care, has developed a technical assistance document, “Optional Purchasing Specifications: Cultural Competence in the Delivery of 

Services Through Medicaid Managed Care,” to help States 

that contract with managed care organizations for provision 

of services for Medicaid-eligible individuals (175). 

Other efforts also seek to ensure that managed care organizations respond to the cultural needs of enrollees in health 

care plans. According to the National Committee for Quality Assurance, the Health Plan Employer Data and Information Set (HEDIS®) has no measures that assess the cultural 

competence of providers, but the “accreditation standards 

require organizations to address members’ cultural needs and 

preferences.” Further, an organization must assess “the cultural, ethnic, racial and linguistic needs of its members and 

adjust the availability of practitioners within its network if 

necessary.” Organizations must also “have quantifiable and 

measurable standards for the number and geographic distribution of primary care providers and specialty care providers” (174). 

 

However, the lack of data on race and ethnicity in health 

plans creates a barrier to assessing the quality of care for minority patients. The Minority Health Report Card Project, a 

collaborative effort of Michigan State University, the Henry 

Ford Health System, Lovelace Clinic Foundation, the University of Texas School of Public Health, and eight health 

plans, was developed in 1998 to assess health care disparities 

among different racial/ethnic groups in managed care. Managed care plans usually do not collect data by race, but the 

project determined other ways to assess health care quality 

for racial and ethnic groups (177,178). 

Research also shows that, although Federal regulations 

require each State to submit a cultural competence plan for 

provision of services, States have varying contract requirements for their Medicaid managed care organizations. Some 

States collect data, but do not use this information to assess 

compliance with cultural competence standards. In some 

States, no specific penalties exist, and compliance is not enforced (176). 

1998 Recommendations 

To Be Attained

1. A need exists to determine desired outcomes for 

cultural competence instruction as well the most 

effective methods to teach and assess cultural 

competence for medical students and residents. 

2. Evaluation is considered critical to any program, 

and much information is available regarding 

evaluation of cultural competence and cultural 

competency training. Nevertheless, a lack of information exists regarding results of evaluation. 
SEVENTEENTH REPORT OF COGME 36

Lack of evaluation or training outcomes contributes to the uncertainty about how and what to 

teach medical students regarding cultural competence and about whether and to what extent 

cultural competency training improves health 

care. 

3. Few medical schools have required courses specifically dedicated to cultural competence. Standards are needed for incorporating cultural competence training into medical school curricula. 

4. The extent and kind of cultural competency 

training in residencies and CME need to be identified. 

5. Not only are specific targets for increasing minority physician representation in managed care 

not being met, but managed care plans appear 

to have difficulty recruiting minority physicians 

because of low numbers of minority physicians 

entering the health care workforce.

6. Although National standards exist, State contract language requiring cultural competence in 

managed care organizations needs to be specific 

and enforced.

Evaluation Considerations

1. The varied definitions of cultural competence 

and approaches to cultural competence instruction suggest a need for further research and 

discussion to determine key objectives, desired 

outcomes, and ways to measure progress toward 

those outcomes in medical education. A National 

conference should be held at which these issues 

can be more fully addressed. 

2. A need exists for more models that can be applied 

to classroom and other training venues for health 

care providers. Such models might include sample cultural competence courses, course syllabi, 

or other modes of education delivery; methods 

of implementing cultural competence training 

and practice; and more assessment of problems 

with and successes of various methods of cultural 

competency training. 

3. Evaluation data need to be collected and disseminated regarding the impact of cultural competence curricula and training. Several kinds of 

evaluations are needed:

• Assessment of participants’ responses to 

cultural competence programs: To what 

extent do educators encounter student 

resistance to the importance of cultural 

competency training, particularly when 

such training must compete with other 

training priorities, including basic sciences and clinical clerkships? 

• Assessment of learners’ perceptions of 

their training: Have they attained the 

knowledge, skills, and attitudes that will 

help them provide culturally competent 

care? 

• Assessment of the impact of cultural 

competency training program: Do patients believe they have been treated in 

ways that indicate culturally competent 

providers and organizational policies 

that reduce cultural or language barriers to health care?

• Prioritization of the objectives of cultural competency training to determine the 

most appropriate outcomes measures: Is 

the objective to provide better care, to 

attract more patients from certain cultural groups, to retain patients already 

receiving care, or some combination of 

these outcomes? 

4. A need exists to identify desired competencies 

for cultural competency training across the continuum of medical education (undergraduate 

through CME). Also, the best ways to ensure 

that medical students and physicians attain these 

competencies and the most effective ways to assess the extent to which they achieve those competencies need to be identified. 

5. The “hidden curriculum” should be assessed. 

What are learners’ attitudes about the importance of cultural competence? A well-established 

formal curriculum may be undermined in the informal networks of student life, and those factors 

should be recognized and assessed. 

6. Health care organizations that manage care need 

to have aggressive plans for recruiting minority 

physicians. 

7. The National Committee for Quality Assurance 

requires managed care organizations to address 

members’ cultural needs and desires. A summary 

of how those standards are being met would be 

helpful. 

8. More research is warranted to assess the extent 

that States evaluate their cultural competence 
SEVENTEENTH REPORT OF COGME 37

monitoring and enforcement procedures. Clear 

indicators for accountability and penalties in 

their contracts with managed care organizations 

need to be developed. 

9. Health care organizations should be encouraged 

to use existing data from other sources to identify 

and address disparities in access to care and quality of care for patients at these organizations. 

ENSURING CULTURAL 

COMPETENCE IN MEDICINE:

RECOMMENDATIONS

1. The varied definitions of cultural competence 

and approaches to cultural competence instruction indicate a need for further research and 

discussion to determine key objectives, desired 

outcomes and competencies, and ways to assess 

progress toward those outcomes in medical education. A National conference should be held at 

which these issues can be more fully addressed.

2. Data are needed to determine whether cultural 

competency training enables medical students, 

residents, and physicians to become more culturally competent and whether that training affects 

patient outcomes. 

3. The Federation of State Medical Boards should 

encourage individual State licensing boards to 

institute voluntary cultural competency training 

for physicians. 
SEVENTEENTH REPORT OF COGME 38
SEVENTEENTH REPORT OF COGME 39

1. United States Department of Health and Human 

Services (DHHS). Council on Graduate Medical 

Education. Minorities in medicine. Rockville(MD): 

DHHS; 1998:3-4. 

2. Association of American Medical Colleges (AAMC). 

Frequently asked questions and answers about the new 

underrepresented in medicine definition. Washington: 

AAMC; 2003:1.

3. Cooper RA. Impact of trends in primary, secondary, 

and postsecondary education on applications to medical 

school. II: considerations of race, ethnicity, and income. 

Academic Medicine 2003;78:864-76.

4. United States Department of Education. National 

Center for Education Statistics. Access to postsecondary 

education for the 1992 high school graduates. 

Washington: Department of Education; 1997. Retrieved 

April 25, 2004, from URL: http://nces.ed.gov/

pubsearch/pubsinfo.asp?pubid=98105

5. AAMC. AAMC data book: statistical information 

related to medical schools and teaching hospitals. Table 

B2. Washington: AAMC; 2003:9-11.

6. United States Department of Education. Digest of 

education statistics, 2002. Chapter 3. Postsecondary 

education. Retrieved April 19, 2004, from URL: 

http://www.nces.ed.gov/programs/digest/d02/tables/

dt264.asp 

7. United States DHHS. Office of Disease Prevention and 

Health Promotion. Healthy People 2010. A systematic 

approach to health improvement. Retrieved November 

16, 2003, from URL: http://www.healthypeople.gov/

Document/html/uih/uih_bw/uih_2.htm

8. Ferguson WJ, Candib LM. Culture, language, and 

the doctor-patient relationship. Family Medicine 

2002;34(5):353-61.

9. Flores G, Abreu M, Olivar MA, Kastner B. Access 

barriers to health care for Latino children. Archives of 

Pediatric Adolescent Medicine 1998;152:1119-25. 

10. Saha S, Taggart SH, Komaromy M, Bindman AB. Do 

patients choose physicians of their own race? Health 

Affairs 2000;19(4):76-83.

11. Phillips KA, Mayer ML, Aday LA. Barriers to care 

among racial/ethnic groups under managed care. Health 

Affairs 2000;19(4):65-75. 

Bibliography

12. Todd KH, Deaton C, Adamo AP, Gee L. Ethnicity and 

analgesic practice. Annals of Emergency Medicine 

2000;35(1):11-16. 

13. Schneider EC, Zaslavsky AM, Epstein AM. Racial 

disparities in quality of care for enrollees in Medicare 

managed care. Journal of the American Medical 

Association 2002; 287(10):1288-94. 

14. Collins KS, Tenney K, Hughes D. Quality of health 

care for African Americans: Findings from the 

Commonwealth Fund 2001 Health Care Quality 

Survey. New York: The Commonwealth Fund; 2002. 

Factsheet. Pub #524. Retrieved July 23, 2003, from 

URL: http://www.cmwf.org/programs/minority/

collins_africanamerican_fs_524.pdf

15. Weech-Maldonado R, Morales LS, Elliott M, Spritzer 

K, Marshall G, Hays RD. Race/Ethnicity, language, 

and patients’ assessments of care in Medicaid managed 

care. Health Services Research 2003;38(3):789-807. 

16. Carrasquillo O, Orav J, Brennan TA, Burstin HR. 

Impact of language barriers on patient satisfaction in 

an emergency department. Journal of General Internal 

Medicine 1999;14:82-87. 

17. Baker DW, Hayes R, Fortier JP. Interpreter use and 

satisfaction with interpersonal aspects of care for Spanishspeaking patients. Medical Care 1998;36(10):1461-70. 

18. Kington R, Tisnado D, Carlisle D. Increasing racial 

and ethnic diversity among physicians: an intervention 

to address health disparities? The right thing to do, the 

smart thing to do: enhancing diversity in the health 

professions. Washington: National Academy Press; 

2001:57-90. 

19. Brotherton SE, Stoddard JJ, Tsang, SS. Minority and 

nonminority pediatricians’ care of minority and poor 

children. Archives of Pediatric Adolescent Medicine 

2000;154:912-17. 

20. Fryer GE, Green LA, Vojir CP, Krugman RD, Miyoshi 

TJ, Stine C, et al. Hispanic versus white, nonHispanic physician medical practices in Colorado. 

Journal of Health Care for the Poor and Underserved 

2001;12(3):342-51. 

21. Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. 

Primary care physicians who treat blacks and whites. 

New England Journal of Medicine 2004;351(6):603-05.
SEVENTEENTH REPORT OF COGME 40

22. United States Census Bureau. Projections of the resident 

population by race, Hispanic origin, and nativity: 

Middle Series. Retrieved November 16, 2003, from 

URL: http://www.census.gov/population/projections/

nation/summary/np-t5-a.txt

23. National Center for Cultural Competence. Georgetown 

University. Module 2: Cultural competence. 

“Definitions.” Retrieved June 6, 2003, from URL: 

http://www.gwu.edu/~iscopes/Cultcomp.htm

24. United States DHHS. Agency for Healthcare Research 

and Quality (AHRQ). Can cultural competency reduce 

racial and ethnic health disparities? A review and 

conceptual model. Rpt. Medical Care Research and 

Review 2000;S57:181-217. 

25. Whitcomb ME. Preparing doctors for a multicultural 

world. Academic Medicine 2003;78(6):547. 

26. United States DHHS. Office of Minority Health. 

National standards for culturally and linguistically 

appropriate services in health care. Executive summary. 

Washington: DHHS; 2001:ix. URL: http://www.omhrc.

gov/omh/programs/2pqprograms/finalreport.pdf

27. Pridaux D. Cultural identity and representing culture 

in medical education: who does it? [editorial]. Medical 

Education 2001;35:186-87. 

28. Kagawa-Singer M, Kassim-Lakha S. A strategy to 

reduce cross-cultural miscommunication and increase 

the likelihood of improving health outcomes. Academic 

Medicine 2003;78:577-87. 

