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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Increasing Racial and Ethnic Diversity Among Physicians: An Intervention to Address Health Disparities? Raynard Kington1 Associate Director of NIH for Behavioral and Social Sciences Research Diana Tisnado UCLA School of Public Health David M.Carlisle2 Director, Office of Statewide Health Planning and Development, State of California INTRODUCTION Health disparities across racial and ethnic groups in the United States have been well documented for over a century and have remained remarkably persistent in spite of the changes in many facets of the society over that period. Despite dramatic improvements in overall health status for the U.S. population in the 20th century, members of many racial and ethnic minority populations experience worse health status along many dimensions compared with the majority white population. These disparities are the result of multiple root causes. Social inequalities resulting directly from discrimination and indirectly from structural factors have led to inequalities in socioeconomic position, health insurance status, and environmental and occupational exposures, all of which influence health status (Kington & Nickens, 2001). Health disparities are associated with cultural and psychosocial factors related to patient perceptions of health, illness, and the health care system, all of which influence health care-seeking behavior and are also influenced by structural characteristics of our health care system. Because many minority neighborhoods have a shortage of physicians (Komaromy, 1996) and less access to medical care, increasing the supply of minority physicians has been proposed as an intervention that may help to ameliorate differences in health status. Programs to increase the numbers of underrepresented minority physicians have been the subject of much debate in recent years. 1 The opinions expressed are those of the author and do not necessarily reflect the official position of the U.S. Department of Health and Human Services or the National Institutes of Health. 2 The opinions expresssed do not necessarily reflect the State of California or the Office of Statewide Health Planning and Development.
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Efforts of colleges and universities to increase the enrollment of minority students also have increasingly become the focus of sharp criticism (Bowen, 1998). While empirical evidence of the impact of diversity in colleges and universities has become a core part of the debate about college admission policies, little attention has been given to rigorously assessing the scientific evidence about the likely impact of increasing the numbers of underrepresented minority physicians, especially as an intervention to improve health care for minority populations and, ultimately, to reduce health disparities in the United States. The goals of this paper are to present a brief overview of racial and ethnic disparities in health and the potential causes of these differences, primarily related to health care, and then to review the conceptual underlying bases and the evidence about the likely pathways by which increasing the diversity of physicians might decrease disparities. We focus on three hypothesized pathways. The first pathway is through the practice choices of minority physicians, which may lead to increased access to care in underserved communities. The second pathway is through improvements in quality of health care due to better physician-patient communication and greater cultural competency. The third hypothesized pathway is through improvements in the quality of medical education that may accrue to medical students as a result of increasing diversity in medical education. BACKGROUND Disparities in Health Status Across Racial and Ethnic Groups in the United States Differences in health status across racial and ethnic groups in the United States have been described for a wide array of diseases, conditions, and outcomes (NCHS, 2000). Despite overall improvements in life expectancy in the past century, African Americans still experience a lower average life expectancy at birth and higher average age-adjusted all-cause death rates than Whites. African Americans also experience higher death rates for many conditions, including coronary disease, stroke, and cancer, and infant morality rates are higher among both African-American and American Indian/Alaska Native populations than among Whites and most Hispanic subpopulations. Mexican Americans experience a higher rate of uncontrolled hypertension than white Americans. Asian and Pacific Islander Americans, African Americans, and Hispanic Americans all have an elevated incidence of tuberculosis compared with the white population. African Americans, Hispanics, and Native Americans have surpassed Whites in the incidence of HIV infection, and die at higher rates than Whites from diabetes mellitus, homicide, and unintentional injuries (NCHS, 2000). With respect to health-related quality of life, higher percentages on African Americans and Hispanics report that they are in fair or poor health as compared to Whites (NCHS, 1994).
