Historically Black Residency Programs-

Transcription

1 *1 On Our Watch: The Continuing Loss of Historically Black Residency Programs- A Strategic Response Eddie L. Hoover, MD Buffalo, New York Key words: historically black institutions a residency training programs * accreditation U residency review committees * minority subspecialists From From the VHAWNY-HSC, Buffalo, NY (chief of surgery) and the State University of New York at Buffalo, NY (professor of surgery). Send correspondence and reprnt requests forj Natl Med Assoc. 2004;96: to: Eddie L. Hoover (112), 3495 Bailey Ave., Buffalo, NY 14215; phone: (716) ; fax: (716) ; eddie.hoover@med.va.gov It was on my watch that the surgical residency program at Meharry Medical College had its accreditation withdrawn in Thus, the consequences of losing minority training programs have always been particularly difficult for me. I recall a session of senior black surgical leaders-both private practitioners and academicians-at the National Medical Association (NMA) annual meeting in New Orleans in 1986, when the status of the Meharry surgical residency program arose. I had never been to Meharry but knew many alumni who were in practice around the country and, therefore, by inference, the quality of its products. Dr. Louis Bernard was en route to the dean's office, and the chair of surgery position was soon to be vacant. Working with the Meharry surgical faculty from , we put the finishing touches on an outstanding group of young men and women recruited by Dr. Louis Bernard and his faculty to produce a cadre of black surgeons who are providing superb surgical care in communities all across America today, including academia and private practice. The Obstetrics/ Gynecology and Pediatrics Programs at Meharry were lost in 1991, a year after surgery was decertified-the common denominator for all three being the paucity and lack of diversity of clinical material. During roughly the same era, Harlem Hospital also lost programs in orthopedic surgery, ophthalmology, and otolaryngology. We are in the twilight of an important part of our history as many African- American physicians who were products of these famed and now-defunct historically black training programs in St. Louis, Kansas City, Philadelphia, Tuskegee, and Chicago are retired, thus, bringing to a close the most fabled period of black residency programs in history, the likes of which will never be seen again. Therefore, it was with great concern and consternation that I learned a similar fate had befallen the surgical training program at King-Drew Medical Center in Los Angeles in October of 2003 after only 31 years of existence.' This program produced six surgeons per year, the majority of whom were African Americans. That leaves us with only two remaining predominantly black training programs in America: Howard University with five graduates per year and Morehouse School of Medicine with two. At present, both ofthese programs are fully accredited under Drs. Clive Callendar and Debra Ford at Howard and Dr. W Lynn Weaver at Morehouse with the support of their respective presidents and deans. Harlem Hospital continues to train black surgeons, but presently only nine of 22 residents are African- American.2 Another program that once produced a significant number of African-American surgeons, UCSF-East Bay, will likely see a reduction in these numbers in the future with Dr. Claude Organ's retirement in In fact, this program matched one black out of a total of seven categorical residents in the year-2004 match.3 Ironically, these losses are occurring at a time when there are more African Americans alive and active who have held top leadership positions in American medicine than ever before, yet we seem unable to capitalize on this prowess in the preservation of our training programs. This statement is not intended to place the responsibility for these conditions on the shoulders of these distinguished leaders but rather to point out some of our available resources. This list includes Dr. Louis Sullivan, founding president of Morehouse Medical College, secretary of Health and Human Services under the first Bush Administration, and a member of the board ofdirectors of several Fortune 500 companies; Dr. David Satcher, past president of Meharry, sur JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 1 1, NOVEMBER 2004

2 geon general of the United States and director of the Centers for Disease Control; Dr. James Gavin, current president and CEO of Morehouse School of medicine, a former director of the Howard Hughes Medical Institute, and a ranking administrator in the Robert Wood Johnson Foundation Minority Faculty Development Program; Dr. Lonnie Bristow, first African-American president of the American Medical Association; Dr. Ezra Davidson of King-Drew, past president of the American College of OB/GYN; Dr. LaSalle Leffall, former professor and chairman of surgery at Howard, first African-American president of the American College of Surgeons, former chairman of the board of the National United Way organization, former president of the American Cancer Society, and former presidential advisor on