29. Tervalon M. Components of culture in health for 

medical students’ education. Academic Medicine 2003;

78:570-76.

30. The California Endowment. Principles and 

recommended standards for cultural competence 

education of health care professionals. Woodland 

Hills(CA): California Endowment; 2003. Retrieved 

July 23, 2003, from URL: http://www.calendow.org/

pub/publications/principles_standards.pdf

31. The National Academy of Sciences. Health 

professions education: a bridge to quality. Washington: 

The Academy; 2003:4. 

32. AAMC. Diversity Initiatives. Retrieved July 22, 

2003, from URL: http://www.aamc.org/diversity/

initiatives.htm

33. Betancourt JR, Green AR, Carrillo JE. Cultural 

competence in health care: emerging frameworks and 

practical approaches. Field Report. New York: The 

Commonwealth Fund; 2002. Retrieved October 27, 

2003, from URL: http://www.cmwf.org/programs/

minority/betancourt_culturalcompetence_576.pdf

34. American Medical Association (AMA). Cultural 

competence compendium. Retrieved July 19, 2003, 

from URL: http://www.ama-assn.org/ama/pub/

printcat/4848.html 

35. American Association of Health Plans. Audio 

conference. Making the case for cultural competencies 

in health care. April 10, 2003. 

36. Kaiser Permanente. A provider’s handbook on culturally 

competent care: African American population. 

Oakland(CA): Kaiser Permanente; 1999. 

37. Kaiser Permanente. A provider’s handbook on culturally 

competent care: Latino population. Oakland(CA): 

Kaiser Permanente; 2000. 

38. Liaison Committee on Medical Education. LCME 

Accreditation Standards. Functions & structure of a 

medical School, part 2. Retrieved July 19, 2003, from 

URL: http://www.lcme.org/functionslist.htm 

39. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus, S. 

General Competencies and Accreditation in Graduate 

Medical Education. Health Affairs 2002;21(5):103-11. 

40. Accreditation Council on Graduate Medical Education. 

ACGME outcome project. General competencies. 

Retrieved July 19, 2003, from URL: http://www.

acgme.org/outcome/comp/compFull.asp 

41. AAMC. Minority students in medical education: facts 

and figures XII. Washington: AAMC; 2002:44.

42. Institute of Medicine. In the nation’s compelling 

interest: ensuring diversity in the health care workforce. 

Prepublication Copy. Washington: The Institute; 2004.

43. AAMC. Assessing medical school admissions policies: 

implications of the U.S. Supreme Court’s affirmativeaction decisions. Washington: AAMC; 2003:9-12. 

Retrieved November 20, 2003, from URL: http://www.

aamc.org/meded/urm/urmfaq.pdf

44. Deville K. Trust, patient well-being and affirmative 

action in medical school admissions. The Mount Sinai 

Journal of Medicine 1999;66(4):247-56.

45. Edwards JC, Elam CL, Wagoner NE. An admission 

model for medical schools. Academic Medicine 

2001;76:1207-12.
SEVENTEENTH REPORT OF COGME 41

46. Tekian A. Minority students, affirmative action, and 

the admission process: a literature review, 1987-1998. 

Teaching and Learning in Medicine 2000;12(1):33-42. 

47. Gonzalez P, Stoll B. The color of medicine: strategies 

for increasing diversity in the U.S. physician workforce. 

Boston: Community Catalyst; 2002:11-12. 

48. Clawson DK. Challenges and opportunities of racial 

diversity in medical education. Clinical Orthopaedics 

and Related Research 1999;362:34-39.

49. Magnus SA, Mick, SS. Medical schools, affirmative 

action, and the neglected role of social class. American 

Journal of Public Health 2000;90(8):1197-1201.

50. AAMC. Expanded Minority Admissions Exercise. 

Retrieved August 18, 2003, from URL: http://www.

aamc.org/meded/minority/emae/start.htm

51. United States Department of Education. Race-neutral 

alternatives in postsecondary education. Retrieved 

November 22, 2003, from URL: http://www.ed.gov/

about/offices/list/ocr/edlite-raceneutralreport.html

52. United States Department of Education. Race-neutral 

approaches to diversity. Retrieved November 22, 2003, 

from URL: http://www.ed.gov/about/offices/list/ocr/

raceneutral.html?exp=0

53. AAMC. Minority students in medical education. Table 

4a:95.

54. White House. President highlights progress in education 

reform. Retrieved August 8, 2003, from URL: http://

www.whitehouse.gov/news/releases/2003/06/200306

10-4.html 

55. United States Department of Education. Office of Public 

Affairs. Paige marks 18-month anniversary of No Child 

Left Behind Act with update to Congress [press release]. 

July 8, 2003.

56. United States Department of Education. Mathematics 

and Science Initiative. What organizations are doing to 

improve mathematics and science education. Retrieved 

July 21, 2003, from URL: http://www.ed.gov/inits/

mathscience/descriptions/index.html

57. United States Department of Education. Upward Bound 

Math and Science Program. Retrieved July 18, 2003, 

from URL: http://www.ed.gov/offices/OPE/HEP/trio/

math-sci.html

58. United States Department of Health and Human 

Services. Office of Minority Health. About the Tribal 

Colleges and Universities Initiative. Retrieved July 

23, 2003, from URL: http://www.omhrc.gov/omh/

tribal%20colleges/2pgTCU/Aboutthe.htm

59. White House. Advisors for Historically Black Colleges 

and University. February 2002. Retrieved November 8, 

2003, from URL: http://www.whitehouse.gov/news/

releases/2002/02/20020212-3.html

60. White House. White House Initiative on Educational 

Excellence for Hispanic Americans. Retrieved 

November 8, 2003, from URL: http://www.yic.gov/

wwa/index.html 

61. White House. The road to a college diploma: the complex 

reality of raising educational achievement for Hispanics 

in the United States. Initiative on Educational Excellence 

for Hispanic Americans. Retrieved November 8, 2003, 

from URL: http://www.yic.gov/paceea/press/interim.

html

62. Butler WT. Project 3000 by 2000: progress during 

tumultuous times. Academic Medicine 1999;74(4):308-

09. 

63. Lumina Foundation. Lumina Foundation announces 

nearly $10 million in grants to improve college access 

[news release]. Retrieved July 23, 2003, from URL: 

www.luminafoundation.org/newsroom/archive_

2002/index.html

64. AAMC. Minority Medical Education Program. 

Retrieved July 20, 2003, from URL: http://www.aamc.

org/students/minorities/mmep

65. Blakely AW, Broussard LG. Blueprint for establishing 

an effective postbaccalaureate medical school pre-entry 

program for educationally disadvantaged students. 

Academic Medicine 2003;78:437-47. 

66. Jackson WE, McGlinn, Rainey M, Bardo H. 

MEDPREP—30 years of making a difference. Academic 

Medicine 2003;78:448-53. 

67. Giordani B, Edwards AM, Segal SS, Gillum LH, 

Lindsay A, Johnson N. Effectiveness of a formal postbaccalaureate pre-medical program for underrepresented 

minority students. Academic Medicine 2001;76: 844-

48. 

68. Strayhorn G. A pre-admission program for 

underrepresented minority and disadvantaged students. 

Academic Medicine 2000;75(4):355-61. 

69. Tekian A, Jalovecky MJ, Hruska L. The impact of 

mentoring and advising at-risk underrepresented 

minority students on medical school performance. 

Academic Medicine 2001:76:1264.
SEVENTEENTH REPORT OF COGME 42

70. Abernathy AD. A mentoring program for 

underrepresented students at the University of 

Rochester School of Medicine. Academic Medicine 

1999;74(4):356-59. 

71. Fang WL, Woode MKA, Carey RM, Apprey M, 

Schuyler JM, Atkins-Brady TL. The Medical 

Academic Advancement Program at the University 

of Virginia School of Medicine. Academic Medicine 

1999;74(4):366-69.

72. Girotti JA. The Urban Health Program to encourage 

minority enrollment at the University of Illinois at 

Chicago College of Medicine. Academic Medicine 

1999;74(4):370-72. 

73. Hardy VD. Premedical enrichment program at East 

Carolina School of Medicine. Academic Medicine 

1999;74(4):373-75. 

74. Segal SS, Biordani B, Gillum LH, Johnson N. The 

Academic Support Program at the University of 

Michigan School of Medicine. Academic Medicine 

1999;74(4):383-85. 

75. Thompson HC, Weiser MA. Support programs 

for minority students at Ohio University College 

of Osteopathic Medicine. Academic Medicine 

1999:74(4):390-92. 

76. Whitten CF. Postbaccalaureate Program at Wayne 

State University School of Medicine: a 30-year report. 

Academic Medicine 1999:74(4):393-96. 

77. Williams MT. Pre-matriculation program at the 

University of Florida College of Medicine. Academic 

Medicine 1999:74(4):397-99. 

78. Soto-Greene M, Wright L, Gona OD, Feldman LA. 

Minority enrichment programs at the New Jersey 

Medical School: 26 Years in Review. Academic 

Medicine 1999;74(4):386-89. 

79. Carline JD, Patterson DG, Davis LA, Irby DM. 

Precollege enrichment programs intended to increase 

the representation of minorities in medicine. Academic 

Medicine 1998;73(3):288-98. 

80. United States DHHS. Health Resources and Services 

Administration (HRSA). Health Careers Opportunities. 

Retrieved August 8, 2003, from URL: http://bhpr.hrsa.

gov/grants/applications/03hcop.htm

81. United States DHHS. HRSA. Centers of Excellence. 

Retrieved August 8, 2003, from URL: http://bhpr.

hrsa.gov/grants/applications/03coe.htm

82. Fincher RME, Sykes-Brown W, Allen-Noble R. Health 

Science Learning Academy: a successful “pipeline” 

educational program for high school students. Academic 

Medicine 2002;77:737-38. 

83. Thomson WA, Ferry PA, King JE, Martinez-Wedig C, 

Michael LH. Increasing access to medical education for 

students from medically underserved communities: one 

program’s success. Academic Medicine 2003;78:454-

59. 

84. Newman PR, Newman BM. What does it take to have a 

positive impact on minority students’ college retention? 

Adolescence 1999;34(135):483-92. 

85. Ramsey PG, Coombs JB, Hunt DD, Marshall SG, 

Wenrich MD. From concept to culture. The WWAMI 

program at the University of Washington School of 

Medicine. Academic Medicine 2001;76:765-75. 

86. Carline JD, Patterson DG. Characteristics of health 

professions schools, public school systems, and 

community-based organizations in successful 

partnerships to increase the numbers of underrepresented 

minority students entering health professions education. 

Academic Medicine 2003;78:467-82. 

87. Harvard University. Four Directions Summer Research 

Project. Retrieved August 14, 2003, at URL: http://

www.hms.harvard.edu/dms/diversity/fdsrpintro.

html

88. University of Minnesota. The Center of American 

Indian and Minority Health. Native Americans into 

Medicine. Retrieved July 19, 2003, from URL: http://

www.d.umn.edu/medweb/caimh/NAM.htm

89. University of Minnesota. The Center of American Indian 

and Minority Health. UM INMED. Retrieved July 19, 

2003, from URL: http://www.d.umn.edu/medweb/

caimh/preceptorship.htm

90. Crump R, Byrne M, Joshua M. The University of 

Louisville Medical School’s comprehensive programs 

to increase its percentage of underrepresented-minority 

students. Academic Medicine 1999;74(4):315-17. 

91. Curran-Everett D, Collins S, Hubert J, Pidick T. 

Science education partnership between the University 

of Colorado and a Denver high school. Academic 

Medicine 1999;74(4):322-25. 

92. DeRosa DA, Phillips C. Boston University’s Biosciences 

Education Program for Boston-area students. Academic 

Medicine 1999;74(4):326-28. 
SEVENTEENTH REPORT OF COGME 43

93. Doyle HJ. UCSF partnership to enrich science teaching 

for sixth graders in San Francisco. Academic Medicine 

1999;74(4):329-31. 

94. Goodell E, Visco R, Pollock P. A program to enhance 

K-12 science education in ten rural New York school 

districts. Academic Medicine 1999;74(4):332-35. 