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Differences in health status between white and minority populations may arise from many causal factors. These include patient-level risk factors, such as differences in education and economic resources, health behaviors, nutrition, genetic predisposition, and environmental exposures. Health care system characteristics that influence access to appropriate health care services and the quality of care also contribute to health status. These factors are especially important because they may be directly effected by public policy. Racial and Ethnic Differences in Access to Health Care An individual’s access to health care may be conceptualized in terms of a model that groups factors into those affecting: 1) the predisposition to use services as suggested by demographic and social characteristics as well as beliefs about health services (predisposing characteristics); 2) the ability to secure services as indicated by personal resources and availability of services in the community (enabling characteristics); and 3) health status, as perceived by the patient and evaluated by a professional (need characteristics) (Andersen, 1978). Access to health care is monitored and evaluated using a number of different indicators, including health insurance status and having a usual source of medical care; rates of utilization of different types of services; rates of negative health outcomes thought to be preventable such as certain diagnoses, complications, and types of utilization such as hospitalization; and structural indicators such as the availability of physicians, clinics, and other types of health services. Three common indicators of access to care are health insurance status, having a usual source of health care, and having a regular physician. While health insurance alone cannot ensure that patients will obtain all needed services, it can help protect individuals and families from the costs of illness and routine health maintenance. Lack of health insurance coverage and a usual source of care have both been associated with lower utilization of preventive and disease-management health services, even when controlling for patient health status (Freeman et al., 1990; Moy, 1995). Having a regular source of care has been shown to be an independent predictor of access to care rather than merely a result of access to care (Kuder, 1985). Usual Source of Care African-American and Hispanic patients have been found to be less likely to have a regular physician than Whites, even after controlling for sociodemographic characteristics (Gray, 1997). In an analysis of nationally representative household surveys over a 20-year period, Hispanics were found to be nearly twice as likely to lack a usual source of care as Whites (Zuvekas & Weinick, 1999). This gap widened over the study period and could not be explained solely by changes in health insurance status over the period studied. In
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions fact, health insurance status explained only approximately one-fifth of the decline in usual source of care among Hispanics. Similar patterns are observed among children. African-American and Hispanic children have been shown to be more likely to lack a usual source of care than white children (Cornelius, 1993; Newacheck, 1996), and may be less likely to obtain as many physician visits as a result (Lieu et al., 1993). Health Insurance Status Lack of health insurance is a barrier to access to health care, and one that is more prevalent among racial and ethnic minorities than Whites (Freeman et al., 1990). In a study of the health insurance status of white, black, and Hispanic Americans in two time periods (1987 and 1996) gaps in coverage were identified between Blacks and Hispanics and Whites (Monheit & Vistnes, 2000). Racial and ethnic minorities continue to be more likely to lack insurance coverage than Whites. The gap in employment-related coverage between white and Hispanic males actually expanded by 6.4 percentage points over the decade, leaving Hispanic males with the highest rates of being uninsured of all racial/ethnic groups (38.9%). Health Services Utilization The utilization of a wide range of health care services varies across racial and ethnic groups. Variations in utilization across subpopulations may be due to differences in patient health care-seeking behavior, health status, and personal preferences for different treatment options and willingness to pay for them. Other reasons for differences in utilization include differences in the availability of services, individual physician or health care organization preferences and their propensity to make certain recommendations, patient differences in ability to pay for desired services, and differences in non-financial factors such as transportation or child care issues. Despite having worse health status, rates of utilization of many types of services—including routine physician visits, preventive services, procedures, and treatments for illness—have long been shown to be lower for many racial and ethnic minorities as compared with Whites. Ambulatory service use has been found to be lower among Blacks and Hispanics as compared with Whites (Cornelius, 1993). Health screening rates for women of reproductive age have been shown to be lower among Hispanics, Native Americans, and Asians and Pacific Islanders (Wilcox, 1993). After gaining access to the health care system, minority patients have a lower likelihood of receiving appropriate management of and treatments for their conditions. Black patients have been found to receive a lower intensity of hospital services than Whites (Yergan et al., 1987), and to experience higher
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions rates of post-discharge problems after hospitalizations for several major conditions in a national study of hospital care (Kahn et al., 1994). Racial variations have been shown in numerous studies of cardiac procedure use and survival after a myocardial infarction. Blacks and Hispanics in New York with angiographically confirmed coronary artery disease were found to be between 36% and 40% less likely to receive bypass surgery than Whites when the surgery was judged medically appropriate, and Blacks were 37% less likely to receive the procedure when judged medically necessary, controlling for disease severity, age, gender, and insurance status (Hannan, 1999). Other studies have found similar results with respect to cardiac care and invasive cardiac procedures, even when controlling for demographic, socioeconomic, and clinical variables (Carlisle et al., 1995; Ferguson et al., 1997). Racial differences have also been observed in the likelihood of receiving care from high-quality cardiac surgeons (Mukamel et al., 2000). In a study of analgesia practices in the emergency department of a large teaching hospital, Hispanics were less likely to receive adequate analgesia for long bone fractures than white patients and were twice as likely to receive no analgesia whatsoever (Todd et al., 1993). Inadequate pain management has also been found to be significantly more likely among black nursing home patients