Racial and ethnic health inequities continue to adversely affect the morbidity and mortality of those in marginalized groups. There is considerable evidence to show that physicians from those same marginalized groups care for these individuals disproportionately and thus represent a way to accelerate access to care for these communities. The rationale for the disproportionate service to marginalized physicians is attributable to race-conscious professionalism, which describes how the physician navigates professional demands while caring for an underserved population (J Health Care Poor Underserved 2015;26:73-81). Further evidence suggests that when minoritized physicians relocate to different environments, due to this sense of duty, belongingness, and inclusion, they tend to resettle their practices in communities of similar demographics (Health Serv Res 2009;44:1290-308). The desire to use their careers to serve the underserved is a principal motivator for medical students as early as the first year, where the Association of American Medical Colleges (AAMC) Matriculating Student Questionnaire finds that nearly 65% of Black, 57% of Indigenous, and 50% of Latinx students report that they want to serve underserved individuals as part of their future practices (asamonitor.pub/3P9JRX8). This is more than twice that of their White and Asian peers who represent approximately 80% of the current medical school class. Upon graduation, the AAMC reports similar percentages for medical students preparing to enter residency. Undergraduate medical education has not had significant influence on changing the career trajectory regarding the underserved or non-underrepresented students in the current curriculum. There is a need for greater teaching and modeling of care, employing cultural humility, for our learners in medicine to change this outcome. We have failed to produce enough minoritized physicians to fulfill the demand for racially concordant care, and so all physicians must practice these measures to deliver high-quality care to marginalized individuals.
Cultural humility is the practice of subjugating one’s own cultural norms, mores, and practices in favor of careful listening and respect for those of the patient one is serving (J Health Care Poor Underserved 1998;9:117-25). It is not imposing one’s own values onto a patient and expecting assimilation or compliance with cultural practices that may not be known to nor practiced by people of a marginalized community. It is not devaluing their beliefs because they are not those of the dominant culture. It involves a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.
Representation of diverse individuals in the physician workforce transcends models of care delivery in its impact on elimination of health inequities. Racially concordant care, as described above, is the observed state of care today. However, it is not a new idea. The 1910 Flexner Report on Medical Education in the United States and Canada revolutionized medical education in the last century and continues to serve as the model for how we train today (Science 1910;32:41-50). In Chapter XIV, The Medical Education of the Negro, Flexner described the importance of racially concordant care for Blacks, as he correctly recognized that while the medical care of the race would never be wholly left to Black physicians, Black physicians serving the role as caregivers to their community can distinctly brighten the outlook for their mental and moral improvement. Such care was necessary because, if left untreated, Blacks will serve as sources of contagion and that self-protection not less than humanity offers weighty counsel. In the denouement of this influential work, five of the seven Black-serving medical schools were closed. Very few predominantly White institutions admitted Black students at that time, and this practice persisted in many medical schools through the 1960s. Recent extrapolation of the impact that the closing of Black medical schools had on the enrollment of Black students suggests that there are 10,000-30,000 fewer Black physicians because of it (JAMA Netw Open 2020;3:e2015220). We are still suffering from this historical deficit, and it has not only adversely affected care access but still more of what Black physicians bring to the improvement of health for minoritized patients.
Evidence suggests that minoritized doctors impact health in a variety of ways. Blacks disproportionately complete preventive medicine residencies at a rate of three-fold their numbers in graduate medical education today. Black doctors disproportionately study the medical problems that impact marginalized individuals and have closer ties to their communities to promote inclusion of diverse individuals into clinical trials. Diverse teams can make better decisions than teams that lack a variety of perspectives. Certain health care outcomes have been shown to improve with racially concordant patient-physician relationships, as have health care utilization costs (Am Econ Rev 2019;109:4071-111; J Racial Ethn Health Disparities 2022;9:68-81). Recruitment of minoritized individuals is improved when there are diverse admissions and selection committees constructed to administer these processes. Mentorship and sponsorship of learners have been shown to be improved in concordant pairings. But there is a hazard in depending on concordant care, and that is the physician-patient relationship constitutes a fraction of all of the determinants of health. Those elements of daily living, referred to as the social or structural determinants of health, influence health care outcomes in ways that transcend that of delivery of concordant care. The social determinants include how one is educated; the nature of work available; whether there is adequate housing, food, transportation, safety, and clean air and water; the exposure to adverse childhood events; racialized trauma; and acts of aggression, discrimination, and poverty (EClinicalMedicine 2021;33:100777). There are also the political determinants of health wherein inequitable policies, politics, practices, regulations, laws, and enforcement of those laws have impaired access to care and contribute to health inequities (The Political Determinants of Health. 2020). Minoritized physicians typically have outsized influence in reaching the broader society to serve as advocates for improving these conditions, but certainly do not hold the solutions to many of these important factors.
As anesthesiologists, we have seen a proliferation of studies documenting the existence of care inequity in a variety of circumstances, including adequate pain treatment, maternal mortality, use of epidural care for labor and operative delivery, use of preventive measures for nausea and vomiting, parental presence at pediatric induction, and many others. Could a more diverse workforce influence these practices in our discipline? With fewer than 100 graduates from our anesthesiology residency programs nationally each year, it will be hard to know. We must be more aggressive in encouraging earlier learners to pursue medical careers, ensure that we make our learning environments more inclusive and supportive for minoritized learners, and prepare those in our programs to consider academic and research careers as readily as we prepare them to provide patient care.
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