95. Helm EG, Parker JE, Russell MC. Education and career 

paths of LSU’s Summer Science Program Students from 

1985 to 1997. Academic Medicine 1999;74(4):336-38. 

96. Little D, Izutsu S, Judd N, Else I. A medical schoolbased program to encourage native Hawaiians to choose 

medical careers. Academic Medicine 1999;74(4):339-

41. 

97. Moore CJ, May VL, Abusharbain E. Partnership to 

engage St. Louis high school students in investigative 

Genetics. Academic Medicine 1999;74(4):342-44. 

98. Moreno NP, Tharp BZ. An interdisciplinary national 

program developed at Baylor to make science exciting for 

all K-5 Students. Academic Medicine 1999;74(4):345-

47. 

99. Palacio-Cayetano J, Kanowith-Klein S, Stevens 

R. UCLA’s outreach program of science education 

in the Los Angeles Schools. Academic Medicine 

1999;74(4):348-51. 

100. Rye JA, Chester AL. WVU-community partnership 

that provides science and math enrichment for 

underrepresented high school students. Academic 

Medicine 1999;74(4):352-55. 

101. Castro GA, Bouldin PH, Farver DW, Maugans LA, 

Sander LC, Booker J. The Intercon Network: a program 

for education partnerships at the University of TexasHouston Health Science Center. Academic Medicine 

1999;74(4):363-65. 

102. Wilson JE, Murphy L. Premedical and predental 

enrichment program for minority students, 1969-1996, 

at Meharry Medical College. Academic Medicine 

1999;74(4):400-02. 

103. Anderson S. Pipeline programs: looking forward to 

promote diversity. AAMC Reporter. Washington, 

DC;September 2003. Retrieved November 20, 2003, 

from URL: http://aamc.org/newsroom/reporter/

sept03/pipeline.htm

104. Malloy, Michael. Filling the pipeline: a “Doctor’s 

Academy” high-school program in California graduates 

its first class. AAMC Reporter. Washington: AAMC; 

June 2003. Retrieved November 20, 2003, from 

URL: http://aamc.org/newsroom/reporter/june03/

pipeline.htm 

105. A Better Chance. Retrieved August 12, 2004, from 

URL: http://www.abetterchance.org

106. AAMC. Learning from others: a literature review and 

how-to guide from the Health Professions Partnership 

Initiative; 2004.

107. United States Department of Education. National Center 

for Education Statistics. Findings from the condition 

of education 1998. College access and affordability. 

Washington: Department of Education; 1999:5-6. 

Retrieved April 25, 2004, from URL: http://nces.

ed.gov/pubs99/1999108.pdf

108. United States Census Bureau. Historical poverty tables. 

Table 4. Poverty status of families, by type of family, 

presence of related children, race, and Hispanic origin: 

1959 to 2002. Retrieved November 17, 2003, from 

URL: http://www.census.gov/hhes/poverty/histpov/

hstpov4.html 

109. United States Department of Health and Human 

Services. Health Resources and Services Administration. 

Kids into Health Careers: history. Retrieved August 8, 

2003, from URL: http://bhpr.hrsa.gov/kidscareers/

introduction.htm 

110. United States Department of Health and Human 

Services. Health Resources and Services Administration. 

Health Careers Diversity and Development. Weiss S, 

Gatling A. Health Careers Adopt-A-School Program. 

PowerPoint Presentation. April 2002.

111. American Medical Association. Doctors Back to 

School. AMA Doctors Back to School program inspires 

new generation of physicians. Retrieved July 19, 2003, 

from URL: http://www.ama-assn.org/ama/pub/

category/7131.html

112. AAMC. Medical career fairs. Retrieved August 

17, 2004, URL: http://www.aamc.org/students/

minorities/medicalcareerfair.htm

113. Society for Advancement of Chicanos and Native 

Americans in Science. Retrieved July 20, 2003, from 

URL: http://www.sacnas.org 

114. Cunningham SL, Kunselman MM. University of 

Washington and partners’ program to teach middle 

school students about neuroscience and science careers. 

Academic Medicine 1999;74(4): 318-321. 

115. Association of American Indian Physicians. National 

Native American Youth Initiative. Retrieved July 19, 
SEVENTEENTH REPORT OF COGME 44

2003, from URL: http://www.aaip.com/activities/

nnayi/nnayi.html

116. Sirica C. Scientists use radio to reach out to kids. 

Science 27 June 2003; 300(5628): 2050-2051. 

117. Gonzalez P, Stoll B:19.

118. Edmond MB, Deschenes JL, Eckler M, Wenzel, RP. 

Racial bias in using USMLE Step I scores to grant 

internal medicine residency interviews. Academic 

Medicine 2001;76:1253-56.

119. AAMC. Minority students in medical education. Table 

7:99. 

120. AAMC. AAMC data book:47. 

121. AAMC. Minority students in medical education. Table 

17a:116. 

122. AAMC. Minority students in medical education. Table 

17c:118.

123. AAMC. Minority students in medical education:35.

124. AAMC. Minority students in medical education:54. 

125. AAMC. Minority students in medical education:119. 

126. AAMC. Minority students in medical education: 59. 

127. American Association of Colleges of Osteopathic 

Medicine (AACOM). Tables on factors affecting 

specialty choice. Lorrie Van Akkeren. Chevy 

Chase(MD): AACOM; 2003. 

128. AAMC. Minority students in medical education: 49.

129. Palepu A, Carr PL, Friedman RH, Ash AS, Moskowitz 

MA. Specialty choices, compensation, and career 

satisfaction of underrepresented minority faculty in 

academic medicine. Academic Medicine 2000;75:157-

60. 

130. AAMC. AAMC Faculty Roster. December 31, 2002. 

Retrieved July 14, 2003, from URL: http://www.aamc.

org/data/facultyroster/usmsf02/table3.xls 

131. AAMC. AAMC Faculty Roster. December 31, 1998. 

Retrieved July 14, 2003, from URL: http://www.aamc.

org/data/facultyroster/usmsf98/table3.xls 

132. AACOM. Tables on U.S. osteopathic medical school 

faculty by race/Hispanic origin, 2001-2002 and 

1998-1999. Lorrie Van Akkeren. Chevy Chase(MD): 

AACOM; 2003. 

133. Bristol-Myers Squibb. Newsroom. Minority students 

from the nation’s top medical schools discuss health 

disparities and medical careers with high school students. 

Retrieved July 29, 2003, from URL: http://www.bms.

com/news/press/data/fg_press_release_3430.html 

134. Wong EY, et al. Promoting the advancement of 

minority women faculty in academic medicine: the 

National Centers of Excellence in Women’s Health. 

Journal of Women’s Health & Gender-based Medicine 

2001;10(6):541-50. 

135. AAMC. Liaison Committee on Medical Education Part 

II Annual Medical School Questionnaire for 2000-2001. 

Number of U.S. medical schools teaching selected 

topics. Compiled by the AAMC Institutional Profile 

System. Retrieved from URL: http://services.aamc.

org/currdir/section2/LCMEHotTopics.pdf 

136. Dogra N, Karnik N. First-year medical students’ attitudes 

toward diversity and its teaching: an investigation at one 

U.S. medical school. Academic Medicine 2003;78:1191-

1200. 

137. Beagan B. Teaching social and cultural awareness to 

medical students: “it’s all very nice to talk about it in 

theory, but ultimately it makes no difference.” Academic 

Medicine 2003;78:605-14. 

138. Wear D. Insurgent multiculturalism: rethinking how and 

why we teach culture in medical education. Academic 

Medicine 2003;78(6):549-54. 

139. Taylor JS. Confronting “culture” in medicine’s “culture 

of no culture.” Academic Medicine 2003;78(6):555-

59. 

140. Wright SM, Carrese JA. Serving as a physician role 

model for a diverse population of medical learners. 

Academic Medicine 2003;78:623-28. 

141. Donini-Lenhoff FG, Hedrick HL. Increasing awareness 

and implementation of cultural competence principles 

in health professions education. Journal of Allied Health 

2000;29(4):241-45. 

142. Dolhum EP, Munoz C, Grumbach, K. Cross-cultural 

education in U.S. medical schools: development of an 

assessment tool. Academic Medicine 2003;78:615-22. 

143. Electronic Resource Center. Management Sciences for 

Health. The provider’s guide to quality and culture. 

Retrieved on July 2, 2003, from URL: http://erc.msh.

org/mainpage.cfm?file=1.0.htm&module=provider

&language=English 
SEVENTEENTH REPORT OF COGME 45

144. United States DHHS. HRSA. Center for Health Care 

Services Financing and Managed Care. Satellite 

broadcast—cross-cultural communication in health 

care. Retrieved on August 7, 2003, at URL: http://

www.hrsa.gov/financeMC/broadcast 

145. United States DHHS. HRSA. Indicators of cultural 

competence in health care delivery organizations: an 

organizational cultural competence assessment profile. 

April 2002. Retrieved August 13, 2003, from URL: 

http://www.hrsa.gov/OMH/cultural1.htm 

146. United States DHHS. HRSA. Health Resources 

Services Administration study on measuring cultural 

competence in health care delivery settings: a review 

of the literature. September 2001. Retrieved October 

16, 2003, from URL: http://www.hrsa.gov/OMH/

cultural/cultural.htm 

147. United States DHHS. HRSA. Bureau of Primary 

Health Care. Some facts about cultural competency. 

Bethesda(MD): DHHS; 2001. 

148. United States DHHS. HRSA. Managed Care Technical 

Assistance Center. Cultural competence workshops 

and technical assistance. Retrieved July 23, 2003, from 

URL: http://www.jsi.com/hrsamctac/documents/

Cultural_Competence.pdf

149. Franklin, G. California’s approach to ensuring cultural 

competent healthcare services in Medicaid managed 

care and SCHIP health plans. Bridging cultures and 

enhancing managed care. Conference proceedings. 

Rockville(MD): HRSA and American Public Human 

Services Association; 2002:19-22. 

150. Hall G, Nieri P. Arizona Health Care Cost Containment 

System (AHCCCS) plans and the provider pocket guide. 

Bridging cultures and enhancing managed care: 22-24. 

151. McNeil J. Model of cultural competency for working 

with African American patients with HIV. Bridging 

cultures and enhancing managed care: 26-28. 

152. Arao-Nguyen, S. Enhancing family-centered care in 

managed care organizations. Bridging cultures and 

enhancing managed care: 29-30. 

153. McNees M. Addressing cultural and linguistic diversity 

in the community health center environment: The 

Sunset Park Family Health Center Network. Bridging 

cultures and Enhancing Managed Care:31-33. 

154. United States DHHS. HRSA. Cultural competence 

works: using cultural competence to improve the quality 

of health care for diverse populations and add value to 

managed care arrangements. Rockville(MD): DHHS; 

2001:1. 

155. United States DHHS. AHRQ. Reducing disparities 

through culturally competent health care: an analysis 

of the business case. Bethesda(MD): DHHS; 2000; rpt. 

Brach C, Fraser I. Medical Care Research and Review 

2000;57(S1):181-217. 

156. United States DHHS. AHRQ. National healthcare 

disparities report. Bethesda(MD): DHHS; 2003. 

Retrieved January 19, 2004, from URL: http://www.

qualitytools.ahrq.gov 

157. National Center for Cultural Competence. Georgetown 

University. Module 2: Cultural competence. “Learning 

objectives.” Retrieved June 6, 2003, from URL: http://

www.gwu.edu/~iscopes/Cultcomp.htm 

158. Kaiser Permanente. Community Wellness Library. 

Clinical videoconferencing network. Retrieved August 

20, 2003, from URL: http://www.crewnoble.com/

KPWellness/ceu_order.html 

159. Adams D. NMA, AMA, other groups launch initiative 

to cut health care disparities. Amednews.com. Retrieved 

August 2, 2003, from URL: http://www.ama-assn.org/

sci-pubs/amnews/pick_02/prsc1028.htm 

160. Ambulatory Pediatric Association. Pediatric General 

Competencies. Retrieved on August 3, 2003, from URL: 

http://www.ambpeds.org/egtest/pedicompquad.htm

161. Ambulatory Pediatric Association. Update on revision 

of the APA. Educational guidelines for residency 

training in general pediatrics (as of 6-3-02). Retrieved 

on August 3, 2003, from URL: http://www.ambpeds.

org/guidelines/index.cfm 

162. United States Medical Licensing Examination. Step 

3 purpose and content. Clinical context of Step 3. 

