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The Rationale for Diversity in the Health Professions: A Review of the Evidence

 

References

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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.

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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