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Figure 1. Recent Trends in Underrepresented
Minority Enrollment in Health Professions
Schools
Source: Grumbach et al. Strategies for
improving the diversity of the health
professions. Woodland Hills, CA: The California
Endowment, 2003.
D-link
D-link
Table 1. Race/Ethnicity of U.S.
Health Professionals Compared to U.S.
Population, 2000
| |
Non-Hispanic
White |
Non-Hispanic
Black |
Hispanic |
Asian/Pacific
Islander |
American
Indian/ Alaska Native |
| U.S. Population (over age 18) |
75.1% |
12.3% |
12.5% |
3.7% |
0.9% |
| Chiropractors |
91.9% |
1.2% |
2.9% |
2.7% |
0.6% |
| Dentists |
82.8% |
3.4% |
3.6% |
9.1% |
0.3% |
| Medical & Health Services Managers
|
78.5% |
10.8% |
5.9% |
3.1% |
1.0% |
| Optometrists |
86.5% |
1.7% |
2.7% |
8.1% |
0.4% |
| Pharmacists |
78.9% |
5.1% |
3.2% |
11.5% |
0.3% |
| Physician Assistants |
76.2% |
8.6% |
8.1% |
4.8% |
0.6% |
| Physicians & Surgeons |
73.6% |
4.5% |
5.1% |
15.3% |
0.3% |
| Podiatrists |
90.0% |
4.6% |
1.7% |
2.8% |
0.3% |
| Registered Nurses |
80.4% |
9.0% |
3.3% |
6.0% |
0.8% |
Adapted from: Minorities in Medical Education:
Facts & Figures 2005. Washington,
DC: Association of American Medical Colleges,
2005.
Data sources: U.S. Census 2000 Special
Equal Employment Opportunity (EEO) Tabulation
Data; and U.S. Census Bureau, Census 2000
Summary File 1 (SF 1) 100-Percent Data.
Table 2. Results of Studies of Health
Professional Service Patterns
| |
Number
of Studies |
Practitioner Race:
|
Black |
Latino |
Asian |
AI/AN |
URM |
| Hypothesis |
+ |
0/- |
+ |
0/- |
+ |
0/- |
+ |
0/- |
+ |
0/- |
| Serve minority/same-race
populations |
12 |
- |
8 |
- |
4 |
- |
1 |
- |
2 |
- |
| Serve underserved/poor
populations |
6 |
– |
4(1) |
– |
1 |
1 |
– |
– |
5 |
– |
+ = supports hypothesis
0/- = does not support/refutes hypothesis
(#) = non-significant trend
URM = underrepresented minority, not broken
down by specific race/ethnicity
Table 3. Numbers of Studies
of Patient-Provider Concordance, by Provider
Category and Concordant Characteristic
| Health Professional
Category: |
Physicians
|
Mental health
providers |
Substance abuse
counselors |
Medical students |
| Race Concordance |
13 |
4 |
4 |
1 |
| Ethnic Concordance |
0 |
7 |
0 |
0 |
| Language Concordance |
7 |
5 |
0 |
0 |
Table 4. Results of Studies
of Patient-Provider Race and Ethnic
| Number
of Studies |
Practitioner
Race:
|
Black |
Latino |
Asian |
Minority |
| Hypothesis |
+ |
0/- |
+ |
0/- |
+ |
0/- |
+ |
0/- |
| Improves access/utilization |
7 |
6 |
3 |
5 |
6 |
2 |
2 |
0 |
| Improves quality |
9 |
5 |
4 |
3 |
1 |
3 |
0 |
0 |
| Improves outcomes |
3 |
6 |
2 |
2 |
3 |
3 |
0 |
0 |
+ = supports hypothesis
0/- = does not support/refutes hypothesis
Table 5. Results of Studies
of Patient-Provider Language Concordance
| Number
of Studies |
Practitioner
Race:
|
Latino |
Asian |
Minority |
| Hypothesis |
+ |
0/- |
+ |
0/- |
+ |
0/- |
| Improves access/utilization |
3 |
0 |
4 |
1 |
2 |
0 |
| Improves quality |
3 |
1 |
0 |
0 |
1 |
0 |
| Improves outcomes |
1 (1) |
2 |
1 |
3 |
1 |
0 |
+ = supports hypothesis
0/- = does not support/refutes hypothesis
(#) = non-significant trend
Appendix A – Service Pattern Evidence
Table
| Author |
Year |
Study design |
Population |
Summary |
Comments |
| Bach |
2004 |
Cross-sectional analysis of Medicare
claims and Community Tracking Study |
Primary care physicians who care
for elderly patients (family medicine,
general medicine, general internal
medicine, geriatrics) |
22% of Black patient
visits nationwide were to Black physicians,
which was substantially greater than
the average proportion of Black physicians
(12.5%) within the areas (Hospital
Service Areas) where Black patients
sought care and the proportion of
Black physicians nationally (5.5%).
