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?

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?

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Bioethics for Breakfast: Values at the End of Life: The Logic of Palliative Care

Bioethics for Breakfast Seminars in Medicine, Law and SocietyRoi Livne, PhD, presented at the Bioethics for Breakfast event on October 4, 2018, offering perspective and insight on the topic “Values at the End of Life: The Logic of Palliative Care.” Leonard Fleck, PhD, moderated this session.

Over the past forty years, “the end of life” has become the center of extensive economic, policy, ethical, and medical discussions. Health economists measure and evaluate its cost; ethicists debate the morality of various approaches to “end-of-life care”; policymakers ponder alternative “end of life”-related policies; and clinicians apply a specialized approach (hospice and palliative care) to treat patients whom they diagnose as being at “the end of life.” How are those many-faceted conversations emblematic of this particular moment in history? How are the limits of what can be done, both medically and financially, to prolong life communicated to severely ill patients and families? Dr. Livne’s analysis drew from a combination of historical and ethnographic work conducted with palliative care clinicians in three California hospitals.

Roi Livne
Roi Livne is an Assistant Professor in the Department of Sociology at the University of Michigan. He received his PhD in sociology from the University of California, Berkeley in 2016. An economic sociologist at heart, he studies everyday economic life and its somewhat awkward intersections with morality. His book, Values at the End of Life: The Logic of Palliative Care is forthcoming this February in Harvard University Press. The book develops a historical and ethnographic account of the deeply personal relationships between financial considerations, emotional attachments, and moral arguments that motivate end-of-life decisions in American hospitals. Livne’s other research is on the techno-politics of sovereign debt management. He has published in the American Sociological Review and Socio-Economic Review.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.

Dr. Cabrera published in ‘Frontiers in Sociology’

Laura Cabrera photoCenter Assistant Professor Dr. Laura Cabrera has a new article in the open-access journal Frontiers in Sociology, titled “Reframing human enhancement: a population health perspective.”

The article is part of the research topic ELSI in Human Enhancement—ELSI stands for “ethical, legal and social implications.” Dr. Cabrera is a topic editor for ELSI in Human Enhancement, along with Dov Greenbaum of Yale University.

The dominant understandings on human enhancement, such as those based on the therapy-enhancement distinction or transhumanist views, have been focused on high technological interventions directly changing biological and physical features of individuals. The individual-based orientation and reductionist approach that dominant views of human enhancement take have undermined the exploration of more inclusive ways to think about human enhancement. In this perspective, I argue that we need to expand our understanding of human enhancement and open a more serious discussion on the type of enhancement interventions that can foster practical improvements for populations. In doing so, lessons from a population health perspective can be incorporated. Under such a perspective, human enhancement focus shifts from changing the biological reality of individuals, to addressing environmental factors that undermine the optimal performance of individuals or that can foster wellness. Such a human enhancement perspective would be consistent with a population health approach, as it pursues more equitable and accessible interventions, on the path to addressing social inequality. Human enhancement does not need to be only about high-technological interventions for a selected group of individuals; rather it should be a continuous project aiming to include everyone and maximize the public benefit.

The full article text is available on the Frontiers in Sociology website.

Dr. Cabrera published in ‘Sociological Methods & Research’

cabrera-crop-2015Center Assistant Professor Dr. Laura Cabrera was recently published in the journal Sociological Methods & Research. The article, “A Novel Sequential Mixed-method Technique for Contrastive Analysis of Unscripted Qualitative Data: Contrastive Quantitized Content Analysis,” was co-authored by Dr. Cabrera and Peter B. Reiner of the National Core for Neuroethics at University of British Columbia. The article was published online ahead of print on August 4, 2016.

Abstract: Between-subject design surveys are a powerful means of gauging public opinion, but critics rightly charge that closed-ended questions only provide slices of insight into issues that are considerably more complex. Qualitative research enables richer accounts but inevitably includes coder bias and subjective interpretations. To mitigate these issues, we have developed a sequential mixed-methods approach in which content analysis is quantitized and then compared in a contrastive fashion to provide data that capitalize upon the features of qualitative research while reducing the impact of coder bias in analysis of the data. This article describes the method and demonstrates the advantages of the technique by providing an example of insights into public attitudes that have not been revealed using other methods.

The full text is available on the Sociological Methods & Research website (note: institutional access, such as access through Michigan State University Libraries, may be required to view the full text).

Dr. Cabrera is a faculty affiliate in the National Core for Neuroethics at University of British Columbia.

Join us for a lecture on medical sociology from 2013 Reeder Award winner Dr. Charles Bosk

bbag-iconMedical Sociology as Vocation

Event flyer: Bosk Flyer

This presentation discusses what it means to speak of ‘medical sociology as a vocation.’ The presentation uses Weber’s classic essay ‘Science as a Vocation’ as its departure point. It describes how medical sociology can play a role in understanding the institution of medicine at multiple levels–from the formulation of national policy to the behavior of front-line workers. It discusses how to best balance objectivity and advocacy.

Nov-13-for-blogJoin us for Dr. Bosk’s lecture on Wednesday, November 13, 2013 from noon till 1 pm in person or online:

In person: The lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Charles Bosk, Ph.D. holds a secondary chair in the University of Pennsylvania Perelman School of Medicine, with appointments in the History and Sociology of Science department, the Annenberg School for Communication and the Leonard Davis Institute of Health Economics.  He is the author of numerous books including Forgive and Remember (University of Chicago Press, 2nd edition 2003), All God’s Mistakes: Genetic Counseling in a Pediatric Hospital (University Of Chicago Press, 1992), and most recently, What Would You Do? Juggling Bioethics and Ethnography (University of Chicago Press, 2008). He has become an authoritative voice in academic and policy debates about professionalism and patient safety. The American Sociological Association recognized his many achievements with the 2013 Leo G. Reeder Award.

Bioethics Brownbag & Webinar Series Special Event: Professor Masahiro Morioka lecture

The Center for Ethics has partnered with the Department of Philosophy and the Asian Studies Center to welcome Masahiro Morioka, Professor of Philosophy and Ethics at Osaka Prefecture University in Japan, for a special lecture in the Bioethics Brownbag & Webinar Series.

Professor Morioka is considered to be one of the most influential thinkers in Japanese philosophy and sociology. He is the director of the Research Institute for Contemporary Philosophy of Life at Osaka Prefecture University, and is the editor-in-chief of the Journal of Philosophy of Life. He specializes in philisophy of life, life studies, bioethics, gender studies, and criticism of contemporary civilization.

Brain Death, the Concept of  ‘Persona,’ and the Principle of Wholeness

Japan is a country where unique discussions on brain death take place not only among specialists but also lay persons. Using narratives, Professor Morioka will present his theories on some philosophical aspects of brain death, that is to say, the concept of ‘persona’ and the principle of ‘wholeness.’

Join us for Professor Morioka’s lecture on Friday, September 28, 2012 from noon till 1 pm in person or online:

In person: The lecture will take place in the International Center on MSU’s East Lansing campus, in Room 303. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Event flyer: BB_Webinar ad morioka event 12_13