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Managing diversity in the workplace.

The term "diversity" encompasses all the ways in which people differ. Diversity ranges beyond race, ethnicity, and gender to age, education, geographic region, religion, sexual preference, and marital and parental status, according to Lee Gardenswartz, PhD, of the consulting firm Gardenswartz and Rowe.

Dr. Gardenswartz's interest in diversity issues intensified when the most frequent requests for help in handling diversity came from her clients in health care. "As we started doing our diversity awareness work, we also got an education about cross-cultural norms as they relate to views about health and medicine--both Eastern and Western--and spiritual and religious implications of the relationship of medicine and culture. We also discovered faux pas made by well-meaning, uninformed practitioners who clearly wanted to avoid any repeat blunders," she says. "Health care institutions need to survive and often do so by vigorous attempts to give excellent customer service. They can't do this without understanding and honoring health care norms of different groups."

Hospitals based in ethnic communities have a ready patient market-- if they take a few steps to capture it. One of Gardenswartz and Rowe's clients provides an example. "With shrinking resources and an increasingly large Armenian population, the administration at Glendale [Calif.] Adventist Hospital realized that it was to its advantage to try to court this patient base," Dr. Gardenswartz says. "This is a closely knit population where word of mouth spreads quickly. Glendale noticed that the Armenians came to visit patients in large extended family structures, and they were reluctant to leave at night," she says. "With a low census and an underutilized facility, the hospital converted many of the rooms into guest rooms and allowed patients' families to stay overnight. This gives Glendale a competitive advantage over the other city hospital."

ACPE Members Recall Experiences

Back in the late 1960s, Charlotte Yeh, MD, pursued a lifelong dream and applied to Johns Hopkins Medical School. But she was turned down. Women were excluded then. Instead, she attended Northwestern University School of Medicine, where she slept in the lounge during OB rotation because there were no female call rooms. During her surgery rotation, male physicians and students finished case discussions in the men's room while Yeh was left standing in the hall. When she tried to get a surgery residency at one hospital, she was discouraged and told that women couldn't handle the program.

"When you're one of the first set of people going through a field, you just have to do a good job," Dr. Yeh says. "People are products of their upbringing. I can't ask them to change just because they meet me."

Dr. Yeh eventually left surgery to enter emergency medicine, but not without a lot of soul-searching. "I thought, if I drop out of surgery, will it hurt other women?" she says. "But I had to do what I wanted. Emergency medicine is a lot more tolerant of women than other specialties are."

Dr. Yeh is one of a growing number of women physicians who have shattered medicine's glass ceiling. She's worked her way up to Chief of the Emergency Department at New England Medical Center Hospitals, Boston. And she's proud of the fact that she is one of the few women to have been elected vice president of the American College of Emergency Physicians. Dr. Yeh is taking aim at the presidency of the group next and hopes to be the first woman to hold that office.

One reason more women are moving up in the medical field is that their ranks have grown dramatically over the past decade or so. In 1980, 54,000 out of a total of 467,000 physicians were women. Last year, the number of women physicians was more than double that figure, according to the American Medical Association. Women now represent 18 percent of all U.S. physicians.

At Presbyterian Hospital, New York, N.Y., the house staff is nearly half women, according to Robert M. Lewy, MD, MPH, Senior Vice President. "We just did a house staff orientation for 238 new staff members; 46 percent are women," Lewy says. "That's the highest proportion we've ever had. Even traditional male bastions of medicine are being filled by women. It creates a situation where we have to plan differently for on-call facilities. We now have men's rooms, women's rooms, and joint facilities." The hospital is also offering women job-sharing and is allowing one woman radiologist to complete her residency on a part-time basis.

Along with the addition of more women, there are significantly more foreign-trained and minority physicians practicing in the United States. In 1980, according to the U.S. Census, there were 98,000 foreign-trained physicians. Last year, the number increased by nearly 50,000.

