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The Rationale for Diversity in the Health Professions: A Review of the Evidence


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:

  1. 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;
  2. 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;
  3. 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
  4. 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.


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.