Race and the Patient-Physician Relationship in 2021
Although nearly 50 years have passed since the article entitled “Does Race Interfere With the Doctor-Patient Relationship?” was published in JAMA in 1973, the question is as relevant today as it was then.1,2 In some ways, many aspects of health care and society have changed, yet in other important ways they have not. There has been progress in stretching the umbrella of health care coverage, access, and quality for more people in the United States than at any other time in US history, and yet, medicine still struggles with how to advance health equity, quash racist beliefs and biases in the profession, and reform racist systems and structures that have created, perpetuated, and exacerbated the health inequities that continue and are experienced by many in US society. If ever there were a time to reexamine the patient-physician relationship thoughtfully and critically, it is today, as the national and global medical community strives to emerge on the other side of a global pandemic.
Why Medical Justice, Health Equity, and a Stronger Patient-Physician Relationship Matter
During this historic and dark moment in US history, while navigating the quadruple pandemic of COVID-19, racial and social tension, mental health crisis, and economic pain, it has become readily apparent that the more things change, the more they stay the same. It is also becoming abundantly clear that the nation is regressing in some instances. For example, in recent years, significant declines in life expectancy occurred across population groups with decreases that have not been seen since World War II. Between 2018 and 2020, overall life expectancy decreased by 2 years in the United States.3 When disaggregated by race, Black individuals lost an estimated 3.3 years and Hispanic/Latinx individuals lost an estimated 3.9 years in life expectancy.3 In the first 6 months of 2020, the Centers for Disease Control and Prevention reported that Black individuals lost an estimated 2.7 years in life expectancy, Hispanic/Latinx individuals lost an estimated 2 years, and White individuals lost an estimated less than 1 year.4 Just before the COVID-19 pandemic struck, the United States was experiencing increases in premature deaths and was projected to decline 21 places in global life expectancy ranking compared with similar countries by 2040.
A national crisis tends to magnify inequities in society, especially when that crisis is an unprecedented global pandemic. However, what is even more concerning is that as the country becomes more racially and ethnically diverse in the coming years, health inequities are projected to worsen unless concerted efforts are taken to proactively and immediately address them.6 While continuing to grapple with the lasting effects of the pandemic, it is of vital importance to use this time to acknowledge, understand, and seriously address the health inequities that have historically plagued the United States for more than 400 years, the determinants and drivers of these health inequities, and the factors impairing strong patient-physician relationships. While working overtime to stem the tide of the COVID-19 pandemic is necessary, equally hard work is also needed to create a more equitable, inclusive, and healthier society.
The 1973 article was intended to highlight the dearth of research and publications on the effects of race on the patient-physician relationship (despite the numerous articles that had been published about this relationship and its many challenges and ramifications) and was written with hope that medicine would correct this imbalance. To be fair, it has to a certain degree. Yet, the undeniable truth is that the medical profession still struggles with this issue today as much as 50 years ago. This is unfortunate because of the current era of increasing concern for community medicine and for improving the delivery of medical care to all people. In discussing the effects of race on the patient-physician relationship, the aim must not be merely to accuse or to place blame but to analyze critically the problem with the goal of improving medical care delivery. The general silence on this issue tends to deny that racism is a major barrier to effective medical care for many people in the United States, when in fact medicine has been caught up in the race problem.
In US society, the forces of racism help to determine the course of lives and the nature of relationships. However, racism knows no geographic or academic boundaries. For instance, racism has been a potent force in the development of the medical profession. It was primarily the discriminatory practices of local chapters of the American Medical Association that led to the birth of the predominantly Black National Medical Association in 1895; this was 13 years before the founding of the National Association for the Advancement of Colored People.7
As late as 1968, a careful evaluation showed that while the Black population was approaching 13% of the US population, only about 2% of physicians were Black, and of these, 50% had been trained at 2 predominantly Black medical schools, Howard University in Washington, DC, and Meharry Medical College in Nashville, Tennessee.8 Today, there is regression in the pipeline of Black medical students despite adding 2 additional predominantly Black medical schools, Charles R. Drew University of Medicine and Science and Morehouse School of Medicine. For instance, although Black male medical students accounted for approximately 3.1% of the national medical student body in 1978, in 2019 they accounted for just 2.9%.9 Studies have also shown underrepresentation of American Indian and Alaska Native, Hispanic, and Native Hawaiian and other Pacific Islander medical students.9,10 It certainly seems that despite superior academic training, the medical profession has been as severely marginalized by racism as other groups in this country, which has led to an unfair dilemma for patients of racial and ethnic minority groups: either accept poor, culturally inadequate medical care or receive no medical care at all. In looking to the next 50 years in medicine, the challenge is clear, and it continues. So, what is the strategy for solving it?
Strategy for Improving the Patient-Physician Relationship and Eliminating Racial Interference
The community must develop trustworthy and competent personnel to help plan for better health care, and the medical profession must undo years of exploitation and discrimination that have led to this point. Therefore, physicians must expand their views and reach as they engage in the practice of medicine in a strikingly different society and in a rapidly changing health system. Physicians’ views as patient advocates must transform to not only address the pathology of disease but also the social and political determinants that created and perpetuated disparate health outcomes for generations in this country. While the political determinants of health may be uncharted territory for some, the US has a long history of leveraging them to exacerbate disparities, which means a model already exists for leveraging them to ameliorate disparities.
The social, environmental, and other determinants of health were designed, implemented, and perpetuated by political, legislative, regulatory, ordinance-related, or legal decisions. These determinants of health all owe their existence and pervasiveness to the political determinants of health. As such, it is incumbent on everyone to more effectively highlight the nexus between the political determinants and their downstream effects. The good news is that structural barriers and the resulting inequities are not permanent.
Deeper understanding of how the foundation of current systems fuels health inequities, how the social and political determinants of health inequities continue to operate and to ravage marginalized and underserved communities, and how these factors contribute to racism will be essential to determine where to go from here. Advancing health equity is a collective venture, one that is powered through unified collaborations and partnerships. With lingering and persistent challenges in strengthening the patient-physician relationship, it is increasingly important for all physicians to remain inspired and compelled to stand at the forefront of this movement to advance health equity for all. The true challenge and opportunity are to become part of the struggle to make a positive difference.
Corresponding Author: Daniel E. Dawes, JD, Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA 30310 (email@example.com).
Conflict of Interest Disclosures: None reported.
Additional Information: Dr Satcher served as the 16th Surgeon General of the United States, from 1998 to 2002.