OUR STORY IN BRIEF!
Founding Director: Office of Medical Education
Institute for Minority Physicians of the Future (IMPF)
Health disparities across racial and ethnic groups in the United States have been well documented for over a century. These disparities 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 African- American populations experience worse health along many dimensions compared with the majority white population (1). Because many minority neighborhoods have a shortage of physicians (2) 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.
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 have 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 “biogenetic inferiority of blacks” justified slavery (3). Conditions in the South after the Civil War were not dissimilar to other post war periods, with many blacks left homeless – refugees in search of a place to live and a way to make a living (4).
Lack of food, water and sanitation exacerbated what had already been extremely poor living conditions. The result was major outbreaks of pneumonia, cholera, diphtheria, small pox, 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. Against the backdrop of sociostructural and institutional racism and legal segregation, Flexnor (5) 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 two black medicals 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 recommendation reflects the tension between the societal goals for improving access to care by training more black physicians, while simultaneously maintaining an unstated goal and trend of restricting entry of blacks into the profession (6). As recently as 1965, only 2% of all medical students were black, and three-fourths of these students attended Howard or Meharry.
The human rights and civil rights movements, the assassination of Malcolm X, Martin Luther King Jr., , and a rash of urban riots and uprisings woke many White Americans up. And academic medicine was one the first to respond to the wake-up call. Dr Jordan Cohn, AAMC President, in his “Bridging the Gap” address, explains the consequences of these sociopolitical events most eloquently.
“This brought about a significant rise in admissions of minorities to medical schools. This wasn’t because of scores on the Scholastic Aptitude Test, grade-point averages and Medical College Admission Test scores of minorities suddenly skyrocketing. Rather, academic medicine began to take affirmative action to increase racial, ethnic and gender diversity in medical school classes. Enrollment of underrepresented minorities in U.S. medical schools rose rapidly to about 8% of all matriculants by early 1970. Then progress stalled in the mid 1970s, with admissions remaining flat for the next 15 years. To make matters worse, the fraction of individuals from the same groups in the U.S. population that were underrepresented in medicine continued to grow during this period¾minority populations increasing from 16% in 1975 to 19% in 1990.”
(Source: www.AAMC.org Dr Jordan Cohn’s AAMC President / Bridging the Gap)“
“Increasing diversity of physicians might decrease disparities in health by three separate pathways”
The first pathway is through the practice choices of minority physicians, which may lead to increased access to care in underserved communities. Since the 1970s and 1980s, when minority students were first admitted to medical schools in large numbers, a number of studies have examined the practice patterns of minority physicians compared with white physicians. Despite their differences, empirical analyses regarding the practice location and patient population of minority physicians have been remarkable consistent. Minority physicians tend to be more likely to practice in underserved areas and to have patient population with a higher percentage of minorities then their white colleague (7-9). Evidence also suggest 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 (10-13).
The second pathway is through improvement in the quality of health care due to better physician – patient communication and greater cultural competency. The foundation of this hypothesis is that for many minority patients, having a minority physician my lead to better health care because minority physicians may communicate better and provide more culturally appropriate care to minority patients. If minority physicians provide high-quality care to minority patients along the interpersonal dimensions of care, including doctor-patient communications and cultural competence, this could result in higher patient trust and satisfaction. This may in turn facilitate better health outcomes (14-21).
The third pathway by which increasing diversity in the health professions might serve to decrease health disparities is through improvements in the quality of medical education that may accrue to medial students as a result of increasing diversity in medical training. This would expose physicians-in-training to a wide 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 (22).At the same time minority populations are increasing, data from the American Association of Medical Colleges show a marked decline in the number of African-Americans and Hispanics admitted to medical schools (23). These declines coincided with two significant events. First, in 1995, the United States Court of Appeals for the Fifth Circuit in Hopwood v. Texas, struck down as unconstitutional an affirmative action program that had been placed in the University of Texas law school. In doing so, the court effectively precluded higher education institutions as well as other entities in the Fifth Circuit, which cover Texas, Louisiana and Mississippi, from taking race or ethnicity into account in the admissions process. Secondly, the Regents of the University of California banned the use of race as a factor in admissions. With the passage of Proposition 209, public higher education institutions in California are no longer free to consider race, ethnicity or gender in admissions decisions, in recruiting programs, or even in planning and implementing minority-targeted outreach activities, such as tutoring programs and educational enrichment courses. California, Texas, Mississippi and Louisiana, these four states alone contain 35% of the minority population that remain underrepresented among medical students, and 75% of those from the Mexican-American community.
