From “Do No Harm” to “Do More Good”

My medical school experience was long and hard. It wasn’t just the academic rigor or the fierce competition among my peers that is typical of medical school. I expected those challenges, and I was prepared to meet them. What made those years especially hard was constantly having to justify my presence in spaces where very few others—my peers, instructors, or other healthcare professionals—looked like me.

In the early days of my three-month surgical rotation, my chief resident (witnessed by other surgeons and scrub nurses) told me I wasn’t intelligent enough to be there—that I was the product of affirmative action. “You’re only here because you’re Black,” my chief resident said. “Black people really shouldn’t be in medical school.”

Later in the rotation, we rounded on a patient, an older Black man who was being treated for diabetic ketoacidosis. My chief resident and two other residents discussed what to do about the patient’s diabetic wounds. The wounds looked serious, but the patient was stable after receiving a full course of antibiotics. The residents proposed a leg amputation—not because it was medically necessary, but because they wanted the practice.

The patient had no family or advocate, and he was not coherent enough to make decisions about his own care. Nonetheless, some of the residents were ready to manipulate him into signing off on a life-altering and very painful procedure just so they could meet their surgery quota. Although I was well aware of our nation’s history of medical exploitation of people of color¹ and the persistence of racism-based beliefs about Black patients (such as “Black people have a higher pain tolerance”),² I couldn’t believe what I was hearing—or that no one else was objecting.

As the only Black person on the team, I went to the chief of surgery with my concerns. The patient’s leg was spared. But any hope of establishing trust between me and my colleagues evaporated. I spent the rest of that rotation studying nonstop on very little sleep so that my chief resident was unable to fail me (which he’d threatened to do) or write a negative evaluation that could doom my career before it had even begun. It was exhausting. To be clear, incidents like this were not limited to my surgical rotation—they occurred throughout my didactic and practical medical training.

By the time I was finally a practicing pediatrician, I had witnessed dozens more patient encounters marked by racial, ethnic, or cultural insensitivity—in some cases, my own insensitivity. These encounters were a symptom of a larger problem: the persistent inequities in the United States that have resulted in few patients from historically underrepresented groups sharing an identity with their clinicians and fewer people from these groups pursuing critical roles in the health professions.³

This has to change.

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The United States is facing a growing shortage of healthcare professionals.⁴ As we seek to grow the workforce caring for our increasingly multiracial and multicultural society, it’s crucial that we focus on diversification. Recruiting and retaining a healthcare workforce that reflects the racial and ethnic diversity of the communities they serve and holding the entire workforce to the goal of providing culturally and linguistically effective care is the only path to equitable outcomes for all.

The need for a more diverse healthcare workforce is well documented. Although Latinx, Black, and Indigenous peoples comprise 18.5, 13, and 2.5 percent of the US population, respectively, they are significantly underrepresented among physicians in the healthcare workforce (5.8, 5, and 0.4 percent, respectively).⁵ According to the 2022 National Nursing Workforce Survey, most registered nurses are white (80 percent) despite white people being 58.4 percent of the population. Just 6.9 percent of registered nurses identified as Hispanic or Latinx, 6.3 percent as Black, and 0.4 percent as American Indian or Alaskan Native. The only racial group represented adequately was Asian American or Pacific Islander, at 7.5 percent (though our history of drawing on Filipino nurses makes this a pyrrhic victory*).⁶

National statistics often understate regional gaps in representation, but tools such as the Mullen Institute Health Workforce Diversity Tracker give a good picture of national and state-level data on workforce diversity.⁷ As one would expect, representation varies by geography, but overall, people of color face underrepresentation in a range of healthcare professions. One exception is in health service occupations. A 2017 report showed that of 30 health occupations, people of color were only well represented, if not overrepresented, in health support, personal care, and other service roles—positions that do not require a college degree and typically pay less and provide fewer benefits than other healthcare roles, which is equally concerning.⁸

Concerted efforts on the part of some medical, nursing, and midwifery school institutions led to a slight enrollment increase for some historically underrepresented populations (American Indian or Alaska Natives and Hispanic or Latinx) in the 2023 matriculation year.⁹ However, the Supreme Court’s 2023 ruling on affirmative action policies for college admission—which deemed consideration of race or ethnicity unconstitutional—is likely to reverse this positive, albeit slow, development. There is precedent for this concern: several states that ended affirmative action programs in previous decades have seen higher education enrollment decline among historically underrepresented populations, and evidence suggests these declines are persistent.¹⁰ In light of this, organizations such as the Association of American Medical Colleges are working to understand the consequences of the ruling and to maintain diversity efforts in medical schools and healthcare training programs.¹¹

Given our nation’s increasing diversity and the growing resistance to diversity, equity, and inclusion efforts,¹² it is more important than ever that we support and sustain diversity across all health professions. This article seeks to help readers understand why diversity is important for all healthcare teams and how unions can push healthcare systems to be part of the solution.

The Case for Representative Care Teams

A common condition that brings children and their families to seek healthcare is ringworm of the scalp. While there are multiple possible treatments, many clinicians typically prescribe an antifungal shampoo that must be applied to the scalp and rinsed out at least three times a week. The treatment sounds easy enough; for Black children and families, it’s often anything but.

