Addressing racial disparities in health outcomes is an urgent priority for many health care organizations, leading health care managers to explore the potential for organization-level interventions to yield substantive health gains. In recent literature, it is suggested that Black patients who are treated by Black physicians may achieve superior health outcomes in some settings. In this case discussion, we consider a case in which a medical director considers implementing a voluntary program to promote racially concordant care for Black patients. Commentators consider the precedent for such a program, both in current informal care networks and 20th century medical history, as well as the burden such a program may place on Black physicians and the risks of reducing patients’ intersectional identities to be solely about race. A subset of commentators suggest that these risks are mitigated by the voluntary nature of the program, whereas others offer caution about relying solely on Black physicians to remedy health disparities. Others view multiple paths as morally defensible but emphasize the need for managers to take proactive steps to communicate and evaluate their choices in the face of such a complex social challenge.
Reducing racial disparities in health outcomes is an urgent priority for many health care organizations, leading to a continual search for novel organization-level interventions that can yield substantive health gains for Black patients, in particular.
One emerging line of research reveals that Black patients treated by Black physicians achieve better health outcomes in several domains, compared with that of Black patients seen by non-Black physicians. Recent studies reveal a 50% reduction in Black–white infant mortality gaps1 and a 19% decline in male cardiovascular mortality with racially concordant care.2
What implications does this line of research have for developing an organizational approach to reducing racial disparities? Do these studies merely underscore the need to improve the diversity of the physician workforce, or are more proactive and, perhaps, uncomfortable steps warranted to improve the health outcomes of racial minorities? How might such efforts be understood in the context of the historical effort to desegregate American medicine?
In this month’s Ethics Rounds, we consider an organizational ethics issue: should a health care system implement a system to facilitate racially concordant care? Commentators include a bioethicist, a sociologist, a historian, and a pair of health management scholars. They consider the potential benefits and detriments as well as potential unintended consequences for such a system.
Dr Pollock is the Chief Medical Officer of Just Healthcare, a health care delivery organization that holds financial risk for roughly 20 000 patients. She is committed to using organizational policy to pursue health equity.
Dr Pollock has reviewed the literature on racial concordance and is considering rolling out a new program to facilitate a match between the organization’s Black physicians and Black patients. Dr Pollock believes the racial concordance literature is strongest with respect to Black-patient outcomes, and the moral urgency to improve Black–white disparities justifies an initial focus on this patient population. Dr Pollock recognizes that Black patients have commonly sought out racially concordant care through informal referral networks and hopes that a program like this would lessen the required legwork for those who opt in.
The key characteristics of this program are as follows:
The program would rely on racial self identification, meaning that both physicians and patients or parents would be asked to indicate their own racial identification according to US Census categories.
The program would be opt in for both physicians and patients or parents.
The program would begin in an outpatient setting.
Several members of Dr Pollock’s senior team have expressed enthusiasm for this idea. They see it as merely formalizing the widespread practice of seeking out concordant care. Others have raised substantive concerns, including the optics of ushering in a return to segregated medicine. Dr Pollock consults the ethics team for further counsel.
Keisha Ray, a Bioethicist, Comments
This case represents a policy solution to the ongoing problem of Black people receiving inferior, racially biased health care. This problem is created by systemic racism embedded in health care (in particular, providers’ racial biases), rather than a problem inherent in the Black population. This is evidenced by the fact that, when we correct for factors such as income, Black individuals still have lesser health outcomes than white people do. For example, infant mortality is 3 times higher for the infants of Black women with advanced degrees than for those of white women with a high school diploma or GED.3 This indicates that even when Black people have access to vital social determinants of health, other external factors also determine their health outcomes, and, because we have no reason to believe that physicians are any less racially biased than the general public, we must examine the role providers’ racial biases play in Black patients’ poor health outcomes. Because the problem is at the institutional level, rather than problems inherent to being Black, the solutions must also be at the institutional level, and this is almost always manifested as policy implementation.
Black people already engage in racially concordant care or “race-matching” to ensure proper care for themselves and their children in response to formal and informal knowledge about racism in health care. Racially concordant care is also informally practiced in some clinical settings in which patients and physicians of the same presumed race are matched. A program that formally facilitates this approach to care, however, would help drive solutions to racial disparities in health in a more organized and efficient manner within its organizations. Although some of the concerns about this racially concordant care policy are worthy of our considerations, we can properly address them while upholding the merits of the policy.