cancer; Dr. Claude Organ, former professor and chairman of surgery at both Creighton University and UCSF-East Bay, current president of the American College of Surgeons, previous chair of the American Board of Surgery, and former member of the Surgical Resident Review Committee; Dr. Harold Freeman, former professor and chairman of surgery at Harlem Hospital, former president of the American Cancer Society, and currently a director at the NIH; Dr. Haile Debas, former professor and chair of surgery and recently retired dean of UCSF, first African-American president of the most prestigious surgical organization in the world-the American Surgical Association, member of the Institute of Medicine, and past chairman of the Council of Deans of the Association ofamerican Medical Colleges (AAMC); Dr. Charles Francis, president of King-Drew and a member of Institute of Medicine; Dr. Danny Jacobs, former professor and chair of surgery at Creighton, current professor and chairman of surgery at Duke University, and also a member of the Institute of Medicine and the editorial board of the New England Journal ofmedicine; and Dr. L.D. Britt, first African-American member of the Board of Regents of the American College of Surgeons, current professor and chair of surgery at Eastern Virginia School of Medicine, and vice chair of the surgical RRC. Many African-American surgical educators were aware of the fact that King-Drew's surgical program had been placed on probation in 2002 after being fully accredited in 1999, yet the issues that required attention apparently were not adequately addressed, since its accreditation was subsequently withdrawn. It is unlikely that anyone outside the institution will know what actually transpired. It has been noted in the print media that all of the remaining Graduate Medical Education (GME) programs at King-Drew may be in jeopardy because of concerns about the sponsoring institution.4 This change in status in 2002 LOSS OF HISTORICALLY BLACK RESIDENCY PROGRAMS could have precipitated a national concern at all levels, perhaps resulting in the creation of a coalition of politicians, black business, the NAACP, the NMA, and black medical leaders of all specialties across the country, perhaps with a more favorable outcome. While at Meharry, I suggested that we needed two separate entities to protect our heritage in medicine: a "Medical Marshall-type program" to garner the support necessary to get all of our institutions up to speed to be competitive, similar to what the United States did for Germany and Japan following World War II, and an "African-American Medical Services Think Tank" that would champion issues, such as this and other initiatives related to the health and well-being of minority populations in America. These initiatives would help us to have a voice in what happens to us as a people. I felt very strongly then that Howard and King-Drew should serve as training sites for future faculty members for Meharry and Morehouse because they had residency programs in areas that complemented ours and it was in these specialties that we experienced difficulty in recruiting staff. The residency programs at Howard and King-Drew are listed in Tables 6 and 7, respectively. Again, a central coordinating forum may have been able to help bring this to fruition. Howard and King- Drew represent 40% and 32%, respectively, of all minority training programs, or an aggregate of 72%. Although King-Drew has only 18 of the combined 57 sponsored programs among the black institutions, it has 41% of the available training positions allotted to our institutions. Obviously, Howard and King-Drew are extremely valuable resources because they train African-American physicians, who are not being trained in the majority programs, in critically needed subspecialty areas for our communities. In 2002, there were only 32 blacks in training in ophthalmology pro- Table 1. The Minimum Number of Cases in Defined Categories Required to Take Part I of the American Board of Surgery Examination Category Minimum Number of Cases 1. Skin and Soft Tissue Head and Neck Alimentary Tract Abdomen Liver 4 6. Pancreas 3 7. Vascular Endocrine 8 9. Thoracic Pediatric Plastic Trauma Endoscopy Laparoscopy 34 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 1 1, NOVEMBER

3 LOSS OF HISTORICALLY BLACK RESIDENCY PROGRAMS grams in the entire country among 121 programs. Howard had eight African-American residents, or 25% of the total, and King-Drew had none at the time.5 That leaves 120 programs training a total of 24 black ophthalmologists or eight graduates per year. The problem of glaucoma-induced blindness in Brooklyn, NY will never be solved as long as this situation exists. A major concern and the rationale for writing this paper was the prospect that one of our major institutions may not survive its next site visit, and all of the programs could be in jeopardy. This has occurred at King-Drew as the institution was informed of a second consecutive "unfavorable" review on April 16, The Liaison Committee on Medical Education (LCME), which accredits medical schools, requires a minimum number of residency programs for continued accreditation