with cancer compared with Whites (Bernabei, 1998). In multiple studies, Blacks and Hispanics with HIV infection have been found to have lower outpatient utilization and less treatment with antiretroviral medications and prophylactic medications (Andersen et al., 2000; Schwarcz, 1997; Moore et al., 1994; Easterbrook et al., 1991). Health Outcomes Patients seek medical care to obtain some improvement or to prevent or delay deterioration in health status. The examination of health outcomes and how they vary across subpopulations is an important tool in the evaluation of the quality of medical care. The health outcomes that can be influenced by health care include physical outcomes (death, complications, and physical functioning), patient satisfaction, and quality of life. In a study of 1993 administrative data for 26.3 million Medicare beneficiaries over the age of 65, age and sex adjusted mortality rates were higher among black men as compared with white men (O.R = 1.19, p < 0.001) and for black women as compared with white women (O.R = 1.16, p < 0.001) (Gornick et al., 1996). Studies have shown that minorities experience higher hospitalization and mortality rates due to conditions that many providers and health services researchers agree should be preventable with appropriate outpatient management (Schwartz, 1990). Blacks experience higher rates of uncontrolled hypertension, contributing to major coronary heart disease-related events (Clark, 1999). Age-adjusted mortality rates from cervical cancer were found to be twice as high among Blacks as compared with Whites in a Chicago sample of women, and the differences remained signifi-
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions cant even after adjusting for income (Samelson, 1994). In a study of U.S. mortality data, African Americans were found to experience higher standardized mortality rates due to asthma than Whites, controlling for income and educational level (Grant, 2000). African Americans and Hispanics who have been in contact with the health care system also tend to report lower satisfaction with medical care than Whites (Blendon et al., 1989; Morales et al., 1999). Physician Supply Other important indicators of access to quality health care include structural characteristics of the health care system, particularly the availability of physician services. Whether the United States as a whole faces a physician oversupply has been a matter of debate for some time (Schwartz, 1988; Ginzberg, 1989). Whether or not there are “too many” physicians in the country overall, many areas remain underserved. Thousands of areas throughout the country are designated as Health Professionals Shortage Areas by the Health Resource Services Administration (HRSA.gov, 2001). In particular, many predominantly minority communities face shortages of health services. In California, research has shown that physician supply is inversely related to the concentration of Blacks and Hispanics in a health service area, even after adjusting for community income level (Komaromy et al., 1996). This relationship was found in both urban and rural areas. Population projections indicate that by the year 2020, the minority populations of many of these regions are likely to increase substantially. As part of a study to project the numbers of minority physicians needed to achieve a race/ethnicity-specific physician-to-population ratio of 218 per 100,000, Libby and colleagues provide data about the numbers of active physicians in 1990 from the Census Bureau’s Equal Employment Opportunity database (1997). A projection model developed by Libby yielded results indicating that in order to reach 218 physicians per 100,000 persons for each racial/ethnic group, the numbers of first year residents would need to roughly double for Hispanic and black physicians, triple for Native American physicians, and be reduced by two-fifths for white and Asian physicians. Although we do not assert that exact racial and ethnic parity in physician-to-population ratios should be an explicit public policy goal, these numbers and projections illustrate the extent to which Blacks, Hispanics, and Native Americans are underrepresented in medicine relative to their numbers in the population. Although underrepresented minority enrollment increased by 43% after 1986, it peaked in 1994, did not increase in 1995, and actually declined by 5% in 1996 (Carlisle et al., 1998). It is likely that gains made in numbers of underrepresented minorities to enter medicine in the early 1990s, a period that saw a 27% increase in underrepresented minority enrollment (Nickens, 1994), are now being reversed by restrictions in affirmative action programs across the country.
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions TABLE 1 Numbers of Active Physicians per 100,000 Persons, 1990, and Average Annual Increase, 1980–1990, by Race/Ethnicity Race/ethnicity 1990 1980–1990 Active physicians Population in thousands Active physicians per 100,000 persons Average annual increase in physicians Hispanic (all races) 27,620 22,354 124 835 Black 20,032 29,216 69 649 Native American 833 1,794 46 31 Asian 60,988 6,968 875 1,813 White, non-Hispanic 453,295 188,128 241 8,746 Total 562,768 248,710 227 12,074 Based on Libby et al., 1997, with data from the U.S. Bureau of the Census Equal Employment Opportunity File (Washington: U.S. Department of Commerce, 1990) and G.Roback, L.Rudolph, and B.Seidman, Physician Characteristics and Distribution in the Unites States: 1992 Edition (Chicago, AMA, 1992). THE IMPACT ON HEALTH DISPARITIES OF INCREASING THE NUMBER OF UNDERREPRESENTED MINORITY PHYSICIANS: A REVIEW OF THE EVIDENCE Medical training for African Americans first became a topic of policy debate in the United States in the context of the post-Civil War South as a way to address the health needs of the African-American community. Disparities between the health status of Whites and African Americans had been observed throughout American history. In the antebellum South, slave owners documented health problems that threatened productivity, and pointed out health disparities between African Americans and Whites to reinforce beliefs that biological differences between the races justified slavery (Savitt, 1985). Common health problems ranged from injuries and malnutrition to pneumonia and tuberculosis. Conditions in the South after the Civil War were not dissimilar to other postwar periods, with many people left homeless—refugees in search of a place to live and a way to make a living (Summerville, 1983). Lack of food, water, and sanitation exacerbated what had already been extremely poor living conditions. The result was major outbreaks of pneumonia, cholera, diphtheria, smallpox, yellow fever, and tuberculosis. Yet, very few white physicians were willing to see black patients, and very few African Americans could afford their fees. The education of African-American physicians and other health professionals was seen as a necessary step to improve the health of Blacks and to protect the public health of the communities where African Americans lived, primarily in the South. African-American medical schools were founded to address this need.
