Chapter 2: Why Diversity Matters

Educators, researchers, policymakers, and the courts have all explored the role of diversity in education and the health professions. While approaching the subject from different angles, they have identified two principal reasons for increasing diversity in our health professions schools:

• Diversity provides a better educational experience for all students.
• Diversity leads to improved access to care.

Similar conclusions have been reached in two highly respected reports on minorities and health care, three Supreme Court decisions, and a variety of scholarly publications. These authoritative sources all agree that diversity matters, and offer compelling reasons why educational institutions should pursue it. In 2010, the Commission on Dental Accreditation (CODA) joined this chorus when its revised Predoctoral Accreditation Standards recognized diversity as an essential component of academic excellence.

Better Educational Experience for All Students

While many might assert that diversity is valuable in its own right, the key question for health professions schools is whether and how diversity might affect their primary mission-to educate students to become competent health care providers.

In 1978, the U.S. Supreme Court issued a landmark decision in the case Regents of the University of California v. Bakke. The court's ruling that, "the State has a substantial interest that legitimately may be served by a properly devised admissions program involving the competitive consideration of race and ethnic origin" prompted researchers to study the educational impact of diversity.

After surveying thousands of students and tracking their early career choices, researchers found that:

• "Because of the racial separation that persists in this country, most students have lived in segregated communities before coming to college."
• "Colleges that diversify their student bodies and institute policies that foster genuine interaction across race and ethnicity provide the first opportunity for many students to learn from peers with different cultures, values, and experiences."
• "Students with frequent interaction with diverse peers while in college demonstrated greater intellectual engagement and active thinking four and nine years after college entry."
• "They also showed a greater capacity to engage in a diverse workplace after college."

Dr. Sylvia Hurtado, Professor and Director of the Higher Education Research Institute at the University of California, Los Angeles, and her former colleagues at the University of Michigan have concluded that: "One of the key implications of this empirical research is that diversity is an asset to learning and important for development of the new thinking skills that are needed in the workplace."

Research by Dr. Hurtado and others is premised on the assertions of psychologist Erik Erikson, educator Jean Piaget, and others who believe that when students' perspectives are challenged, this spurs their intellectual growth. Opportunities to see the world in a new light are more likely to occur when the composition of the student body is diverse, as suggested by a white student in his evaluation of a course on intergroup relations at the University of Michigan:

I come from a town in Michigan where everyone was white, middle-class and generally pretty closed-down to the rest of the world, although we didn't think so. It never touched us, so I never questioned the fact that we were "normal" and everyone else was "different." Listening to other students in the class, especially the African American students from Detroit and other urban areas just blew me away. We only live a few hours away and yet we live in completely separate worlds. Even more shocking was the fact that they knew about "my world" and I knew nothing about theirs. Nor did I think that this was even a problem at first. I realize now that many people like me can go through life and not have to see another point of view, that somehow we are protected from it. The beginning for me was when I realized that not everyone shares the same views as I, and that our different experiences have a lot to do with that.

—From Diversity and Higher Education: Theory and Impact on Educational Outcomes

The Difference: An Empirical Analysis of Diversity

In the introduction to his book The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies, theorist Scott E. Page asserts that diversity trumps ability when it comes to problem solving. He takes pains to make clear that he does not mean that ability does not matter, only that diversity matters, too. He acknowledges that certain conditions must be met for differences between people to produce benefits. For starters, he says diversity must be relevant to the problem at hand, and the people in a diverse group must be able to get along. Given these conditions, he believes that a group of diverse problem solvers will outperform groups of high-ability problem solvers, and he has created a mathematical model to demonstrate this premise.

Page's work implies that a student body composed of diverse individuals who possess complementary skills, abilities, and perspectives will enhance learning for the entire class. His work also suggests that benefits might accrue to society at large when a more diverse cohort of students enters the workforce. Page closes the introduction to The Difference with these words: "In difference lies the potential to contribute."

Improved Access to Care

As an influential report pointed out in 2004, "The lack of minority health professionals is compounding the nation's persistent racial and ethnic health disparities. From cancer, heart disease, and HIV/AIDS to diabetes and mental health, African Americans, Hispanic Americans, and American Indians tend to receive less and lower quality health care than whites, resulting in higher mortality rates. The consequences of health disparities are grave and will only be remedied through sustained efforts and a national commitment. "

ADEA's long-held position has been that, without minority practitioners, access to care will be limited or absent in minority communities throughout the nation. Dental practice data from both the American Dental Association (ADA) and ADEA support this position.

Getting the conversation started

Look at the slides below. These slides illustrate the practice characteristics of U.S. dentists as reported in a 1996 ADA survey. Note that only 8% of practicing dentists come from underrepresented minority groups. The second slide reveals that white, black, and Hispanic dentists are more likely than other dentists to treat patients of their own race. This fact supports the notion that minorities will not achieve full access to care unless they are proportionately represented in the health care work force.