1. Kington, R.S., & Nickens, H.W. (2001) Racial and ethnic differences in health: Recent trends, current patterns, and future directions. In America becoming: Racial trends and their consequences, NJ Smelser, WJ Wilson, and F Mitchell. (Eds). Washington, DC, National Academy Press.
2. Komaromy, M.; Grumbach, K., et al. (1996). The role of black and Hispanic physicians in providing health care for underserved populations. New England Journal of Medicine; 334, pp. 1305-1310.
3. Savitt, L. (1985). Black health on the plantation: masters, slaves and physicians. In Sickness and health in America, J. Leavitt & R. Numbers (Eds.) University of Wisconsin Press.
4. Summerville, J. Educating Black Doctors: a History of Meharry Medical College. University, Alabama: University of Alabama Press, 1983.
5. Flexnor, A. (1910). Medical Education in the United States and Canada. Carnegie Foundation for the Advancement of Teaching. Merrymount Press: Boston, MA.
5. Starr, P. The Social Transformation of American Medicine. New York: Basic Books, 1982.
7. Rocheleau, B. (1978). Black physicians an ambulatory care. Public Health Reports; 93(3):278282.
8. Lloyd, S.M., & Johnson, D.G. (1982). Practice patterns of black physicians: Results of a survey of Howard University College of Medicine Alumni. Journal of the National Medical Association; 74(2), pp. 129-141.
9. Keith, S.N.; Bell, R.M., et al. (1985). Effects of affirmative action in medical schools: A study of the class of 1975. New England Journal of Medicine; 313, pp. 1519-1525.
10. Davidson, R.C., & Lewis E.L. (1997). Affirmative action and other special consideration admissions at the University of California, Davis, School of Medicine. JAMA; 278(14), pp. 1153-1158.
11. Moy, E.; Bartman, B.A.; & Weir, M.R. (1995). Access to hypertensive care. Effects of income, insurance, and source of care. Archives of Internal Medicine; 155(14), pp. 1497-1502.
12. Cantor, J.C.; Miles, E.L., et al. (1996). Physician service to the underserved: Implications for affirmative action in medical education. Inquiry, summer; 33, pp. 167-180.
13. Gray, B. Stoddard, J.J. (1997). Patient-physician pairing: Does racial and ethnic congruity influence the selection of a regular physician? Journal of Community Health; 22(4), pp. 247-259.
14. Department of Health and Human Services OOMH. (2000). Office of Minority Health national standards on culturally and linguistically appropriate services (CLAS) in health care. Federal Register; 65(247).
15. Lavizzo-Mourey, R., & Mackenzie, E.R. (1996). Cultural competence: Essential measurements of quality for managed care organizations. Annals of Internal Medicine; 124, pp. 919-921.
16. Coleman, M.T., Lott, J.A., & Sharma, S. (2000). Use of continuous quality improvement to identify barriers in the management of hypertension. 17. American Journal of Medical Quality; 15(2) pp. 72-77.
17. Chinman, M.J.; Rosencheck, R.A.; & Lam, J.A. (2000). Client-case manager racial matching in program for homeless persons with serious mental illness. Psychiatric Services; 51(10):1265-1272.
18. Rosenbeck, R., Fontana, A., & Cottrol, C. (1995). Effect of clinician-veteran racial pairing in the treatment of posttraumatic stress disorder. American Journal of Psychiatry; 152(4), pp. 5550-5563.
19. Thom, D.H., Ribisl, K.M., Stewart, A.L., et al. Further validation and reliability testing of the trust in physician scale. Medical Care; 37(5), pp. 510-517.
20. Saha, S., Komaromy, M. et al. (1999). Patient-physician racial concordance and the perceived quality and use of health care. Archives of Internal Medicine; 159, pp. 997-1004.
21. Morales, L.S., Cunningham, W.E., & Brown, J.A. et al. (1999). Are Latinos less satisfied with communication by health care providers? Journal of General Internal Medicine; 14, pp. 409-417.
22. Rathore, S.S.; Lenert, L.A. et al. (2000). The effects of patient sex and race on medical students’ ratings of quality life. American Journal of Medicine, 108(7), pp. 561.566.