These results suggest that high rates
of race concordance between Black
patients and physicians are due to
both physicians' disproportionately
serving Black communities and patients'
disproportionately seeking care from
Black physicians. |
| Brotherton |
2000 |
Survey |
Pediatricians graduating from U.S.
medical schools in 1983-1989, including
both generalists and subspecialists |
URMs were 4 times more likely to
have NHSC obligations, were less likely
to have done a subspecialty fellowship,
and had higher educational debt upon
graduation from medical school. URMs
were significantly more likely to
care for minorities and uninsured/publicly
insured children. Those who had NHSC
obligations also saw more minority
patients, for both URM and non-URM
pediatricians. |
Stratified random sample, including
half URM and half non-URM; average
age of physicians at time of survey
was 37 yrs |
| Cantor |
1996 |
Cross-sectional data from surveys
at 2 time points
Longitudinal data with 4-yr follow-up
of respondents to initial survey
|
Physicians age 40 or less, in practice
at least 1 year |
Black physicians were significantly
more likely than White physicians
to self-report care for poor patients
and Black patients. Latino physicians
were more likely than Whites to report
care for Latino patients, poor, and
uninsured. In all cases, women minorities
were more likely to do so than men.
White women were slightly more likely
than men to report care for poor patients.
Measures of physician SES background
were weakly associated with increased
care of underserved patient groups.
Educational debt was unrelated to
care of underserved populations. In
the longitudinal cohort, few changes
were seen in service to the underserved
over a 4-year period. Independent
of race/ethnicity, physicians caring
for a high proportion of underserved
were less likely to report high satisfaction
with current practice, experienced
more discrimination, and earned less
than they considered adequate incomes. |
Minorities oversampled; 44% longitudinal
response rate; controlled for SES
background of MDs. |
| Gray |
1997 |
Analysis of 1987 National Medical
Expenditure Survey |
National sample of patients, focused
on those reporting a usual provider |
Minority patients were less likely
to have a regular physician (71% nonminority;
55% Black; 51% Latino). This trend
persisted after controlling for SES.