Some clinicians do not know that many Black people do not wash their hair this frequently. Black hair types have different needs than other hair types; additionally, some Black people straighten their hair or wear protective styles that do not hold up well with frequent washing. So while Black families may accept the shampoo prescription, many will only use it on their normal washing schedule—which is not often enough to be effective. At the follow-up visit, the child’s scalp may be little improved or show worsening hair loss. In my experience, many clinicians in this situation have become frustrated, commented that such families are uncaring or lack parenting abilities, or made threats about noncompliance.

I have had to explain that Black children’s hair dries out easily with too many washings, and that it is time consuming to wash and then comb out thick hair multiple times per week. My hope is that next time these clinicians will respond with cultural understanding and respect—and offer an oral antifungal that can clear up the infection much more quickly, perhaps in conjunction with the shampoo just once per week. The children would return with an improved scalp, and the clinician-patient relationship would be furthered. But I also have a broader hope: that these clinicians will approach the next family with an open mind. Even with deeper awareness, we can’t predict everything that will impede compliance—but we can create spaces in which families feel welcome to share their questions and concerns, and in which we take the time to engage with and learn from them.

Examples like this illustrate why we need a more diverse healthcare workforce—and also a more representative one. Diverse healthcare teams include professionals from many different backgrounds and identities, including race, ethnicity, language, religion, socioeconomic status/class, ability, sexual orientation, and gender identity.^† Representative teams go a step further, cultivating as much concordance as possible between the team and the community being cared for. To optimize patient outcomes and staff well-being, it’s imperative to focus diversity efforts on groups with predictably worse outcomes and with less access to joining health professions.

It’s also crucial to note that diverse and representational healthcare teams can improve outcomes for all patients and well-being for all staff. This broader argument, often left out, is needed to sway those who may be leery of the effort involved in recruiting and supporting diverse staff. Diversification is not a zero-sum game: it is a process that supports us all. More specifically, a diverse healthcare workforce:

1.  Improves cultural understanding. Increasing diversity among students entering health professional training programs creates space for more inclusive conversations that can lead to greater understanding of medical conditions and treatments.¹³ And increasing the number of diverse health professionals in the workplace creates opportunities for clinicians to increase their cultural awareness by learning to recognize that patients have different life experiences.¹⁴ They can then listen and ask meaningful questions when seeking to engage patients, collaborate with colleagues, and improve individual outcomes.¹⁵

2.  Enhances clinician-patient trust and patient outcomes. Increasing representational diversity within health professions can improve patient satisfaction and outcomes—especially for patients of color.¹⁶ Research has shown that racial concordance (i.e., when a patient and clinician share a racial identity) can lead to more trusting relationships, increased patient satisfaction, and often improved outcomes.¹⁷ In two studies, for example, Black and Latinx men seen by physicians who shared their racial and/or cultural background^‡ were more likely to adhere to treatment plans, engage in preventive services, and agree to care recommendations.¹⁹

Other research suggests that language concordance (i.e., when a patient and clinician speak the same language) is associated with higher patient perceptions of healthcare quality and higher patient experience ratings.²⁰ Language concordance has also been shown to improve patients’ health and safety outcomes.²¹ For this reason, identifying, recruiting, and supporting bilingual health professionals is a necessary goal for all healthcare institutions. While there is a federal requirement to provide language services for those with limited English proficiency,²² this does not always occur.

3.  Boosts health professionals’ well-being. The healthcare staffing crisis has critical implications for health professionals’ well-being. Heavier workloads (including higher patient-to-clinician ratios) lead to increased exhaustion, burnout, and risk of moral injury^§ and decreased job satisfaction and mental well-being.²³ These outcomes may be attenuated and even prevented if an institution is willing to expand the candidate pool when recruiting employees in order to address the staffing shortage.²⁴

Racism and discrimination in the workplace cause additional harm to healthcare professionals who are already experiencing work-related stress, contributing to burnout and turnover. A 2021 national survey of more than 5,600 nurses revealed that 63 percent of all nurses—and 92 percent of Black nurses—had experienced a racist act in the workplace, and 75 percent had witnessed one.²⁵ A 2023 survey of 3,000 healthcare workers reported that most (and particularly those working in facilities serving majority-Black or majority-Latinx patients) had experienced stress related to discrimination.²⁶ Increasing diversity of the healthcare team can reduce the level of implicit biases and stereotyping, and it may lead to improved interactions²⁷ between colleagues as well as between clinicians and the patients and families they care for.

4.  Increases patient access to care. The US Health Resources and Services Administration has designated specific geographies, populations, and facilities as Healthcare Professional Shortage Areas due to their inability to recruit or retain primary care, dental, or mental health care clinicians.²⁸ Recruiting a diverse array of clinicians is likely to directly impact these shortage designations, improving clinician supply and increasing patients’ access to care.** Research suggests that clinicians from historically underrepresented groups in a variety of specialties are more likely to work in shortage areas, accept Medicaid (which has a lower reimbursement rate than other insurers), see more patients from historically underrepresented groups, and spend more time with patients.²⁹

5.  Strengthens recruiting and retention. Expanding the pool of people from which an organization hires increases the number of applicants—and most applicants highly value organizational diversity. One employee study found that for more than 75 percent of job seekers, diversity is an important factor in evaluating potential employers.³⁰ Applicants who perceive an organization does not prioritize diversification efforts may be unwilling to join, leaving the remaining staff to face the negative patient and personal consequences of staffing shortages.