of the undergraduate medical school. Thus, the entire King-Drew University of Medicine and Science could be in jeopardy. While it is uncomfortable to think that such a thing could happen, it always starts with one or two failed programs and quickly escalates to include the entire institution. If King-Drew, one of the major urban trauma centers in America, could not maintain its critical surgery residency, and its Internal Medicine residency has probationary accreditation, that does not bode well for the smaller programs at the school. While at Meharry, I also discovered that our students were fiercely loyal to the institution. Anyone we sent to Howard or King-Drew likely would have returned to Nashville as faculty members. Our plan was to then use national venues, such as the Robert Wood Johnson Minority Faculty Development Program, to help mentor and develop these young people. Why are we in such dire straits? The overall number of programs approved for training residents and fellows has steadily increased over the past five years from 7,861 in 1998 to 7,946 in 2000 and 8,064 in So why are African-American programs closing? I posed this question to a high-ranking official of the Accreditation Council on Graduate Medical Education (ACGME) at the NMA meeting in Honolulu, HI in 1996 with respect to surgery. The answer was very interesting. I was informed that the surgical Residency Review Committee (RRC) imposed upon itself the most stringent rules and regulations of the entire specialty RRCs and that this was not an ACGME directive. Prior to the late 1980s, apparently the surgical RRC could occasionally afford some latitude to programs that met most but not all of its requirements. About this time, they imposed a very rigid requirement for a minimum number of operations in 15 organ systems (Table 1). Continued accreditation was based upon a strict interpretation of these plus other guidelines. It did not matter that no surgical resident on the planet really knew how to do a major liver resection after completing the minimum requirement of four liver procedures. The playing field had to be the same for all programs, and it did not matter that the graduates of these programs may have been superbly trained in all of the other defined categories. Absent 100% compliance in an eclectic array of organ system surgeries, your program could be terminated. This is what transpired at Meharry and probably a significant number of other historically black programs that were terminated. Our surgical programs at Meharry, Morehouse, and Harlem Hospital have had to send trainees to other facilities to gain the required experience in clinical services not available on site. In fact, when I arrived at Meharry in the fall of 1987, it had been necessary for Dr. Bernard to send residents as far away as Jersey City, NJ and Columbus, OH for clinical experiences not available at Hubbard Hospital in Nashville, TN and for which he could not arrange rotations at local hospitals. The RRC obviously looks with great disdain on these long-distance affiliations, and justifiably so because of educational quality assurance and resident quality-of-life issues. In 1989, when we tried to reorganize the surgical residency program at Meharrv to obtain these services locally, we were Table 2. Current Status of Residency Training Programs at Meharry Medical College** Program Status Date of Last Site Visit Number of Residents Family Medicine Accredited 8/01 19 (1974) Internal Medicine Accredited 1/03 34 (1 920s) Psychiatry Accredited 4/00 18 (1965) ** General surgery lost its accreditation in 1990, followed by Pediatrics and OB/GYN in OB/GYN has been approved to start a new program beginning July 1, 2004 with an ultimate target of three residents per year JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 1 1, NOVEMBER 2004

4 unable to secure the cooperation of a single medical institution in middle Tennessee for this purpose. The only regional institution which offered assistance was Dr. Hiram Polk at the University oflouisville. We even considered a partnership with our colleagues at the equally struggling program at Morehouse, but our needs were too similar. In fact, the surgery residency at Morehouse was sending its residents to a private hospital in Columbus, GA because of inadequate clinical volume and variety available to them in Atlanta when this program was initiated by Drs. Arthur Lee and Mark Walker. The concept of "separate but equal" had been bestowed upon Meharry Medical College in the mid-1980s, when an acute medical-surgical unit was created at the Murfreesboro Veterans Administration Medical Center (VAMC), previously a long-term care psychiatric facility 40 miles from Nashville. This conversion was done to avoid having Meharry share the public VAMC, which was affiliated with Vanderbilt in Nashville. The same doctrine was applied to the Morehouse Medical School, which was given access to the VAMC in Tuskegee after a "token" role at the Atlanta VAMC, which was affiliated with Emory University. Similarly, Howard University has never had general surgery residents at the Washington, DC VAMC, which has always been