Of those with a regular physician,
88% of non-minorities, 19% of Blacks,
29% of Latinos and 26% of other minorities
reported race concordant MDs. After
controlling for SES, Latinos and Blacks
were over twice as likely to have
a minority physician than non-minorities,
with race concordant relationships
most common. |
Controls for patient SES |
| Johnson |
1989 |
1985-86 survey of graduates of Howard
University College of Medicine |
Survey spanning 49 graduating classes
from Howard University College of
Medicine |
Patient panels of Black
physicians were 64% Black and 19%
"very poor." Black graduates
cared for slightly more poor patients
than non-Black graduates of Howard
University, an historically Black
medical college. |
| Keith |
1985 |
Survey and secondary data analysis |
All minority graduates and a stratified
random sample of nonminorities in
a single class (1975) of US medical
school graduates |
Minorities were more likely to choose
primary care specialties (especially
Ob/Gyn and pediatrics). Minorities
practiced in federal manpower shortage
areas at nearly twice the rate of
nonminorities (true in all specialty
categories). SES background of minorities
did not significantly impact specialty
choice or location in shortage areas
(in contrast to nonminorities). Black
MDs were significantly more like to
care for Black patients; the same
pattern was observed for Latino, Asian,
American Indian, and White MDs. Minority
physicians were not more likely than
Whites to care for other (nonconcordant)
minority groups. Black and Hispanic
MDs were more likely to treat Medicaid
patients than White MDs. Minorities
were 40% less likely to be board-certified. |
Oversampled nonminorities to match
preadmission characteristics and medical
schools of minorities; included Ob/Gyn
in primary care; controlled for SES
background and medical school performance
of physicians |
| Komaromy |
1996 |
Survey |
California statewide analysis of
per capita workforce of primary care
physicians |
Population race and
ethnicity were inversely related with
per capita primary care physician
workforce. Black physicians were more
likely to practice in areas in the
top 85% of communities in terms of
proportion of population who were
Black. Similar results were found
for Latino physicians and Latino communities.
Black physicians cared for 42.9% more
Blacks than other physicians. In unadjusted
analyses, Black physicians saw more
patients insured by Medicaid, and
Latino physicians saw more uninsured
patients as compared to physicians
of other race/ethnicity. |
| Mofidi |
2002 |
Survey |
Dentists who had participated in
NHSC, and had post-service obligation |
Strongest predictor
of continuing to work with underserved
was Black race. Latinos were also
more likely to continue working with
the underserved in bivariate analyses,
but were grouped with nonAfrican-Americans
in multivariate analysis. Also independently
associated was altruism towards serving
underserved prior to NHSC position. |
| Moy |
1995 |
Analysis of 1987 National Medical
Expenditure Survey |
National sample of patients, limited
to those reporting a specific physician
as their usual source of care |
Overall, 14% of patients
identified a nonWhite physician as
their usual source of care (34% of
minorities, 11% of non-Hispanic Whites).
Medically indigent patients were more
likely to see nonWhite physicians.
Black and Latino patients were more
likely to receive care from Black
MDs. Black and "other" minorities
more likely to receive care from Asian
MDs. Medically indigent patients were
more likely to receive care from Black
and Asian MDs than other patients.
Those identifying a nonWhite physician
had poorer self-reported health status.
Adjusting for physician gender, specialization,
workplace, and geographic region did
not affect the results. |
| Murray-Garcia |
2001 |
Analysis of administrative data
of patients and visits to resident
continuity clinics |
Residents at Children's Hospital
Oakland 1998-99 |
Highest proportions of visits by
Blacks, Asian, and Latino patients
were made to residents of same racial
or ethnic group, most notably for
Latino patients. Latino patients were
more likely to see Latino residents
than Spanish-speaking non-Latino residents.
|
High minority patient population
(5% White); no information on how
patients were assigned or chose resident
physicians |
| Pathman |
1996 |
Survey |
NHSC physicians located in non-metropolitan
communities |
Minority physicians
were less likely to be board certified
than nonminorities within each specialty
(most pronounced for general internal
medicine). Minorities were less interested
in practicing in rural areas than
nonminorities, and more interested
in having "amenities of city
living," and on average practiced
in larger towns. Minorities anticipated
serving in rural areas for a shorter
duration than nonminority counterparts.
Minority physicians placed a higher
value on serving a particular racial/ethnic
group than nonminority physicians.
Minority physicians cared for a disproportionately
high number of minorities within their
communities. |
| Penn |
1986 |
Survey of University of California
at San Diego graduates |
Survey of all graduates admitted
under a program targeting socioeconomically
disadvantaged students between 1973-81,
and an equal number of randomly selected
graduates admitted under traditional
admissions process, matched by year
of graduation. |
More students in the special admissions
group (who were predominantly Black
and Hispanic) practiced in rural and
inner city settings than those in
traditional admissions group. Additionally,
the special admissions group reported
caring for a greater percentage of
minority patients, in a race concordant
manner. |
No statistical analyses were conducted.
