How can the physician workforce be diversified?

The Affordable Care Act (ACA) will increase insurance coverage for the poor, uninsured and minorities, but will it improve access to care and population health? The answer depends critically on whether or not physicians are available to care for the newly insured. Many health policy experts fear there may not be.

While the ACA contains some modest pay increases for doctors willing to see patients with Medicaid (the means-tested joint federal-state program that the ACA will expand), these incentives are likely to be too small to dramatically boost physicians’ willingness to care for disadvantaged patients or to affect the underlying national shortage of primary care physicians.

How then can we help ensure that the health care needs of disadvantaged patients are better met as ACA implementation proceeds? In the February 1st, 2014 print issue of JAMA Internal Medicine we reported the results of a study that may provide part of the answer: train more minority physicians.

Our study analyzed data from a federal survey of 7,070 patients and found that compared to other patients, the disadvantaged were more likely to be cared for by a minority physician. This was true regardless of how “disadvantaged” was defined, i.e. by low income, minority race/ethnicity, having Medicaid, being uninsured, being non-English speaking, or being in less-than-good health. For instance, patients with Medicaid were one and a half to two times more likely to be cared for by a minority physician than a white physician. Black, Hispanic and Asian patients were 19-26 times more likely to be cared for by a minority physician of the same race. And patients in fair to poor health were 20-44 percent more likely to see a minority physician.

We hope to one day live in a fully integrated society where everyone has the same, comprehensive health coverage, race and ethnicity matter less, and everyone has access to high quality health care professionals. However, until that day comes, we need to recognize the disproportionate role of minority physicians in meeting the health care needs of the poorest and sickest Americans.

Organizations such as the Institute of Medicine, the American Medical Association and the Association of American Medical Colleges have affirmed a need to train more minority physicians. In spite of this, African-Americans, who represent 12 percent of the population, only account for 6.3 percent of U.S. physicians. Hispanics make up 16 percent of the population but account for just 5.5 percent of physicians. These proportions have changed little in 20 years.

How can the physician workforce be diversified? Increased efforts to identify talented minority students and help prepare them for medical careers are needed. In addition, decreasing the exorbitant tuition costs of medical schools would disproportionately benefit minority students.

However, the change that would have the most direct impact is a revamping of medical school admissions priorities. Although a recent Supreme Court decision requires admissions committees to show that diversity could not be achieved by other means before resorting to race-conscious selection criteria, it nonetheless affirmed a compelling government interest in achieving diversity. All medical schools should set diversity as an explicit institutional priority and adopt admissions criteria that give preference to students (of any race/ethnicity) who bring diversity to the profession. Such policies might also favor students with a history of volunteering or working in underserved communities and those who seek careers serving disadvantaged patients.

In the United States today, the poor die six years younger than the affluent, blacks die nearly four years younger than whites, and patients from most ethnic minorities have markedly worse access to needed medical care. Medical schools need to do more than bemoan these grim realities; they should act to change them. America’s medical schools have just completed another application cycle and have decided who will or will not become a physician. In the next few years, they must be willing to commit to training more high-quality minority health care providers. By changing the complexion of the nation’s physician workforce, medical schools prepare a physician workforce to better meet the needs of all Americans.

Lyndonna Marrast is a primary care physician, Cambridge Health Alliance. Danny McCormick is an associate professor, Harvard Medical School and a primary care physician, Cambridge Health Alliance.

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  • Dr. Drake Ramoray

    Two points to make.

    First you are living in a dream world. A two tier system with inferior insurance and those with the means with better insurance or cash pay is what is what is likely to result. A case can be made that that would be better than our current system with those without insurance.

    Second, leaving the question aside as to whether or not Medicaid makes people healthier in the first place which is at least debatable given the Oregon study and some other surgical outcome studies, doctors don’t take Medicaid because it doesn’t pay. In my state Medicaid actually pays pretty well. It’s the hassles red tape and formulary coverage that the issue.

    This has become an increasing problem for diabetics even with private insurance since the turn of the new year. My group is an under served area (most Endo offices are). So years now things are more equal. As of March this year if you have diabetes, regardless of insurance, we unfortunately have a wait list.

