When black patients see non-black doctors

By Austin Frakt

African American men live about 4.6 fewer years than non-Hispanic white men. There are many causes contributing to the difference, including a learned mistrust of the health system by African Americans. Another set of potential factors arises when non-black physicians treat black men. According to a study published earlier this year, that care just isn’t as good as when they see black doctors.

The study, by Marcella Alsan, Owen Garrick, and Grant Graziani, was a randomized controlled trial testing receipt of preventive care by 1,300 African American men in the Bay Area. The men were randomly assigned to see black or non-black primary care physicians in Oakland, California.

Before they saw a doctor — though after they knew which doctor they would see and viewed a photo of that doctor — the men were asked which of several cardiovascular preventive care services they would like to receive: BMI measurement, blood pressure check, diabetes screening, and cholesterol screening. They were also asked if they would like to receive a flu shot.

Then the subjects saw their assigned doctor and the researchers tracked which services they actually received. The results:

• The number of preventive services selected before seeing the doctor was the same for those seeing a black vs non-black doctor.
• But, the number of preventive services actually received was 18% lower for those seeing non-black doctors.

So, black patients who see black doctors get more preventive care. Why? And does this matter?

Taste-based discrimination (Becker 1957) on the part of the patient or doctor could imply that individuals are averse to interacting with those who do not share their racial background. On the other hand, internalized racism, or negative beliefs about one’s racial group, could lead to the opposite phenomenon. Third, a common racial background might facilitate communication — a critical component of clinical care as both patient and physician have potentially life-saving information to exchange. Fourth, and not mutually exclusive, concordance may foster trust leading to cooperation (i.e. compliance with doctors’ advice or willingness to engage).

The study found evidence to support the hypothesis of better or more complete information exchange between black doctors and black patients than between non-black doctors and black patients. A separate survey by the study authors found that a majority of black respondents felt that a black doctor would better understand their concerns.

Another explanation is that the black doctors in the study were of higher quality. However, doctors’ age, experience, and medical school rank were balanced across the study arms. And both sets of doctors received high ratings from the patients they saw.

The 18% difference in receipt of preventive care due to patient-provider racial matching is clinically meaningful. If the additional, positively screened patients receive guideline-recommended care, the authors calculate that it would reduce the the black-white cardiovascular mortality rate by 19% or 8% of the total black-white male life expectancy gap.

So, it’s meaningfully better for black men to see black doctors. However, that may not be possible until there is a change in the composition of the clinical workforce. Though blacks make up about  13% of the U.S. population, only 4% of current physicians and less than 7% of recent medical school graduates are black.