Discussion
We conducted a review of publicly available
studies addressing four separate hypotheses
linking increased racial, ethnic, and
socioeconomic diversity among health professionals
to improved public health. We found a
large and consistent body of evidence
suggesting that minority health professionals,
particularly physicians, disproportionately
serve minority and other medically underserved
populations. Data generally supported
the notion that minority patients receive
better interpersonal care from practitioners
of their own race or ethnicity, particularly
in primary care and mental health settings.
Patient-practitioner language concordance
similarly was associated with better interpersonal
care, greater medical comprehension, and
greater likelihood of keeping follow-up
appointments, particularly in mental health
care. For two of our hypotheses—that
greater health professions diversity leads
to greater trust in health care and greater
advocacy for disadvantaged populations—empirical
evidence was scant or lacking.
Collectively, the studies in our review
suggest several mechanisms by which increasing
numbers of minority and socioeconomically
disadvantaged health professionals in
the United States. might lead to improved
health outcomes. First, minority physicians,
and to a lesser degree those from socioeconomically
disadvantaged backgrounds, serve as a
usual source of care for many of the nation’s
underserved populations, including those
who are uninsured or underinsured. Studies
have established that having access to
a usual source of care improves health
outcomes. (15-17) To the extent that future
minority health professionals follow this
pattern of disproportionately caring for
the underserved, increasing minority representation
among health professionals should increase
access to health care for underserved
groups and thereby improve population
health.
Second, increasing health professions
diversity would afford minority patients,
particularly those from groups underrepresented
in the health professions, greater opportunity
to see practitioners of their own racial
or ethnic background. Increased diversity
would thereby improve the quality of interpersonal
care that minority patients receive, and
potentially increase their likelihood
of receiving and accepting appropriate
medical care, which would in turn lead
to improved health. One study in our review
supported this contention by demonstrating
that African-American patients received
life-prolonging medications for HIV/AIDS
in a more timely manner from African-American
as opposed to White physicians.
Finally, increasing the presence of underrepresented
Latino and Asian health professionals
in particular might afford more limited
English-proficient patients the opportunity
to see practitioners that speak their
native language. The observation of higher-quality
care in language concordant relationships—most
likely a result of effective communication
and possibly of cultural congruence—suggests
that greater linguistic diversity among
health professionals will lead to improved
health outcomes and greater patient safety.(75-77)
This is particularly relevant in the current
context of limited funding for and use
of medical interpreter services.(78)
Some caveats to these arguments for health
professions diversity warrant mention.
First, considering minority practitioner
service patterns as the primary rationale
for diversity programs may lead to the
problematic expectation that minority
health professionals should all serve
underserved patient populations. It is
important to remember that our review
supports the notion that increasing workforce
diversity will lead to greater access
to care through the choices of minority
practitioners (to serve underserved populations)
and minority patients (to seek care from
minority practitioners). We would consider
it unethical to require practitioners
to serve specific populations based on
their race, ethnicity, or socioeconomic
background.
Second, we caution against the conclusion
that, because race concordance is associated
with higher quality care, patients should
always be paired with practitioners of
their own race. Although studies in our
review suggested that interpersonal care
was on balance better in race concordant
patient-practitioner relationships, and
that patients tended to prefer practitioners
of their own race, these findings did
not apply to all patients and practitioners.
In most studies, the majority of patients
had no preference regarding practitioner
race and were very satisfied with the
care they received from race discordant
providers. The association between race
concordance and interpersonal quality
indicates that greater diversity might
improve overall quality of care by affording
those who do have a preference, and who
do experience better care in race concordant
relationship, greater opportunity to have
such relationships.
Finally, it is important to note that
we were not able to determine the separate
effects of language concordance alone
vs. language plus ethnic concordance.
One path to greater patient-practitioner
language concordance for limited English-proficient
patients is to increase racial and ethnic
diversity in the health professions. Another
path is to train non-minority health professionals
to speak non-English languages. This latter
strategy could enhance language concordance
but would lack the potential benefit of
combined language and ethnic concordance.
We were not able to determine whether
this combined concordance was more beneficial
than language concordance alone. Thus,
while our review suggested a potential
benefit from increasing language concordance
in patient-practitioner encounters, it
did not establish whether achieving this
benefit is best accomplished by training
more minority health professionals or
by training existing and future health
professionals to speak non-English languages.
Study Limitations
There were several limitations to our
review. Our search strategies may not
have captured all relevant studies. We
took several measures to ensure a comprehensive
search, including reviewing reference
lists and Web sites and consulting with
experts. It is possible, though, that
important studies were missed. We only
searched for publicly available studies.
Some studies relevant to our review may
have been conducted by private institutions
that did not disseminate their findings
to the general public. It is also possible
that our review was affected by publication
bias, as some authors may have selectively
chosen not to publish results either supporting
or refuting the hypotheses we addressed.
