VII. Minority Physicians

This section explores physician supply and demand issues as they pertain to minority physicians and discusses the implications for a country that is growing more racially and ethnically diverse.

A.   Minority Representation in the Physician Workforce

Approximately one in four Americans is either Black or Hispanic, yet together these two minority groups constitute only 9 percent of the physician workforce (Exhibits 69 and 70).  Advocates for increased minority representation in the physician workforce argue that minority under representation is more than simply an equity concern, but that increasing minority representation among physicians will improve access to care for minorities and vulnerable, underserved populations.

Exhibit 69. Physician Workforce, 2000

[D]

Source: AMA (2002)

Exhibit 70. U.S. Population, 2000

[D]

Source: U.S. Census Bureau

During the last 3 decades, racial and ethnic minorities doubled as a proportion of the U.S. population from approximately 16 percent in 1970 to 31 percent in 2000.  Minority representation among U.S. medical school applicants, candidates accepted, and graduates also increased during this time; however, this representation remains substantially below the proportion of racial and ethnic minorities in the U.S. population (Exhibit 71).

Even if there were a dramatic increase in minority representation in U.S. medical schools, the overall racial/ethnic composition of the physician workforce would change slowly because of the long length of time to train new physicians and because only a small portion of the current workforce retires each year.

Exhibit 71. Minority Graduates from U.S. Medical Schools: 1970-2000

[D]
Sources: Census Bureau, AAMC (2001).

Although minorities are underrepresented in U.S. medical schools, approximately one in five practicing physicians in the United States graduated from an international medical school, and the majority of these IMGs are racial or ethnic minorities.  India, Pakistan, and the Philippines together produce approximately 40 percent of the IMGs practicing in the United States (AMA, 2002).

Exhibit 72.  Distribution of IMGs by Country of Graduation

[D]

Source: AMA (2002) fact sheet.

Minority physicians are under represented in academic medicine and relatively few hold senior positions.  Palepu et al. (1998), in their study of medical school faculty, find statistically significant differences between minority and non-Hispanic White physicians in promotion rates and representation in senior positions.  The authors report that controlling for tenure, White faculty are more likely to attain a senior position and are more likely to be tenured or on a tenured track than are minority physicians.  While White faculty had more first-authored and total peer-reviewed publications than their minority colleagues, there were no differences in the types of research grants or the median number of grants held.  In terms of academic productivity, all groups reported similar hours for a typical work week, although minority physicians in academic medicine spend more time in patient care and less time in research activities compared to their non-minority colleagues (Palepu et al., 2000).  Controlling for differences in productivity, the authors still find that minority faculty are less likely to be promoted to associate or full professor positions as compared to non-Hispanic white faculty.  Black faculty are significantly less likely than White faculty to hold a senior position.  Hispanic and Asian faculty are also less likely than their non-Hispanic White colleagues to hold a senior position, but this difference is not statistically significant.  Some have argued that increasing the number of minority physicians in higher levels of academic medicine provides role models that can help to recruit more minorities into the medical profession.

The percent of physicians who are either Black or Hispanic differs significantly by specialty. AMA (2004) reports that although Blacks constituted 4 percent of the physician workforce in 2002 (for those physicians who report race and ethnicity), Blacks had greater representation in general preventive medicine (8 percent), obstetrics/gynecology (7 percent) and public health (5 percent).  Blacks had lower representation in specialties such as medical genetics (2 percent), radiation oncology (2 percent) and allergy and immunology (2 percent).  Similarly, Hispanics constituted 5 percent of the physician workforce in 2002, but Hispanics had greater representation in general and family practice (11 percent), child psychiatry (7 percent) and pediatrics (7 percent).  Hispanics had lower representation in orthopedic surgery (2 percent), radiology (3 percent), and dermatology (3 percent).

There exists a paucity of research on the specialty choice of minority physicians and the reasons why minority representation differs substantially by specialty.  One possibility is that minority physicians have a greater propensity to choose primary care specialties that are in high demand in largely minority, rural and inner-city areas that are Federally designated as health professional shortage areas (HPSAs). Studies have found that minority physicians have a greater propensity than do White, non-Hispanic physicians to practice in HPSAs and to serve uninsured and Medicaid patients.

