The Burden of Serving: Who Benefits?

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Karen Kelly-Blake, PhD

“We overworked, underpaid, and we underprivileged
They love us, they love us (Why?)
Because we feed the village”

– Killer Mike of Run the Jewels
“Lie, Cheat, Steal,” Run the Jewels 2 (2014)

In the United States, persons of color suffer disproportionately from a host of health care disparities related to racism, discrimination, lack of access, and undertreatment. When considering this disproportionate suffering, it is relevant to note the impact of the current physician shortage. That shortage is especially acute for underrepresented in medicine (URiM) physicians. Moreover, it is equally salient to recognize that URiM physicians provide care for underserved populations at levels disproportionate to their professional representation. There is a powerful narrative that a diverse and representative medical workforce, one reflecting general population characteristics, can effectively address access issues, increase satisfaction, and ultimately improve health outcomes. It seems reasonable to surmise that shared concordant characteristics (e.g. race/ethnicity, language, gender, geographic location, etc.) between patients and physicians might lead to improved communication and satisfaction in the clinical setting. Alsan et al. found that black patients paired with black physicians were more likely to agree to preventive screening, leading the authors to conclude that the racial/ethnic concordance between patient and physician was a significant factor for the observed increase in screening adherence. Kelly-Blake et al. found that the most mentioned rationales for increasing patient-physician concordance were patient-physician relationship and service commitment to care for the underserved.

A 2001 IOM (now the National Academy of Medicine) report warned that “we must be vigilant against the potentially pernicious effects of creating the expectation that minority physicians are being trained solely to provide health care services to minority patients or to research minority health issues.” It is now 2019 – nearly 20 years on – and so it seems a good time to revisit that prudent caution. Have we heeded the IOM’s prescient warning? I invite you to join me for a brief thought experiment. Suppose we made the profession of medicine responsible for caring for our most vulnerable—the sickest sick and poorest poor? Imagine that all patient panels included a significant number of homeless, poor, mentally ill, and uninsured. Imagine an equal, fair, and just distribution of medical care service to the underserved. The described distribution would lighten the service expectation on URiM physicians. We know that URiM physicians bear a disproportionate burden of providing care for the most vulnerable patients in the most challenging resource poor environments. It’s not unreasonable to imagine how such a burden might substantially constrain their ability to meet quality care metrics for reimbursement. Moreover, as we move from volume to value for reimbursement, for those URiM physicians who carry comparably higher educational loan debt and work to a greater degree than their white counterparts in resource poor communities with the sickest sick, the challenge of achieving measurable improvements in quality care would seem untenable.

The individual altruistic motivations of URiMs to “give back,” “make a difference,” and “help the community” are powerful. And indeed, those motivations are likely influenced by “community” expectations that people will return “home” to practice. Certainly, URiMs have valuable insider experiential knowledge about navigating the challenging, socially-layered U.S. landscape. Those perspectives would undoubtedly bring an enhanced sociocultural perspective to the clinical encounter. Community expectations align with similar sentiments. Individuals coming from underserved communities who desire to become a physician are often supported, encouraged and, yes, expected to come back to serve in the community. The community understandably holds out hope that someone from the neighborhood will come back and do good work for the community. While understandable, is such a community expectation fair?

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Image description: an individual with angel wings wearing blue surgical scrubs, a face mask covering their mouth, a cap, and glasses is standing with their arms crossed in front of a neutral background. They have a stethoscope around their neck. Image source: Sathish Kumar Periyasamy from Pixabay.

Desire to serve and to give back are laudable and admirable virtues, but is the “narrative of service” subtext disproportionately and perhaps unfairly limiting URiM potential professional opportunities? In our desire to have URiMs serve the underserved as physicians, are we paradoxically denying them opportunities to serve the profession of medicine as Chairs of Departments, Deans of Medical Schools, Chief Executive Officers of Hospitals, or Heads of NIH? Are we saying, “welcome to the house of medicine, but we need you to work in the basement kitchen”? If URiM have become the workhorses of medicine, who then is provided the opportunity to become the stallions and thoroughbreds? White medical student and physician counterparts do not receive the same targeted messaging about service commitment.