Recommendations for Future Research
Our review revealed several gaps in the
evidence base related to health professions
diversity that we believe are important
areas for future research. Notably, nearly
all the studies we found related to service
patterns examined physician practices.
More studies are needed to determine whether
the service patterns of other 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.
Likewise, studies of patient-practitioner
racial and ethnic concordance were limited
primarily to physicians and mental health
practitioners. It would be useful to know
about the impact of concordance between
patients and other health professionals,
particularly nurses, who interact closely
with patients—in hospitals, long-term
care facilities, doctors’ offices,
and even in patients’ homes—and
whose interpersonal interactions are therefore
likely to substantially influence patients’
experiences.
Future studies of racial and ethnic concordance
should look beyond the quality of interpersonal
care (e.g., patient satisfaction) and
begin to study the impact of concordance
on more objective measures of quality,
including process measures (e.g., receipt
of influenza vaccination among elderly
and chronically ill patients) and health
outcomes (e.g., glycohemoglobin level
among patients with diabetes). In designing
and conducting such studies, researchers
should choose measures that are likely
to be strongly influenced by interpersonal
interactions between health care providers
and patients, i.e., those for which a
link with patient-practitioner concordance
makes sense. Researchers should also be
mindful in conducting these studies that,
relative to measures of interpersonal
quality, process and outcome measures
are influenced by numerous factors other
than the patient-practitioner interaction.
Studies examining process and outcome
measures must therefore take these potentially
confounding factors into account and be
adequately powered to detect the influence
of concordance amidst the influence of
many other variables. Using data from
large clinical and administrative databases
is one way to harvest the kind of power
that may be needed for such studies, but
it will require that the databases contain,
or at least can be linked to, data on
patient and practitioner race. Organizations
such as Aetna, who are now collecting
these data routinely,(79) may serve as
a resource and a model for other health
care organizations interested in health
professions diversity.
Studies of language concordance to date
have not adequately examined the relative
contributions of language concordance
alone vs. combined language and ethnic
concordance. It is not clear, therefore,
whether the observed effects in these
studies are attributable solely to language
concordance or are in part explained by
the ethnic (and perhaps cultural) concordance
that are often present in language concordant
encounters. The policy implications of
language concordance studies depend, at
least in part, on the relative contributions
of these separate effects. If common language
accounts for all of the benefits of language
concordance, then interventions to enhance
practitioners’ non-English skills
(e.g., Spanish language courses) might
suffice to improve care for patients with
limited English proficiency. If ethnic
concordance were influential, policies
to increase ethnic diversity among health
professionals would likely be needed.
Therefore researchers should 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.
In conducting such studies, researchers
should pay attention to and measure non-English
fluency among practitioners and English
fluency among patients, since language
concordance is best conceived as a continuous
(or ordinal), rather than dichotomous
variable.
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 (or with the option to receive
care at) health care facilities with differing
levels of staff diversity. It is important
that such studies account for other differences
across institutions that might affect
patients’ attitudes and choices.
Because minority professionals are more
likely to practice in underserved communities,
the facilities they work in may be less
well reimbursed than facilities staffed
predominantly by non-minority professionals.
Patients’ attitudes toward certain
health care facilities may appear negative,
despite their diversity, if those institutions
have long waiting times, inadequate resources,
or even an unattractive physical appearance.
It is also important in studies of the
effects of institutional diversity to
measure both structural diversity—the
proportion of a facility’s staff
from different racial/ethnic groups—and
interactional diversity—the degree
to which patients interact with staff
from different racial or ethnic groups.
Structural diversity alone may be important,
in that patients may trust an institution
more, simply because it has a diverse
workforce. But it is more likely that
the influence of diversity on patients’
trust and use of services, if such an
influence exists, will be mediated by
their experiences and interactions with
individuals within that institution.
Finally, research is needed to test the
proposed hypothesis that a greater presence
of professionals from minority and socioeconomically
disadvantaged backgrounds in the health
care workforce will lead to greater leadership
and advocacy, and ultimately better access
and quality of care for disadvantaged
populations. This research could begin
with a simple survey assessing the priorities
of health care leaders from different
racial, ethnic, and socioeconomic backgrounds.
Another study might examine the research
portfolios of researchers from different
backgrounds. Do minority researchers spend
relatively more effort on issues important
to minority and other disadvantaged patient
populations? This could be done, for instance,
by examining the portfolios of NIH-funded
researchers. The National Academy of Sciences
(NAS) conducts periodic evaluations of
NIH programs aimed at recruiting minority
scientists and fostering their careers.(80)
The NAS could incorporate into these evaluations
an investigation of the research focus
and populations studied among beneficiaries
of these programs, as compared to other
researchers.
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