Retrieved July 25, 2003, from URL: http://www.usmle.

org/step3/clincon.htm 

163. Accreditation Council for Continuing Medical 

Education. Accreditation policies. Definition of CME. 

Retrieved August 4, 2003, from URL: http://www.

aacme.org/incoming/pol_05_def_cmd.pdf 

164. University of California Continuing Medical Education. 

Retrieved August 6, 2003, from URL: http://cme.ucop.

edu/listing.php?event_id=492 

165. University of Vermont. College of Medicine. Continuing 

Medical Education. Third annual cultural conference 

workshop. April 28, 2003. Retrieved August 6, 2003, 

from URL: http://cme.uvm.edu/sell.asp?s=Sell&Eve

ntId=2857 
SEVENTEENTH REPORT OF COGME 46

166. State of New York. New York State Assembly. Bill 

Summary A07991. E-mail Correspondence. Hoferer J, 

Cain, F. Federation of State Medical Boards. Retrieved 

August 17, 2004, from URL: http://www.senate.state.

ny.us

167. State of New Jersey. Bills 2004-2005. Bills S144 and 

A492. E-mail Correspondence. Hoferer J, Cain F. 

Federation of State Medical Boards. Retrieved August 

17, 2004, from URL: http://www.njleg.state.nj.us

168. State of California. 2003 Sessions. CA Assembly 

Bill 801. E-mail Correspondence. Hoferer J, Cain F. 

Federation of State Medical Boards. Retrieved August 

17, 2004, from URL: http://www.leginfo.ca.gov/

pub/bill/asm/ab_0801-0850/ab_801_bill_20030630_

amended_sen.html 

169. State of Illinois. Illinois General Assembly. Bill SB3067. 

E-mail Correspondence. Hoferer J, Cain F. Federation 

of State Medical Boards. Retrieved August 17, 2004, 

from URL: http://www.legis.state.il.us 

170. United States DHHS. AHRQ. Planning culturally and 

linguistically appropriate services: a guide for managed 

care plans. Summary. February 2003. Retrieved on 

July1, 2003, from URL: http://www.ahrq.gov/about/

cods/plancias.htm 

171. United States DHHS. AHRQ. Oral, linguistic, and 

culturally competent services: guides for managed care 

plans. Retrieved on July1, 2003, from URL: http://

www.achcpr.gov/about/cods/cultcomp.htm 

172. United States DHHS. AHRQ. Providing oral linguistic 

services: a guide for managed care plans. Summary. 

February 2003. Retrieved on July1, 2003, from URL: 

http://www.ahrq.gov/about/cods/oralling.htm 

173. United States DHHS. Centers for Medicare & Medicaid 

Services. Conditions of participation. Conditions for 

coverage. Quality improvement system for managed 

care. Retrieved July 1, 2003, from URL: http://www.

cms.hhs.gov/cop/2d.asp 

174. National Committee for Quality Assurance. Policy 

technical support. Gitimu C. E-mail correspondence. 

August 7, 2003. 

175. George Washington University Medical Center 

School of Public Health and Health Services. Optional 

purchasing specifications: cultural competence in the 

delivery of services through Medicaid managed care—a 

technical assistance document;2001:1,5-6.

176. Stork E, Scholle S, Greeno C, Copeland VC, Kelleher 

K. Monitoring and enforcing cultural competence in 

Medicaid managed behavioral health care. Mental 

Health Services Research 2001;3(3):169-177.

177. Nerenz DR, Gunter MJ, Garcia M, Green-Weir RR, 

Wisdom K, Joseph C. Developing a Health plan report 

card on quality of care for minority populations [field 

report]. New York: The Commonwealth Fund; 2002. 

Retrieved August 10, 2003, from URL: http://www.

cmwf.org/publist/publist2.asp?CategoryID=13

178. Nerenz DR, Bonham VL, Green-Weir R, Joseph C, 

Gunter M. Eliminating racial/ethnic disparities in health 

care: can health plans generate reports? Health Affairs 

2002;21(3):259-263. 

179. AAMC. Government Affairs and Advocacy. Democrats 

introduce minority health bill. November 14, 2003. 

Retrieved November 16, 2003, from URL: http://www.

aamc.org/advocacy/library/washhigh/2003/111403/_

4.htm

180 United States Census Bureau. Detailed Tables—

American FactFinder. P4. Hispanic or Latino, and not 

Hispanic or Latino by race. Census 2000 Summary 

File 1. Retrieved November 16, 2003, from URL: 

http://factfinder.census.gov/serlet/DTTable?_

ts=87297641703

181. Rivadeneyra R, Elderkin-Thompson V, Silver RC, 

Waitzkin H. Patient centeredness in medical encounters 

requiring an interpreter. American Journal of Medicine 

2000;108:470-74. 

182. Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM, 

Levinson W, Thisted RA. Impact of interpreter services 

on delivery of health care to limited-English-proficient 

patients. Journal of General Internal Medicine 

2001;16:468-74. 

183. United States DHHS. Centers for Disease Control and 

Prevention (CDC). National Center for Health Statistics 

(NCHS). Highlights: major findings. Health, United 

States, 2003. Retrieved November 17, 2003, from 

URL: www.cdd.gov/nchs/products/pubs/pubd/hus/

highlits.pdf 

184. United States Census Bureau. Poverty in the United 

States: 2002. Washington: Census Bureau; 2003. 

Retrieved November 19, 2003, from URL: http://www.

census.gov/prod/2003pubs/p60-222.pdf

185. United States Census Bureau. American Factfinder. 

Census 2000 Summary File 4. Detailed Tables. PCT86. 

Sex by occupation for the employed civilian population 

16 years and older. Retrieved November 10, 2003, from 

URL: http://factfinder.census.gov/servlet/DTTable 
SEVENTEENTH REPORT OF COGME 47

186. AAMC. Newsroom. Applicants to U.S. medical 

schools increase. Retrieved November 16, 2003, 

from URL: http://www.aamc.org/newsroom/

pressrel/2003/031104.htm

187. AAMC. AAMC data book. Table B5:16-18. 

188. AACOM. 2002 Annual report on osteopathic medical 

education. Table 6. Chevy Chase(MD): AACOM; 

2003:25. 

189. United States DHHS. CDC. NCHS. National Vital 

Statistics Report. Table 17. Number, birth rate, and 

percent of births to unmarried women by age and race, 

and Hispanic origin of mother: United States, 2000. 

Hyattsville(MD): DHHS; 2002;50(5):46. 

190. United States DHHS. CDC. NCHS. National Vital 

Statistics Report. Table 20. Birth rates by age and race 

of father: United States, 1980-2000. Hyattsville(MD): 

DHHS; Revised July 3, 2002;50(5):50. 

191. Fry R. Hispanic youth dropping out of U.S. schools: 

measuring the challenge. Washington: Pew Hispanic 

Center; June 8, 2003. 

192. AAMC. Minority students in medical education. Table 

10a. Table 10b:104.

193. AACOM. 2002 Annual Report of Osteopathic Medical 

Education. Table 5. Chevy Chase(MD): AACOM; 

2003:24. 

194. AAMC. Minority students in medical education. Table 

12a. Table 12b:107. 

195. United States Department of Education. National 

Center for Education Statistics. Do gatekeeper courses 

expand education options? Washington: Department 

of Education; 1999. Retreived April 25, 2004, from 

URL: http://nces.ed.gov/pubsearch/pubsinfo.

asp?pubid=1999303 

196. American Medical Association. Amednews.com. 

Doctors divided over use of affirmative action by 

medical schools. Retrieved August 3, 2003, from URL: 

http://www.ama-assn.org/sci-pubs/amnews/pick_

03.prsb0602.htm 

197. Bollinger LC. The need for diversity in higher education. 

Academic Medicine 2003;78:431-36. 

198. Whitla DK, Orfield G, Silen W, Teperow C, Howard 

C, Reede J. Educational benefits of diversity in medical 

school: a survey of students. Academic Medicine 

2003;78:460-66. 

199. McGaghie WC. Assessing readiness for medical 

education. 2002;288(9):1085-90. 

200. Baker HH, Cope MK, Fisk R, Gorby JN, Foster RW. 

Relationship of preadmission variables and first- and 

second-year course performance to performance on 

the National Board of Osteopathic Medical Examiners’ 

COMLEX-USA Level 1 examination. Journal of the 

American Osteopathic Association 2000;100(3):153-

61. 

201. Tekian A, Han Y, Hruska L, Krainik AJ. Do 

underrepresented minority medical students differ 

from nonminority students in problem-solving ability? 

Teaching and Learning in Medicine 2001;13(2):86-91. 

202. AACOM. Debts, plans and opinions of osteopathic 

medical students in 2002. Chevy Chase(MD): AACOM; 

2003:13. 

203. AAMC. Minority students in medical education. Table 

17b:117. 

204. AAMC. Minority students in medical education. Table 

18:119.

205. AAMC. Minority students in medical education:60. 

206. AAMC. Minority students in medical education:51.

207. AACOM. Debts, plans and opinions of osteopathic 

medical students in 2002:24. 

208. AACOM. Debts, plans and opinions of osteopathic 

medical students in 2002. Table 6:21. 

209. United States Department of Education. National 

Center for Education Statistics.1999-2000 National 

Postsecondary Student Aid Study. Percentage of 

undergraduates receiving financial aid for postsecondary 

education and among those receiving aid, the average 

amount of aid received: 1999-2000. NPSAS; 2000. 

210. United States Department of Education. National 

Center for Education Statistics.1999-2000 National 

Postsecondary Student Aid Study. Average amount 

of financial aid received by aided full-time, full-year 

graduate and first-professional students, by source of 

aid, type of degree, and selected student characteristics: 

1999-2000. NPSAS; 2000. 

211. AACOM. Debts, plans and opinions of osteopathic 

medical students in 2002:40-41. 

212. American Medical Association. Report of the council 

on medical education: USMLE—feedback on failing 
SEVENTEENTH REPORT OF COGME 48

scores. Retrieved August 1, 2003, from URL: http://

www.ama-assn.org/ama1/upload/mm/annual02/

cme5a02.doc 

213. Xu G, Veloski JJ, Hojat M. Board certification: 

associations with physicians’ demographics and 

performances during medical school and residency. 

Academic Medicine 1998;73:1283-89.

214. Kwakwa F, Jonasson O. The longitudinal study of 

surgical residents, 1994 to 1996. Journal of the American 

College of Surgeons 1999;188(6):575-85. 

215. Rettie CS. Recruiting students into surgery. Journal of 

Surgical Research 2003;114(2):258.

216. Race matters in the university of the 21st century: report 

of the proceedings, October 4-5, 2002; Dartmouth 

College; 2003. Retrieved August 12, 2004, from URL: 

http://www.dartmouth.edu/~news/releases/2003/

june/062503.html

217. Minority Medical Faculty Development Program, 

established by the Robert Wood Johnson Foundation. 

Retrieved from URL: http://www.mmfdp.org/about.

htm

218. Pechura, CM. Programs of the Robert Wood 

Johnson Foundation to develop minority medical 

careers. American Journal of the Medical Sciences 

2001;322(5):290-92. 

219. The role of diversity in the training of health 

professionals. The right thing to do, the smart thing 

to do. Institute of Medicine. Washington: National 

Academy Press; 2001:52. 

220. Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards 

a culturally competent system of care: a monograph 

on effective services for minority children who are 

severely emotionally disturbed. Washington: CASSP 

Technical Assistance Center, Georgetown University 

Child Development Center; 1989. 

221. Betancourt JR. Cross-cultural medical education: 

conceptual approaches and frameworks for evaluation. 

