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October 2006
Executive Summary
Several racial and ethnic minority groups
and people from socioeconomically disadvantaged
backgrounds are significantly underrepresented
among health professionals in the United
States. Underrepresented minority (URM)
groups have traditionally included African-Americans,
Mexican Americans, Native Americans, and
mainland Puerto Ricans. Numerous public
and private programs aim to remedy this
underrepresentation by promoting the preparedness
and resources available to minority and
socioeconomically disadvantaged health
professions candidates, and the admissions
and retention of these candidates in the
health professions pipeline and workforce.
In recent years, however, competing demands
for resources, along with shifting public
opinion about policies aimed to assist
members of specific racial and ethnic
groups, have threatened the base of support
for “diversity programs.”
Continued support for these programs will
increasingly rely on evidence that they
provide a measurable public benefit.
The most compelling argument for a more
diverse health professions workforce is
that it will lead to improvements in public
health. We therefore examined the evidence
addressing the contention that health
professions diversity will lead to improved
population health outcomes. Specifically,
we searched for, reviewed, and synthesized
publicly available studies addressing
four separate hypotheses:
- The service patterns hypothesis:
that health professionals from racial
and ethnic minority and socioeconomically
disadvantaged backgrounds are more likely
than others to serve racial and ethnic
minority and socioeconomically disadvantaged
populations, thereby improving access
to care for vulnerable populations and
in turn, improving health outcomes;
- The concordance hypothesis: that
increasing the number of racial and
ethnic minority health professionals—by
providing greater opportunity for minority
patients to see a practitioner from
their own racial or ethnic group or,
for patients with limited English proficiency,
to see a practitioner who speaks their
primary language—will improve
the quality of communication, comfort
level, trust, partnership, and decision
making in patient-practitioner relationships,
thereby increasing use of appropriate
health care and adherence to effective
programs, ultimately resulting in improved
health outcomes;
- The trust in health care hypothesis:
that greater diversity in the health
care workforce will increase trust in
the health care delivery system among
minority and socioeconomically disadvantaged
populations, and will thereby increase
their propensity to use health services
that lead to improved health outcomes;
and
- The professional advocacy hypothesis:
that health professionals from racial
and ethnic minority and socioeconomically
disadvantaged backgrounds will be more
likely than others to provide leadership
and advocacy for policies and programs
aimed at improving health care for vulnerable
populations, thereby increasing health
care access and quality, and ultimately
health outcomes for those populations.
We reviewed a total of 55 studies:17
for service patterns, 36 for concordance,
and 2 for trust in health care. We were
not able to identify any empirical studies
addressing the hypothesis that greater
health professions diversity results in
greater advocacy or implementation of
programs and policies targeting health
care for minority and other disadvantaged
populations. Our review generated the
following findings:
- URM health professionals, particularly
physicians, disproportionately serve
minority and other medically underserved
populations;
- minority patients tend to receive
better interpersonal care from practitioners
of their own race or ethnicity, particularly
in primary care and mental health settings;
- non-English speaking patients experience
better interpersonal care, greater medical
comprehension, and greater likelihood
of keeping follow-up appointments when
they see a language-concordant practitioner,
particularly in mental health care;
and
- insufficient evidence exists as to
whether greater health professions diversity
leads to greater trust in health care
or greater advocacy for disadvantaged
populations.
These findings indicate that greater
health professions diversity will likely
lead to improved public health by increasing
access to care for underserved populations,
and by increasing opportunities for minority
patients to see practitioners with whom
they share a common race, ethnicity or
language. Race, ethnicity, and language
concordance, which is associated with
better patient-practitioner relationships
and communication, may increase patients’
likelihood of receiving and accepting
appropriate medical care.
Several areas warrant further research.
Most studies of health professional service
patterns are limited to physicians. Studies
are needed to determine whether the service
patterns of non-physician professionals
who serve as many patients’ usual
source of health care (e.g., nurse practitioners,
physician assistants) vary according to
race, ethnicity, or socioeconomic background.
Studies of racial and ethnic concordance
are primarily limited to physicians and
mental health practitioners. Future studies
should examine the impact of concordance
between patients and other health professionals,
particularly nurses, who interact closely
with patients. Studies have not adequately
examined the relative contributions of
language concordance vs. combined language
and ethnic concordance, an issue that
has significant implications for which
policy solutions will most enhance quality
of care for patients with limited English
proficiency. Researchers should thus compare
the quality of care in encounters and
relationships in at least three categories:
concordant language/ethnicity, concordant
language/discordant ethnicity, and discordant
language/ethnicity.
Studies of the effect of institutional
diversity on patients’ trust in
health care and propensity to use health
care services are lacking. Research in
this area could start by measuring trust,
perceived access, satisfaction, and likelihood
of using services among patients receiving
care at institutions with differing levels
of staff diversity. Finally, research
is needed to test the proposed hypothesis
that a greater presence of health professionals
from minority and socioeconomically disadvantaged
backgrounds will lead to greater advocacy,
and ultimately better access and quality
of care, for disadvantaged populations.
In summary, we found that current evidence
supports the notion that greater workforce
diversity may lead to improved public
health, primarily through greater access
to care for underserved populations and
better interactions between patients and
health professionals. We also identified
several gaps in the evidence and proposed
an agenda for future research that would
help to fill those gaps. Conducting this
research will be essential to solidifying
the evidence base underlying programs
and policies to increase diversity among
health professionals in the United States.
Acknowledgements
This publication was prepared under Contract
No. 03-0285P for the U.S. Department of
Health and Human Services, Health Resources
and Services Administration by Somnath
Saha, MD, MPH and of the Portland VA Medical
Center and Oregon Health & Science
University, and Scott A. Shipman, MD,
MPH, of Dartmouth Medical School.
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