Supporting diversification has also been cited as a way to improve retention of all staff. Results of an employee survey suggest healthcare systems that do not prioritize diversity lose twice as many employees as their more diverse counterparts³¹—leading to not only significant institutional costs to hire and train new staff but also worsening patient outcomes along with increased burden and risk of burnout, higher dissatisfaction and turnover, and decreased well-being for staff who remain.³²

6.  Enriches team and organizational performance. Healthcare team diversity has been shown to improve team communication and the accuracy of clinical decision making, in addition to improving patient outcomes.³³ Although research on productivity and performance related to healthcare workforce diversity is more recent and still fairly limited, studies focusing on organizations with parallels to healthcare show that diverse work environments foster greater productivity and performance for the entire team—and demonstrate financial benefits for the organization.³⁴ These studies also show that diversifying teams across an organization, including on the governing board, can lead to greater innovation, challenges to past thinking, and new ideas that can help improve performance (e.g., risk assessments, problem solving new workflows, and solutions to improve care or efficiencies).

While these benefits demonstrate that health professional diversity is sorely needed, it should not supplant student choice. Federal, state, and local policies often seek to “diversify” professions in ways that only serve their interests—such as diversifying lower-paying jobs without offering career pathways to higher-paying, more specialized positions. But students must have the freedom to choose the course of their profession particularly because diversity is needed (and lacking) across all types of health professions, including primary care, specialty care, nurse practitioners, phlebotomists, radiology technicians, community health clinicians, and more. We need, for example, diverse dermatologists who can diagnose melanoma across various skin colors and provide culturally and linguistically effective care just as much as we need diverse primary care physicians.

Additionally, the benefits of workforce diversity noted above require diverse representation within all levels of the workforce and an environment in which teams share power so that all voices are heard and all team members can share ideas and wisdom. Medicine is a hierarchical system; if only leadership voices count, and those voices are not representative of the larger community, having diverse members among the rest of the team will not have the same positive effects. Returning to the ringworm example, a Black certified nursing assistant could have explained the issue with the shampoo—but only if the higher-level clinicians created an environment in which speaking up was valued.

A Call for Cultural Humility

While diverse healthcare representation is crucial, diversification alone will not ensure more equitable outcomes. It is but one important piece of the solution. Another essential piece is ensuring that all health professionals learn how to provide and are accountable for providing culturally and linguistically effective care. This is impossible without developing what pediatrician and community activist Melanie Tervalon termed cultural humility (which entails learning to listen to and respect patients’ expertise about the cultural contexts of their lives and health needs).³⁵ Cultural humility is often developed through experience—including from mistakes like one I made early in my career.

In my third year of pediatric residency, I worked in a hospital on a Native American reservation. On my third day, I saw a two-week-old patient with a high fever. I didn’t even have to think; my years of training kicked in. The baby needed an immediate workup to rule out sepsis (which is a fairly invasive procedure) and antibiotics.

The parents told me to wait; they first needed to speak to their medicine person and agree on a treatment plan. I pressured them; I even used scare tactics. I told them that there was no time to waste because sepsis in infants can lead to damage to the brain and other organs or even death. They needed to act immediately.

In distress about the infant’s health and truly agitated that these parents did not seem to understand the urgency of the situation, I sought out my preceptor, an older white family practitioner who was the hospital’s medical director. He listened to my problem and then asked a question: Had I tried to understand what this family wanted and why?

I hadn’t.

My preceptor returned with me to the exam room to talk with the family. A short time later, they’d consulted with their medicine person, who was just 10 minutes away, and returned for the sepsis workup and antibiotics. (And the baby improved.)

I’ll never forget what my preceptor told me afterward: “Yes, pediatrics is your expertise, and you were doing what you thought was best. But this is not about you. It’s about patient-centered care. You have to stop talking and listen.”

This experience taught me to put aside my agenda and prioritize cultivating rapport with patients and families based on deep respect for their culture, knowledge, and experiences. I also learned the value of colleague-to-colleague trust, support, and modeling of strategies that lead to greater cultural awareness and humility. Healthcare professionals aren’t perfect and can’t know everything. But in listening to patients and being accountable to each other to deliver culturally or linguistically effective care, we more completely fulfill our obligation to patients—not to “first, do no harm,” but instead to “do more good.”

The Way Forward: Diversifying the Health Professions

Despite the many challenges to improving representational diversity in the health professions, there are reasons to be optimistic. Several programs and practices designed to increase access to the health professions and decrease turnover have been successful, and we can learn from their work.

Building Health Professions Pathways

Pathway programs that support entry of young people from historically excluded populations into the health professions have been shown to help diversify the healthcare workforce. These historically excluded populations often face several barriers to entering health professions, including being redirected or discouraged from pursuing health careers due to discrimination, lack of knowledge of how to gain entry, lack of K–12 academic supports, and lack of money. Pathway programs offer the supports needed to reverse these and other barriers. A recent study³⁶ identified key components of these programs: academic enrichment, financial support, and social and institutional supports.