affiliated with George Washington and Georgetown universities, although in recent years, the Howard orthopedics program has provided all residents for this service. King-Drew was never involved with either of the VA Medical Centers in the greater Los Angeles area. African Americans have fought and died in every war in America's history, but their offspring cannot be trained at the very hospitals committed to care for them. I am not sure that the Congressional Black Caucus was even made aware of these difficulties at the time or even now. Table 3. Independent Residency Training Programs at Harlem Hospital in 1987 and * Child Psychiatry * Child Psychiatry * Dentistry * Dentistry * Medicine * Medicine * Obstetrics and * Oral Surgery Gynecology * Psychiatry * Oral Surgery * Surgery * Ophthalmology * Plastic Surgery * Pathology de-certified in 2004 * Pediatrics * Plastic Surgery * Psychiatry * Radiology * Surgery LOSS OF HISTORICALLY BLACK RESIDENCY PROGRAMS I have often stated that managing a residency program is analogous to baking a cake: The RRCs, through the "Green Book," told you the ingredients and the order of mixing, and all you have to do is follow the recipe.7 Very often, the program director and/or chair of a particular department may not have the resources at his or her command to acquire all the ingredients, absent the checkbook of the president and dean of the institution. Presidents and deans would not deliberately withhold essential ingredients from their chairs, which means they too may have to go to someone with "hat in hand." If this happens to be local county, city, or state political officials, then pressure must be brought to bear upon them to provide these resources. Anyone familiar with the trauma statistics in south central Los Angeles will agree that this is an impossible situation without the surgical residency program at King-Drew, and patients may eventually suffer. It is extremely unlikely that the attending staffwill be able to supplant the residents, as this is one ofthe busiest trauma centers in America. In fact, the U.S. Army once sent its surgeons there for a trauma experience as King-Drew treated and released more gunshot wounds from its emergency room in a week than the stateside military hospitals saw in an entire year.8 The citizens of south central Los Angeles, both black and Latino, should have been alarmed and angry at the impact of this action on their medical care. So what will be the fate of our medical students with the loss of our residency programs? While it is true that the vast majority ofafrican-american medical students no longer attend Howard, Meharry, King-Drew or Morehouse, and even fewer are graduates oftheir GME programs, these programs were and continue to be important repositories of our history and culture. They also serve as custodians of minority health issues, including access to treatment with special emphasis on the diseases of western civilization that affect blacks disproportionately-cancer, obesity, diabetes, hypertension, and heart disease. I spent considerable time in the archives at Meharry and was amazed at the wealth of material there that is still waiting to be catalogued and made use of by medical historians and others. This surely pertains to Howard as well and perhaps less so with King-Drew and Table 4. Integrated Residency Programs Between Columbia University and Harlem Hospital in 1987 and * Neurology None * Orthopedics * Urology JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 1 1, NOVEMBER

5 LOSS OF HISTORICALLY BLACK RESIDENCY PROGRAMS Morehouse because oftheir infancy. While it is not a requirement for a medical school to have residency programs in all specialties to be fully accredited by the LCME, this surely impacts on the quality of student education, mentoring, and the quality of residency programs that these students secure through the match. It will also impact on the quality and academic intensity of faculty at these institutions. Most academicians are drawn to a particular institution because of resident/fellowship programs, targeted/ focused research initiatives or specialized areas of clinical volume/expertise, and not medical students. When the surgical program at Meharry was terminated, a decision was made to send the third-year medical students to UT-Memphis, UT-Knoxville, and UT-Chattanooga. This left no clear reason for academic staff to remain in Nashville. This scenario will likely be repeated at any school that loses its training programs. The decision by city officials to close DC General Hospital in 2001 clearly impacted the clinical volume for Howard University's residency programs in surgery, medicine pediatrics, and neurology-all of which rotated through that facility. Howard currently does not rotate any residents through the substitute facility, Greater Southeast Hospital. A recent article in The Washington Post indicated that the mayor was exploring the concept of building a new hospital in the District, which would be staffed by Howard faculty and residents.9 The question remains as to the impact this will this have on Howard's residency programs while this initiative meanders