No comparisons made of URMs admitted
through standard admissions process
with those admitted through special
admissions process. |
| Perloff |
1997 |
Analysis of 1993 and 94 AMA Socioeconomic
Monitoring System survey |
Primary care physicians in urban
areas, excluding those who were employees
or in large medical groups |
By self-report, African-American
and Hispanic physicians were more
likely than White physicians to participate
in Medicaid, and among those participating
to have a higher percent of patients
covered by Medicaid. In multivariate
analysis including personal, practice,
community, and State Medicaid policies,
African-American race was the only
personal or practice characteristic
predicting increased service to the
Medicaid population (OR 3.45). |
| Rabinowitz |
2000 |
Survey |
Family/general physicians, general
internists, general pediatricians |
Factors independently associated
with providing substantial care to
the underserved included URM (strongest
association), grew up in inner-city
or rural area, participation in NHSC,
and strong interest in underserved
practice prior to entering med school.
Factors not associated (in multivariate
analysis): gender, family income when
growing up, clinical experience with
the underserved during medical school. |
Stratified (by specialty and quartile
rank of medical school for proportion
of primary care physicians produced)
random sample of physicians; substantial
care to underserved included practice
in a designated underserved area,
more than 40% of patients uninsured,
on Medicaid, or poor |
| Saha |
2000 |
Analysis of 1994 National Comparative
Survey of Minority Health Care (Commonwealth
Fund) |
Black, Latino and White respondents
who reported a regular physician |
Black (4% of all U.S.
physicians) and Latino physicians
(5%) cared for a disproportionate
number of Black and Hispanic patients
(25% and 23%, respectively). Analyses
indicate this is due to both chosen
practice locations of these physician
groups, coupled with patient preferences
for race concordant physicians. |
| Saha |
2003 |
Analysis of 2001 Health
Care Quality Survey (Commonwealth
Fund) |
Patient-physician race
concordance for Blacks, Latinos and
Asians was high. However, only 10%
of respondents reported a preference
for a physician of their own race/ethnicity. |
| Xu |
1997 |
Survey and analysis of American
Medical Association Physician Masterfile
data |
Family physicians, pediatricians,
and general internists who graduated
from medical school in 1983 or '84 |
URMs were more likely
to have grown up in inner-city or
rural area and to have had a lower
childhood family income, and a higher
mean debt upon graduation. NHSC obligations:
50% of Blacks, 25% of Latinos 10%
Whites, and 8% Asians. URMs reported
caring for a higher proportion of
underserved populations. URM race
was a stronger predictor of serving
poor and Medicaid patients than NHSC
obligations. All race/ethnic groups
reported a significant degree of race
concordance with their patient population. |
Appendix B – Race Concordance
Evidence Table
| Author |
Year |
Study Design & Methods |
Patient Population |
Health Professional Group(s) |
Concor-dance Type |
Outcome(s) |
Results |
Comments |
| Chen |
2001 |
Retrospective cohort
Medical record review
|
35,676 White and 4,039 Black Medicare
beneficiaries > 65, hospitalized
for acute myocardial infarction, 1994-95 |
Attending physician of record during
hospital stay |
Race |
1. Receipt of cardiac catheterization
[ut]
2. Mortality [oc]
|
Race concordance was not associated
with differences in cardiac catheterization
use or mortality. |
The attending physician may or may
not have been the PCP. |
| Chen |
2005 |
Cross-sectional
Telephone survey
|
3,884 Black, Latino, and White adults
in the U.S., 1999 |
PCP |
Race |
1. Satisfaction with physician [qu] |
Race concordance was associated
with greater patient satisfaction
among Blacks, Latinos, and Whites
who explicitly preferred a race concordant
PCP. For those who preferred a race
discordant PCP or had no preference,
race concordance was not associated
with satisfaction. |
The results were not adjusted for
potential confounding factors. Patients'
preferences for race concordant PCPs
was associated with perceived racism
in the health care system. |
| Cooper |
2003 |
Cross-sectional
Written surveys and audiotape analysis
|
142 Black and 110 White patients
in 16 primary care practices in the
Baltimore, MD, and Washington, DC
areas, from 1998-99 |
PCP |
Race |
1. Patient-physician communication
content [qu]
2. Patients' ratings of physicians'
participatory decision making style
[qu]
3. Patient satisfaction with visits
[qu]
|
Race concordance was associated
with longer average visit duration
(17 vs. 15 minutes), slower speech
speed, and more positive patient affect.