First, the concern that this policy puts an undue burden on Black physicians is a warranted concern. Black physicians participating in the program would likely still be expected to care for their normal patients, including Black patients who would like a Black physician. Yet, there are simply not enough Black physicians to satisfy every Black patient who would like to be cared by one without overworking Black physicians and without forcing them to only see Black patients. The concerns are especially valid given that Black physicians themselves must overcome racism from coworkers and patients, challenges to their credentials and qualifications, and other burdens that their white coworkers do not have to think about. We must protect Black physicians while also doing our best to provide quality care to Black patients. One way to do this is to enforce the policy’s opt-in feature. If racially concordant care is done on a volunteer basis, then physicians have the freedom to opt in when they can and opt out when they feel overwhelmed. Black patients too have the freedom to participate at their will. For the opt-in feature to work, however, organizations must create an environment in which Black physicians feel safe and free from judgement and punishment should they opt out. This feature of the policy may create longer wait times for patients to see a Black physicians; however, given the research that supports better health outcomes for Black patients if they are cared for by Black physicians, longer wait times may be a small price to pay for the care, comfort, and assurance Black physicians can provide Black patients because their medical condition is presumably not an emergency, and, because this policy will be implemented in an outpatient setting and not in an emergency setting, we can allow Black patients the autonomy to determine when waiting for a Black physician is appropriate and when seeing any available physician is best. Implementing this policy while also educating and training non-Black physicians to better care for Black patients removes the force of this concern.
Secondly, the concern that racially concordant care is a reification of race-based medicine is unwarranted. Racially concordant care is not what we know race-based medicine to be. Race-based medicine typically refers to using a patient’s race as a guide for how to treat them. For example, race-based medicine can normally be seen in the diagnostic or care recommendation phase of care, such as when a physician uses an adolescent patient’s Black race to determine appropriate asthma interventions. What makes race-based medicine problematic is that it gives physicians an excuse to circumvent proper and thorough care; it allows them to rely on shallow and unscientific explanations of race, such as skin color indicating race and the conscious and unconscious biases they associate with Black people. Instead, this policy uses people’s self-identified race to better treat Black patients. It removes physicians whose racial biases may lead to inferior care from treating Black patients and encourages Black physicians, who may be less inclined to mistreat Black patients, to treat Black patients. So, the concern that this policy is race-based medicine is correct in that it relies on race, but it is not in the same category as traditional race-based medicine as we know it.
I recommend that Dr Pollock’s policy be implemented alongside other long-term solutions to racial disparities in health care. This approach can provide Black patients with a better experience of health care and better health outcomes and begins to repair the damaged relationship between Black individuals and health care by proving health care to be worthy of Black people’s trust.
Helen-Maria Lekas, a Sociologist, Comments
This case highlights the persistent health inequities that manifest on the individual, interpersonal, institutional, and societal levels. Although not unequivocally, the literature suggests that racial concordance between patients and physicians is associated with positive health and health care use outcomes, especially for Black patients. Hence, implementing an opt-in clinic program matching Black physicians with Black patients appears uncontroversial and an effective organizational strategy to reduce health inequities. However, this strategy also entails risks worth considering. I use the 3 constructs, habitus, intersectionality, and institutional agency, to discuss the program’s risks.
Habitus is used to refer to the dispositions or tendencies individuals develop through socialization and experience. These tendencies are expressed in our perceptions and evaluations of the world around us and underlie our behavior.4 Our dispositions to act in particular ways are fostered at the intersection of social structure and individual choices. Race, gender, social class, age, and sexual orientation largely determine our place in the social structure and the opportunities we are afforded and/or the barriers we confront. Opportunities and/or barriers interface with our choices to shape our habitus. Habitus sponsors our behavior that over time and with repetition becomes the patients’ health lifestyle and the physicians’ workstyle. Therefore, we can conceptualize the patient–physician relationship as the interface between the patient and the physician’s habitus and behavior. Socialized in a racist society that limits opportunities and generates barriers, Black patients and Black physicians share, to an extent, similar habitus and behavior. This shared habitus probably contributes to a patient-centered relationship and Black patients’ positive health outcomes. The Black patients and physicians’ shared habitus will also increase the likelihood that physicians and patients will opt in the proposed program.