Research has shown that higher numbers of primary care physicians lead to better health and decreased mortality. Despite the call and the need for more primary care physicians, medical students are not choosing primary care specialties. Mona Signer, CEO of The Match, suggests that income is a factor because choosing a non-primary care specialty means a higher paycheck. The highest paying specialties remain overwhelmingly white and male. Who then is allowed the unfettered freedom to make the non-primary care specialty choice? Who gets to have access to opportunities untied to community and societal expectations? The burden of serving exhausts URiM talent and expertise. So, who reaps the benefits? If the argument is that: 1) society benefits from more primary care physicians in underserved areas, especially critical in rural areas, 2) medical schools benefit by meeting more stringent LCME accreditation requirements for student diversity, and 3) patients benefit by having physicians in their community that look like and sound like them, then undertaking strategies to ensure a broadly representative medical workforce is indeed a national priority. But, if the argument is that URiM value is to “serve the underserved” then the IOM warning has indeed been ignored. Racial congruity alone is insufficient to address the disparities gap in U.S. health care, and like-to-like patient-physician matching may dangerously and perversely heighten discrimination against URiM physicians.

URiM should not be selectively steered, based solely on assumptions of their background, to pursue a particular medical career pathway. The healthcare workforce should reflect the nation’s population and equally, it is still fair and just to question why we are channeling URiMs to do work not expected of the entire medical workforce. How might we ensure equity of healthcare work practice? Ensuring such equity is a moral obligation and the right thing to do. Professional fairness and responsibility within medicine mandate that the medical workforce equitably and fairly assume shared responsibility for meeting the healthcare needs of the underserved. Continuing an expectation of burdening the already overburdened is not just health care.

Karen Kelly-Blake photoKaren Kelly-Blake, PhD, is an Associate Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine in the Michigan State University College of Human Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 1, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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More Bioethics in the News from Dr. Kelly-Blake: Patient dumping: why are patients disposable?Incarcerated AND Sick: At Risk for Pain, Injury, and DeathWhite Horse, White Faces: The Decriminalization of Heroin AddictionRacism and the Public’s Health: Whose Lives Matter?Concussion in the NFL: A Case for Shared Decision-Making?

References

  1. AAMC Underrepresented in Medicine Definition. Accessed July 2, 2019. https://www.aamc.org/initiatives/urm/
  2. Alsan M, Garrick O, Graziani GC. Does Diversity Matter for Health? Experimental Evidence From Oakland. National Bureau of Economic Research (2018). NBER Working Paper No. 24787. Issued in June 2018, Revised in May 2019. NBER Program(s):Health Economics. https://www.nber.org/papers/w24787
  3. Gore J, Patfield S, Fray L. The burden of expectation in widening participation, Medical Education. 2018;52(9):889-890. https://onlinelibrary.wiley.com/doi/10.1111/medu.13653
  4. IHS Markit Ltd. The 2019 Update: The Complexities of Physician Supply and Demand: Projections from 2017 to 2032. Washington, DC: Association of American Medical Colleges April 2019. https://www.aamc.org/data/workforce/
  5. Kelly‐Blake K, Garrison NA, Fletcher FE, Ajegba B, Smith N, Brafford M, Bogdan‐Lovis E. Rationales for expanding minority physician representation in the workforce: a scoping review. Medical Education 2018;52(9):925–35. https://onlinelibrary.wiley.com/doi/full/10.1111/medu.13618
  6. Kelly-Blake, K. Patient dumping: why are patients disposable? MSU Center for Ethics Bioethics in the News. msubioethics.com/2018/07/26/patient-dumping-why-are-patients-disposable/. Posted July 26, 2018.
  7. Knight V. American Medical Students Less Likely to Choose to Become Primary Care Doctors. Kaiser Health News, July 3, 2019. Accessed July 8, 2019. https://khn.org/news/american-medical-students-less-likely-to-choose-to-become-primary-care-doctors/
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  15. Vedantam S. Researchers may have found a way to improve black men’s life expectancy. NPR, Accessed June 4, 2019. https://www.npr.org/2019/06/13/732270787/researchers-may-have-found-a-way-to-improve-the-life-expectancy-of-black-men
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