Lack of Black, Hispanic allergy and asthma trainees represents ‘alarming issue’
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A lack of Black and Hispanic students in the allergy and immunology education pipeline could impact care among these populations, according to an editorial published in The Journal of Allergy and Clinical Immunology.
Black individuals have a higher risk for asthma than their white counterparts, Mahboobeh Mahdavinia, MD, PhD, chief of the division of allergy and immunology at Rush University Medical Center, and colleagues wrote in the editorial. Also, in 2019, Blacks with asthma had a mortality rate of 23.9 per million, whereas the corresponding rate among whites was 9.9 per million.
However, Blacks make up 13.3% of the population in the U.S. but only 5% of practicing physicians, with corresponding rates of 19.8% vs. 5.8% among Hispanics and 1.6% vs. 0.3% among Native Americans.
Mahdavinia and colleagues wrote that a greater number of specialists from the same racial and ethnic backgrounds can improve trust, reach and access for underserved populations, because patients tend to trust physicians with whom they identify.
Underrepresentation among trainees
Mahdavinia and her co-authors traced disparities in the workforce to the population of trainees undergoing medical education.
Only 5.1% of the allergy and immunology trainees in 2019-2020 were Black, and 6.1% were Hispanic, the authors wrote. Meanwhile, 47.5% were White, and 20.2% were Asian.
Overall, Blacks comprised only 5.3% of medical school graduates in the U.S. between 2010 and 2020, and Hispanics comprised only 6.2%. During the same period, Blacks comprised 3.9% to 5.1% of internal medicine residents and 3.8% to 5.1% of pediatric residents, and Hispanics comprised 4.3% to 6.3% of internal medicine residents and 5.1% to 8.4% pediatric residents, two fields considered “feeders” for allergy and immunology.
Similarly, Blacks accounted for a high of 5.4% of all fellowships in 2014 and a low of 1.5% in 2020 in a 10-year review of Accreditation Committee for Graduate Medical Education data, indicating the data may not stand to improve in the future. Percentages of Hispanics in fellowship ranged from 4.9% to 2.7% in the same time frame.
“An alarming issue is the down-trending number of individuals of underrepresented minorities from residency applicants to matched residents, to fellowship applicants, and finally to matched fellows,” Mahdavinia and colleagues wrote. “We also see a downward trend for Black and Hispanic medical school applicants, medical school matriculants and medical school graduates which sounds a growing alarm for years to come. This forecasts a malfunctioning and concerning pipeline for training of future allergy and immunology specialists, academicians and leaders.”
Unknown workforce impact
Mahdavinia and colleagues wrote that although these data might indicate a “gross underrepresentation in the workforce,” the scarcity of data on race and ethnicity among the allergists and immunologists creates an unclear picture.
The last report from the American Academy of Allergy and Immunology (AAAAI) on the workforce was in 2012 — which showed a largely unchanged rate of underrepresented minorities in the workforce from 3% in 1998 to 5% in 2009 — and the organization does not track the race or ethnic demographics of its Division Directors Committee or of the national Program Directors Assembly that it cosponsors with the American College of Allergy, Asthma and Immunology (ACAAI).
Also, the American Board of Allergy and Immunology intentionally does not capture race and ethnicity data pertaining to certification candidates or diplomates, but it and other boards now are planning on seeking and monitoring these data to eliminate unrecognized bias and increase opportunities for representational diversity in their governance.
Needs and solutions
Between 2018 and 2033, the authors wrote, the non-Hispanic Black population will grow by 13.3% and the Hispanic population will grow by 31.4%, requiring more than 37,000 Black and 41,000 Hispanic physicians to meet the increase in demand.
But without minority physicians in leadership positions, the authors wrote, the visions, missions, budgets, policies and procedures at training institutions may never embrace the racial equity that’s necessary to ensure a fully diverse pipeline and workforce that can meet these growing demands.
In fact, the authors called the lack of diversity in the allergy and immunology workforce and throughout the pipeline a “recipe for continued failure to meet the ever-growing needs of diverse patient populations afflicted with allergic and immunologic disorders.”
To solve this problem, Mahdavinia and colleagues proposed that elementary and middle school students from underrepresented minorities be exposed to the biomedical sciences, while high school students should be encouraged to explore “pre-med” tracks in college.
Also, organizations such as AAAAI, ACAAI, the National Medical Association and the National Hispanic Medical Association can improve their collaboration in improving representation in the pipeline.
Finally, financial support would help medical students and trainees from underserved and underrepresented populations continue advanced training in subspecialties, which would help increase their representation as well.
Perspective
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Cherie Zachary, MD
An increase in physician workforce diversity continues to be needed. A recent study by Dan P. Ly, MD, PhD, MPP, highlights this. In 1900, 11.6% of the population were Black, but only 1.3% of the physicians were Black. In 1940, 9.7% of the population were Black, but only 2.8% of the physicians were Black. And in 2018, 12.8% of the population were Black, but only 5.4% of the physicians were Black.
Black, Hispanic and American Indian/Alaska Native students remain underrepresented among medical school matriculants compared with the U.S. population, according to a study by Lett and colleagues. Much work remains to be done.
To address these issues, the Diversity Task Force of ACAAI has worked to strengthen and develop programs to increase exposure to, and access for, underrepresented minorities to the subspecialty of allergy, asthma and immunology.
Programs include the initiation of the Chitra Dinakar Visiting Professor Program to expose undergraduate and medical students at historically Black colleges, universities and medical schools to the subspecialty of allergy, asthma and immunology.
Also, SPARK scholarships for medical students from historically Black colleges and universities help to expose residents who might be considering a career in allergy, asthma and immunology to the specialty.
Students additionally are mentored by an allergy fellow in training and interact with training program directors and other allergists as they attend the ACAAI Annual Scientific Meeting, where they are exposed to a wide variety of sessions covering all aspects of allergy/immunology.
Podcasts to raise awareness of the challenges, strategies and resources to address equity in allergy and asthma are being developed as well.
We hope that through these initiatives, we will be able to move the needle in increasing minority representation in our specialty.
References:
- Ly DP. J Gen Intern Med. 2021;doi:10.1007/s11606-021-06745-1.
- Lett LA, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.10490.
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