This idea of an a priori shared habitus, however, raises some individual and interpersonal risks. Considering Black race the sole social determinant of patients’ and physicians’ habitus and behavior is an oversimplification of Black lives that disregards the role of gender, social class, age, and sexual orientation that also contribute to habitus and behavior. Black patients who inhabit other identities (such as being female gender, being poor, and/or being a lesbian, gay, bisexual, transgender and/or queer person) and have experienced sexism, classism and/or heteronormativity in the health care system might be alienated by the proposed program. The choice of a racially concordant physician might be insufficient, if not disrespectful because it erases their other key identities. With intersectionality, we recognize that a person’s habitus and behavior are shaped by their place at the intersection of multiple, interlocking social hierarchies that rank individuals according to the gender, social class, age, sexual orientation, and race.5 A Black lesbian woman, for instance, is at risk for being exposed to sexism, heteronormativity, and racism in the health care system. We must adopt an intersectional approach to understand whether she experiences the proposed program as a meaningful expansion of her choice and autonomy. Black physicians’ intersecting identities also shape their habitus and behavior toward their patients. The program’s sole focus on physicians’ Black race assumes a shared habitus and disregards potential differences between Black physicians and patients (ie, social class) that can threaten the therapeutic relationship. Because these relationships unfold in the clinic, we should consider how clinic practices impact patient–provider relationships using the construct of institutional agency.
By “institutional agency,” we refer to the discretionary power of institutions to differentially impact social groups through not only overt policies, regulations but, also, unwritten routine practices.6 Whereas Black patients have experienced the racist agency of the health care system, Black physicians have experienced the implicit racism that underlies the institutional agency of medical schools and the health care system and manifests in unwritten institutional practices and criteria of professional evaluation and advancement. The proposed program is a manifestation of the clinic’s institutional agency that can generate moral and professional dilemmas for Black physicians who are acutely aware of the deleterious effects of racism for themselves and their patients. This awareness will generate a moral and professional pressure to opt in the program, despite any reservations that it reifies race as a health and health care category, resegregates medicine, and silos Black physicians. Aware of implicit racism, Black physicians will also be concerned that opting out will be deemed a professional deficit by the institution and their colleagues, despite the program’s appearance as voluntary. Therefore, most Black physicians will opt in the program and endeavor to provide patient-centered care to a heavy and vulnerable patient load, given the scarcity of Black colleagues and the well-justified distrust of health care among Black patients that has been linked to not accessing health care or adhering to treatment, all outcomes of historical racism.7
Assigning the task of rectifying our racist, sexist, classist, and heteronormative health care system solely to Black physicians is unfair. The clinic’s prioritization of racial matching is based on the subtext that race is the sole determinant of health and health care. This message obscures the fact that race is a social construction, promotes the reification of race, and reproduces the existing racial hierarchy. Lastly, given the aforementioned pressures to opt in the matching program, Black physicians’ own voices on how to improve the quality of care for their Black patients are silenced. My recommendation to Dr Pollock would be to elicit the Black physicians and patients’ voices on how best to provide patient-centered care, instead of imposing another institutionally driven program.
Adam Biggs, an Historian, Comments
Debates over the benefits and pitfalls of concordant care have a meaningful place in Black American history and the history of medicine. Throughout the 20th century, Black communities looked to Black doctors as hopeful signs of racial achievement and expanding civic inclusion. Although symbolically meaningful, however, the specters of Jim Crow discrimination and racial inequity often accompany visions of concordant care and raise doubts about the ability of Black physicians to overcome the structural barriers that generate disparities.
In my research on Harlem Hospital in the early 1920s, the demand for concordant care appears as one of the mobilizing forces behind efforts to promote desegregation. As Harlem’s growing Black population gained political influence, Black civic activists called attention to the lack of Black doctors on the hospital’s staff and justified their call for desegregation by pointing to several incidents of Black patients suffering from mistreatment at the hands of white physicians. Stories of expectant mothers and young children exposed to unsanitary conditions, neglectful staff, or improper care fueled desires to incorporate Black doctors into the hospital.
Harlem Hospital’s administration yielded slowly but agreed to gradually integrate Black practitioners onto its staff. A handful of Black doctors received appointments to the outpatient department before several were promoted to provisional positions on the in-house staff in 1923. Steadily, Black practitioners gained access to internships, residencies, and more permanent positions.