    In the Endo world it’s largely about the red tape and hassles not the pay. Soon I suspect we will be thyroid only concierge.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I think the implied argument here is that minority physicians are more willing to accept lower fees and worse working conditions. So instead of improving fees and working conditions for all, we should train more people who, presumably for altruistic reasons, are willing to sacrifice more. It’s cheaper that way.

      • Dr. Drake Ramoray

        I am a minority physician, and first generation native born American. Apparently I don’t fit their mold. Most endocrinologists don’t either. The Endocrine Society Meetings could fairly be mistaken for the UN.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Not sure anybody fits that mold….

          • ninguem

            The old Yankee doc who was Chief of Staff at the hospital where I was born, and practiced there for a while.

            Slender, tall, ramrod-straight, Oxford shirt, bow tie, khaki pants, buck oxford shoes, a Harvard uniform at one time.

            He came from an old Yankee family that had been rich since forever, old interests in establishment law (city legal in-house counsel, land use, the lawyers who didn’t need to advertise). That sort of thing.

            He remarked he was considered the “black sheep of the family” for entering medicine. He got his hands dirty.

            First-generation American from immigrant family is actually a classic fit for “the mold” of an American physicians.

        • ninguem

          Actually, first generation Americans of immigrant parents…..fits the mold for American physicians perfectly.

          I used to look at the graduation photo collages of graduates from my school, founded in the 1890′s, and my postgraduate programs and the hospital where I taught, mostly founded in the 1920′s.

          Medicine…….music……law…….there are certain fields that had historically allowed a person to advance based on personal skills alone, not political connections, and allowed that person the opportunity to make a living from that ethnic community (assuming the larger community might not accept that newcomer). Didn’t require the capital to start a business.

          I’d say Dr. Drake was a classic American physician based on the track record of the last seventy-five years or more.

          Second-generation American for me. I had one uncle with a bachelor’s in business, so I reckon I was the second one, on either side of my family, with a college degree of any kind.

        • querywoman

          My first endocrinologist was class Anglo Saxon, like me, with a very Anglo name. He was an uptight jerk who had no flexibility at all.
          I know that that’s not necessarily related to being a white boy, but he was like milk toast. Dull!
          Oddly enough, most of my current doctors are foreign-board. I live in a large urban area with plenty of native and foreign docs.

      • Dr. Drake Ramoray

        And I aware I ignored the point about “diversity” and rather than feeling like I’m attending an AMSA meeting I wated to point out another egg head that says we don’t take Medicaid because of the pay and that we have nothing to look forward to but rainbows and sunshine.

        • goonerdoc

          Precisely. Shaking my head at this affirmative-action-rally-cry tripe.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Affirmative action is about creating more opportunities for previously exploited people to achieve personal success. This here has a different, more mercenary and almost selfish ring to it: let’s create more minority doctors so they can take care of their own, and the “majority” doesn’t have to bother…. or something equally ludicrous.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    That’s exactly what we should be doing… instead of perfecting the art of poor health care for poor people.

    • ninguem

      I like to think I have brought poor health care to a fine art.

      With more time and study, I can become absolutely crappy.

  • Suzi Q 38

    IMHO, There is plenty of physician diversity.
    I have and have had eleven Asian doctors, one from Cuba, one from Poland, and three Anglo doctors.

    Whatever. I don’t pick a physician for h/her color.
    Sometimes for other patients, there may be a language barrier.

    The Asians prefer to go to doctors who are not only good but speak their Asian language. Health issues can be challenging and scary for the patient. Imagine trying to speak in a second language when you are not good or comfortable to do so.

    Ditto for Latino Spanish speakers.

  • ninguem

    Healthcare access is poor in rural America.

    It is shown, from long experience, that the best way to get doctors to practice in rural areas, is to train doctors who are FROM those rural areas.

    You want “affirmative action” for minority physicians?

    Add an “affirmative action” program for rural whites.