through the political process. The current status of the remaining training programs at Harlem Hospital, Meharry, Morehouse, Howard, and King-Drew is outlined in Tables 2-7. These tables also highlight programs that have been lost over the past 15 years. This is a trend that bears close watching and due diligence, particularly those involved in leadership positions in American medicine. Very little that has been proposed to make our plight better in American medicine has met with success to date, including the 3,000 by 2,000 program, which had the backing of the Association of American Medical Colleges as well as the NMA.'0 If we do not take drastic measures, we will be limited to a few primary care and internal medicine programs, and our students will have limited access to subspecialty training. It has been clearly demonstrated that people of color provide care for people of color and that even affluent black patients have less access to high-quality care than their white counterparts." Therefore, if there are no black interventional cardiologists, ophthalmologists, urologists, surgical oncologists, endocrinologists, cardiac surgeons, orthopedic surgeons OB/GYN surgeons, then blacks and other minorities will have even less access to the healthcare system than they presently experience. This will only accentuate the growing disparities in healthcare among minorities outlined by the Institute of Medicine in its 2002 report.'2 In conclusion, time is running out on our training programs. We can either gain control of our own destinies or let the system continue to dismantle our institutions. We need to either partner with existing foundations with an interest in minority health issues and health disparities, such as the Robert Wood Johnson or the Kellogg Foundations, or create one of our own to address this and related issues. There is a plethora of influential African Americans in diverse areas throughout the country who understand the importance ofthe health of our people and the maintenance of our educational institutions. These include but are not limited to the former president of the Ford Foundation; president and CEO of Business Enterprise; president and CEO ofamerican Express; president of Brown University; president of MIT; and Dr. William Cosby, who is both an artist and an educator. Again, the intent here is not to place this responsibility solely on the shoulders of the leaders but rather to acknowledge the fact that the talent pool exists to address Table 5. Current Status of Residency Training Programs at the Morehouse School of Medicine Program Year Started Status Last Site Visit Total Number of Residents Family Medicine 1981 Accredited 10/9/01 15 Internal Medicine 1992 Accredited 1/8/02 48 OB/GYN 1997 Accredited 1/29/02 12 Pediatrics* 2001 Provisional 2/3/04 15 Psychiatry 1991 Accredited 10/10/01 16 Preventive/Public 1986 Accredited 10/11/01 8 Surgery 1993 Accredited 11/5/03 22 Morehouse School of Medicine started in 1975 and enrolled its first two-year class in 1978; Full LCME accreditation was granted in 1985; The first graduates of the four-year school occurred in 1985; The current LCME accreditation extends through 2005; The last ACGME site visit was 3/16/04; * This is a new program, all of which are initially given provisional accreditation 1496 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 1 1, NOVEMBER 2004

6 these issues. Perhaps it is not too late for a concerted effort by all ofus to regain control over our remaining institutions, not limited to just medical schools or residency training programs. I would recommend the following actions steps: That we establish a think tank with a dedicated executive director and staff and that it be housed at one of our institutions. The immediate goal would be to LOSS OF HISTORICALLY BLACK RESIDENCY PROGRAMS develop an agenda designed to protect and expand black training sites and to facilitate the entry of minorities to majority training programs in critical areas at majority institutions. While this is not a recommendation for a quota system among residents, the federal government pays the majority of these salaries. Perhaps those institutions that have never trained a black should have to show some accounta- Table 6. Residency Programs in place at Howard University Program Status Number of Residents Anesthesiology Voluntary withdrawal 6 Emergency medicine Accreditation withdrawn 9 Family practice Accredited 18 Internal medicine Accredited 62 Cardiology Accredited 7 Dermatology Accredited 5 Endocrinology Accredited 3 Gastroenterology Accredited 5 Hematology Accredited 3 Infectious disease Accredited 2 Oncology Accredited 2 Pulmonary Accredited 3 Neurology Accredited 6 OB/GYN Accredited 13 Ophthalmology Accredited 8 Orthopedics Accredited 20 Pathology Provisional 8 Pediatrics Accredited 47 Psychiatry Accredited 14 Radiology (diagnostic) Provisional 10 Radiology (interventional) Accredited 0 Radiation oncology Provisional 3 Surgery Accredited 31 Urology Withdrawn 2 Table 7. Sponsored Programs at King-Drew University School of Medicine and Science Program Status Number of Residents Anesthesiology Probation 16/24 Dermatology Accredited 6 Emergency Medicine Accredited 40 Endocrinology Accredited 4 Gastroenterology Accredited 4 Geriatric Medicine Accredited 7 Infectious Disease Accredited 2 Internal Medicine Probation 42/47 Family Practice Probation 22 OB/GYN Accredited 14 Ophthalmology Accredited 6 Orthopedics Accredited 10 Otolaryngology Accredited 4 Pediatrics Accredited 36 Neonatal/Perinatal Withdrawn (6/30/04) 3 Psychiatry Accredited 25 Radiology (diagnostic) Withdrawn (6/30/04) 16 Surgery Withdrawn (6/30/04) 38 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 1 1, NOVEMBER