• Komaromy et al. (1996), in a study investigating the association between physician supply and the demographics of 394 communities in California, found an inverse relationship between the concentration of Blacks and Hispanics and the number of physicians per population.  In urban areas, a 10 percent increase in the proportion of residents who are Black is associated with an 8.9 decrease in the number of primary care physicians per 100,000 residents.  This inverse relationship is also present in rural communities.
• Keith et al. (1985) also find that new, minority physicians are more likely to practice in Federally designated HPSAs than are non-Hispanic Whites (11.6 percent versus 6.1 percent of new physicians).  Furthermore, among those who were Black and Hispanic, physicians generally practiced in areas with relatively high proportions of their own race and ethnic group.  In fact, Black physicians practiced in areas where the mean percentage of black residents was four times as high as in areas where other physicians practiced (P < .001) and Hispanic physicians practiced in areas where the mean percentage of Hispanic residents was considerably higher than in areas where non-Hispanic physicians practiced (P < .001).
• Moy and Bartman (1995) find that minority physicians are more likely than are non-minority physicians to provide care to Medicaid beneficiaries.  This finding is consistent with those of Komaromy et al. who find that Medicaid beneficiaries accounted for 45 percent of patients of Black physicians, 30 percent of patients of Asian physicians, 24 percent of patients of Hispanic physicians, and 18 percent of the patients of non-Hispanic White physicians.  Hispanic physicians had the highest percentage of patients who were uninsured compared to physicians of other racial/ethnic groups.  Moy and Bartman find that medically indigent patients are between 1.4 and 2.6 times more likely to receive care from non-White physicians than are affluent patients.  

Thus, increasing minority representation in medical schools could help to reduce geographic imbalances in physician supply and, in particular, could improve supply in areas with large, vulnerable populations.

B.  Minority Patients and Demand for Physician Services

Demand for health care services by minorities is increasing as the population of minorities grow and become a higher percentage of the U.S. population.  Between 2000 and 2020, the percentage of total patient care hours physicians spend with minority patients will rise from approximately 31 percent to 40 percent (BHPr, 2003).

Because age distribution and health care utilization patterns differ substantially by race and ethnicity, there is substantial variation across physician specialties in the percent of total patient care hours spent serving minority patients (BHPr, 2003).  For example, in 2000 an estimated 13 percent of total patient care hours were spent providing care to Black patients (Exhibit 73).  Black patients’ percent of total patient care hours was highest in emergency medicine (38 percent), obstetrics/gynecology (17 percent) and pediatrics (16 percent).  The percent of total patient care hours spent providing care to Black patients was lowest in the surgical specialties.

The percentage of total physician time spent caring for Hispanic and other non-Black minority patients in 2000 was 21 percent.  The proportion of patient care hours provided to non-Black minority patients was highest for radiology (31 percent), pathology (29 percent) and pediatrics (23 percent), and lowest for urology (11 percent), ophthalmology (11 percent) and general and family practice (13 percent). 

Research suggests that there is a strong tendency for minority patients to use minority physicians as their usual care providers.  What is not clear is whether this is a supply or demand phenomenon.  In a study investigating the relationship between physician race and the care of minority and medically indigent patients, Moy and Bartman (1995) determined that more than a third of minority patients are treated by minority physicians.  Only 11 percent of non-Hispanic, White patients are treated by minority physicians.  The authors also find that minority physicians, in particular Asian and Black physicians, are more likely to care for patients outside their own minority group than are non-Hispanic, White physicians.

Much attention has been paid to the issue of culturally competent care, which argues that more effective care is provided when clinicians and patients have similar cultural backgrounds and speak the same language.  To the extent that minority physicians provide more culturally competent care than do non-minority physicians, or that patients prefer to receive care from physicians of similar race or ethnicity, significant increases in the number of minority physicians—and in particular Black and Hispanic physicians—are needed to meet the growth in demand for physician services by minority populations.

Exhibit 73. Estimated Percentage of Patient Care Hours, by Race of Patient

Source: BHPr (2003). ^a These projections assume that per capita utilization patterns remain constant over time, although utilization patterns can differ by patient age, sex, and race/ethnicity. Note: percentages might not sum to 100 percent due to rounding.