Race concordance was also associated
with higher patient ratings of physicians'
participatory decision making and
higher patient satisfaction. |
|
| Cooper-Patrick |
1999 |
Cross-sectional
Telephone survey
|
784 White and 814 Black patients
in 32 primary care practices associated
with a single urban managed care organization
in the Washington, DC metropolitan
area, from 1996-98 |
PCP |
Race |
1. Patients' ratings of physicians'
participatory decision making style
[qu]
2. Patient satisfaction with visits
[qu]
|
Race concordance was associated
with higher patient ratings of physicians'
participatory decision making and
higher patient satisfaction. |
|
| Fiorentine |
1999 |
Prospective cohort
Face-to-face and telephone interviews
|
302 clients (96% Black, Latino,
or White) at 25 substance abuse treatment
facilities in the LA metropolitan
area |
Substance abuse counselors |
Race |
1. Perceived counselor empathy [qu]
2. Engagement in therapy (frequency
of participation) [qu]
3. Abstinence [oc]
|
|
|
| Flaskerud |
1990 |
Retrospective cohort
Administrative database analysis
|
543 episodes of outpatient mental
health care for Southeast Asian patients
(mainly Vietnamese & Cambodian)
in Los Angeles (LA) County, 1983-88 |
Social workers, psychiatrists, psychologists,
psychiatric nurse specialists, unlicensed
mental health workers |
Ethnicity
Language
|
1. Mental health visits [ut]
2. Dropout from therapy [ut]
3. Improved GAS scores [oc]
|
Controlling for sociodemographic,
diagnostic, and treatment variables,
and severity of illness, language
concordance, but not ethnic concordance,
was associated with a higher number
of visits. Neither language nor ethnic
concordance predicted dropout from
therapy, with the exception that language
concordance between Cambodian patients
and non-Cambodian therapists predicted
higher dropout rates. There were no
associations with improved GAS scores. |
Many patients studied were likely
refugees with history of emotional
trauma. Dropout rates in this population
were low (16%). GAS scores improved
for fewer than ½ of patients. |
| Flaskerud |
1991 |
Retrospective cohort
Administrative database analysis
|
1,746 episodes of outpatient mental
health care for Chinese, Korean, Filipino,
& Japanese patients in LA County,
1983-88 |
Social workers, psychiatrists, psychologists,
psychiatric nurse specialists |
Ethnicity
Language
|
1. Mental health visits [ut]
2. Dropout from therapy [ut]
3. Improved GAS scores [oc]
|
Controlling for sociodemographic,
diagnostic, and treatment variables,
both ethnic and language concordance
were significantly associated with
a higher number of visits. Ethnic
+ language concordance (but neither
alone) was predictive of lower dropout
rates. This appeared to be driven
by ethnic concordance, as ethnic concordance
was predictive of lower dropout rates
even among English-speaking Asian
clients. There were not associations
with improved GAS scores. |
GAS scores improved for fewer than
½ of patients. |
| Flaskerud |
1986 |
Retrospective cohort
Chart review
|
300 Black, Mexican, Asian, Vietnamese,
Filipino, & White clients at 4
community mental health agencies in
Southern California, 1981-82 |
Mental health social workers (2/3),
psychiatrists, psychologists, psychiatric
nurse specialists |
Ethnicity
Language
|
1. Dropout from therapy [ut] |
Controlling for sociodemographic,
diagnostic, and treatment variables,
both ethnic and language concordance
were significantly associated with
lower dropout rates and were among
the strongest predictors of continued
therapy. |
|
| Fujino |
1994 |
Retrospective cohort
Administrative database analysis
|
1,132 Asian women, 800 Asian men,
1,568 White women, and 1,264 White
men using outpatient services in LA
County mental health facilities, 1983-88
|
Social workers, psychiatrists, psychologists,
psychiatric nurse specialists, unlicensed
mental health workers |
Ethnicity (and gender) |
1. Mental health visits [ut]
2. Dropout from therapy [ut]
3. Improved GAS scores [oc]
|
Joint ethnic/gender concordance
was associated with lower dropout
rates and longer duration of therapy
for Asian and White women (compared
to joint ethnic/gender discordance).