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions Against the backdrop of institutionalized segregation, Flexnor (1910) echoed both social justice and public health arguments for training black physicians in his famous report, with the underlying assumption that the best way to meet the great health needs of black communities in the United States was by providing more black physicians. His recommendation was to concentrate resources on the two black medical schools out of seven that he believed had the best chance of meeting the standards being set for modern medical training programs, Howard and Meharry. The preface to his recommendations reflects the tension between the societal goals of improving access to care by training more physicians and changing requirements to standardize and improve the quality of practicing physicians, while simultaneously an unstated goal and trend was also restricting entry into the profession (Starr, 1982). As recently as 1965, only 2% of all medical students were black, and three-fourths of these students attended Howard or Meharry. In sum, the social and public policy questions and debates regarding the training of minority physicians have been with us for some time, and are not likely to be resolved in the near future. Practice Choices of Underrepresented Minority Physicians Since the 1970s and 1980s, when minority students were first admitted to medical schools in larger numbers, a number of studies have examined the practice patterns of minority physicians as compared with white physicians. These studies have varied in terms of study samples, data sources, and methodologies. These studies have also examined alternative hypotheses through various methods, including statistically controlling for potential confounders and conducting additional analyses to address certain additional questions raised by the main analyses. Despite their differences, empirical analyses regarding the practice locations and patient populations of minority physicians have been remarkably consistent. Minority physicians tend to be more likely to practice in underserved areas and to have patient populations with a higher percentage of minorities than their white colleagues. Some evidence also suggests that minority physicians tend to have a higher percentage of patient populations with lower incomes and worse health status and who are more likely to be covered by Medicaid. Underserved Practice Locations A good deal of interest has focused on whether minority physicians are any more likely to practice in underserved areas than white physicians. One of the early studies to describe the practice patterns of black physicians was based on data from the 1975 National Ambulatory Medical Care survey, a nationally representative survey conducted by the federal government. These data confirmed
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions that black physicians practice predominantly in metropolitan areas. The analysis showed that 4,679,145, or (91.8%) of ambulatory visits by black patients to black physicians and 583,491 (94.4%) of ambulatory visits of white patients to black physicians occurred in metropolitan areas. In contrast, 28,842,477 (69.3%) of visits of black patients to non-black physicians and 369,081,473, or 72.6% of visits of white patients to non-black physicians occurred in metropolitan areas (Rocheleau, 1978). The 1975 data set was designed to over-sample black physicians to obtain more information about their practices than had previously been available. However, only crude measures of differences in practice location by race were presented. Race was only available classified as white, black, and other, and practice location was divided only into metropolitan area or non-metropolitan area. In other studies, Howard University College of Medicine alumni were surveyed about their current or planned practice patterns. The study by Lloyd et al. (1978) surveyed Howard College of Medicine alumni from seven selected classes that had graduated between 1955 and 1975. More recent classes were over-sampled. Of the 729 individuals surveyed, 311 responded (49%). Older individuals were more likely to respond, as were graduates in medical specialties (85% vs. 75%). An additional analysis of the survey data only included data provided by black alumni in the analysis (Lloyd & Johnson, 1982). The additional analyses also explicitly compared the responses regarding practice patterns of earlier graduates (1955–1970) to the planned practice patterns of the more recent graduates (1973–1975). Black Howard alumni were slightly less likely to respond than were non-black alumni (81% vs. 85%). Statistical tests with respect to characteristics associated with non-response were not reported. The results showed that the majority of respondents (59.9%) reported practicing or planning to practice in a large city (500,000 population or more). Of all respondents, 32% reported practicing or planning to practice in an inner-city area. Interestingly, the authors noted, this figure is higher than the proportion of respondents who reported growing up in an inner-city area (22.1%), attending college in an inner-city area (25.7%), or who planned to work in an inner-city area at the time of applying to medical school (18%). A higher percentage of earlier graduates (1955–1970) reported inner-city practice. The authors speculate that this may be the result of more opportunities outside of inner cities being available to more recent graduates, as well as fewer of the more recent graduates having come from an innercity background. Keith and colleagues (1985) sought to examine for minority and nonminority physicians of the “affirmative action era” the choices of practice location, specialty, specialty board certification, and patient population served. The authors examined data collected from class of 1975 medical school graduates by the American Association of Medical Colleges. The class of 1975 was chosen because of the concern that physicians who graduated earlier may have had less