Academic enrichment. Many underrepresented populations attend schools that do not offer rigorous, advanced classes due to historical and ongoing segregation and inequitable distribution of resources. These students may require enrichment supports to help them gain entry to and succeed in health professional schools. Through components like make-up courses in the summer before college, internships, and academic advising and career supports, academic enrichment programs can help level the playing field as young people enter and seek to graduate from health professional training programs.

Financial support. Students from historically excluded groups who want to become doctors need an array of financial supports (including for living expenses) that are not conditional on choosing primary care or service in underserved communities so they are able to choose medicine over other shorter training programs. Postsecondary and postgraduate education are expensive, and many cannot afford the delayed financial gratification; additionally, many must focus on meeting current individual or family financial needs.

Social supports. Study participants repeatedly mentioned mentoring—beginning as early as middle school and continuing through professional degree attainment and into clinical practice—as essential to helping them navigate educational demands and professional development opportunities and deal with microaggressions and implicit bias. Noting the importance of exposure to various clinical disciplines, many participants expressed the need for mentors who could help them explore or enter other specialties if desired. In addition, study participants noted a need for mentoring in college and postgraduate education to support retention. Because of the lack of diversity within health professional leadership and teaching positions, historically excluded students often had difficulty finding a racially or ethnically concordant mentor who could guide them through discrimination, career discouragement, and other social barriers they faced.

Institutional supports. Institutional supports are those that not only facilitate entrance into pathway programs but also sustain the welcoming, inclusive environment necessary for successful graduation and equity in educational and work settings—such as institution-wide championing of diversity, equity, and inclusion practices and commitment to continual development or refining of pathway interventions.

Supportive institutions hold individuals and systems accountable when students face racial discrimination or hostility. As noted earlier, a large percentage of nurses have witnessed or experienced racism on the job.³⁷ Unless institutions hold the perpetrators accountable, the hostile work environment will lead to decreased entry and retention of underrepresented students, increasing the workload of those who remain.

It is important to note that many pathway programs have and continue to face significant challenges that must be addressed to ensure their efforts are successful and sustainable. These include but are not limited to anti-affirmative action policies that limit pathway access, lack of access to sustainable funding, lack of institutional support, and lack of institutional recognition of the importance of retention efforts.

Increasing Retention Through Workforce Investments

Systems that strive to increase the entry of diverse workers into the health professions must consider how they will retain these workers. The strategies below focus on cultivating welcoming workplaces with supportive policies to ensure that both new hires and existing care team members feel valued and desire to remain in practice.

Develop effective policies to ensure a safe, hostility-free workplace. Workplace violence is an ongoing crisis affecting worker well-being and retention. Studies among nurses have shown that workplace violence increases burnout, stress, job dissatisfaction, and staff turnover³⁸—and workplace violence increases with understaffing and when staff have high levels of stress.³⁹ Workers must know that their safety is important and will be protected. Organizations must develop, implement, and adhere to equitable policies to prevent workplace violence, and establish consequences when it occurs, including violence perpetrated by patients.⁴⁰ These policies must also ensure protections for staff who report safety issues, including those related to racism or discrimination. Healthcare professionals who have come forward have reported being dismissed, sidelined or forced out, and seen as not being a “good fit,”⁴¹ which only contributes to an even more unsafe, hostile work environment.

Implement equitable workload, professional development, and financial supports. Healthcare professionals of color often receive less pay, are not compensated for higher workloads they carry because of participation in equity endeavors, and have a harder time receiving promotions and mentorship. To increase equity in this area, consider the following strategies:

1.  Compensate those who lead or support diversity and equity work. Leaders and workers of color (particularly women of color) are often expected to inform or lead organizational efforts to increase diversity and equity in addition to their other commitments.⁴² Compensating these individuals through funding, time, promotions, or other benefits and increasing the expectation that all staff engage in and lead diversity work can improve this dynamic.

2.  Provide qualified language services. To provide linguistically effective care to patients with limited English proficiency, bilingual clinicians often have to carry their workload and support their nonbilingual colleagues without additional resources. They also may not have the necessary vocabulary to provide medically accurate interpretation.⁴³ Ensuring access to qualified interpreters can help alleviate the burden on these clinicians. However, it is important to have bilingual clinicians and recommend that others on the healthcare team learn a new language, even if at just a basic level to help build rapport with patients and their loved ones.⁴⁴

3.  Provide equitable salaries and benefits. Healthcare professionals’ financial concerns also affect retention. Workers of color across the healthcare professions experience wage disparities⁴⁵ and are overrepresented in lower-paying fields and careers,⁴⁶ which limits their ability to repay educational loans, meet family needs, and accumulate wealth. Addressing this barrier requires equalizing pay across racial groups, increasing salaries and benefits in some historically lower-paying fields, and building career pathways that provide upskilling and increased access to all health professions.⁴⁷