Academic Medicine 2003;78:560-69. 

222. Crandall SJ. George G. Marion GS. Davis S. Applying 

theory to the design of cultural competency training 

for medical students: a case study. Academic Medicine 

2003;78:588-94. 

223. Drouin J, Rivet C. Training medical students to 

communicate with a linguistic minority group. Academic 

Medicine 2003;78:599-604.

224. Crampton P, Dowell A, Parkin C, Thompson C. 

Combating effects of racism through a cultural 

immersion medical education program. Academic 

Medicine 2003;78:595-98. 

225. United States DHHS. HRSA. Office of Minority Health. 

Gwen Clark. E-mail correspondence. August 18, 2003. 

226. Kaiser Family Foundation. Help understand why. 

Retrieved August 2, 2003 from URL: http://kff.org/

whythedifference 

227. McGravey AR, Bithoney WG, Nethersole S, Carrillo 

JM. Serving the underserved: residency training issues. 

Ambulatory Child Health 1996;1(3):244-49. 

228. Ambulatory Pediatric Association. Training residents to 

serve the underserved: a resident education curriculum. 

Retrieved September 10, 2003, from URL: http://www.

ambpeds.org/publications.cfm 

229. Culhane-Pera KA, Like RC, Lebensohn-Chialvo P, 

Loewe R. Multicultural curricula in family practice 

residencies. Family Medicine 2000;32(3):167-73. 

230. Kaiser Permanente. Culturally competent health 

care. Retrieved August 20, 2003, from URL: http://

www.kp.org/medicine/permjournal/winter00pj/

competent.html

231. The Leadership Alliance. Retrieved August 12, 2004, 

from URL: http://www.theleadershipalliance.org

232. Annual Biomedical Research Conference for Minority 

Students. Retrieved August 12, 2004, from URL: http://

abrcms.org
SEVENTEENTH REPORT OF COGME 49

APPENDIX: A Review of Educational Pipeline 

Programs and Collaborations

PIPELINE PROGRAMS

Project 3000 by 2000

The Association of American Medical Colleges’ 

(AAMC’s) Project 3000 by 2000 helped increase diversity 

in medical schools by facilitating and encouraging pipeline 

and upstream programs at all levels. Together with the National Science Foundation (NSF), the National Institutes of 

Health (NIH), and other organizations, Project 3000 by 2000 

promoted the need and opportunities for minority students 

in science and health. Based on surveys from the 125 United 

States (U.S.) allopathic medical schools, medical school partnerships and opportunities for high school students increased 

between 1990 and 1995, as excerpted below: 

• Science education partnerships with local school 

districts increased from 8 to 72.

• Magnet health science high schools increased from 

8 to 44.

• Classroom-based academic enrichment programs 

for high school students increased from 44 to 82. 

• Laboratory internships for high school students remained high at 102. 

• Academic enrichment programs for college students 

increased from 59 to 77.

• Postbaccalaureate programs increased from 26 to 

47.

• Articulation agreements coordinating curriculum 

and/or admissions with an undergraduate college 

and/or a high school increased from 3 to 59 (62).

Further, this project helped increase diversity in medical schools. When the program began in 1991, a total of 

1,584 underrepresented minorities (URMs) matriculated in 

medical school, and in 1994, that number had increased to 

2,024. Further, surveys from the 125 U.S. allopathic medical 

schools indicate that, between 1990 and 1995, the number 

of postbaccalaureate programs increased from 26 to 47; and 

“articulation agreements coordinating curriculum and/or admissions with an undergraduate college and/or a high school 

increased from 3 to 59” (62). 

Lumina Foundation Programs

The Lumina Foundation offers assistance to increase 

opportunities for minorities in undergraduate colleges and 

universities. Among the Lumina Foundation’s 2003 projects 

are many that enhance the pipeline to medical school:

• The Council of Independent Colleges received a 

$67,300 grant to commission a collection of essays 

from college presidents discussing effective ways to 

recruit and educate disadvantaged students.

• A $329,100 grant was awarded to Berea College to 

study the relationship between “labor, work and service in student persistence and success.” 

• Brevard College received $1.4 million to support 

“Hallmarks of Excellence in the First College Year,” 

a program that seeks to “establish standards for success in first-year programs” and to design an evaluative process for colleges to reach those standards.

• The National College Access Network, which identifies successful college access programs and establishes a “national blueprint” for similar programs, 

was awarded $124,500. 

• The American Association for Higher Education received $4,515,200 to improve academic achievement 

for African American, Hispanic/Latino, and Native 

American students attending institutions that serve 

minorities. These institutions will use information 

from the National Survey of Student Engagement to 

enhance teaching, curricula, and learning environments for improving those students’ academic success.

• The American Association of Community Colleges 

was awarded $305,200 to help community college 

students complete baccalaureate degrees.

• The Indiana Humanities Council was awarded 

$436,300 to test a family-intervention program addressing the “college-going behavior of low-income 

and first-generation students and students of color.”

• The Regents of the University of California received 

$250,000 “to document the relationship between access program intervention and success in college.” 
SEVENTEENTH REPORT OF COGME 50

• Indiana University and Purdue University were 

awarded $100,000 for programs aiming to increase 

the success of African American and Latino freshmen in introductory courses.

• Purdue University won a $100,000 grant for a “multicultural learning” communities project and for 

evaluation of its success in increasing the persistence of participating students.

• The Trustees of Indiana University received a 

$100,000 grant to enhance student success through 

engaging first-generation students in “service learning” projects in introductory courses. 

• A $100,000 grant was awarded to the University of 

Notre Dame to increase student persistence by creating intensive interactive learning in an introductory 

genetics class. The program emphasizes historically 

underserved students (63). 

Health Careers Opportunity Program

The Health Resources and Services Administration’s 

(HRSA’s) Health Careers Opportunity Program (HCOP) provides assistance to disadvantaged students to help them enter 

and graduate from a health or allied health professions school. 

Grants are available to allopathic and osteopathic schools of 

medicine, allied health programs, and public or private nonprofit health and educational organizations. To meet HCOP 

objectives, grantees must conduct the following activities: 

• Recruit disadvantaged individuals.

• Facilitate entry of disadvantaged individuals.

• Provide counseling, mentoring, and other services.

• Disseminate financial aid information.

• Expose students to primary health care in public or 

private community-based facilities.

• Partner with other institutions of higher education, 

school districts, and other community-based organizations to develop a more competitive applicant 

pool. 

Grantees are expected to take a “comprehensive approach” that includes formal partnerships with a network of 

entities working together in a geographic region. The partnership plan must include a health or allied health program, 

an undergraduate institution, school districts, a communitybased organization, formal signed agreements, and activities 

fostering cultural competence. The HCOP provided approximately $1.58 million to support five 3-year grants at an average of $316,000 per year (80).

Centers of Excellence

HRSA’s Centers of Excellence program helps fund 

centers of excellence in health professions education for minority students. Schools of medicine, dentistry, pharmacy, 

and graduate programs in behavioral or mental health are eligible for support for 3-year projects. The grants support the 

enhancement of diversity in the health professions through 

six legislative requirements that applicants must address: 

• Creating a competitive applicant pool

• Improving academic performance

• Supporting faculty development to train, recruit, 

and retain URM faculty

• Attending to minority health issues in clinical training, curricula, and information resources

• Supporting faculty and student research in minority 

health

• Providing community-based training in clinics serving large numbers of minority patients

Grants may also be used to provide stipends for minority students underrepresented in the health professions (81). 

Centers of Excellence may have four designations: 

Historically Black Colleges and Universities (HBCUs), Hispanic Centers of Excellence, Native American Centers of Excellence, and “Other” Centers of Excellence, which must enroll URMs at rates above the National average. The Hispanic 

and Native American Centers of Excellence are required to 

form alliances with other community-based organizations 

that serve those minorities or to partner with other institutions of higher education that have high enrollments of those 

minority groups. The HBCUs and the “Other” Centers of 

Excellence are encouraged to partner with appropriate entities to conduct program activities. The Centers of Excellence 

program provides approximately $15.2 million in FY 2003 

for 10 grants, each an estimated $640,000 annually, to help 

fund programs of excellence in health professions education 

for minority students (81). 

Health Professions Partnerships 

Initiative

Grants from the Robert Wood Johnson Foundation and 

the W.K. Kellogg Foundation helped create the Health Professions Partnerships Initiative (HPPI), an AAMC initiative 

to increase the participation of URM students, especially African Americans, Hispanics, and Native Americans, in health 

professions schools. The initiative develops educational 

partnerships and early intervention programs among medi-
SEVENTEENTH REPORT OF COGME 51

cal schools, other health professions schools, undergraduate 

colleges, and K-12 schools with the intent of improving students’ academic performance and developing their interest in 

health careers (32). 

Minority Medical Education Program

The Minority Medical Education Program (MMEP) is 

a pipeline initiative sponsored by the AAMC and funded by 

the Robert Wood Johnson Foundation to facilitate the admission of promising minority students into medical schools by 

providing an intensive 6-week enrichment summer program. 

The success of the program is indicated by the admission of 

63 percent of participants into medical school. Eleven medical schools conduct the MMEP: 

• University of Alabama School of Medicine 

• Baylor College of Medicine and Rice University 

• Case Western Reserve University School of Medicine 

• Chicago Summer Science Enrichment Program 

• Columbia University College of Physicians and 

Surgeons 

• Duke University School of Medicine 

• Fisk University and Vanderbilt University Medical Center (The College Fund/UNCF Summer Premedical Institute at Fisk University and Vanderbilt 

University Medical Center) 

• New Jersey Medical School 

• University of Virginia School of Medicine 

• Western Consortium (University of Washington 

School of Medicine and the University of Arizona 

College of Medicine) 

• Yale University School of Medicine (64)

University of California, Davis, 

Postbaccalaureate Program

A replicable 10-week summer postbaccalaureate 

program to assist disadvantaged students, including URM 

Californians who were rejected by all medical schools to 

which they applied, has been established at the University 

of California, Davis (UC-Davis) . The program targets those 

students likely to practice in medically underserved communities or among disadvantaged populations. The curriculum addresses study skills, test-taking skills, Medical College Admission Test (MCAT) and math review, and critical 

reasoning and problem-solving skills. Students also identify 

their two weakest areas on the MCAT and work on those topics in review sessions. Participants take the Summer MCAT 

exams and confer with a counselor regarding their progress. 

They then enroll at UC-Davis for the next academic year as 

limited-status students taking courses uniquely suited to each 

student’s needs. The program has improved students’ MCAT 

scores, and from 1991-1999, 104 of the 115 participants were 

accepted by various medical programs, 93 of which were major U.S. medical schools (65). 

Southern Illinois University’s 

Medical/Dental Education 

Preparatory Program 

The Medical/Dental Education Preparatory Program 

of the Southern Illinois University (SIU) School of Medicine has provided a yearlong academic preparation course for 

more than 1,000 minority and disadvantaged students since 

1972. Of current students, 95 percent are URMs. During its 

history, 68 percent of students have been accepted into professional schools, 92 percent of which were medical schools. 

The core curriculum focuses on basic chemistry, physics, and 

biology along with more advanced science courses. Students 

also improve reading, writing, test-taking, and interview 

skills. After completing the core curriculum, students take 

advanced premedical courses at the SIU Carbondale campus. 

The program is funded through State allocations and Federal 

grants (66). 