7 LOSS OF HISTORICALLY BLACK RESIDENCY PROGRAMS bility. The NIH now requires more than a token effort to enroll minorities and women in clinical trials. Perhaps the same logic might be applied to residency training programs. The current process does not work, and there is no driving force behind these institutions to change. While this think tank may have to rely heavily on trust and public disclosure, until it is able to demonstrate its capabilities, there are models of success. The Joint Center for Political and Economic Studies based in Washington, DC and Braamfontein, South Africa established a new "Health Policy Institute" in 2003 with assistance from the Kellogg Foundation to explore health issues of concern to African Americans (wwwjointcenter.org). This organization was founded in 1970 by black intellectuals and professionals to provide training and technical assistance to black elected officials and is recognized today as one of the nation's premier think thanks on issues of concern to African Americans. The Kellogg Foundation also provides funding for the newly created Louis W Sullivan Commission on Diversity in the Healthcare Workforce, which is currently focused on the decreasing enrollment in medical school among blacks, Hispanics, and Native Americans. Perhaps its mission statement could be expanded to include minority Graduate Medical Education issues as well. The most pressing issue at the moment is to insure the survival and vitality of the entire King- Drew University and all of its programs. The Robert Wood Johnson Foundation has, perhaps, the most extensive background ofprograms related to minority issues and might be persuaded to assist in such a venture. Finally, the NMA should assign a high priority to this problem and create a standing committee in the House of Delegates with easy access to the executive director and the elected officials of the organization to work on behalf of our institutions. ACKNOWLEDGEMENTS The author would like to thank the following people for their assistance with data acquisition in the preparation of this manuscript: Dr. Claude H. Organ Jr., professor and chair emeritus, UCSF-East Bay Program, Oakland, CA; Dr. Soli Oluwole, surgical program director, Harlem Hospital, New York, NY; William Booth, Graduate Medical Education Office at Morehouse School of Medicine; Paula Hill, Graduate Medical Education Office at Meharry Medical College, Nashville, TN; and Dr. Sharon Ashley, associate dean for Graduate Medical Education at the King- Drew University College ofmedicine and Science. REFERENCES 1. Fleming AW. Martin Luther King, Jr. General Hospital and the Charles R. Drew Postgraduate Medical School. In: Organ Jr CH, Kosiba MM, eds. A Century of Black Surgeons. Normal, OK, Transcript Press. 1987: Personal communication with Dr. Soji Oluwole, Surgical program director, Harlem Hospital, New York, NY. 3. Personal communication with Dr. Claude H. Organ Jr., UCSF-East Bay, Oakland, CA. 4. Personal communication with Ms. Paula Hill, office of GME, Meharry Medical College, Nashville, TN. 5. Graduate Medical Education. Appendix 11, Table 1. JAMA. 2003:290: Brotherton SE, Rockey PH, Etzel SI. U.S. Graduate Medical Education, Table 1. JAMA. 2003;290: Graduate Medical Education Directory: A Fred Donini-Lenhoff Medical Education Product. American Medical Association, 515 N. State St., Chicago, IL Personal communication with Dr. Arthur W. Fleming. Former professor and chairman of surgery at King-Drew Medical Center. 9. The Washington Post, Saturday, City Section, November 1, AAMC News Room: Press releases: AAMC's project 3000/ / htm 11. Keith SA, Bell RM, Swanson AG, et al. Effects of affirmative action in medical schools: A study of the class of NEJM. 1985;313: Swift EK, ed. Guidance for the National Healthcare Disparities Report. Committee on Guidance for Designing a National Healthcare Disparities Report. Institute of Medicine, Washington, DC. National Academy Press, U THE UNIVERSITY OF SOUTH ALABAMA COLLEGE OF MEDICINE IS CURRENTLY RECRUITING FOR FACULTY POSITIONS IN THE FOLLOWING AREAS Family Medicine Internal Medicine Obstetrics and Gynecology Orthopaedic Surgery Pediatrics Physiology Radiology Surgery FOR SPECIFIC INFORMATION AND DETAILS PLEASE CONTACT THE DEPARTMENT OF INTER- EST DIRECTLY University of South Alabama College of Medicine 307 University Blvd. Mobile, Alabama The University of South Alabama is an Affirmative Action/ Equal Opportunity Employer. Women, minorities and persons with disabilities are encouraged to apply JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 1 1, NOVEMBER 2004