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PERSPECTIVE
Diversifying the Racial and Ethnic Composition of the Physician Workforce
Neil R. Powe, MD, MPH, MBA, and
Lisa A. Cooper, MD, MPH
3 August 2004 | Volume 141 Issue 3 | Pages 223-224
This position paper from the American College of Physicians states that a diverse workforce of health professionals is an important part of eliminating disparities among racial and ethnic groups in the United States (1). An implicit assumption underlying this position is that increasing the number of ethnic minority providers will not only reduce health care disparities but also improve the health of minorities. Arguably, the most definitive and direct evidence for this assumption would be a clinical trial that randomly assigned patients to minority and majority physicians and followed them longitudinally while assessing changes in objective measures of health status. This trial does not exist and is extremely unlikely to be performed because many patients would object to random assignment to physicians. Choosing a physician is a very personal matter that most people who have a choice do not leave to chance.
Since direct evidence does not exist, one could try to construct a chain of logic by using observational data from separate studies. This chain might lead inexorably to the conclusion that a diverse workforce would improve health. How solid is this chain of logic? Ample evidence suggests that minority physicians are more likely to return to communities from which they came and that minority physicians are more likely to treat patients with lower socioeconomic status (2-7). While evidence has shown that more health care (and possibly physician care) does not always lead to better health status in relatively well-insured populations (8, 9), providing health care to a geographic area where none to little existed may influence health status.
Furthermore, concordance (patients and their physicians sharing similar characteristics, such as race or ethnicity, language, and sex) is associated with better patient-reported outcomes. In race-concordant visits, patients are more satisfied with their care and feel that they are more involved in decision making about their care (10, 11). Language concordance also has these effects and results in improvements in self-reported health status (12, 13). Unfortunately, we do not clearly understand why concordance leads to better patient-reported outcomes. If we did, we could teach all physicians how to achieve these outcomes whether or not they and their patients were of the same race or ethnicity. Differences in communication patterns in race-concordant and race-discordant relationships do not explain why patients in race-concordant relationships rate their care more highly (11).
In arguing to expand the number of minority clinicians, is it necessary to claim that concordance improves health outcomes? Suppose that patients' health status was the same in race-concordant and race-discordant relationships. Would not patients choose to enter a relationship that brought greater satisfaction and participation in decision making? Some patients might even prefer greater satisfaction and participation in health care to slightly better health status, although this is unproven.
Furthermore, projections from the 2000 U.S. Census indicate that the U.S. population will grow more diverse from 2000 to 2050 (18% to 27.9% ethnic minorities and 12.6% to 24.4% Hispanics) (14). Many believe that the social and economic future of the United States depend on how well the workforce reflects the population it serves. They argue that diversity can bring value not only through better services but also through better workforce functioning. Other segments of our global society recognize this value. So might the health care industry. Therefore, although the direct evidence that increasing the diversity of the physician workforce improves health status is not ironclad, we believe that the College's position paper takes a reasonable stance in supporting actions to diversify the health professional workforce.
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Author and Article Information
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From the Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
Potential Financial Conflicts of Interest: None disclosed.
Request for Single Reprints: Neil R. Powe, MD, MPH, MBA, Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21205; e-mail, npowe{at}jhmi.edu.
Current Author Addresses: Dr. Powe: Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21205.
Dr. Cooper: Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21205-2223.
1. Racial and ethnic disparities in health care. A position paper of the American College of Physicians. Ann Intern Med. 2004;141:226-32.[Abstract/Free Full Text]
2. Keith SN, Bell RM, Swanson AG, Williams AP. Effects of affirmative action in medical schools. A study of the class of 1975. N Engl J Med. 1985;313:1519-25. [PMID: 4069161].[Abstract]
3. Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305-10. [PMID: 8609949].[Abstract/Free Full Text]
4. Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995;273:1515-20. [PMID: 7739078].[Abstract]
5. Xu G, Fields SK, Laine C, Veloski JJ, Barzansky B, Martini CJ. The relationship between the race/ethnicity of generalist physicians and their care for underserved populations. Am J Public Health. 1997;87:817-22. [PMID: 9184512].[Abstract/Free Full Text]
6. Brotherton SE, Stoddard JJ, Tang SS. Minority and nonminority pediatricians' care of minority and poor children. Arch Pediatr Adolesc Med. 2000;154:912-7. [PMID: 10980795].[Abstract/Free Full Text]
7. Cantor JC, Miles EL, Baker LC, Barker DC. Physician service to the underserved: implications for affirmative action in medical education. Inquiry. 1996;33:167-80. [PMID: 8675280].[Medline]
8. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-98. [PMID: 12585826].[Abstract/Free Full Text]
9. Ashton CM, Souchek J, Petersen NJ, Menke TJ, Collins TC, Kizer KW, et al. Hospital use and survival among Veterans Affairs beneficiaries. N Engl J Med. 2003;349:1637-46. [PMID: 14573736].[Abstract/Free Full Text]
10. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583-9. [PMID: 10450723].[Abstract/Free Full Text]
11. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139:907-15. [PMID: 14644893].[Abstract/Free Full Text]
12. Lee LJ, Batal HA, Maselli JH, Kutner JS. Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic. J Gen Intern Med. 2002;17:641-5. [PMID: 12213146].[Medline]
13. Perez-Stable EJ, Napoles-Springer A, Miramontes JM. The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. Med Care. 1997;35:1212-9. [PMID: 9413309].[Medline]
14. U.S. Census Bureau. U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Washington, DC: U.S. Census Bureau; 18 March 2004 Accessed at http://www.census.gov/ipc/www/usinterimproj/ on 3 May 2004.
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