4.  Champion loan repayment and scholarship programs. Educational loan repayment programs can help improve workforce representation along race, ethnicity, socioeconomic status, and other parameters; yet, it is a huge ask to expect students from historically excluded groups to take on large debt with only a possibility of loan repayment upon training completion. For this reason, scholarships may be more effective. It’s worth noting again that such programs would be more beneficial if they did not have narrow parameters such as requiring primary care and/or working in underserved areas.⁴⁸

5.  Increase transparency around promotion opportunities. Healthcare professionals of color are significantly less likely to advance to senior leadership positions than their white counterparts. Thus, the American College of Healthcare Executives developed comprehensive recommendations for increasing and sustaining racial diversity that include greater transparency about promotion qualifications.⁴⁹ I would add that organizations should also expand their promotion criteria so that time spent on equity and community initiatives and other often ignored but critical endeavors count toward tenure alongside more traditional criteria like publication. If young people don’t see a clear path for their entry, success, and retention in the health professions, they may be less willing to engage.

6.  Provide job shadowing and exploration experiences. In a 2022 study, many nurses of color noted they only knew the pathway to nursing because a family member had been a nurse. They emphasized the need to highlight the existence of varied health professional careers and to explain entry requirements.⁵⁰ Through job shadowing and career exploration opportunities, young people from historically excluded groups can not only discover health professional careers that are available to them but also better understand the paths to entering and remaining in these professions.^††

What Unions Can Do

Making meaningful progress in diversifying the healthcare workforce despite longstanding, purposeful, systemic barriers requires an all-hands-on-deck approach. It requires determination, understanding of historical efforts (both successful and less so), and expanded partnerships. Unions, with their varied healthcare members and community partners, can be a powerful and welcome voice for change.

Unions are an important part of the advocacy structure that can persuade policymakers, educational institutions, and employers to prioritize representational diversity in their communities and beyond. They can also use collective bargaining to support entry and retention of historically excluded groups in healthcare organizations. Below is a list of tools, policies, and processes that might be included in bargaining:

• Annual collection of employment data and surveys (conducted anonymously to prevent targeting) to understand the scope and experiences of diversity within the organization (e.g., Who is in the organization? How long have they worked here? How do they feel about diversity in the workplace? Have they experienced or witnessed biased remarks or actions? Are wages and benefits equitable across race, ethnicity, gender, and other variables that should not affect compensation?).
• Quarterly collection of data on workplace violence to understand when incidents occurred and how they were resolved, and to consider how they could have been prevented. Additionally, collection of workplace safety protections that are enforced.
• Implementation of the Institute for Healthcare Improvement’s Joy in Work framework for decreasing staff burnout, moral injury, and turnover while increasing engagement and well-being.⁵¹
• Staff compensation (financial or time) for community-based mentoring activities intended to increase diverse youth knowledge of and entry into health professions.
• A fair appeals process and whistleblower protections for those who speak out against racism and discrimination within the organization, along with a yearly public report on complaints and how they were resolved.
• Ongoing supports and programs to help healthcare professionals pay for continuing education, upskill training, language courses, and other activities that can increase both workforce diversity and culturally and linguistically effective care. Importantly, programming for “all participants” must recognize that participants have differing barriers and levels of opportunity that may lead to inequitable treatment and outcomes in terms of hiring, promotion, retention, and physical and mental well-being.
• Adoption of transparent hiring, promotion, and retention practices that reward efforts to ensure a diverse and welcoming work environment for all employees.

Equitable patient outcomes should be a goal of all healthcare systems, practitioners, and policymakers. We cannot hope to do more good for our patients, families, and communities without diversifying the health professional workforce and providing the support and respect that students and practitioners need to enter and remain in their chosen professions. The fact that barriers created to sustain inequitable healthcare access and outcomes still challenge this work does not mean we should turn away from the goal; it simply means we should be honest about what is needed to achieve success. Though improved patient outcomes is a North Star driving healthcare diversification efforts, organizational leaders and staff of all identities accrue meaningful benefits that should encourage us to work together for lasting change.

Kimá Joy Taylor, MD, MPH, is the founder of Anka Consulting, a healthcare consulting firm, and a nonresident fellow at the Urban Institute. Previously, she was the director of the Open Society Foundations’ National Drug Addiction Treatment and Harm Reduction Program, a deputy commissioner for the Baltimore City Health Department, a health and social policy legislative assistant for Senator Paul Sarbanes, and a pediatrician at a federally qualified health center in Washington, DC.

