Source: STAT News
April 14, 2023 — Black people in counties with more Black primary care physicians live longer, according to a new national analysis that provides the strongest evidence yet that increasing the diversity of the medical workforce may be key to ending deeply entrenched racial health disparities.
The study, published Friday in JAMA Network Open, is the first to link a higher prevalence of Black doctors to longer life expectancy and lower mortality in Black populations. Other studies have shown that when Black patients are treated by Black doctors, they are more satisfied with their health care, more likely to have received the preventive care they needed in the past year, and are more likely to agree to recommended preventive care such as blood tests and flu shots. But none of that research has shown an impact on Black life expectancy.
The new study found that Black residents in counties with more Black physicians — whether or not they actually see those doctors — had lower mortality from all causes, and showed that these counties had lower disparities in mortality rates between Black and white residents. The finding of longer life expectancy persisted even in counties with a single Black physician.
“That a single Black physician in a county can have an impact on an entire population’s mortality, it’s stunningly overwhelming,” said Monica Peek, a primary care physician and health equity researcher at UChicago Medicine who wrote an editorial accompanying the new study. “It validates what people in health equity have been saying about all the ways Black physicians are important, but to see the impact at the population level is astonishing.”
“This is adding to the case for a more diverse physician workforce,” said Michael Dill, the director of workforce studies at the American Association of Medical Colleges and one of the study co-authors. “What else could you ask for?”
Lisa Cooper, a primary care physician who directs the Johns Hopkins Center for Health Equity and has written widely on factors that may explain why Black patients fare better under the care of Black doctors, called the study “groundbreaking” and “particularly timely given the declining life expectancy and increasing health disparities in the U.S. in recent years.”
“These findings should serve as a wake-up call for health care leaders and policymakers,” she told STAT.
The team of researchers, from the Health Resources and Services Administration of the U.S. Department of Health and Human Services and the AAMC, started their work by analyzing the representation of Black primary care physicians within the country’s more than 3,000 counties during 2009, 2014, and 2019. Even this first step resulted in a stark finding: Just over half of the nation’s counties had to be excluded from analysis because they contained not a single Black primary care physician.
“I knew it was a problem,” said Dill, “but ooh, those numbers are not good.”
The team’s analysis of the 1,618 counties that had at least one Black primary care physician in one of the three years found that the more such physicians a county contained, the higher life expectancy was for Black residents. (They’d like to repeat the analysis in the future to see how counties with Black doctors fared during the Covid-19 pandemic, which disproportionately affected people of color.)
The team found life expectancy increased by about one month for every 10% increase in Black primary care physicians. While extending life by a few months may not sound like much given that the life expectancy gap between Black and white Americans nationally is nearly six years, picking up such a signal on a population level is significant, the authors said.
The study found that every 10% increase in Black primary care physicians was associated with a 1.2% lower disparity between Black and white individuals in all-cause mortality. “That gap between Black and white mortality is not changing,” said John Snyder, a physician who directs the division of data governance and strategic analysis at HRSA and who was one of the lead authors. “Arguably we’ve found a path forward for closing those disparities.”
The study did not directly address the reason Black people fare better in counties with more Black physicians, nor does it prove a cause-and-effect relationship. While earlier research suggests “culturally concordant” medical care is of better and higher quality for patients, the new study indicates that one factor may be that Black physicians are more likely to treat low-income and underinsured patients, taking on new Medicaid patients more than any other racial or ethnic group, for example. The study found that improvements in life expectancy were greatest in counties with the highest rates of poverty.
“I wasn’t expecting that,” said Rachel Upton, an HHS statistician and social science analyst who was one of the report’s lead authors. “It shows having Black physicians is not only helpful across the board, but it’s particularly useful with counties with high poverty.”
Many studies have found that communication is improved when patients and physicians are of the same race. Owen Garrick co-authored a 2019 study in Oakland, Calif., finding that cardiovascular disease could be curbed more in Black patients who are seen by Black doctors because they are more likely to engage in preventive health care. He noted during his study that Black patients were not only more likely to talk with Black doctors about subjects like upcoming birthday parties or weddings, they were also more likely to invite them to the events.
But good communication is not the only factor: A 2020 study found that in infant care, where verbal communication from the doctor is not an issue, mortality rates for Black infants were reduced when they were treated by Black physicians; the authors suggested stereotyping and implicit bias may play a role when doctors treat patients outside their racial and ethnic groups.
The current study looked past the patient-doctor relationship and showed that patients may fare better simply by living in counties with Black doctors even if they are not directly treated by those doctors. Living in a county where Black doctors work and thrive “may be a marker for living in a community that better supports Black lives,” Snyder said.
Another factor, said Peek, is that Black physicians may be more likely to do unpaid health-related work outside of the health care system, such as providing expertise to community organizations, being politically involved in health-related matters, and encouraging medical societies to advocate for public health.
That’s the case with Peek, who has spent two decades working with a nonprofit that helps Black women in public housing become health navigators and advocates. She also spends a good deal of time providing a second opinion to her network of friends and family — and their friends and families — who do not personally know any physicians and may have issues of mistrust with the medical system.
“With my non-Black colleagues, it’s like ‘Both my parents were doctors! Everyone’s a doctor!’” she said. “Their social network is not all paranoid when they enter the health care system.”
She said the study also pointed to problems with racism within medicine and bias toward Black patients that has created a “chasm” between non-Black physicians and their Black patients. She’s struck, she said, by the number of Black people who come up to her after she speaks at a local church to give her their detailed medical history and ask her opinion because they don’t trust their own medical team. “I look like them,” Peek said. “They trust I have their best interest at heart.”
The authors of the new paper said they were not advocating segregated care and all doctors should improve their cultural competency. Patients of all races and ethnicities would be helped by increased diversity in the physician workforce, they said.
But increasing the number of Black physicians remains a stubborn problem. Despite decades of attention to the matter, a 2021 study showed the number of Black and Native American medical students, particularly males, has stagnated. The AAMC has reported a recent uptick in admissions of Black medical students, possibly due to a renewed focus on diversity in recent years, but an upcoming Supreme Court decision expected to limit the use of race as a factor in admission could cut into such gains.
The current study did not address how the presence of physicians from other groups underrepresented in medicine, including Hispanic and Indigenous people and Pacific Islanders, affects health outcomes. Upton said she hoped other researchers could focus on such groups in the future and that more researchers would conduct “within group” studies to examine the health of people within a single racial or ethnic group and not just examine how such groups compare to other, usually white, populations.
“Oftentimes we just look at the disparities,” she said. “I would like people to be looking at how people are doing within their own groups and what can help within those groups.”
Correction: An earlier version of this story misspelled Monica Peek’s name.