As highlighted by the Surgeon General's 2001 report, there is a need to eliminate mental health disparities among ethnic minorities that are underserved (1). Healthcare disparities have resulted in decreased access to bilingual services for underrepresented and underserved minorities, increased risk for misdiagnosis, more inpatient hospitalizations, and less follow-up after hospitalizations (2, 3). The current mental-health workforce is also deficient with respect to diversity. In 2007, 16% of psychiatry trainees were from underrepresented groups such as African American, Hispanic American, Native American, or of Pacific Islander descent. Also, 24% were of Asian descent. Even smaller proportions of the membership of the American Psychiatric Association (APA) (4) or of psychiatric faculty (5) belong to the underrepresented ethnic groups. Although the need for mentoring has been described as an important part of academic medicine, fewer than 50% of medical students and, in some fields, less than 20% of faculty are reported to have a mentor (6). Members of underrepresented groups and women have been shown to have more difficulty in establishing a mentoring relationship (7). Many models have been implemented to improve the recruitment, retention, and promotion of minorities in medical school and academic departments across the country (8–12), although there is only generally limited evidence to support the efficacy of mentorship (13). In this article, we describe the development and implementation of a program of mentorship and cultural-competence education that targets the elimination of mental-health disparities. This program, the Texas Regional Psychiatry Minority Mentor Network (TRPMMN), has three goals: 1) to interest minority medical students in psychiatry as a profession; 2) to increase the cultural competence of mental-health providers; and 3) to increase retention through mentorship and support of the minority faculty. We also report data on some academic accomplishments of the medical students, residents, and junior-faculty program participants from the first 18 months of the program's implementation.
The TRPMMN was begun as a regional extension of APA's National Minority Mentor Fellowship Program in collaboration with both Houston-area medical schools, Baylor College of Medicine (BCM) and the University of Texas Health Science Center–Houston (UTHSC–H). In May of 2007, TRPMMN leaders developed subcommittees of local, regional, and national participants that targeted mentoring and cultural competence. These subcommittees met to review existing structures within the academic institutions and community entities. To assist with mentor-matching, we gathered information from participating institutions and community professional psychiatry organizations. One key feature of the TRPMMN program was to involve all levels of training and faculty; a total of 83 individuals expressed an interest in participating in this mentor program, including 13 medical students (6 African American, 5 Asian American, 1 Latino American, and 1 Egyptian American), 28 residents (17 African American, 6 Asian American, 4 Latino American, and 1 Native American, along with two Asian American international medical graduates who were pending residency acceptance), and 12 junior faculty members (6 Asian American, 4 African American, and 1 Latino American). The mentors included 16 local senior faculty members (11 Caucasian, 3 Asian American, 1 African American, and 1 Latino American), 6 community mentors (5 African American and 1 Latino American), and 6 national mentors (3 African American, 2 Asian American, and 1 Latino American). “Mentor families” were constructed, based on mutual and academic career interests as identified by written information that was collected before joining the program. Each of the five mentor families consisted of individuals involved in academic psychiatry, community psychiatry, medical education, public psychiatry, and independent practice, and included senior mentors, junior psychiatry faculty members, psychiatry residents, and medical students. Senior mentors included faculty members with advanced academic standing, and community and national psychiatrists who expressed interest in participating in the program. The national psychiatry mentors, who currently work as mentors within APA and the American Academy of Child and Adolescent Psychiatry, provided an additional layer of expertise and leadership for TRPMMN participants. Entire mentor families met once quarterly, and individuals were encouraged to have monthly contacts with their senior mentors.
TABLE 1.Diversity Results After the Texas Regional Psychiatry Minority Mentor Network (TRPMMN) Program
TRPMMN developed the model to include quarterly skills-building workshops that were designed to improve the abilities of participants to become successful in research and in career pursuits. During these quarterly meetings, areas covered included publication strategies and techniques, information about promotion within the departments of psychiatry at BCM and UTHSC–H, selection of research versus clinician-educator tracks for career progression, the identification of career paths and leadership opportunities in psychiatry, and the negotiation of employment positions and benefits. These educational opportunities continued at least quarterly in a variety of settings that included scheduled didactics in the psychiatry training programs. TRPMMN leaders assisted with the enhancement of existing cultural-competence educational activities (i.e., grand rounds, scheduled didactics) within the departments of psychiatry at the two medical schools and assisted with initiating the development and implementation of cultural-competence education for medical students, faculty, and community practitioners. Also, TRPMMN disseminated information regarding national, regional, and community events that promoted cultural competence and the elimination of mental-health disparities. In all of these ways, the program sought to modify any attitudinal barriers that might impede the advancement of minority students, residents, and junior faculty. One result was the appointment of a diversity director at one of the medical schools.
