Medical Segregation: Most Minority Patients See Minority Doctors

A Hispanic couple consult with an Asian doctor (National Cancer Institute via Wikimedia Commons)

A Hispanic couple consult with an Asian doctor (National Cancer Institute via Wikimedia Commons)

A paper just out in the journal JAMA Internal Medicine finds a striking state of segregation in American medicine: “Nonwhite physicians cared for 53.5% of minority and 70.4% of non–English-speaking patients,” sums up the study, which was led by Cambridge Health Alliance doctors.

And that racial-ethnic split has changed little since a similar look a quarter-century ago, the paper notes.

As Obamacare kicks in, the rolls of the newly insured are expected to include many members of minorities and recent immigrants. Those newly covered people are expected to boost the demand for doctors, particularly in primary care. But will they be able to get access to care?

From the press release:

“There is a lot of concern that there will not be enough physicians willing and able to care for them,” said Danny McCormick, MD, MPH, the study’s senior author, a physician at Cambridge Health Alliance, and an associate professor of medicine at Harvard Medical School. “In order to increase the number of Black and Hispanic physicians, medical schools will need to more fully consider the physician workforce needs of the health care system as a whole in admissions decisions.”

An accompanying commentary in JAMA Internal Medicine calls for medical schools to admit more minority applicants, even if some of their science and other academic scores are lower, because minority physicians show more commitment to serving poor and minority populations.

The study’s lead author, Dr. Lyndonna Marrast, argues similarly: “Medical schools need to redouble their efforts to recruit and train minority students,” she said, “and we need policies at both the federal and institutional levels on a much larger scale than what we have now.”

These efforts to train more minority doctors would be “stopgap measures,” she said, because “ideally, we would live in integrated neighborhoods and everyone would have equal access to health care. Instead, we have members of society who are from marginalized groups, often geographically and culturally isolated, and they have a hard time accessing health care.”

How about getting more white doctors to serve more minorities?

In the commentary, Dr. Somnath Saha favors instead recruiting more minority doctors, because experience shows it works:

Underrepresented minority status is more predictive of serving the underserved than SES [socio-economic status], rural or urban upbringing, or participation in the National Health Service Corps, a federal program providing financial incentives for health professionals to work in underserved areas.

And of course, many patients may want doctors from the same racial or ethnic group.

Dr. Marrast says the data, gleaned from government surveys, doesn’t “point the arrow as to, ‘Is it the patient or is it the physician?’ It’s really a combination of both, and we’re not able to say, is it 90 percent the patients or 90 percent the physician. But we do feel our data is a reflection of choices made by physicians as to where to practice, and the choices made by patients.”

In essence, “It’s almost more of a supply and demand issue,” she said. “If patients are making this choice and there are more types of patients in society who potentially would make this choice, we should somehow find a way to provide a supply to meet their demand, or desire.”

From the Cambridge Health Alliance press release:

Cambridge, Mass. – Black, Hispanic, and Asian physicians play an outsized role in the care of disadvantaged patients nationally. Patients who have low incomes, are from racial and ethnic minority backgrounds, have Medicaid insurance, or who do not speak English – groups that historically have difficulty in accessing medical care – are substantially more likely to receive their care from a minority physician, according to a new study published online today by the journal JAMA Internal Medicine.

The study found that minority physicians care for 54 percent of minority patients and 70 percent of non-English-speaking patients. Other related findings include:

* Asian, Hispanic, and Black patients were 19-26 times more likely to be cared for by a minority physician of their same race.

* Low-income patients were 1 1/2 to 2 times more likely to be cared for by Black, Hispanic, and Asian physicians.

* Medicaid patients were 2 times to nearly 4 times more likely to be cared for by Black, Hispanic, and Asian physicians. Currently, African-Americans and Hispanics are substantially underrepresented in the physician workforce. Despite making up over 25 percent of the U.S. population, African-Americans and Hispanics make up less than 15 percent of the physicians….

“Our findings do not argue for strengthening the existing de facto segregation of medical care,” said Steffie Woolhandler, MD, MPH, professor of public health at City University of New York and a study co-author. “But it is clear that doctors’ decisions on where to practice and patients’ decisions on where to go for care combine to create an outsized role for minority physicians in caring for the underserved.”

Readers, thoughts? Tune in to Radio Boston at 3 p.m. today to hear Dr. Marrast discuss the paper.

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  • Jan Dumas

    I have been a patient at CHA for almost 10 years. We don’t get to choose our doctor, one is assigned to us as a new patient. I have gone through 3 primary care doctors, one chose to leave the practice, a second moved to another office, the new doctor and I are just starting to get to know each other. All 3 like me are white. I also see 3 specialist through CHA, all also white, all 6 are female. All of them were assigned to me by the practice, so I wonder, is CHA self selecting?

    There are very few things I expect out of my doctors, one is competency, so I get nervous at any suggest to lower standards.

  • Reasonable?

    I am an Harvard Medical School graduate and Africain American. Many of my friends and fellow graduates who are Black and Hispanic have chosen to care for traditionally underserved populations ( Health care for the Homeless, Hospitalist services at BMC, surgeons at community hosptials, etc).
    It is an interesting phenomenon because graduates of places like Harvard certainly have the choice to enter ANY area of practice and to serve whatever patient population they desire. Serving the underserved is an explicit choice grounded in sense of service during upbringing and eduation that is more compelling than maximizing the potential financial rewrds within one’s profession. It is an extremely commendable act.
    However in primary care there is also a significant trend of Nurse Practicioners and Physician Assistants/Extenders taking on more primary care responsibility. This trend is very important because many students interested in health professions are daunted by the length of training and debt for a traditional medical degree. My casual observation is that many Black and Hispanic students interested in health professions are leaning towards the NP/PA route for time/debt reasons.
    My recommendation:
    In addition to promoting the traditional MD pipeline there shoud be a parallel focus on the NP/PA pipeline. The latter many be a faster and more cost effective way to address the primary care gap for underserved populations and in general.
    Great story!