    • Thomas D Guastavino

      40 years ago when I was applying to med school I was rejected by almost all. Two admitted that if I were “black” I would have been admitted. The first time I was in to much in shock to craft a response, but by the second my response was ” Yeah, and if my father was dean this medical school I would also have been admitted”! All I got was a blank stare as it was clear that this would have never have been said to a white from a family of power and influence. After admission it became quite apparent that a new minority had been created, the middle class white male. There were so few of us that we all became close friends. I am happy to say that every one of us became quite successful in his chosen career.
      By the way, was “changing the complexion of the nations physician workforce” a freudian slip?

      • Suzi Q 38

        My husband is white, and his family is from Italy.
        When he graduated from college, the local cities were looking for minorities to fill most city municipality positions.
        He was one of the best graduates at his college, with a nearly perfect GPA.
        It took him awhile to find a job, because the cities were seeking men and women of “color.”
        Being Asian, I was so surprised and a bit confused.
        I never viewed my husband as white, because he is 100% Italian.
        I asked him incredulously, why are you WHITE???
        I thought I married an Italian, LOL.

        • querywoman

          Is he one of those darker Italians with the deep rich black hair and the brownish skin? I love that type!

          Isn’t your “Asian” Hawaiian? Did you ever live there? I’ve heard that natural blondes like me are discriminated against in Hawaii.

          • Suzi Q 38

            “Is he one of those darker Italians with the deep rich black hair and the brownish skin? I love that type!”
            No, but the other members of his family are dark Italians from the island of Sicily. I think the city they are from was Palermo.
            My husband looks very light, with light brown hair and greenish blue eyes. Sometimes his eyes look grey.

            Yes, I am Asian-Hawaiian, a true “mixture…”
            Yes, I lived there for a short time when I was very young. We moved to the “mainland” when I was five. You haven’t gone to Hawaii to find out about the reverse discrimination there for yourself?? If not, you are in for an experience.
            Even I do not qualify as a “local.”
            I have to intensify my “pidgin” English in order to get a rental car or nice hotel room without a hassle.
            This takes work.

          • querywoman

            I like Italians. Some look kind of mousy to me but still cute. Is your husband like that?
            Hmmm, Hawaii would be interesting for a big, busty, tall, pale blonde.
            Some people think of me as very Texan but I am not Native American.
            A bus driver said I speak like a city Texan. That’s what I am. No cowgirl in me. But I do have fine Texas redneck in me. I learned from the cowboys and their girlfriends in my first high school.

  • PoliticallyIncorrectMD

    I guess it is not sufficient to make sure that everyone is equal when it comes to medical school admissions. Some people should be made more equal than others.

  • guest

    I can’t quite put my finger on it, but somehow it seems like there are at least a few things wrong with saying “let’s give preferential med school admission to minority applicants so we will have more doctors willing to take care of minority patients.”

  • Dr. Drake Ramoray

    You and evolutionary biologists are discussing society as a whole. You can make a case from an affirmative action standpoint for more diversity (this is becoming ore controversial), but this article suggests we new more minorities to treat minorities to improve their healthcare. That seems to me to say thatt either whites or too racist and inept to fix the problem, or it’s so unpleasant to take care of poor people and minorities that maybe if we train minority docs they will do it. I just can’t square the article in a positive light.

    Back to evolutionary biology, even if the zombie apocalypse only leaves physicians to reproduce Im pretty sure human civilization will survive.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Diversity is very good. Segregation, on the other hand, not so much.

  • guest

    I am sorry, but I don’t believe that the study cited in any way demonstrated that “diversity improves outcomes.”

    As it was described, it appeared to document that minority patients were more likely to be cared for by minority doctors. This is not the same as an “improved outcome,” nor does it logically follow that if there were more minority doctors, access to care for minorities would be improved.

  • Dr. Drake Ramoray

    Thank you for responding just as I predicted someone would, also the reason why I intentionally didn’t include these comments in my first post. I do hope you have a nice day.

  • Dr. Drake Ramoray

    =============================================

    Your reaction appears visceral, which is not to say is necessarily a negative reaction. Most good studies will have this effect on us.

    ================================================

    I thought the purpose of studies was to further the the body of knowledge of science and improve patient care, not generate visceral reactions. If the goal is to generate visceral reactions, then there is a different motivation behind the study.