The slow pace of desegregation, however, caused political pressure to build and, in 1929, led Mayor James Walker to orchestrate a massive overhaul of the municipal hospital administration. His reforms resulted in several new hires and, by 1930, Black doctors composed 40% of the hospital’s medical staff, including heads of department and membership on the administrative board.8
Concordant care, however, was not a miracle cure for Black Harlem’s health concerns. Even with Black practitioners staffed throughout the facility, larger systemic issues had a determinant impact on patient care. Competing social justice goals split Harlem’s Black medical community into opposing factions. Some maintained the hospital should develop into an integrated research center dedicated to advancing medical science pertinent to Black Americans. Others argued it should focus on the training of Black medical personnel.9
As tempers flared, bitter rivalries formed, creating a toxic environment. Local and national organizations, like the Abyssinian Baptist Church, National Association for the Advancement of Colored People, and National Medical Association, joined the fray, escalating tensions. Combined with structural inadequacies like overcrowding and limited resources, morale at the hospital suffered and practitioners struggled to provide patients with adequate care. Unfavorable press reports detailed a slew of misdiagnoses, patient disregard, and one of the highest death rates among New York City hospitals.10
In 1935, tensions in Harlem came to a head, when a riot broke out. Although not the principal cause, investigators determined poor conditions and discord at the hospital were aggravating factors. Mayor Fiorello La Guardia took steps to quell the unrest, but many Black Harlemites had already lost confidence in Harlem Hospital and were questioning the benefits of concordant care. Aubré Maynard, one of the first Black doctors to serve as a resident, recalled how public distrust continued to torment the facility. “Most Negroes in the community,” he explained, “were outspoken about racial pride” but still tended to be “critical or…deprecatory of [the hospital’s] services and its professional personnel.” In more than one instance, he recalled Black patients questioning his professional expertise. “You’re just another nigger,” one told him, “just like me. Ain’t no way you can know as much as the white man. I want me a white doctor.”11 Even in the years after La Guardia’s reforms, concerns about the treatment of expectant mothers and reports of high infant mortalities continued to plague the hospital.
Concordant care may have noteworthy benefits for Black patients, but, in implementing her policy, Dr Pollock should be cognizant of how larger structural forces may impact its success. Attitudes about concordant care are rarely stagnant and reforms do not occur in a clinical vacuum. Communicating her program’s goals and rationale (through a media campaign, for example) could prove an effective tool in building and maintaining public trust and the support of her colleagues. If she is sensitive to demographic shifts, changing political climates, tensions within the medical profession, socioeconomic inequities, competing social justice goals, and evolving public opinion, she will be better positioned to respond to emergent developments and mitigate their impact on her work, when they appear. Recognizing that societal factors are constituent, rather than peripheral, elements of medical practice, Pollock’s vigilance will allow her to better address the needs of Black patients and reduce the likelihood of inadvertently reifying the racial disparities she seeks to eradicate.
Osaze Udeagbala and Lauren Taylor, Health Management Scholars, Comment
We find this case compelling because it focuses attention on a question about which we, as authors, remain uncertain. Namely, what, if any, information can justifiably be assumed about a person on the basis of their race? The studies of racial concordance that Dr Pollock references appear to indicate that Black patients and physicians take important information from the race of their counterparts in a therapeutic relationship. It is not immediately clear what information is being exchanged, but authors have hypothesized that it relates to the physician’s trustworthiness, relatability, and predisposition to openly listen to patient concerns, among other factors. Implicit in these findings is a belief on the part of patients that physicians who “look like me” will provide better, more compassionate care. The studies in question reveal an empirical reality about the value of racial concordance in doctor–patient relationships, but Dr Pollock faces a normative question of whether she should actively facilitate such concordance.
Dr Pollock’s dilemma stems, in part, from an inherent tension in evidence-based management: things that can be statistically known about study samples can only render probabilistic judgements about real-world individuals. In other words, even if Dr Pollock can feel confident on the basis of the literature that her Black-patient population will, on average, achieve better outcomes when paired with Black physicians, she must remain humble about what she can know about any specific patient, physician, or pair. Dr Pollock cannot know for sure that a particular Black physician will deliver relatively superior care for a Black patient. Is it defensible to proceed in light of the risk that an individual patient will not benefit from being matched with a racially concordant provider? Conceivably, a patient could even be harmed by receiving care from a racially concordant provider if either party carries internalized racist beliefs. Analogous uses of probabilistic reasoning in medicine have met with a range of receptions. On one hand, medical professionals routinely use medications that they know will create adverse effects in some small number of patients because they are, on the whole, helpful. On the other, physicians who rely on information about a patient’s race to make probabilistic judgements about a diagnosis have been roundly criticized, as Dr Ray points out in her commentary.