"When I came here, there weren't too many Asian doctors. I was one of the very, very few," says Asir U. Ahmad, MD, Vice President, Medical Services, North Oakland Medical Center, Pontiac, Mich. "When I started my internship in Massachusetts, there were none. In Arizona, there were a few Mexican physicians, a South American, and one Cuban. When I came to Michigan, there were a few Indian doctors. The number has increased at this institution. We now have 30 to 40 percent foreign-born physicians."

While Dr. Ahmad is heartened by these statistics, he also believes there's a negative side. "I refer to specialists," he says. "Sometimes, I'll seek out those from my ethnic background. So do others. Hopefully, this trend will reverse; it's not very healthy. If you are only going to send patients to physicians of your background and culture, you will exclude people who may have greater knowledge."

Dr. Lewy says that Presbyterian Hospital is looking at ways of luring more foreign-born physicians through an innovative program. "In our community, there are a lot of foreign medical graduates who, for one reason or another, haven't gotten a medical license in New York. It may be for language reasons," Lewy says. "We're looking at providing training in language and updating their skills so they can practice in this community. We're looking at either providing the training in return for service or getting outside funding for a demonstration project."

The African-American and Hispanic medical populations are also on the rise. According to the U.S. Census, there were 13,000 black physicians and 19,000 Hispanic physicians in 1980. The 1990 census showed an increase of nearly 7,000 black physicians and 10,000 Hispanic physicians.

There is a huge Hispanic population in Presbyterian Hospital's service area, and Dr. Lewy says Spanish is sometimes the only language of patients. "We made accommodations by providing language training to all incoming physicians," Dr. Lewy says. "It's a 5-day program with two people to one instructor. They learn medical history-taking and medical terminology. They come out of the course with a working knowledge of Spanish. This year, about 70 incoming house staff members participated. It's a voluntary program. For those who don't take the program, we have translators available."

Dr. Yeh also deals with a heavily ethnic population at New England Medical Center. "One of my hospitals is in Chinatown," she says. "My background is Mandarin. I might as well be dealing with another population. But I know their mentality. I know what they complain about and what they don't. I understand their use of alternative medicine. The hospital has interpreters, and there are members from the Chinatown community who sit on a committee [at the hospital]."

John Anderson, MD, JD, FACPE, is Vice President, Medical Care, at West Paces Medical Center, Atlanta. As a black man who attended school in Washington, D.C., during segregation, he is sensitive to other cultures. When he first became a physician, he noticed "minorities would refer to each other because it was the only way to get referrals." But he says there's less of that now.

Having served for many years as a military physician, Anderson notes, "Everything in the military is codified. The military was the first to break through racial barriers by policy, not incidentally. The same thing is happening with females. In the military, everything is clear-cut. In civilian life, things are not as clear-cut. You have to observe and make sure people are treated fairly."

How Physician Executives View Diversity

"Understanding cultural diversity is absolutely critical," said Anderson. "If you're going to talk about health care, you have to have an understanding of people from different cultures. We have a polyglot of different cultures that make up the U.S."

Anderson says he would encourage those entering medicine to "take a big dose of liberal arts, learn about other cultures. Learn a foreign language, economics, world history, understand different experiences. It's too late once you get into medical school. There's not enough time." For those who don't heed this advice, Anderson recommends getting involved in the community, volunteering at clinics where cultural diversity thrives.

Anderson also points out that women, foreign-born, and minorities in medicine should be evenly distributed at all levels of employment, not lumped in certain areas. "Make sure they are comfortable and that they have an appreciation for the value of the organization," he says. Providing child care is one way employers can contribute, because 60 percent of the hospital work force is female, he says. It's an opportunity for hospitals in the same community to collaborate.

Dr. Yeh found, as she attended numerous meetings over the years, that men and women approach problem solving very differently. "I found I had to change my style," she says. "Women tend to ask for feedback before making decisions rather than being confrontational. When I did that, the feedback was that I was wishy-washy, soft, and undecided. Now, I'm loud and outspoken, and they say, "She knows what she wants."