In order to document intermediate outcomes of the TRPMMN, we administered a short questionnaire to all participants. The questionnaire included both closed-ended and open-ended items, adapted from the questionnaire by Berk et al. (13). The mentee was asked to indicate the outcomes of his or her mentoring experience in the program (products or experiences that would not have otherwise occurred without the program), including publications, presentations, political activity, service on a professional organization, grant writing/submissions, development of educational program, etc. Mentees were also asked to provide information regarding the various products or activities that were associated with the program.
Of the 35 students who entered psychiatry residency from both schools in 2005 and 2006, 14 were ethnic minorities; whereas, after implementation of the program (2008, 2009) 13 of the 26 students were ethnic minorities. Nearing the end of the second year of this program, seven medical students who participated in the program from either underserved or underrepresented ethnic groups have chosen psychiatry as a profession.
In conjunction with mentorship from residents and faculty, medical students in this network have been awarded eight national awards, two institutional awards, and one grant. They have also received invitations to submit two manuscripts to Academic Psychiatry and have presented four scientific posters in national and regional venues. In almost all cases, the mentees were informed about available awards for which to apply and were supported by faculty during the application process. TRPMMN faculty directly contributed to all four of the medical student national presentations and the one publication. Similarly, the psychiatry residents have received seven national awards, one institutional award, one grant, and opportunities for academic leadership with five appointments to chief residencies. TRPMMN faculty contributed directly to the two international and 8 of the 11 national presentations by residents. From a career standpoint, the junior faculty members of TRPMMN have progressed with international, national, and local recognition, which includes one international award, two national awards, six institutional awards, and one grant. Invited presentations have included 8 international, 37 national, and 4 grand rounds. Similarly, TRPMMN faculty contributed to 8 of the 8 international and 36 of the 37 national presentations and to all 3 publications by junior faculty. Also, two junior faculty members were promoted to the rank of associate professor. Moreover, three faculty members were appointed to leadership positions within academic centers, spanning from residency training director, director of diversity and cultural-competence education, and department chair.
One important limitation of our data, however, is that we cannot be sure how many of these achievements, including academic promotions and leadership appointments would have been obtained in the absence of the TRPMMN program. In particular, there was no comparison or control group for the TRPMMN model. Although the questionnaire focused on the outcomes of the program, it also asked mentees to write about barriers to the program. Barriers identified by mentees and mentors included 1) failed communication attempts via electronic mail for data collection and notification of events; 2) sparse funding for educational and social activities, and no funding for salary support; 3) decreased proximity of the institutions inside and outside the Houston area and community partners; 4) limited time availability for participation; and 5) difficulties with the coordination of events.
TRPMMN has made a promising start in addressing the lack of diversity in the psychiatric workforce and mental-health disparities. Our initial results suggest that the program has promoted scholarly activities, leadership opportunities, presentation opportunities, and awards that participants indicated would not have otherwise occurred. Although our outcomes seem promising, the data are based on self-report.
Additional evaluation will occur throughout the program in relation to ongoing evaluation and assessment of the efficacy of the program in achieving its goals. Along with addressing the barriers identified above, TRPMMN intends to evaluate cultural competence of participants within clinical contexts. The participating academic institutions will also be challenged to develop a program to improve the provision of mental-health services to underserved and underrepresented groups. These institutions have pledged to support “community-engaged scholarship,” which will allow for an increased collaboration and integration of the model between institutions. We hope that the TRPMMN model will serve to stimulate implementation and model development and evaluation in other settings in order to seek to eliminate mental-health disparities and foster diversity among the psychiatry workforce.