If the matching program were to benefit all participating patients or even participating patients on average, Dr Pollock may still reasonably harbor ethical concerns. Establishing a matching program risks reifying an assumption that matched Black people will share certain innate understandings of one another, be it of socioeconomic status, language, preferences for clinical care, and so on. Perhaps it would be the case that a Black patient and Black physician who are matched according to Dr Pollock’s proposal attend the same local church or spend time in the same social circles (and perhaps these elements of shared experience can be used to facilitate a therapeutic relationship) but for management to send the signal that these types of shared experiences can be reliably anticipated ex ante is misguided.
It is more likely that the only generalization that can hold true about Black people in a clinical setting is that they share an experience of navigating institutional environments that privilege whiteness. But even if Dr Pollock were to determine that matching is justified based solely on this aspect of shared experience, the appearance of such program would be indistinguishable from a program premised on the belief that there are other substantive inferences to be made from a person’s race. Thus, even a matching program that is based on careful thinking can appear to erase the internal diversity of Black people and set back the project of defanging the racialized imaginary.
Facilitating racial concordance may be a managerially expedient means of addressing certain racial disparities, but Just Healthcare would be poorly served by a program that appeared to suggest that likeness between patients and physicians is necessary for understanding and good care. First-hand experience of a patient’s circumstance is but one way for a physician to achieve understanding. Physicians can be trained to listen and be responsive to those who are radically different from them. Developing these skills should be part of Just Healthcare’s longer-term efforts to improve the health outcomes of Black patients, as should the training and hiring of far larger numbers of physicians of color.
Reasonable people may disagree about the seriousness of the concerns we have raised. Some may view them as substantial, whereas others may suggest that a matching program would only slightly exacerbate problematic assumptions about race that are already pervasive. Similarly, reasonable people may disagree about the size of the potential health benefits that could be achieved when the kind of matching studied in the literature is scaled up within Just Healthcare. The complexity of the issues at hand and the uncertainty of social change means Dr Pollock can likely reach more than one decision with integrity and will, nonetheless, be vulnerable to thoughtful critiques. This being the case, the process by which the decision is communicated and implemented may be even more important than the content of the decision. We suggest that Dr Pollock engage with this complexity directly and transparently. Objections will be inevitable, but she can earn herself and the organization credibility by relaying the rationale by which she reached a decision.
After consultation, the ethics team proposed piloting the program, with a predetermined time line for review and conditions for ending the pilot. The team stressed the importance of including Black physicians in deciding how the program is implemented and considering outcome metrics, including but not limited to Black-patient wait times and Black-physician pay. It also suggested that evaluation be undertaken from the outset to identify the mechanisms by which racially concordant care creates benefit. The team added that close communication with participating physicians and patients would be essential to avoid misperceptions about the intent and assumptions of the program.
Armand H. Matheny Antommaria, Section Editor, Comments
Healthcare organizations are struggling to reduce racial disparities in health outcomes. Researchers suggesting racially concordant care produces better outcomes for Black patients suggest 1 potentially attractive intervention. The commentators helpfully identify several potential risks of facilitating racially concordant care, including imposing undue burdens on Black health care providers and focusing inordinately on 1 aspect of individuals’ identity. The commentators also identify several conditions that should be present, if such programs are implemented, including involving Black patients and physicians in developing and implementing programs, evaluating programs regularly, implementing a larger bundle of interventions to reduce disparities, and attending to the larger structural forces that may affect the programs’ success. In identifying these issues and making these recommendations, the commentators reinforce the importance of organizational ethics and the value of multidisciplinary perspectives.
We acknowledge the Harvard Medical School Center for Bioethics for initially hosting a robust discussion of this case and the underlying questions in its Organizational Ethics Consortium. We extend special thanks to Kelsey Berry, Charlotte Harrison, and Jim Sabin for their leadership.
Drs Taylor and Udeagbala conceptualized the article, solicited the participation of other commentators, drafted their commentaries, and reviewed and revised the full manuscript; Drs Lekas, Biggs, and Ray drafted their commentaries and reviewed and revised the full manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.