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions freedom of choice regarding practice location and patient populations due to segregation and overt discrimination in many communities. Of the 13,428 individuals who received M.D. degrees between June 1974 and July 1975, the AAMC provided data on 12,065, including 574 Blacks, 36 Native Americans, 78 Mexican Americans, 27 mainland and Commonwealth Puerto Ricans, 9,467 Whites, and 219 Asians. Whites and Asians were classified as non-minorities. On average, non-minorities were found to have come from higher socioeconomic status (SES) backgrounds, based on parent education and occupation. Non-minorities also had higher scores on a pre-med performance index, which uses undergraduate science GPA and four components of the MCAT and was designed to predict scores on Part II of the NBME test. Therefore, non-minorities that most resembled minorities in terms of these characteristics as well as medical school attended and other pre-admission characteristics were over-sampled. In addition, all non-minority graduates of Howard and Meharry were included in the sampling frame. Nonetheless, differences persisted between the minority and non-minority samples (1.1 S.D. on the performance index and 0.6 S.D. on the SES index). Questionnaires were mailed to all of the sampled individuals for whom the AMA Masterfile or medical schools could provide addresses. Response rates were 77% for the minority sample and 85% for the non-minority sample. Non-respondents did not differ significantly from respondents on the performance index or in terms of SES. Non-minority primary care physicians did respond less frequently than other specialists; however, this was only a 1.1% difference. The results of this study showed that overall, almost twice the proportion of minority graduates as non-minorities were practicing in federally designated manpower shortage areas (11.6% vs. 6.1%, p < 0.001). This trend appeared in each of the eight specialty categories included in the study. One hypothesis is that minority physicians practice in underserved areas because they face more difficulties obtaining work elsewhere when they wish to. However, the authors found this argument to be inconsistent with one measure of potential competitiveness—a performance index score. The mean score on the performance index for minority physicians practicing in manpower shortage areas actually exceeded that of minority physicians who practiced in non-shortage areas. The location of minority physicians in manpower shortage areas was not explained by socioeconomic status. Although lower socioeconomic status was associated with the likelihood of non-minority physicians practicing in shortage areas, SES did not explain the effect of race/ethnicity. Significantly more underrepresented minority physicians chose primary care specialties as compared with white physicians, and family and general practitioners were the most likely to serve manpower shortage areas for both groups. A study of graduates of California medical schools assessed whether minority and non-minority physicians differed in terms of practice patterns, particularly in terms of practicing in areas of California with health personnel shortages and
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions serving underserved populations (Davidson & Montoya, 1987). The study examined data collected using a survey of 1974 and 1975 graduates of seven of California’s eight medical schools. Alumnae of one school were excluded due to the school’s religious medical missionary focus, which leads to many of its graduates going abroad after graduation. The years 1974 and 1975 were selected as the earliest in which significant numbers of minorities graduated from California medical schools. Contact information for minority (black, Mexican American, mainland Puerto Rican, and American Indian) and non-minority graduates was provided by the medical schools. All minority graduates and a sample of nonminority graduates were selected for a final study population of 144 minority and 145 non-minority graduates. Of 289 questionnaires mailed, 138 were returned, for a response rate of 48%. Response rates differed slightly between minority (46%) and non-minority (50%) subjects, but this difference was not significant at the 0.05 level. Response rates did not differ by school, with the exception of one school that required graduate permission before the release of contact information. Respondents and non-respondents did not differ by likelihood of serving underserved areas except for this school, whose respondents were more likely to report serving underserved areas. Since these subjects were given prior information about the nature of the study, it is possible that only the graduates who were most committed to issues of the underserved chose to release their contact information in order to participate in the study. The study findings revealed that minority physicians were more likely than white physicians to be practicing in or adjacent to areas designated as having a health care personnel shortage (53% vs. 26%). Although the numbers of physicians in the survey were relatively small (45 minorities and 53 non-minorities), the differences were statistically significant at the 0.01 level. These findings were unadjusted for physician characteristics that might have explained the observed effect of physician race/ethnicity on practicing in an underserved area. A 1996 study examined the racial and ethnic background of physicians in California and the characteristics of the communities in which they practice (Komaromy et al., 1996). This study took a multiple-step approach. Data from the AMA Masterfile and from the U.S. Census were used to explore the geographic distribution of California physicians and the characteristics of the communities they served. To learn about the association between physician race/ethnicity and the characteristics of the patient population served, a sample of California physicians was then surveyed. The questionnaire included items regarding physician racial/ethnic identification, and the racial/ethnic makeup and distribution of health insurance status of the physicians’ patient populations. First, physician shortages were examined in relation to community racial/ethnic makeup. Areas with shortages of physicians were defined as those with fewer than 30 office-based primary care physicians per 100,000 population. Using the AMA Masterfile and the census data, the examination of the distribution of office-based primary care physicians—including family practitioners,