University of Michigan’s 

Postbaccalaureate Pre-medical 

Fellowship Program

The University of Michigan’s Postbaccalaureate Premedical Fellowship Program (UM-PB) is a yearlong academic enrichment program that provides opportunities for 

enhancing the academic preparation of those desiring to matriculate in medical school. Program participants must be 

either URMs or disadvantaged persons. The success of the 

program was evaluated by examining the academic outcomes 

of enrolled students at the University of Michigan Medical 

School from 1993-1996. Of these students, 15 had completed 

the UM-PB, 58 had finished postbaccalaureate work elsewhere, and 443 were traditional medical school students. The 

traditional students had significantly higher GPA’s than the 

other two groups, and the UM-PB students had lower scores 

on the MCAT exam than the other groups. However, both 

postbaccalaureate groups demonstrated competency in the 

first year of medical school coursework consistent with the 

traditional students (67). 
SEVENTEENTH REPORT OF COGME 52

URM students. Of the 23 students in the first cohort, 16 (70 

percent) completed the survey, and 11 (73 percent) of the 15 

mentors replied to the survey. Twelve of the students evaluated the reflection groups and had attended an average of six 

sessions. Using a scale of 1 (not at all valuable) to 7 (very 

valuable), students’ assessment resulted in a mean score of 

4.2 for the overall value of the meetings, 5.0 for valuable insights from faculty presentations, 4.9 for discussions during 

faculty presentations, and 4.8 for discussions during clinical 

students’ presentations. The lowest mean score was 3.8 for 

helpfulness in handling racial or cultural bias, a rating that 

prompted a shift in emphasis of discussions the following 

year. Students met with mentors an average of three times 

during the academic year. Mentors stated that they had discussed a range of topics, including racial issues, with some 

success, and students considered mentors’ “openness and 

honesty as critical factors in facilitating discussion of this potentially sensitive issue” (70). 

University of Virginia’s Medical 

Academic Advancement Program

To increase its minority and disadvantaged medical 

school matriculants, the University of Virginia created the 

Medical Academic Advancement Program, a 6-week summer 

residential program enrolling approximately 130 students annually in a program designed to help prepare students for the 

MCAT exams. The program has admission requirements, 

including a minimum 3.0 GPA, and uses lectures, problem 

solving, simulated MCAT examinations, and small-group activities such as clinical visits. Between 1984 and 1999, of the 

1,497 participants, 80 had graduated from the University of 

Virginia School of Medicine, and 174 were currently attending the medical school (71). 

University of Illinois at Chicago’s 

Urban Health Program

The Urban Health Program at the University of Illinois at Chicago attempts to increase the number of URMs 

who graduate from the College of Medicine. The program 

has four goals: “1) identify a potential qualified pool of minority students and nurture . . . [them], 2) increase the acceptance and enrollment rates for qualified minority students, 

3) . . . facilitate the graduation of qualified minority students, 

and 4) train . . . culturally sensitive physicians dedicated to 

health care delivery in medically underserved areas.” The 

program uses the AAMC’s MedMAR list to identify Illinois 

students taking the MCAT and recruits them for application. 

It monitors the application process and provides an “open 

house” to promote the school to URMs. Upon admission, a 

pre-matriculation program helps prepare them for the rigors 

of medical school, and additional academic support is offered 

in the form of small group review sessions and preparation 

for the USMLE Step 1 and Step 2. The program’s success is 

indicated by the 695 URMs who matriculated between 1989 

and 1998 with a 90 percent retention rate (72). 

University of North Carolina’s 

Medical Education Development 

Program

The Medical Education Development Program 

(MEDP), a joint program of the University of North Carolina’s medical and dental schools, is an intensive 9-week 

program for URMs and economically disadvantaged students 

who have shown potential to complete medical or dental 

school. A follow-up study of 371 participants in the program 

between 1980 and 1989 revealed that 76 percent were accepted into medical school, and 88 percent of those graduated 

from medical school. The acceptance rate of the MEDP URM 

participants was significantly higher than the National acceptance rates for both URMs and non-URMs (68). 

 

University of Illinois at Chicago 

College of Medicine’s Program for 

At-Risk Students

Eighty-nine URMs who matriculated in the University 

of Illinois at Chicago College of Medicine as “at-risk” students were studied to determine the influence that advisors 

or mentors may have had on them. “At risk” was defined as 

likely to experience academic difficulty. These students were 

later classified either as “no delay” (having passed all courses as well as Step 1 and Step 2 of the USMLE) or as “delay/withdrawn.” Twenty students from each of these groups 

were randomly selected, and those agreeing to participate 

were interviewed about their mentors. Of the nine “no delay” 

respondents, seven had physician mentors, and two had no 

mentors. Of the 13 “delay/withdrawn” respondents, three had 

physician mentors, five had other mentors, and five had no 

mentors. Although conclusions were inconsistent, those who 

had physician mentors experienced less academic difficulty 

(69). 

University of Rochester School of 

Medicine’s Medical Student 

Mentoring Program

The Medical Student Mentoring Program at the University of Rochester School of Medicine was funded by the 

New York State Department of Health in response to the 

needs of URM and non-URM faculty to help facilitate the 

success of URMs in medical school. The program was conducted during the 1995-1996 and 1996-1997 academic years. 

Of the 28 URM students in the first- and second-year classes, 

23 were assigned a mentor, and 21 met with their mentors at 

least once. Mentors attended two mentor development workshops. Students were invited to attend monthly discussion 

meetings or “reflection groups” at which URM faculty, residents, and advanced students shared their experiences as minorities. An average of eight students attended each meeting. 

The program was evaluated by surveys of both mentors and 
SEVENTEENTH REPORT OF COGME 53

East Carolina University School of 

Medicine’s Summer Program for 

Future Doctors

The Summer Program for Future Doctors at East Carolina University School of Medicine helps URMs and disadvantaged students prepare for entry into medical school. 

The program admits as many as 24 students into an intensive 

8-week summer program that focuses on science instruction, 

MCAT preparation, learning skills, and communication and 

writing skills. From 1994-1997, the program had 69 participants, 51 of whom applied to medical school. Twenty-four of 

these were accepted, and 17 of this group were URMs. Twelve 

other participants chose other health professions (73). 

University of Michigan School of 

Medicine’s Academic Support 

Program

The University of Michigan’s School of Medicine has 

created an Academic Support Program designed to intervene 

when a student has academic difficulties. Referrals into the 

program may come from the student, academic advisor, or 

faculty member. Reasons for intervention include failed academic coursework or failure of Step 1 of the USMLE exam. 

Once a student is referred, an assessment is conducted at the 

Office of Services for Students with Disabilities. The student 

is interviewed by a clinical psychologist, completes behavioral screening checklists, and sometimes takes an academic 

achievement test. Action is recommended based on the evaluation. The student is sometimes referred to other agencies 

within the university, such as the University Health Center, 

and ultimately referred back to the medical school for academic support. During 1994-1998, 28 students, 24 of whom 

were URMs, were referred to the program. The difficulties 

arose during either the first year in coursework or the third 

year with the USMLE testing. Of the 28 students, 26 either 

graduated or continued progress with their studies. None received probation again. Two discontinued the program for 

academic reasons (74). 

Ohio University College of 

Osteopathic Medicine Programs

The Ohio University College of Osteopathic Medicine 

has one of the strongest minority representations of all osteopathic medical schools. Enrollment of URMs increased 

from 11 percent in 1982-1983 to 23 percent in 1997-1998. 

The College has six programs that support minority students 

in undergraduate school and medical school. The Summer 

Scholars Program seeks to strengthen the academic preparation of URMs for medical school admission. Of the 210 

students who participated by 1998, 78 had matriculated in 

the medical school, and 33 had graduated. The Academic Enrichment Program assists matriculating students with issues 

ranging from academic difficulties to financial aid. Approximately 22 students per class participate. The Prematriculation Program enrolls students admitted to the medical school 

and helps them prepare for their first year. In 1998-1999, all 

but 6 of the 28 eligible students participated. Program ExCEL supports URMs at Ohio University to enhance their 

academic preparation and increase interest in going to medical school. The Summer Enrichment Program is an optional 

6-week program to assists URMs who plan to study premed 

at Ohio University. The Postbaccalaureate Program provides 

academic enrichment for students who have applied to medical school but were not admitted. Each program targets a different group, but all attempt to increase the number of URM 

physicians (75). 

Wayne State University’s 

Postbaccalaureate Program

The first postbaccalaureate program in the Nation was 

created in 1969 at Wayne State University specifically to assist African American students who had applied but failed 

to be admitted to medical school. Students were guaranteed 

admission to the medical school if they maintained a B average as a postbaccalaureate student. The yearlong program has 

evolved as successes and failures have been analyzed. Participants take courses in inorganic chemistry, biochemistry, 

and other sciences and also improve their academic skills. By 

1997, the medical school had graduated 493 African American students, 30 percent of which (160 students) had entered 

the program through the postbaccalaureate program (76). 

University of South Florida 

College of Medicine’s Summer 

Pre-Matriculation Program

The University of South Florida College of Medicine 

initiated the Summer Pre-Matriculation Program (SPP) in 

response to the academic difficulties experienced by URMs 

entering in 1995. Of 13 matriculating URMs, 6 failed at least 

one course in the first semester. All URMs of the 1997 entering class were encouraged to attend, and all entering students 

were eligible. Of the 14 participating students, 5 were URMs. 

After the first semester, all but one SPP student received a 

B or better in gross anatomy, compared to 80 percent of the 

class as a whole. The one student received a C, whereas 17 

percent of the class received a C and two failed. In biochemistry, both the SPP and class average was 87. Again, all but 

one SPP student received a B or better, and the one student 

received a C. In human embryology, all but two SPP students 

received a B or better, and the two made a C, whereas 37 

percent of the class received a C and two failed. The program 

seeks to strengthen the academic preparation of students so 

that they can successfully navigate their first year of medical 

school (77). 
SEVENTEENTH REPORT OF COGME 54

comparison or control groups also limited conclusions about 

causal effects of these programs (79). 

COLLABORATIVE PROGRAMS 

The AAMC’s Health Professions 

Partnerships Initiative

Grants from the Robert Wood Johnson Foundation and 

the W.K. Kellogg Foundation helped create the Health Professions Partnerships Initiative (HPPI), an AAMC initiative 

to increase the participation of URM students, especially African Americans, Hispanics, and Native Americans, in health 

professions schools. The initiative develops educational 

partnerships and early intervention programs among medical schools, other health professions schools, undergraduate 

colleges, and K-12 schools with the intent of improving students’ academic performance and developing their interest in 

health careers (32). 

The AAMC has published Learning from Others, a literature review of HIPPI partnerships and guide to forming 

partnerships to enhance academic opportunities for URMs 

(106). Another study assessing the qualities of successful 

HIPPI programs revealed the following criteria as predictive 

of successful HIPPI collaborations: 

• “Vision and commitment to community”

• “Willingness to listen to partners and respect them”

• “Leaders and staff who foster the program through 

commitment and consistency”

• “Prior experience in diversity programs”

Characteristics of school districts and individual 

schools involved in successful partnerships include the following:

• “Vision and leadership”

• “Selection of strong schools”

• “Support of teachers”

• “Strategies to involve parents and families”

The study concludes that more research is needed to show 

that successful partnerships lead to successful educational 

practices that support the pipeline to health professions education (86).

University of Medicine and 

Dentistry—New Jersey 

Medical School Programs

The University of Medicine and Dentistry—New Jersey Medical School has 11 different programs to increase the 

number of URMs entering medical school, several of which 

target students from eighth through twelfth grades. Programs 

exist for academic enrichment and promotion of interest in 

health careers for levels extending from the eighth grade to 

first-year medical and dental students. In addition, a Saturday 

Science Academy is open to students from eighth through 

twelfth grades. Two programs target Hispanic students, the 

Hispanic Center of Excellence Summer Youth Program and 

Infomed, which offer informational seminars and monthly 

workshops to help Hispanic students improve their chances 

of success in medicine and health professions. Undergraduates have an opportunity to participate in the Students for 

Medicine and Dentistry Program to enhance academic and 

non-academic skills, and first-year medical students make the 

transition between undergraduate school and medical or dental school with the assistance of the Freshman Introduction to 

Resources, Skills, and Training course. From 1972-1998, a 

total of 1,722 students were involved in the pre-college programs; 1,875 participated in the college programs, and 683 

participants attended the pre-matriculation programs (78). 