*To learn about the outsized role nurses trained in the Philippines play in the US healthcare workforce, see “Investing in Our Future” in the Fall 2021 issue of AFT Health Care: aft.org/hc/fall2021/bailey_moon. (return to article)

^†While we often discuss identity categories separately, especially in research, people who hold those identities cannot separate out how they experience them. To learn more about how intersecting identities affect LGBTQ people of color in healthcare spaces, see “Improving Care of LGBTQ People of Color” in the Fall 2021 issue of AFT Health Care: go.aft.org/by0. (return to article)

^‡I am not arguing for, nor do I believe in, racial concordance to the point of resegregation, where patients are only treated by clinicians with whom they share a racial identity. Not only is this unfeasible, as we are dispersed across the nation, but it is not equitable and denies the diverse and intersectional identities within patient populations. Consider, for example, that neither racial nor language concordance ensures culturally effective care (i.e., healthcare that respects a patient’s cultural identity and heritage as well as the cultural factors that can affect health).¹⁸ Even as health professions diversify, all clinicians will still have a responsibility to get to know their patients so as to offer the best possible care. (return to article)

^§AFT Health Care has published several articles on moral injury documenting the challenges healthcare workers face and how to address them; see go.aft.org/78a. (return to article)

**Of course, it is not possible to recruit clinicians who do not exist. The representational entry of students into healthcare training programs is also necessary to increase access to care in these shortage areas. While equalizing opportunities to learn from birth through higher education is outside the scope of this article, everyone concerned with equitable patient care should be advocating and voting for fully funding public schools and for family supports (like early childhood education) to give underrepresented youth opportunities to become health professionals. (return to article)

^††To read about a high school in a hospital that introduces youth to the full range of healthcare careers, see “Creating a Healthy Community” in the Spring 2024 issue of AFT Health Care: aft.org/hc/spring2024/hummer. (return to article)

Endnotes

1. A. Nuriddin, G. Mooney, and A. White, “Reckoning with Histories of Medical Racism and Violence in the USA,” The Lancet 396, no. 10256 (October 2020): 949–51.

2. K. Hoffman et al., “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites,” Proceedings of the National Academy of Sciences 113, no. 16 (April 2016): 4296–4301.

3. K. Taylor et al., Improving and Expanding Programs to Support a Diverse Health Care Workforce (Washington, DC: Urban Institute, May 2022), urban.org/sites/default/files/2022-05/Improving%20and%20Expanding%20Programs%20to%20Support%20a%20Diverse%20Health%20Care%20Workforce%20.pdf; and E. Salsberg et al., “Estimation and Comparison of Current and Future Racial/Ethnic Representation in the US Health Care Workforce,” JAMA Network Open 4, no. 3 (2021): e213789.

4. A. Džakula, D. Relić, and P. Michelutti, “Health Workforce Shortage—Doing the Right Things or Doing Things Right?,” Croatian Medical Journal 63, no. 2 (April 2022): 107–9; and Health Resources & Services Administration, “Workforce Projections,” US Department of Health and Human Services, data.hrsa.gov/topics/health-workforce/workforce-projections.

5. V. Lopez-Carmen et al., “Equitable Representation of American Indians and Alaska Natives in the Physician Workforce Will Take Over 100 Years Without Systemic Change,” The Lancet Regional Health Americas 26 (October 2023): 100588.

6. Taylor et al., Improving and Expanding Programs.

7. Fitzhugh Mullan Institute for Health Workforce Equity, “Health Workforce Diversity Initiative,” George Washington University, gwhwi.org/diversitytracker.html.

8. National Center for Health Workforce Analysis, Sex, Race, and Ethnic Diversity of U.S. Health Occupations (2011–2015) (Washington, DC: US Department of Health and Human Services, August 2017), bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/diversity-us-health-occupations.pdf; and E. Blakemore, “Latinos Underrepresented Among Physicians, Overrepresented as Aides,” Washington Post, August 6, 2023, washingtonpost.com/wellness/2023/08/06/latino-underrepresented-health-care-degrees.

9. Association of American Medical Colleges, “New AAMC Data on Diversity in Medical School Enrollment in 2023,” press release, December 12, 2023, aamc.org/news/press-releases/new-aamc-data-diversity-medical-school-enrollment-2023#:~:text=Diversity%20of%20enrollees,4.5%25%20since%202022%2D23.

10. M. Long and N. Bateman, “Long-Run Changes in Underrepresentation After Affirmative Action Bans in Public Universities,” Educational Evaluation and Policy Analysis 42, no. 2 (2020): 188–207.

11. P. Boyle, “How Can Medical Schools Boost Racial Diversity in the Wake of the Recent Supreme Court Ruling,” Association of American Medical Colleges, July 27, 2023, aamc.org/news/how-can-medical-schools-boost-racial-diversity-wake-recent-supreme-court-ruling; Long and Bateman, “Long-Run Changes”; and American Medical Association, “Affirmative Action Ends: How Supreme Court Ruling Impacts Medical Schools & the Health Care Workforce,” July 7, 2023, ama-assn.org/medical-students/medical-school-life/affirmative-action-ends-how-supreme-court-ruling-impacts.

12. J. Asare, “The History of DEI Resistance in America,” Forbes, July 13, 2023, forbes.com/sites/janicegassam/2023/07/13/the-history-of-dei-resistance-in-america; and N. Ellis and C. Thorbecke, “DEI Efforts Are Under Siege. Here’s What Experts Say Is at Stake,” CNN, January 11, 2024, cnn.com/2024/01/07/us/dei-attacks-experts-warn-of-consequences-reaj/index.html.