According to the a 2002 Institute of Medicine Report,Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, patients are drawn to health professionals of the same race or ethnicity because they believe these providers will be better able to relate to their concerns.

Ask: Should the responsibility of providing care to URM populations reside solely with URM practitioners? How can our institution's diversity policies engage all students in extending access to care to the underserved?

Look at the box below. Annual surveys of practicing dentists and dental school seniors affirm that individuals educated in diverse settings are far more likely to work and live in racially and ethnically diverse environments after graduation.

Sources of additional evidence that diversity promotes improved access to care include:

• A 2002 report by the Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care(PDF)

This report warns that minorities face "unequal treatment" when encountering the health care system. Using data from the U.S. Department of Health and Human Services, the report states that "racial and ethnic minority providers are more likely to serve in minority and medically underserved communities."

The report recommends increasing "the proportions of underrepresented U.S. racial and ethnic minorities among health professionals" and says that "to the extent legally permissible, affirmative action and other efforts are needed" to reach this goal.

• Missing Persons: Minorities in the Health Professions (PDF), a 2004 report by the Sullivan Commission on Diversity in the Healthcare Workforce, funded by the W. K. Kellogg Foundation.

The report calls for increasing diversity in America's health professions education and training programs with a goal of increasing the numbers of health professionals from underrepresented and underserved communities. The report outlines three principles that it deems essential to fulfilling this vision:

• To increase diversity in the health professions, the culture of health professions schools must change.
• New and nontraditional paths to the health professions should be explored.
• Commitments [to diversity initiatives] must be at the highest levels.

The report notes the urgent need to bring more URM students into the health professions. "While African Americans, Hispanic Americans, and American Indians, as a group, constitute nearly 25 percent of the U.S. population, these three groups account for less than 9 percent of nurses, 6 percent of physicians, and only 5 percent of dentists." The report recommends:

4.9 Dental and medical schools should reduce their dependence upon standardized tests in the admissions process. The Dental Admissions Test and the Medical College Admissions Test should be used, along with other criteria in the admissions process, as diagnostic tools to identify areas where qualified health professions applicants may need academic enrichment and support.

4.10 Diversity should be a core value in the health professions.

5.2 To reduce the debt burden of underrepresented minority students, public and private funding organizations for health professions students should provide scholarships, loan forgiveness programs, and tuition reimbursement strategies to students and institutions in preference to loans.

6.4 Accrediting bodies for programs in medicine and the other health professions should embrace diversity and cultural competency as requirements for accreditation.

Supreme Court Decisions

Beginning with the historic Regents of the University of California v. Bakke case in 1978, a series of Supreme Court decisions have recognized the educational benefits of diversity as a "compelling interest." While prescribing some restrictions on how and when institutions of higher learning can apply race, gender, and other factors in admissions, these decisions make clear that admissions practices that are narrowly tailored to achieve the educational benefits of diversity may be used to create a diverse student body.

See Chapter 5 for a fuller discussion of the legal issues related to increasing diversity in educational institutions.

CODA Predoctoral Accreditation Standards

In 2010, the Commission on Dental Accreditation (CODA) approved new Accreditation Standards for Predoctoral Dental Education Programs. These state:

1-4. The dental school must have policies and practices to:

• achieve appropriate levels of diversity among its students, faculty and staff;
• engage in ongoing systematic and focused efforts to attract and retain students, faculty and staff from diverse backgrounds; and
• systematically evaluate comprehensive strategies to improve the institutional climate for diversity.

The new standards recognize diversity as an essential component of academic excellence. They call on dental schools to educate dentists with the interpersonal and communication skills needed to manage a diverse patient population. They further assert that the diversity of the student body, faculty and staff, and curriculum is essential to creating a learning environment that improves patient outcomes for people from all backgrounds.

The standards present diversity as having three dimensions in the academic context. These are defined as follows:

• Structural: Structural diversity, also referred to as compositional diversity, focuses on the numerical distribution of students, faculty and staff from diverse backgrounds in a program or institution.
• Curriculum: Curriculum diversity, also referred to as classroom diversity, covers both the diversity-related curricular content that promote shared learning and the integration of skills, insights, and experiences of diverse groups in all academic settings, including distance learning.
• Institutional Climate: Institutional climate, also referred to as interactional diversity, focuses on the general environment created in programs and institutions that support diversity as a core value and provide opportunities for informal learning among diverse peers. While this guide directly addresses one aspect of diversity in higher education, the structural diversity of the student body, the new standards make clear that institutions will be expected to look at diversity broadly and adopt appropriate policies and practices that impact other domains.