Other Precollege Programs

A 1998 article discusses 27 precollege programs seeking to increase diversity in medicine. These programs are 

classified by five characteristics: 

• “Academic enhancement”: programs that enhance

students’ academic skills 

• “Motivation”: programs that encourage students to 

consider a medical career

• “Mentorship”: programs that provide students with 

a mentor in a medical student, physician, or other 

health care worker

• “Research apprenticeship”: programs that offer 

students laboratory research experience 

• “Academic partnership”: alliances between medical schools and school systems to improve students’ prospects for success in health careers

Of the 27 programs described in the article, most are 

academic enhancement programs. Evaluation is an important 

component of any program, and only 12 of the 27 programs 

had evaluation components. Further, only five programs attempted to assess the quality of the program using formative 

research methods such as pre- and post-test scores. A lack of 
SEVENTEENTH REPORT OF COGME 55

Medical College of Georgia’s 

Health Science Learning 

Academy

A Health Professions Partnership Initiative at the 

Medical College of Georgia’s (MCG’s) Schools of Medicine 

and Nursing has created an alliance consisting of the College, 

two Augusta high schools attended primarily by URMs, three 

HBCUs, the Fort Discovery National Science Center of Augusta, community service organizations, and MCG student 

organizations. The high school science program, called the 

Health Science Learning Academy (HSLA), seeks to enhance 

students’ academic preparation and interest in science and 

health. The HSLA began with ninth graders and expanded 

during its second year to include ninth through twelfth graders. Enrichment classes, offered for 3 hours on 18 Saturday 

mornings during the academic year, include work in SAT 

preparation, English composition, math, and biology. Since 

its inception in 1996-1997, 203 students have participated, 

and the 38 students who completed all 4 years have enrolled 

in college. The mean SAT score for those students was 1,066, 

compared to the mean of 923 for all college-bound students 

at the participating high schools (82). 

Southern Illinois University’s 

Summer Programs 

Southern Illinois University offers two summer programs to pre-college minority and disadvantaged students. 

The Health/Science Careers Pathway (HSCP) Program provides high school minority students opportunities to increase 

their awareness and interest in health and science professions. 

The Summer Research Apprenticeship Program matches disadvantaged high school students with faculty mentors in a 

research laboratory. Students learn lab safety, conduct handson research, collect data, and produce and present a research 

paper. A Science on Saturday program was also initiated for 

middle school students who received tutoring from students 

in the MEDPREP program, a postbaccalaureate preparation 

program to facilitate admission to medical school (66). 

Baylor College of Medicine and 

University of Texas-Pan American’s 

Premedical Honors College

Baylor College of Medicine (BCM), together with and 

the University of Texas-Pan American (UT-PA), has created 

the Premedical Honors College (PHC), a combined Bachelor 

of Science-Medical Doctor (B.S.-M.D.) program that seeks 

to increase the number of physicians providing care to Texas’s underserved communities. Since its beginnings in 1994, 

the program has had 159 matriculants and 71 graduates, and 

60 of these have matriculated in medical school. By comparison, in 1994, only four students from all five South Texas colleges (30,000 students) were accepted into medical school. 

The Texas legislature has acknowledged the program’s success and has passed a bill to replicate the program in the Joint 

Admission Medical Program (JAMP). PHC students are 95 

percent Mexican American, indicating that, as of 2001, the 

PHC produced over 40 percent of the 386 Mexican American 

medical school matriculants nationwide. 

The program targets 13 South Texas counties, all of 

which are designated as medically underserved, and 11 of 

which are designated health professions shortage areas. The 

program is open to all high school students, who, upon acceptance into the program, attend college at UT-PA and receive 

conditional acceptance to BCM. The students must meet certain requirements, such as maintaining an overall GPA of 3.2 

and a science GPA of 3.0. In addition to coursework, they 

receive tutoring and support services, enrichment activities, 

clinical activities, and mentoring. They also attend summer 

enrichment programs throughout their college years. Since 

the program’s initiation, declared premed majors at UT-PA 

have doubled, and graduates matriculating in medical school 

have increased seven-fold (83). 

Ohio State University’s 

Young Scholars Program

The Young Scholars Program seeks to motivate URMs 

and disadvantaged youth of Ohio to enroll in post-secondary 

school. Students are nominated for the program when they 

are in the sixth grade, when students and parents sign a contract that promises admission into Ohio State University as a 

freshman and a loan-free financial aid package that stipulates 

a GPA requirement of 2.0 or better to maintain the assistance. 

Students must participate in year-round and summer activities, complete college preparation courses, and maintain a 

minimum 3.0 GPA in high school. Participants attend the 

University’s Summer Institute for 1 to 3 weeks to complete 

coursework and career exploration. The first group of Young 

Scholars enrolled in 1994. After 2 academic years, their retention rate was 72 percent. The rate for the campus as a 

whole was 70 percent. A comparison group adjusted for family income, race, gender, and high school GPA had a retention 

rate of 62 percent (84). 

University of Washington School of 

Medicine’s Washington, Wyoming, 

Alaska, Montana, Idaho Program

The Washington, Wyoming, Alaska, Montana, Idaho 

(WWAMI) program, which provides regional medical education for States nearest to the University of Washington School 

of Medicine, attempts to increase primary care physicians in 

this largely rural and underserved region. The program has 

established collaborative programs with K-12 and undergraduate students to enhance recruitment of students. The Minority Medical Education Program allows students to come to the 

University of Washington campus every summer for 6 weeks 
SEVENTEENTH REPORT OF COGME 56

ner Schools in this county participate in the Comprehensive 

Partnership for Minority Student Achievement, an NSF project that focuses on science and math preparation for URM 

students. The HPP enhances science education across the 

continuum, including math and chemistry instruction at the 

high school level. HPP students attend a summer enrichment 

program before they enter undergraduate school. When students prepare to take the MCAT exam, they participate in the 

MCAT Undergraduate Training Conference. All URM students are invited to participate in a prematriculation program 

during the summer before their medical school coursework 

begins. They can also participate in a structured preparation 

course for the USMLE Step 1 exam (90). 

Colorado Medical Explorers Program

Manual High School in Colorado, a school with a high 

minority population, reformed its science education curriculum with assistance from the University of Colorado’s Health 

Sciences Center. This partnership promotes science education 

and has components to stimulate interest in science and careers in medicine. The Medical Explorers program provides 

ninth graders with a weekly yearlong experience in science 

and health. All students are invited to participate, and in its 

first year, the program had 16 applicants. In addition, sixth 

graders have an opportunity to do hands-on activities during 

10 yearly outreach trips. This medical partnership promotes 

science education and “a rich diversity of students who pursue careers in medicine” (91). 

Boston University School of 

Medicine’s CityLab

CityLab, a centralized biotechnology learning laboratory at the Boston University School of Medicine, assists 

in promoting science education for students and teachers in 

Boston area junior high and high schools. Funded by NIH, 

the lab’s goal is to provide students with first-hand experience in science. Students working in the lab learn that they 

can understand science and pursue careers in science and 

health. Able to accommodate 200 students weekly, CityLab 

served 16,000 students and 1,200 teachers between 1992 and 

1999. Some teachers have even started CityLab satellites at 

their own schools. Students and teachers have responded positively to CityLab, and satellites have been replicated across 

the U.S. (92). 

University of California,

San Francisco’s Medteach Program

Medteach, a partnership of the University of California, San Francisco (UCSF), and San Francisco’s public 

middle schools, is a program in which three to five volunteer first-year medical students teach lessons on biology and 

health to assigned classes 10 to 12 times during an academic 

year. Coordinated by UCSF’s Science and Health Education 

of science courses, health care lectures, MCAT preparation, 

and information about application and admission to medical school. The Medical Scholars Program began outreach 

work with students from rural areas and from URM groups. 

This program promotes health careers through “a week-long 

‘immersion in medicine’.” Further, Federal grant funds and 

matching funds from the University developed enrichment 

courses for high school minority, disadvantaged, and rural 

students. The University of Washington is also a designated 

Center of Excellence for Native Americans and recruits this 

URM group into health care careers, conducts research in 

Native American health issues, and provides faculty development for Native American physicians (85). 

Four Directions Summer Research 

Project

The Four Directions Summer Research Project is a 

summer program designed for Native American undergraduate students to perform research at Harvard Medical School. 

The program is designed and run by Native American physicians and medical students within the Harvard Medical community. The program, which has had over 75 participants in 

10 years of existence, seeks applicants interested in improving the health status of Native Americans (87). 

University of Minnesota’s 

Native Americans into 

Medicine Programs

Native Americans into Medicine is a 6-week summer enrichment program of the Center of American Indian 

and Minority Health at the University of Minnesota (UM). 

Open to college students or high school graduates preparing 

to enter college, the program provides a curriculum in introductory science courses like anatomy and microbiology and 

allows students to explore careers in medicine and health 

(88). The UM INMED program is a summer Preceptorship 

open to students who are at least 14 years old and who are 

planning to enroll in post-secondary education. It is a 4- to 

6-week program in which students work with health care 

providers and gain an overview of Native American health 

from the provider’s perspective (89). 

University of Louisville School of 

Medicine’s Professional Education 

Preparation Program

 The University of Louisville School of Medicine started 

activities to increase minority matriculation as early as 1981 

through the Professional Education Preparation Program, enhanced in 1996 by a Health Professions Partnership (HPP) 

grant. In this program, the medical school has increased its 

partnership with the Jefferson County Public Schools, which 

educates large numbers of African American students. Part-
SEVENTEENTH REPORT OF COGME 57

Partnership (SEP), the medical students align their lessons 

with the teacher’s classroom plans and receive feedback from 

the teachers as well as advice from the SEP staff. The program 

has been popular, as indicated in the number of requests by 

teachers for a Medteach team. The program served approximately 350 sixth graders in 1997-1998. Some key reasons for 

its success include a sustained relationship between teachers 

and medical student teams; consistency of teams to facilitate 

small groups; access to materials, tools, and models; financial 

support; and a committed SEP coordinator who provides lesson plans, support, and feedback. Those desiring to replicate 

the program should consider the following advice:

• Become familiar with the local public schools.

• Identify a committed group of volunteers.

• Seek out resources for support.

• Visit teachers and classrooms (93). 

New York’s Rural Partnership for 

Science Education

 The Rural Partnership for Science Education is an alliance of rural students and teachers in 10 New York State 

school districts and several New York institutions: the Research Institute of Bassett Healthcare (an academic medical center affiliated with the Columbia University College 

of Physicians and Surgeons), Hartwick College, the State 

University of New York at Oneonta and its biological field 

station, the Science Discovery Center in Oneonta, Corning 

Science Products Division in Oneonta, the Clark Scholarship 

Foundation, and the New York Academy of Sciences. The 

program is designed to stimulate the interest of students and 

teachers in science and to enhance the teaching and learning of science. One-week summer workshops are offered to 

approximately 70 teachers each year. Students from grades 

three through eight also participate in weeklong summer exploration camps. Surveys of elementary students of teachers 

who have attended Partnership workshops indicate that these 

students’ rating of science is significantly higher than ratings 

of students of non-attendees. Another instrument, the Children’s Academic Intrinsic Motivation Inventory, measures 

student motivation in five areas—general studies, science, 

reading, math, and social studies. Partnership schools administered these surveys to seventh graders each year from 1992-

1996, and results consistently showed that science had the 

highest mean score. Further, the program coordinator visits 

classrooms during the year to present lessons, and pre- and 

post-tests for these lessons show that students move from 

pre-test averages of 54-66 percent correct to post-test mean 

scores of 76-93 percent correct (94). 

Louisiana State University School of 

Medicine’s Enrichment Activities for 

Minority Youth

 The Louisiana State University (LSU) School of Medicine’s Office of Community and Minority Health Education, 

supported by HRSA’s Health Careers Opportunity Program, 

provides enrichment activities for minority high school students in the New Orleans area. The initiative includes outreach to science clubs; “Awareness Days,” when health professionals make presentations and science demonstrations or 

provide tours of the medical school or labs; “Competition 

Day,” when students compete in academic skills events; and 

an 8-week High School Summer Science Program. Students 

must be admitted to the summer program, and 70-118 students have participated annually since 1990; 90 percent of 

participants are African American. Students each have a faculty mentor from the LSU School of Medicine and, based on 

the student’s interest, is assigned to clinical or basic science 

research sites. Students work at the sites for 8 hours Monday 

through Thursday and for 4 hours on Friday, when they spend 

the afternoon at lectures covering such topics as the admissions process and financial aid. A 1997-1998 survey of participants from 1985-1997 revealed that 282 of 594 respondents 

had science or pre-health professions undergraduate majors, 

and 31 were enrolled in or had graduated in medicine (95). 