13. Association of American Medical Colleges, “Importance of Diversity in Health Care,” aamc.org/about-us/mission-areas/medical-education/my-story-matters#:~:text=Incorporating%20diversity%2C%20equity%2C%20and%20inclusion,to%20provide%20better%20medical%20care; T. Sinha et al., “Integration of Disability Awareness Improves Medical Students’ Attitudes Toward People with Disabilities,” Medical Science Educator 34 (2024): 561–69, link.springer.com/article/10.1007/s40670-024-02004-0; and J. Greene, J. Blustein, and B. Weitzman, “Race, Segregation, and Physicians’ Participation in Medicaid,” Milbank Quarterly 84, no. 2 (June 2006): 239–72, ncbi.nlm.nih.gov/pmc/articles/PMC2690164/#:~:text=Black%20and%20Asian%20physicians%20were,slightly%20less%20likely%20to%20participate.

14. American Nurses Association, “How Nurse Leaders Can Promote Diversity in Nursing,” ANA Nursing Resources Hub, September 14, 2023, nursingworld.org/content-hub/resources/workplace/promote-diversity-in-nursing/#:~:text=diversity%20in%20nursing.-,Why%20Is%20Diversity%20in%20Nursing%20Important%3F,from%20one%20another's%20diverse%20perspectives.

15. E. Ihara, “Cultural Competence in Health Care: Is It Important for People with Chronic Conditions?,” Georgetown University, Health Policy Institute, hpi.georgetown.edu/cultural.

16. L. Zephyrin, J. Rodriguez, and S. Rosenbaum, “The Case for Diversity in the Health Professions Remains Powerful,” blog, Commonwealth Fund, July 20, 2023, commonwealthfund.org/blog/2023/case-diversity-health-professions-remains-powerful#:~:text=Research%20shows%20that%20a%20diverse,especially%20for%20patients%20of%20color.

17. Taylor et al., Improving and Expanding Programs.

18. Agency for Healthcare Research and Quality, “Improving Cultural Competence to Reduce Health Disparities for Priority Populations,” US Department of Health and Human Services, July 8, 2014, effectivehealthcare.ahrq.gov/products/cultural-competence/research-protocol#:~:text=Culturally%20competent%20care%20is%20defined%20as%20care,Department%20of%20Health%20and%20Human%20Services%2C%20established.

19. Taylor et al., Improving and Expanding Programs; Zephyrin, Rodriguez, and Rosenbaum, “The Case for Diversity”; and Greene, Blustein, and Weitzman, “Race, Segregation.”

20. E. Harrison et al., Understanding Training and Workforce Pathways to Develop and Retain Black Maternal Health Clinicians in California (Washington, DC: Urban Institute, May 2023), urban.org/sites/default/files/2023-05/Understanding%20Training%20and%20Workforce%20Pathways%20to%20Develop%20and%20Retain%20Black%20Maternal%20Health%20Clinicians%20in%20California.pdf.

21. H. Al Shamsi et al., “Implications of Language Barriers for Healthcare: A Systematic Review,” Oman Medical Journal 35, no. 2 (March 2020): e122.

22. National Health Law Program, “Federal Laws and Policies to Ensure Access to Health Care Services for People with Limited English Proficiency,” healthlaw.org/wp-content/uploads/2018/09/Federal-Language-Access-Laws.pdf.

23. L. Haddad, P. Annamaraju, and T. Toney-Butler, “Nursing Shortage,” StatPearls Publishing, February 13, 2023, ncbi.nlm.nih.gov/books/NBK493175; and N. Sabine and T. Gibbs, “Unraveling Healthcare Shortages in Delaware and Charting a Course for Equity and Resilience,” Delaware Journal of Public Health 9, no. 5 (December 2023): 14–18.

24. P. Kalina, “Increase Inclusion to Decrease Physician Burnout and Increase Wellness,” Journal of Hospital Management and Health Policy 3 (July 2019): 18.

25. American Nurses Association, “Survey Shows Substantial Racism in Nursing,” 2022, nursingworld.org/practice-policy/workforce/racism-in-nursing/national-commission-to-address-racism-in-nursing/survey-shows-substantial-racism-in-nursing.

26. H. Fernandez et al., “Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients,” Commonwealth Fund, February 15, 2024, commonwealthfund.org/publications/issue-briefs/2024/feb/revealing-disparities-health-care-workers-observations.

27. T. Green and A. Kalev, “Discrimination-Reducing Measures at the Relational Level,” Hastings Law Journal 59, no. 6 (2008).

28. Health Resources & Services Administration, “What Is Shortage Designation?,” US Department of Health and Human Services, bhw.hrsa.gov/workforce-shortage-areas/shortage-designation.

29. K. Walker, G. Moreno, and K. Grumbach, “The Association Among Specialty, Race, Ethnicity, and Practice Location Among California Physicians in Diverse Specialties,” Journal of the National Medical Association 104, no. 0 (April 8, 2014): 46–52; Greene, Blustein, and Weitzman, “Race, Segregation”; and Institute of Medicine, Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the US Healthcare Workforce, In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce, ed. B. Smedley, A. Stith Butler, and L. Bristow (Washington, DC: National Academies Press, 2004), ncbi.nlm.nih.gov/books/NBK216011/#ddd00037.

30. Glassdoor, “Glassdoor’s Diversity and Inclusion Workplace Survey,” October 1, 2020, glassdoor.com/blog/glassdoors-diversity-and-inclusion-workplace-survey.