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions and service use or outcomes (Chinman, 2000). Other work in mental health lends some support to the cultural competence hypothesis. Studies have found that black clients paired with white providers had lower program participation and less improvement (Rosenheck et al., 1995), that ethnic pairing is related to length of treatment and, among non-English speakers, with outcomes (Sue et al., 1991), and that changes in a community mental health system, including an increase in the diversity of mental health providers, were associated with an increase in the mean numbers of visit, particularly among minority clients (O’Sullivan et al., 1989). However, many of these studies examined only case management services rather than physician services. Moreover, with the exception of one study that measured linguistic competence, the outcomes of interest were only indirectly associated with racial/ethnic concordance, while details of the provider-patient relationship that might relate to cultural competency were unmeasured. Important factors to measure might include physician communication skills, patient trust, and patient satisfaction. A study of the role of race and the effectiveness of drug treatment programs examined the racial makeup of the client population, rather than of the medical staff. Results suggested that race is not a predictor of treatment success when other effects of other characteristics of the treatment environment such as socioeconomic status of the organization’s service area, organizational factors and treatment practices were controlled in the analysis (Howard et al., 1996). Another study of the influence of patient-physician racial concordance on the quality of nursing home care found no effect. Among a sample of elderly nursing home residents in the south, African-American patients with hypertension were more likely to receive medication and to adhere to their prescribed medication regimen than white patients, regardless of white-African American or African American-white patient-provider racial concordance (Howard, et al. 2001). Finally, a recent study of Medicare beneficiaries hospitalized for myocardial infarctions found that black patients had lower rates of cardiac catheterization regardless of whether the patient’s attending physician was white or black (Chen et al., 2001). Patient Trust and Satisfaction Physicians require the trust of their patients in order to treat them effectively. Work by Thom et al. (1999) to measure patient trust has shown that trust can be measured and demonstrated to be a related but distinct construct from patient satisfaction. The authors found that after controlling for age, education, length of relationship with physician, active choice of a physician, and preference for care, trust was highly predictive of continuity with a physician, self-reported adherence to medications, and satisfaction after six months with a physician,. A study by LaVeist and colleagues found that this mistrust is signifi-
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions cantly associated with lower satisfaction with care among African-American cardiac patients (2000). Historically, some minority groups have had negative experiences with the health care system (Thomas et al., 1991; Gamble, 1997; White, 2000). Research abuses, racism, and race-related misconceptions and stereotyping contribute to mistrust among African Americans of the U.S. health care system. Native American, Latino, and Asian patients have other historical and cultural experiences contributing to suspicion and skepticism of the U.S. health care system and physicians. Minority mistrust of physicians can prove to be a stumbling block to the development of a productive clinician-patient relationship. Some hypothesize that this may result in sub-optimal quality of care and, ultimately, lower health status. One small study found no evidence of patient preferences about the race or ethnicity of their physician. In interviews with 66 patients, patients reported being more concerned that physicians were caring, competent, and able to listen and understand what they had to say than they were over the race/ethnicity of their physician. However, this study included a convenience sample of patients of only three physicians in a single clinic, and included too few Latino or Asian patients to analyze (Bertakis, 1981). A more recent investigation used national data from the Commonwealth Fund’s Minority Health Survey. In this study, Saha et al. (1999) found that black and Hispanic patients were more likely to rate care as excellent and very good from physicians of the concordant race. Blacks with racially concordant physicians were more likely to rate them as excellent in terms of providing health care, treating them with respect, explaining medical problems, listening to concerns, and being accessible. Black and Hispanic patients reported that they were more likely to choose a physician of their same race because of personal preferences and also because of ability to speak the patient’s language. Patients with racially concordant physicians were also more likely to report that they had received preventive services and needed medical care during the previous year. There is further evidence in support of the hypothesis that racial concordance can be beneficial to the doctor-patient relationship. A study of African-American patient adjustment to vitiligo, a de-pigmentating skin condition, found that patients treated in an outpatient hospital clinic with a predominantly African-American patient population and clinical staff showed better adjustment to their condition than African-American patients who received comparable treatment in a similar clinic with a predominantly white patient population and clinical staff. African-American patients treated in the predominantly African-American clinic were also more likely to report that their doctor adequately explained the disease to them compared with African-American patients treated in the predominantly white clinic. In addition, the patients treated in the predominantly African-American clinic reported more satisfaction with levels of trust,