Ethnic concordance was associated
with longer duration of therapy and
improved GAS scores for Asian men. |
|
| Gamst |
2000 |
Retrospective cohort
Administrative database analysis
|
4,554 Black, Latino, Asian, and
White adult mental health outpatients
in eastern LA County, 1994-98 |
Psychologists, social workers, family/marriage
counselors, other mental health professionals,
substance abuse counselors |
Race |
1. Improved GAF scores [oc]
2. Mental health visits [ut]
|
No consistent
patterns were observed. Race concordance
was associated with fewer visits
for Latino and Black patients, more
visits for Whites, and no difference
for Asians. Race concordance was
associated with GAF scores as follows:
|
Whereas "dropout" from
therapy represents discontinuation
despite recommended continuation,
the meaning of results for total number
of visits is less clear. Also, it
is not clear whether concordance influenced
outcomes because of better therapy
or different judgments of therapeutic
outcomes by therapists from different
ethnic backgrounds. Finally, the authors
examined race concordance (e.g., Asian-Asian),
but not the more specific ethnic concordance
(e.g., Chinese-Chinese). |
| Garcia |
2003 |
Cross-sectional
Focus groups
|
49 Black, Latino, and White patients
at an academic general medicine clinic
in Sacramento, CA, 1998-99
|
PCP |
Race |
1. Quality of patient-PCP interactions
[qu] |
Black men and women and Latino men
generally perceived better communication
with race concordant PCPs, due to
greater interpersonal comfort and
shared culture. Latina women denied
the importance of PCP race, but non-English
proficient Latinas did validate the
importance of language concordance. |
|
| Gotthie |
1994 |
Design and methods not described |
634 patients (92% Black) undergoing
intake evaluation for first-time admissions
to a public outpatient cocaine treatment
center in a large Northeastern US
city |
Substance abuse counselors |
Race |
1. Return visits after initial intake
[ut] |
Black patients had similar return
rates whether evaluated initially
by a White or Black counselor. |
The study included 8 counselors,
5 Black and 3 White. |
| Howard |
2001 |
Cross-sectional
Face-to-face interviews
|
1,416 Black and 1,451 White elders
(> 65) with hypertension, in 4
rural and 1 urban county in North
Carolina, 1986-87 |
Usual-care physician |
Race |
1. Medication prescription [qu]
2. Medication adherence [ut]
3. Care-seeking delays [ac]
4. Emergency department use [ut]
5. Satisfaction with care [qu]
|
For Black elders, race concordance
was not associated with any of the
outcome measures after accounting
for other demographic and health-related
variables (race concordance appeared
to be associated with lower patient
satisfaction among Blacks, but the
authors do not comment on the statistical
significance of this finding). For
White elders, race concordance was
associated with a lower likelihood
of delaying care-seeking and greater
satisfaction with care. |
Black physicians in this study were
less likely than White physicians
to be board certified and more likely
to work in primary care and community
health centers. The authors also note
| |