31. Press Ganey, “Press Ganey Study Uncovers Impact of Diversity and Equity on Retention,” October 27, 2021, pressganey.com/news/press-ganey-study-uncovers-impact-of-diversity-and-equity-on-retention.

32. X. Peng et al., “The Impact of Nurse Staffing on Turnover and Quality: An Empirical Examination of Nursing Care Within Hospital Units,” Journal of Operations Management 69, no. 7 (2023): 1124–52.

33. L. Gomez and P. Bernet, “Diversity Improves Performance and Outcomes,” Journal of the National Medical Association 111, no. 4 (August 2019): 383–92; and J. Dreachslin, P. Hunt, and E. Sprainer, “Workforce Diversity: Implications for the Effectiveness of Health Care Delivery Teams,” Social Science & Medicine 50, no. 10 (2000): 1403–14.

34. Gomez and Bernet, “Diversity Improves Performance.”

35. M. Tervalon and J. Murray-García, “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education,” Journal of Health Care for the Poor and Undeserved 9, no. 2 (May 1998): 117–25; and H.-M. Lekas, K. Pahl, and C. Lewis, “Rethinking Cultural Competence: Shifting to Cultural Humility,” Health Services Insights 13 (2020): 1178632920970580.

36. Taylor et al., Improving and Expanding Programs.

37. National Commission to Address Racism in Nursing, “Racism’s Impact in Nursing,” https://nursingworld.org/~48f9c5/globalassets/practiceandpolicy/workforce/commission-to-address-racism/infographic--national-nursing-survey_understanding-racism-in-nursing.pdf.

38. S. Kafle et al., “Workplace Violence Against Nurses: A Narrative Review,” Journal of Clinical and Translational Research 8, no. 5 (2022): 421–24.

39. C. Jones, Z. Sousane, and S. Mossburg, “Addressing Workplace Violence and Creating a Safer Workplace,” PSNet, Agency for Healthcare Research and Quality, US Department of Health and Human Services, October 31, 2023, psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace; and M. Lim et al., “Workplace Violence in Healthcare Settings: The Risk Factors, Implications, and Collaborative Preventive Measures,” Annals of Medicine and Surgery (London) 78 (June 2022): 103727.

40. CENTEGIX, “Workplace Safety Aids in Recruitment and Retention of Healthcare Professionals,” blog, October 28, 2022, centegix.com/blog/workplace-safety-aids-in-recruitment-and-retention-of-healthcare-professionals.

41. U. McFarling, “‘A Target on My Back’: New Survey Shows Racism Is a Huge Problem in Nursing,” STAT, May 31, 2023, statnews.com/2023/05/31/nursing-racism-survey.

42. J. Trejo, “The Burden of Service for Faculty of Color to Achieve Diversity and Inclusion: The Minority Tax,” Molecular Biology of the Cell 31, no. 25 (November 30, 2020): 2749–2862; and P. Lin and L. Kennette, “Creating an Inclusive Community for BIPOC Faculty: Women of Color in Academia,” SN Social Sciences 2, no. 11 (2022): 246.

43. David Geffen School of Medicine, “The Benefits of Bilingual Physicians: Increasing Access to Care and Improving the Patient Experience,” blog, University of California, Los Angeles, September 4, 2018, medschool.ucla.edu/blog-post/the-benefits-of-bilingual-physicians.

44. A. Kozan, “The Importance of Eliminating Language Barriers in Healthcare,” Critical Language Scholarship, December 21, 2023, clscholarship.org/news/2023/the-importance-of-eliminating-language-barriers-in-healthcare.

45. B. Frogner and M. Schwartz, “Examining Wage Disparities by Race and Ethnicity of Health Care Workers,” Medical Care 59, no. 10, supplement 5 (October 2021): S471–S478; and V. Bailey, “Physician Compensation Varied by Gender, Race Despite Overall Raises,” TechTarget, April 19, 2022, revcycleintelligence.com/news/physician-compensation-varied-by-gender-race-despite-overall-raises.

46. D. Ly and A. Jena, “Trends in Diversity and Representativeness of Health Care Workers in the United States, 2000 to 2019,” JAMA Network Open 4, no. 7 (July 2021): e2117086.

47. County Health Rankings & Roadmaps, “Career Pathways Programs,” University of Wisconsin Population Health Institute, May 17, 2022, countyhealthrankings.org/strategies-and-solutions/what-works-for-health/strategies/career-pathways-programs.

48. Taylor et al., Improving and Expanding Programs.

49. American College of Healthcare Executives, “Increasing and Sustaining Racial/Ethnic Diversity in Healthcare Leadership,” November 16, 2020, ache.org/about-ache/our-story/our-commitments/policy-statements/increasing-and-sustaining-racial-diversity-in-healthcare-management.

50. Taylor et al., Improving and Expanding Programs.

51. J. Perlo, IHI Framework for Improving Joy in Work (Cambridge, MA: Institute for Healthcare Improvement, 2017), ihi.org/resources/white-papers/ihi-framework-improving-joy-work#downloads.

[Illustrations by Elizabeth Montero]