The Right Thing to Do, The Smart Thing to Do Enhancing Diversity in the Health Professions -- Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. (2001) / Chapter Skim
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Increasing Racial and Ethnic Diversity Among Physicians: An Intervention to Address Health Disparities?
Increasing Racial and Ethnic Diversity Among Physicians: An Intervention to Address Health Disparities?
Pages 57-90
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From page 57... ...
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.
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From page 58... ...
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.
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From page 59... ...
Lack of health insurance coverage and a usual source of care have both been associated with lower utilization of preventive and diseasemanagement 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~.
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From page 60... ...
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~.
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From page 61... ...
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~.
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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~.
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From page 63... ...
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~.
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From page 64... ...
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.
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From page 65... ...
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.
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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.
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From page 67... ...
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.
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The following sections review the evidence regarding service to potentially vulnerable patient populations irrespective of practice location. Service to Vulnerable Patient Populations Rochelau's analysis of data from the 1975 National Ambulatory Medical Care Survey (NAMCS)
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From page 69... ...
Thus, black physicians saw higher proportions of black patients than other physicians, and Hispanic physicians saw higher proportions of Hispanic patients. Black patients made up 56% Of the patient populations of the black physicians, as compared to 8% to 14% of the caseloads of other physicians.
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From page 70... ...
Respondents provided detailed data regarding their own personal characteristics, health services utilization, physical and mental health status, functional status, and characteristics of their regular physicians including racial/ethnic group. Patients of minority physicians, including black, American Indian, Asian, and other physicians were compared to patients of white physicians.
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Patients covered by Medicaid were 2.62 times as likely to receive their care from a minority physician as a white physician. Patients with worse health status were also more likely to receive care from minority physicians than white physicians.
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From page 72... ...
Of 4,581 respondents in 1991, the racial/ethnic distribution was 85.1% white, 3.0% black, 3.4°/0 Hispanic, and 8.5% other. In bivariate analysis, black physicians were found to serve relatively high proportions of black patients, and Hispanic physicians were found to serve relatively high proportions of Hispanic patients.
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From page 73... ...
In an analysis of data from the 1987 National Medical Expenditure Survey, the same data source used in the study by Moy, Gray and Stoddard (1997) sought to test He hypothesis that minority patients are more likely than white patients to report a minority physician as their regular source of care, independent of socioeconomic status.
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From page 74... ...
This conclusion, while a plausible hypothesis, may be unwarranted based on the results of this study alone, which did not address physician characteristics that might be associated with serving a particular patient population. As a result of concerns over shortages of prunary care physicians in the United States, a recent study focused specifically on the practice patterns of generalist physicians and the predictors of their providing care to underserved populations (Rabinowitz et al., 2000~.
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It also controlled for sex, family background, and experience with the underserved in medical school. For the purpose of testing whether minority physicians are more likely than others to serve the underserved, the authors may have overcontrolled for confounding by including physician interest in serving the underserved and participation in the National Health Service Corps in the multivariate model.
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If underrepresented minority physicians provide higher-quality care to minority patients along the interpersonal dimensions of care, including doctor-patient communication and cultural competence, this could result in higher patient trust and satisfaction. This may in turn facilitate better health outcomes.
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From page 79... ...
Since hypertension is a such a common and important risk factor for coronary heart disease-related events in African Americans, risk prediction algorithms that fail to take this into account may have less predictive value in this population than in others. With regard to understanding treatment efficacy, hypertension in African Americans as compared with Whites is, in general, more responsive to monotherapy with diuretics and calcium channel blockers than to beta blockers or ACE inhibitors.
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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~.
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A study of AfricanAmerican 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 AfricanAmerican 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.
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From page 82... ...
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.
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From page 83... ...
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.
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From page 84... ...
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.
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From page 85... ...
Although we believe that the evidence supports efforts to increase diversity among health providers to address disparities, we also recogruze 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, Were 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 He impact of diversity on We quality of medical education for all students and on We quality of health care.
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(1998~. The entry of underrepresented minority students into US medical schools: An evaluation of recent trends.
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(1997~. Under the shadow of Tuskegee: African Americans and health care.
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(1982~. Practice patterns of black physicians: Results of a survey of Howard University College of Medicine Alumni.
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(1978~. Black physicians and ambulatory care.
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(1992~. Rates of avoidable hospitalization by insurance status in Massachusetts.
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