But there are traits she didn't have to change, and Dr. Yeh attributes them to her heritage. "My Chinese background makes me patient," she said. "I don't display anger. It makes it hard for people with a confrontational style to deal with me."

As Chief of the Division of Emergency Medicine, Dr. Yeh sometimes has to handle ticklish situations. For instance, when staff nurses complained about how they were treated by a Latin American physician on staff, Dr. Yeh had to step in. "He's very bright and compassionate," she says, "but his ways of dealing with men and women were very different. The nurses on the staff perceived him as a chauvinist and demeaning. But it was a matter of style. I had to sit down and tell him. He was behaving in a way that was normal for him; he was not being malicious or arrogant. I also sat down with the nurses and explained that his behavior was more a matter of his upbringing. There's a delicate balance there. You don't want to characterize the country (stereotype), but you want to point out that this may be a factor in his behavior."

Kenneth Cummings, MD, FACPE, Vice President for Medical Affairs at St. Joseph Health Center, Kansas City, Mo., says his hospital is "cognizant of racial mix in our medical staff and the entire hospital population, but we make no active effort to change the balance for balance's sake. We pursue high-quality physicians regardless of their ethnic backgrounds."

Although his hospital aggressively recruits minority physicians, Cummings says, "If we work first to bring the optimum talent and experience to our workplaces, cultural diversity will follow." He believes that the advent of clinical practice parameters will bring physicians into "closer intellectual proximity. It will highlight some of our subtle differences and force us to confront and overcome them."

Kathleen Musser, MD, Executive Director/Medical Director, CIGNA Health Plan of Oklahoma, says men are in the minority at her workplace. "In managed care, there's a different perspective," she says. "A lot of companies are very committed to obtaining diversity. There is a large magnifying glass large companies are put under for employment. They take very seriously their compliance with regulations." Dr. Musser contends that, without cultural diversity, "we'll end up very inbred and get tunnel vision."

Michael Langberg, MD, Vice President, Medical Affairs, Cedars-Sinai Medical Center, Los Angeles, Calif., views the issue of cultural diversity as crucial at his institution. "We've always been sensitive to that concept, but everyone had their sensitivity heightened by what happened last year [the Rodney King case and ensuing riots]," he says. "Our employee bases are extremely diverse racially and ethnically. We probably have every race, religion, and culture represented in the institution. As a result, we've created a variety of vehicles to sensitize people of different cultures."

Some of the vehicles are the hospital's annual culture festival, the Martin Luther King Jr. Day celebration, and a Holocaust remembrance. There are also programs to help foreign members of the staff improve their English and reduce their accent so they can better communicate with patients and staff. "In our organization, there are committees and task forces that deal with cultural diversity as a topic," he says. "The Medical Executive Committee on Cultural Diversity has been meeting monthly for seven or eight years."

In addition, Cedars-Sinai staff visits the three area medical schools and talks about what the hospital is doing about cultural diversity, Langberg says. "The populations around us have changed," Dr. Langberg says. "There are more Koreans, more Asians. We have a whole department devoted to international medicine and organizations that have identified themselves as translators."

Dr. Gardenswartz believes that "if an organization ignores diversity, it does so at its peril." People are drawn to places where there are "people who look like, sound like, and, in many ways, are like them--or who at least value and understand them." She also believes that it is the physician executive's responsibility to take the cultural diversity reins. "Physician executives should first of all educate staff about cultural norms and their impact in dealing with their patient population," Dr. Gardenswartz notes. "Pay particular attention to norms that affect service and care. Physicians should then reward the behaviors they are striving to see consistently displayed in the environment. "Finally," she says, "look at policies and procedures, and see how they impede a more fluid, open environment."

Donna Vavala is a Contributing Editor of Physician Executive and Managing Editor of College Digest, ACPE's bimonthly newsletter, and PRICE, a quarterly newsletter reporting on cost management in health care delivery.
COPYRIGHT 1993 American College of Physician Executives
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Copyright 1993, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:Vavala, Donna
Publication:Physician Executive
Date:Nov 1, 1993
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