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions comfort, and feeling that the doctor was interested in and showed concern for the patients (Porter & Beuf, 1994). Doctor-Patient Communication Language is naturally a key component of physician-patient communication. Many health care organizations lack effective access to interpreters with an understanding of medical concepts and terminology. When patients speak some English and the need for an interpreter is not readily apparent, misunderstandings often go unrecognized. A study of patient ratings of satisfaction with their physicians (Morales et al., 1999) showed that overall, Hispanics were more dissatisfied with their communications with Whites. Moreover, Hispanic Spanish-language respondents were significantly more dissatisfied with care compared with Hispanics who had responded in English and compared with non-Hispanic Whites when asked about 1) whether medical staff listened to what they had to say, 2) receiving answers to their questions, 3) explanations about prescription medications, 4) explanations about medical procedures and tests, and 5) reassurance and support from medical staff. The multivariate model included controls for potentially confounding differences in demographic (age, sex), socioeconomic (education, income, marital status, household size), health insurance, and physical and mental health status characteristics. Other studies of the doctor-patient relationship and doctor-patient communication have examined the construct of participatory decision making (PDM) (Kaplan et al., 1995; Cooper-Patrick et al., 1999). Among patients in the Medical Outcomes Study, Kaplan found that higher PDM styles were associated with greater patient satisfaction and less likelihood of switching physicians. She also found that minorities tended to rate their physicians as being less participatory than white patients did. Cooper-Patrick specifically examined the relationship between patient PDM ratings of their physicians and race/ethnicity, including PDM, in race-concordant and -discordant physician-patient dyads. Overall, minority patients rated their physicians as having lower PDM scores than nonminority patients. Patients in race-concordant relationships with physicians reported that their physician visits were significantly more participatory than did patients in race-discordant relationships, although the magnitude of the difference in scores was small (2.2%, p < 0.02). Patient satisfaction was higher with higher PDM styles across ethnic groups in the study. Kaplan also found that PDM score was significantly related to time spent with patients, a variable that was not controlled for in the Cooper-Patrick analysis. Black and Hispanic physicians were found to spend more time on office visits on average in several of the aforementioned studies on physician practice pattern by race. However, this alternative hypothesis does not explain why white patients rated visits with white physicians as more participatory than did black patients of white physicians. Patient PDM ratings also varied with other charac-
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions teristics that could be related with patient comfort level and willingness to be involved during a physician visit, such as patient education and having been a patient of the same physician for a longer period of time. This suggests that PDM is not merely a proxy for average length of office visit alone. Rather, it seems likely that PDM represents a construct related to trust, familiarity with the health care system, communication style, and satisfaction. In summary, there is little consistent empirical evidence to support or refute the hypothesis that cultural competence influences patient health outcomes, or that training more minority physicians could improve the quality of care delivered to minority patients through improved cultural competence. Indeed, there is currently little agreement with respect to the definition or measurement of cultural competence. Moreover, we must take care to avoid the erroneous assumption that physician race/ethnicity is a proxy for cultural competence or sensitivity, or that patients of similar cultural backgrounds necessarily have similar expectations and preferences. Models from the fields of medical anthropology and sociology remind us that the provider-patient relationship is influenced by many factors including but not limited to characteristics of the patient and the provider, their respective cultural identities, models of health and illness, expectations of one another, and the social distance between them. More research is needed to define and measure cultural competence and to demonstrate its linkages to patient outcomes. DIVERSITY AMONG MEDICAL STUDENTS AND THE QUALITY OF MEDICAL EDUCATION The third hypothesized mechanism by which diversity may improve disparities in health status is through the effect of diversity on medical education. Increasing diversity in medical training may expose physicians-in-training to a wider range of different perspectives and cultural backgrounds among their colleagues in medical school, residency, and in practice. Such exposure may provide physicians with experiences and interactions that will broaden their interpersonal skills and help in their interactions with patients. These skills may increase the effectiveness of health care providers in addressing health disparities. There is suggestive evidence that medical students bring racial prejudices with them to medical school. In a study of the physician contribution to differences in quality of care, medical student perceptions of model actors were examined and compared (Rathore, 2000). Students were randomized to view a video of a black woman or a white man reporting identical symptoms of angina. Non-minority students rated the health state described by the black woman as less severe than that described by the white man, while the ratings provided by minority students did not differ. These results suggest that there is reason to suspect that medical students are not significantly different from the rest of the population in that they bring with them to medical school differing perspectives based upon their pre-
