Exactly Why Is It That We Need More Black Hospitalists and HMG Leaders?

Following my last post on increasing racial diversity in hospital medicine’s leadership ranks, I had an interesting back-and-forth with my friend, colleague, and co-blogger, Brad Flansbaum. While he offered me kudos for my post, he posed a piercing and insightful challenge to me: “Tell me more about why you think proportionality is important.”

Wow. Gotta admit I hadn’t completely thought through the issue and implications of proportional representation in medicine, per se. It’s a tricky question and full of land mines, especially since it was posed by a Jewish doctor.

Just to provide a little perspective, it hasn’t been that long since Jews were openly discriminated against in medicine in general and in medical school admissions specifically. See this 1939 paper in the publication Jewish Social Studies. Or this 2009 New York Times article, which talks about the quotas that were often in place in the early-to-mid-20^th century to limit the number of Jews admitted to each medical school class to their approximate population in that state, and to limit opportunities for career and academic advancement for Jewish doctors. It’s actually a great story about Dr. Tracy Putnam, head of Columbia University’s Neurological Institute in the 1940s, who hired and protected a number of European refugee Jewish doctors. After being instructed by higher-ups in 1947 to fire all the “non-Aryan” neurologists, he refused and was eventually forced to resign for standing up to protect them.

The U.S. Census Bureau does not recognize “Jewish” as a racial group, nor does it collect mandatory data on religious affiliation. But according to the Pew Research Center, people claiming the Jewish faith accounted for about 2% of the U.S. population in 2019. The most recent data I could find on the proportion of U.S. doctors that are Jewish was from a 2005 Journal of General Internal Medicine paper assessing the religious characteristics of U.S. physicians; it reported that 14.1% of physician survey respondents said they were Jewish. So, if one accepts that Jews are significantly over-represented in medicine relative to their presence in the larger population, I can understand the basis for Brad’s question.

When we talk about increasing the representation of any particular group of people, that increased representation will necessarily come at the expense of the level of representation of other groups. In an ideal world, the increased representation of any minority group would result in a decrease in the majority’s over-representation. But what if it ends up disadvantaging other minorities instead? I don’t have a good answer for that one.

There’s another intriguing alternative, though, suggested by my friend Brad. What if, instead of (or in addition to) changing the size of the pie slices, we were to make the whole pie bigger? Could we figure out a way to graduate several thousand more doctors each year, all or most of whom are people of color?

The idea seems intriguing, especially since the AAMC (admittedly they have a dog in the race) just confirmed a serious and growing future U.S. physician shortage in both primary care and specialties – estimated to be in the range of 54,100 to 139,000 physicians by 2033. The projected physician shortages get even larger if under-served populations begin to utilize healthcare at levels similar to those with fewer barriers to access.

But I can see some big problems with it, too. For one thing, the nature of how health care is being delivered in this country is changing rapidly, and it’s hard to say how the growing presence of NPs and PAs, and rapid technology advancement, will affect the demand for physician services in the future. In addition, such a significant move to expand physician supply would probably need to be linked to both lower medical education costs and a proportional income drop for all doctors across all specialties to make it cost-neutral to the healthcare system. (Could shifting income from away from other doctors to fund incomes for more physicians of color perhaps even represent some rudimentary form of reparations?) I know any serious policymaker would get pilloried for suggesting such a thing in today’s environment, but every BHAG, every revolutionary change, always starts with the small seed of an idea put forward somewhere.

Back to Brad’s original question, though. I don’t think I see strict proportionality as an important principle in and of itself. I also realize it would be an unrealistic goal in any event. But I do think it’s important to support the increased presence of people of color in medicine, HM specifically, and HM leadership because:

• No one should be denied or discouraged from pursuing a career in medicine because of the color of their skin or because of longstanding systemic disproportionate access to the resources that could help them get there, such as social/cultural support, education, economic opportunity, financial assistance, etc. (or because they don’t even consider it a field open to them). To the extent that the reason Black and brown people are underrepresented in medicine is that they lack equal opportunity or resources, that’s a problem we need to work hard to address. If on the other hand, for example, people of color were to be under-represented because there were equally good alternatives they preferred to pursue and we as a society were comfortable with a medicine workforce that didn’t match its patient population in terms of diversity, that would be another thing altogether.
• A lot can be accomplished through cultural awareness and sensitivity training (e.g., SHM’s 5 Rs of Cultural Humility). But I’m not sure any cultural sensitivity training can match the value of working every day alongside colleagues who are people of color and learning first-hand from their perspectives, approaches, and experiences.
• I am also convinced there’s a meaningful benefit to our patients in having a diverse medicine workforce. I was particularly struck by Ryan Brown’s description of the misunderstanding and mistrust so many Black people have of our healthcare system, and how clearly that impacted his determination to become a doctor. The Wall Street Journal recently interviewed Dr. Valerie Montgomery Rice, president of Morehouse School of Medicine, about her efforts to recruit more Black people – and especially more Black men – into medicine. (Dr. Montgomery Rice points out that Black women entering medicine outnumber Black men, two to one.) She pointed out that “When people are like their providers that influences whether or not a patient is going to feel comfortable, where they’re going to feel like they’re seen or heard….Black male physicians caring for Black males, the data is clear, there’s a higher level of compliance with preventive diagnostic testing and recommendations for treatment or therapies. We believe that this matters significantly.” So do I, and it seems like a good reason to seek greater representation by people of color in medicine, in and of itself.
• Finally, as I said in my earlier post, HM leaders are becoming more and more influential in their organizations and across the US healthcare system. Many of them will eventually be CMOs, CEOs, CIOs, and influential policymakers and administrators in various levels of government. It’s crucial that we support more people of color moving into these roles because these roles provide a genuine seat at the table where real policy and functional decisions get made. We need the unique perspective of people of color in policy-making and operational leadership. And we need their unwavering commitment to change, in order to support our own commitment when it starts to falter or gets pulled in other directions by other priorities.

So the bottom line is that while I’m not saying I think strict proportionality is important or necessary, one relatively simple way to measure whether people of color are gaining opportunities and seats at the table is to measure their relative representation against the larger population. I’m sure that over time we will develop more sophisticated measures.