When Junko Takeshita, MD, PhD, MSCE, began practicing dermatology in Philadelphia, she’d had limited experience caring for Black patients during her medical training in the Pacific Northwest. So when she gave a Black patient a prescription for a medicated shampoo to treat scalp psoriasis, Takeshita assumed that the woman would use the shampoo every day.
When the condition had not improved by the patient’s next visit, Takeshita asked if she’d been using the shampoo daily. The patient said no; the doctor asked why not. Only then did Takeshita, who is of Asian background, learn that many Black women wash their hair anywhere from every few days to every week or so, because frequent shampooing can damage their naturally dry hair.
Takeshita realized that her lack of experience with a similar hair type caused her to initially provide a plan that wasn’t compatible with the patient’s practices. They developed a revised treatment plan based on the patient’s hair care regimen.
That illustrates one of the many subtle ways that the health care of Black patients might be affected by the race of their doctor. A growing body of research aims to better understand how and why patient and doctor race can influence care. Studies have shown correlations including a reduction in infant mortality, greater patient adherence to health care guidelines, higher patient satisfaction, and better patient understanding of cancer risks. One recent study found that the life expectancy of Black residents increased in counties with greater percentages of Black primary care physicians.
However, other studies have shown less benefit of racial concordance (i.e., alignment between the race of the patient and physician), and few have tried to link Black doctor–Black patient relationships to measurable health outcomes.
“Can we say that if you [a Black patient] have a Black doctor, you’re going to have better health outcomes? Yes, we can, because the evidence shows Black doctors provide better care for Black patients,” says Karey Sutton, PhD, scientific director of health equity research at the MedStar Health Research Institute in Maryland. Previously, as director of health equity research workforce at the AAMC, Karey oversaw a systematic literature review (not yet published) of 3,000 studies on the impact of physician and patient race.
Here is what some of the evidence shows and what the implications might be for health care providers.
Doctor and patient perceptions
In much of the research, a common factor is patient perceptions of interactions with their doctors, reflected in measures of trust, satisfaction, and understanding. For example:
- A study led by Takeshita, assistant professor of dermatology and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, looked at the scores that more than 117,000 patients gave their doctors on the Press Ganey survey of patient experiences. Doctors who cared for patients of the same race were far more likely to get the highest scores. Other studies have found similar links between racial concordance and patient satisfaction.
- A study by the National Human Genome Research Institute gave volunteer patients a virtual reality visit with a 3D animated doctor to assess their risk of developing lung cancer, with researchers changing the racial appearances of the physician for each patient. Black patients who perceived that they had been advised by a Black physician subsequently gave more accurate summaries of their lung cancer risks, leading researchers to conclude that patients’ racial perceptions can “impact their processing” of information from a doctor.
The implications go beyond feelings. Some studies find that Black patients are more likely to follow medical recommendations after visiting Black doctors.
- In a study led by researchers at Stanford University School of Medicine, more than 1,300 Black men in Oakland, California, were recruited to fill out a health questionnaire, after which they could get a free physician consultation and health screenings. The men assigned to a Black doctor were significantly more likely to bring up specific health concerns to the doctors and to go through screenings for diabetes and cholesterol after the consultation.
- A study from New York University Grossman School of Medicine and NYU Langone Health found that patients with hypertension and symptoms of cardiovascular disease were more likely to adhere to the medication guidelines when they were treated by doctors of the same race (including Black, Hispanic, and Asian).
To be sure, such findings can be affected by numerous factors, including the health conditions of the patients, their previous experiences in health care, and various elements of the doctor–patient visit (such as waiting time) — which the studies attempted to take into account. And the impact of outright racism (both individual and structural) on patient care has been documented in numerous studies, such as those showing health care workers minimizing Black patients’ complaints of pain and Black patients experiencing racism in emergency departments.
But the racial concordance studies illuminate the subtle ways that race affects how patients and doctors communicate and make decisions, regardless of either person’s intent. Physicians and patients bring subconscious racial perceptions to their conversations.
“We all have biases,” Takeshita says. “Most people go into it [a medical visit] trying not to be biased, but there are biases on both sides.”
Another factor is the inclination for people to connect quickly with others who appear to be similar to them.
“When you share ascriptive characteristics with somebody — be it race, be it gender — that can facilitate trust between the patient and the physician, which usually increases communication between them,” says Brad Greenwood, professor of information systems and operations management at George Mason University (GMU) in Virginia, who has studied the impact of racial concordance on infant mortality.
Those shared characteristics can include not only appearances, but also life experiences such as growing up rich or poor, coming from a certain region of the country, or having similar family backgrounds.
“It is also important to understand the lived experience of an individual,” Sutton says. If the doctor and patient come from different worlds — perhaps because of their social, economic, or cultural differences — “then there isn’t that automatic connection sometimes because you don’t have that shared experience.”
When that inherent connection is there, it can instantly facilitate more trust, comfort, and frank communication between doctor and patient. For example, the Oakland study that offered screenings to Black men for certain health conditions found that the men “were more likely to bring up other health problems when assigned to a Black doctor, and Black doctors were more likely to write notes about their patients.”
The conclusion, they wrote, is that “better communication between Black subjects and Black doctors explains our results.”
“Each person comes in with their own experiences that are going to affect that [doctor–patient] relationship before it has started,” Takeshita says.
Health impacts
The health impact of these improved interactions remains unclear. Few studies have tracked clinical outcomes like decreases in blood sugar levels.
“As for that actual direct linkage” to the measurable health of Black patients seen by Black doctors, “it’s not there” in most of the evidence, Sutton says.
One study that does present such evidence is the GMU study of infant mortality, which looked at the deaths of newborns among 1.8 million hospital births in Florida from 1992 through 2015. For newborns born to Black mothers, the study found that death rates were far higher when the physician delivering and caring for the newborn was White.
“When Black newborns are cared for by Black physicians, the mortality penalty they suffer, as compared with White infants, is halved,” the study found. But being treated by a Black doctor does not completely erase the difference, as “Black infants experience inferior health outcomes regardless of who is treating them.”
Greenwood says these factors could include that Black babies and their mothers suffer more from certain health conditions than White babies and their mothers. He notes, for example, that preterm delivery is higher among Black mothers than White mothers in the United States.
Stressing that “you have to be careful about pathologizing” Black babies, Greenwood said that “it could be that Black newborns are more medically challenging to treat, and Black physicians are more attuned to the potential health issues” because they have lived in Black families and communities.
Another study showed a strong correlation in health outcomes in communities with more Black doctors. A study of county-level health data led by the Health Resources and Services Administration concluded that on average, every 10% increase in the representation of Black primary care physicians was associated with 30.6 days of greater life expectancy among Black people in that county. (The study did not look at which doctors cared for which patients.)
One possible reason for this correlation is that residents of those counties had a greater choice of doctors of diverse backgrounds, including more Black doctors, says one of the researchers, Michael Dill, director of workforce studies at the AAMC.
The study “adds to the growing body of evidence” about the value of diversifying the physician workforce, Dill says. Diversification “improves provider choice for everyone. If it improves health outcomes for Black people, that is in everybody’s best interest.”
Implications
That points to one takeaway from these studies: Increasing the number of Black physicians would give all patients more choice and give many Black patients a better chance of working with doctors with whom they can easily identify and connect. Only 5.7% of physicians in the United States are Black, according to the AAMC. Medical colleges and associations have been trying to increase that number for decades, and have made slow progress.
While diversification is an important long-term goal, researchers say it would be a mistake to interpret their findings about racial concordance to mean that Black patients should see only Black doctors.
“The provision of health care to minority patients should not fall solely to minority physicians,” according to Takeshita’s study on patient satisfaction. “It is imperative that we also improve cultural mindfulness among all physicians so that they are prepared to care for a diverse patient population in an equitable manner.”
That requires specific education in medical school and continuing medical education for practicing professionals to communicate effectively with patients of races and cultures different from their own, Takeshita says, and to be aware of the impact of race on health. “We need to make sure that every physician feels comfortable approaching whoever comes in front of them,” she says.
Sutton stresses that increasing physician diversity and helping all physicians work with people of different cultures are not mutually exclusive.
“I want to push for physician diversity, but I also want to push for everyone to be a good doctor,” Sutton says. “It’s everyone’s job to be able to provide care in an equitable manner, in an anti-racist manner.”