John Burns School of Medicine’s 

Summer Program for the 

Enhancement of Basic Education

 The John Burns School of Medicine, Hawaii’s only 

medical school, houses the Ho’ola Post Baccalaureate Program and the Native Hawaiian Center of Excellence, both 

funded by HRSA’s Division of Disadvantaged Assistance. 

The center targets Native Hawaiians in public schools to try 

to increase their enrollment in medical school. In 1992, the 

center initiated a 6-week Summer Program for the Enhancement of Basic Education, but only one Native Hawaiian was 

admitted during the first 3 years because of lack of competitiveness. With additional funding, six positions were set aside 

for Native Hawaiians, who, upon admission, are required to 

fulfill the program’s academic requirements. After special 

recruitment of Native Hawaiians, the six set-aside positions 

were utilized, and soon thereafter, Native Hawaiians were 

admitted into the program through the regular admissions 

process. In 1995, 1996, and 1997, eight Native Hawaiians 

participated each year. Of the 1995 group, all went to college, 

three in pre-med; of the 1996 group, all went to college, five 

in pre-med. All members of the 1998 group were attending 

college at the time the program was reported; two were planning to major in pre-med. One received a prestigious Regents 

Scholarship by the University of Hawaii at Manoa. The program illustrates the need to develop a pathway for Native Hawaiians and other URMs as early as elementary school (96). 

Modern Genetics Program

 The Modern Genetics Program is a hands-on science 

education program conducted through a partnership of Washington University scientists, “implementation specialists” at 

the Mathematics and Science Education Center of the Coop-
SEVENTEENTH REPORT OF COGME 58

and UCLA faculty and staff together to create software that 

will enable students to gain problem-solving skills. Teachers receive a stipend to attend and receive unlimited use of 

the software. From 1993 to July 1998, 275 teachers from 67 

schools participated in activities. Preliminary testing showed 

that students who performed IMMEX problem solving as 

part of classroom activities scored significantly better “on an 

independent test of problem-solving skills” than a class not 

exposed to IMMEX problems (99). 

West Virginia University’s 

Health Sciences and Technology 

Academy

 The Health Sciences and Technology Academy was 

formed to help increase the number of health professionals 

in the State of West Virginia, most of which is rural. The 

academy is a partnership among West Virginia University 

(WVU) (including the Health Sciences Center, the College 

of Arts and Sciences, and the College of Human Resources and Education) and secondary-school teachers, health 

care professionals, and other community leaders. Targeting 

URMs in high school, the academy sponsors communitybased extracurricular activities and a Summer Institute on the 

WVU campus. The institute recruits students to participate 

in leadership development and science activities during 1- to 

3-week periods during the summer. Clubs meet during the 

school year either weekly or bi-weekly, and secondary science teachers coordinate activities and are a major influence 

in academic enrichment for students. Retention of students 

in the academy increased from 54 percent to 75 percent from 

the 1995 group to the 1996 group. Of the original cohort, 26 

students were retained, and 11 more were recruited to add to 

this group. At the time the program was reported, all 37 students had applied and been accepted to college. Responding 

to whether the academy had increased their interest in health 

careers, approximately 72 percent responded “yes” for each 

year’s program activities, and 80 percent responded “yes” 

for the Summer Institute. The West Virginia Legislature has 

passed a bill that will allow tuition and fee waivers for students who complete the academy (100). 

University of Texas at Houston 

Health Science Center’s Intercon 

Network

 The University of Texas at Houston (UT-Houston) 

Health Science Center has partnered with other post-secondary institutions throughout Texas, such as the University of 

Texas at El Paso, the University of Texas Pan-American, 

and Texas Southern University, to increase the enrollment 

in medicine of disadvantaged persons, who are often African American or Hispanic in Texas. In 1998, 108 students 

from those universities enrolled in research or professional 

internships at UT-Houston. The university has also partnered 

with inner-city, suburban, and rural K-12 school districts in 

erating School Districts of St. Louis, project evaluators from 

Southern Illinois University at Edwardsville, and high school 

biology teachers in St. Louis, Missouri. Participating schools 

represent diverse student bodies. Project staff include a parttime scientist, a full-time implementation specialist, and a 

half-time evaluator. The implementation specialist meets 

weekly with teachers and provides supplies and logistical 

support. Teachers and key personnel participate in monthly 

workshops and also attend a 2-week summer workshop. Preand post-tests that assessed knowledge and knowledge gains 

of students indicate that, in 1995-1996, of 62 biology classes 

having 1,275 participants, 60 classes showed statistically significant gains. During the following year, 64 classes having 

a total of 1,322 students participated, and all classes showed 

significant increases in knowledge. All classes also showed 

gains in positive attitudes toward science (97). 

Baylor College of Medicine’s 

My Health My World Project

 Baylor College of Medicine’s My Health My World 

Project seeks to improve science education and to close the 

achievement gap in science that appears early in elementary 

school for URM groups, who were outperformed by whites 

and Asians at all grades tested (fourth, eighth, and tenth) in 

the 1996 National Assessment of Academic Progress science evaluation. Modeled on the National Science Education 

Standards, the project makes materials available and trains 

teachers in elementary science education. The project unit 

materials are age appropriate and focus on the relationship 

of the environment and health. They include “an adventure 

storybook, a language arts supplement, a guide to hands-on 

science activities, and a colorful mini-magazine, Explorations. . . .” At the time the program was reported, one project 

unit had been field tested each year by over 1,000 students 

from kindergarten through grade five, and 1,380 teachers had 

attended workshops. Teachers’ ratings of the field testing are 

uniformly high, and when students are asked to draw or write 

about something they have learned, 87 percent of students 

responded with key content points either in drawings or in 

writing (98). 

University of California, Los Angeles, 

School of Medicine’s Interactive 

Multi-media Exercises Project

 The University of California, Los Angeles (UCLA), 

School of Medicine has developed an Interactive Multi-media Exercises (IMMEX) Project to facilitate teachers’ work in 

developing students’ problem-solving skills. Most students in 

the project are in the Los Angeles Unified School District, an 

urban educational system with an enrollment of over 800,000 

students, 60 percent of whom have limited language proficiency, and 70 percent are URMs. The goal of IMMEX is 

to increase students’ interest and achievement in science and 

math. A 4-week IMMEX Training Institute brings teachers 
SEVENTEENTH REPORT OF COGME 59

an “InterCon” network and conducts a high school science 

internship, a professional development program for teachers, 

a curriculum development program for high school medical 

sciences and technologies, and other innovative programming. The projects to promote science education in K-12 will 

help meet the goal of the UT-Houston Health Sciences Center 

to recruit more minorities into medicine and the goal of the 

Texas Higher Education Coordinating Board to enroll more 

disadvantaged Texans in graduate and professional schools 

(101). 

Meharry Medical College’s 

Health Careers Opportunity 

Pre-Baccalaureate Program

Meharry Medical College has had an academic enrichment program to improve the academic preparation of undergraduate students for medical school since 1969. In 1997, the 

Biomedical Sciences Program merged with other programs 

and now functions as the Health Careers Opportunity PreBaccalaureate Program. The original program is described 

as targeting sophomores and prejuniors to provide them with 

scientific knowledge to consider medical and dental training, 

to facilitate their admission into health professions programs, 

to foster awareness of these programs, and to provide minority role models. Students for the program were recruited from 

feeder schools from which most of the matriculating medical 

students graduate. Information was mailed to health career 

advisors at all HBCUs. Applications included faculty letters 

of recommendation and career goals expressed in writing, 

and program participants had to have a B average overall 

and a B in science and math. Pre-tests, post-tests, and weekly 

exams were conducted to measure the effect of coursework 

on performance. Tracking was used to evaluate long-term effects of the program. Of 1,025 former participants to whom 

evaluations were mailed, 445 (43 percent) responded to the 

survey. Seventy percent had applied to professional schools, 

83 percent of which were medical schools, 15 percent were 

dental schools, and 2 percent were graduate schools. Of those 

applying to medical school, 198 (77 percent) were admitted, 

and all had graduated. The 46 who applied to dental schools 

were all admitted, and all graduated. Of those applying to 

graduate schools, all had received Ph.D.’s in biomedical sciences (102).

Trinity College’s Consortium on 

High Achievement and Success

Trinity College in Hartford, Connecticut, has joined 

with over 30 other colleges and universities to form the 

Consortium on High Achievement and Success, a group 

dedicated to facilitating the success of minority students at 

predominantly white college campuses. Trinity College has 

created the Barrier Course Project, which provides supplemental instruction for students struggling in science classes. 

The program also trains teachers to provide encouraging 

feedback, and students also learn to study and work collaboratively (102). 

University of Alabama at 

Birmingham School of Medicine’s 

Bridge to Health Care

The Center for Community Outreach Development at 

the University of Alabama at Birmingham School of Medicine has created the Bridge to Health Care, a project that seeks 

to increase minority participation in medicine by providing 

academic enrichment and laboratory and clinical setting experiences for fifth-, seventh-, and ninth-grade students in the 

Birmingham City Schools. The medical school credits the 

program’s success to the strong partnership with the school 

system and also the school’s dedication to the community. 

For example, students learn about such diseases as diabetes 

and sickle cell disease, which affect their own communities 

disproportionately. The students are exposed to health information and to medical career information that can influence 

their future (103).

Mount Sinai School of Medicine’s 

Pre-College Programs

 The Mount Sinai School of Medicine collaborates with 

the Gateway Institute for Pre-College Education to encourage students living in the school’s New York City community 

to attend college and pursue professional careers. The institute works with 10 high schools, targeting the preparation of 

minority and low-income students for professional careers, 

including science and medicine. The medical school also provides college preparatory curriculum to the Queens Gateway 

to Health Sciences Secondary Schools and the Life Sciences 

Secondary School in east Harlem. The program enables students who may not have high academic qualifications, but 

who are highly motivated, to pursue careers in science or 

health (103).

Doctor’s Academy

 Sunnyside High School’s “Doctor’s Academy” is a 

program initiated in 1999 by the Latino Center for Medical 

Education and Research, which is on the Fresno campus of the 

University of California, San Francisco. The program helps 

disadvantaged students primarily from minority backgrounds 

to get intensive academic preparation for college and, eventually, medical careers. Students in the academy take an extra 

class at the end of the day and focus on college preparatory 

courses. They also have after-school, weekend, and summer 

internships. During the summer before their senior year, they 

intern with a physician mentor. The $1.2 million funneled into 

the program by the Latino Center comes from such sources as 

HRSA grants, California State funds and California Endowment funds, the AAMC’s Health Professions Partnership Initiative, and W.K. Kellogg Foundation donations. This highly 
SEVENTEENTH REPORT OF COGME 60

competitive program graduated its first 32 students in June 

2003 (104). 

 

The Leadership Alliance

 The Leadership Alliance, a consortium of 31 U.S. research and teaching academic institutions, seeks to promote 

the participation of underserved and underrepresented students in graduate studies, including doctoral programs, and 

in research. The alliance provides educational opportunities 

through undergraduate internships and mentoring, graduate 

support and fellowships, faculty development opportunities, 

and research exchanges (231). 

Annual Biomedical Research 

Conference for Minority Students

The Annual Biomedical Research Conference for Minority Students is a National conference that promotes advanced studies in the biomedical sciences to minority students. The conference is sponsored by The National Institute 

of General Medical Sciences, Division of Minority Opportunities in Research Program, and is managed by the American Society for Microbiology. At the conference, students 

participate in scientific sessions, professional development 

workshops, and poster sessions and exhibits. The students 

also have opportunities to network and to benefit from faculty mentoring (232).