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions existing beliefs, values, and experiences, and are challenged in medical school to learn essential skills about interacting with patients and colleagues from differing perspectives. However, the ways in which increasing diversity in medical education might affect the educational environment and the quality of physicians it produces have not been systematically studied, and as a result there is currently no evidence to support or refute the hypothesis that having a diverse student body enriches the education of all medical students, resulting in better-educated, more culturally competent physicians and better health outcomes for minority patients as well as majority patients. THE COMING CHALLENGE Variations in medical care by patient race/ethnicity are at least in part attributable to differences in severity of illness and comorbidities. These factors may be influenced by many patient-level characteristics, including genetic factors, health behaviors, and environmental factors. They are also influenced by patient-level variables that affect access to care, such as socioeconomic status and health insurance status. In addition, access to care is influenced by the physical availability of care, the ease of use of care, and the ability to develop a meaningful doctor-patient relationship. The goal of increasing the diversity of the physician workforce in the United States in a sense dovetails with other efforts to alter medical education by reflecting a greater emphasis on development of core competencies in interpersonal skills that affect the care of patients. As they shape the entering classes of their institutions, admissions committees may increasingly emphasize diversity of background; life experiences, including cross-cultural experiences; and language and interpersonal skills as well as excellence in the classroom. However, evidence is needed to demonstrate whether such efforts have an impact on the overall quality of medical education or the quality of care ultimately delivered by physicians. Numerous programs have been implemented over the past 20 years aimed at increasing the numbers of underrepresented minority physicians and improving service to underserved communities. Recent limits on affirmative action pose a serious challenge to many such interventions. This threat is of particular concern as the proportion of racial and ethnic minorities in the U.S. population continues to increase. As minority populations grow, the importance of the supply of minority physicians is likely to increase. Keeping up with this need will require premedical education programs, medical school admissions policies, and physician workforce planning to include explicit strategies to increase the supply of underrepresented minority physicians. However, the racial and ethnic composition and life experiences of minority populations in the United States are constantly in flux. Programs and policies should be constantly reassessed in light of these changes.
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The Right Thing to do, The Smart Thing to do Enhancing Diversity in the Health Professions The goal of this paper has been to review and synthesize the scientific thinking and evidence related to the potential impact of increasing the racial and ethnic diversity of U.S. physicians on racial and ethnic differences in health status. Strong, compelling evidence suggests that minority physicians are indeed more likely to provide precisely those services that may be most likely to reduce racial and ethnic health disparities, namely primary care services for underserved poor and minority populations. It is the opinion of the authors that the strength of that evidence alone is sufficient to support continued efforts to increase the numbers of physicians from underrepresented minority groups. Some evidence also supports the hypothesis that some patients prefer physicians from their own racial or ethnic group, suggesting the possibility that diversity among physicians may provide greater choices for patients to choose physicians with whom they feel most comfortable. Clearly, the low numbers of physicians from underrepresented minority groups will limit choices for patients. Although we believe that the evidence supports efforts to increase diversity among health providers to address disparities, we also recognize that we must be vigilant against the potentially pernicious effects of creating the expectation that minority physicians are being trained solely to provide health care services to minority patients or to research minority health issues. Finally, there is a great need to apply rigorous scientific methods to assess the impact of the race and ethnicity of physicians and patients on health outcomes and the impact of diversity on the quality of medical education for all students and on the quality of health care. We must bring these research findings to bear on continued efforts to assure diversity among health care providers. REFERENCE Aday, L.A., & Andersen R.M. (1981). Equity of access to medical care: A conceptual and empirical overview. Medical Care; 19(12, supp), pp. 4–27. Andersen, R.M., & Aday, L.A. (1978). Access to medical care in the U.S.: Realized and potential. Medical Care; 16(7), pp. 533–546. Andersen, R.M., Bozzette, S.A., Shapiro, M.F. et al. (2000). Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the U.S. Health Services Research; 35(2), pp. 389–416. Bernabei, R.; Gambassi, G.; Lapane, K.; Landi, F.; Gatsonis, C.; Dunop, R.; Lipsitz, L.; Steel, K.; & Mor, V. (1998). Management of pain in elderly patients with cancer. SAGE Study Group. JAMA; 279(23), pp. 1877–1882. Bertakis, K.D. (1981). Does race have an influence on patients’ feelings toward physicians? The Journal of Family Practice. 13(3), pp. 383–387. Blendon, R.J.; Aiken, L.H.; Freeman, H.E.; & Corey, C.R. (1989). Access to medical care for black and white Americans. A matter of continuing concern. JAMA; 261(2), pp. 278–281. Bowen, W.G., & Bok, D. (1998). The shape of the river: Long term consequences of considering race in college and university admissions. Princeton University Press, Princeton, NJ.
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Representative terms from entire chapter: