Bright, Cedric M. MD
Dr. Bright is president, National Medical Association, Silver Spring, Maryland, and assistant dean of special programs, Department of Medical Education, and admissions and associate professor of internal medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.
Editor’s Note: This is a commentary on Peek ME, Wilson SC, Bussey-Jones J, et al. A study of national physician organizations’ efforts to reduce racial and ethnic health disparities in the United States. Acad Med. 2012;87:694–700.
Correspondence should be addressed to Dr. Bright, University of North Carolina at Chapel Hill School of Medicine, Department of Internal Medicine, 506 Berryhill Hall, Chapel Hill, NC 27599; e-mail: firstname.lastname@example.org.
A study by Peek and colleagues in this issue reveals that although racial and ethnic health disparities are recognized as a major national challenge, few physician organizations with both the influence and ability to change practice standards and address disparities appear to be effectively directing their resources to mitigate health disparities. In this commentary, the author examines the history of U.S. health disparities through the lens of social justice. He argues that today, physician organizations have the opportunity to change the paradigm of medicine from being a reactive industry to becoming a proactive industry through collaborations such as the Commission to End Health Disparities, which brings together more than 60 organizations, and the National Medical Association’s “We Stand With You” program to improve health and combat disparities. Physician organizations can also address health disparities through advocacy for fair reimbursement policies, funding for pipeline programs to increase the diversity of the workforce, diversity in clinical trials, and other issues. Health disparities present to us in organized medicine a challenge that is cleverly disguised as an immovable object but that is truly a great opportunity for innovation, improvement, and growth. Physician organizations have a unique opportunity to provide avenues of innovation and accomplishment.
In the study reported by Peek and colleagues,1 the authors state that although racial and ethnic health disparities are recognized as a major national challenge, few physician organizations with both the influence and ability to change practice standards and address disparities appear to be effectively directing their resources to mitigate health disparities. Peek and colleagues concluded that despite the national priority to eliminate health disparities, more than half of national physician organizations are doing little to address this problem. Primary care and minority organizations and those with committees dedicated to addressing disparities may provide leadership to extend the scope of the disparity reduction efforts.
Physician organizations vary in their missions and visions depending on the composite of their intended membership and goals; thus, it is not surprising that this study reports that more attention was given to health disparities by primary care and minority organizations. However, with the potential to address health disparities through primary care medical homes, advocacy, and a diverse workforce of physicians, there is a need to encourage medical organizations to contribute through organized and focused efforts to address and eliminate health disparities. There are some good examples of where collaboration is already making progress toward reducing health disparities. One particular collaboration of note is the Commission to End Health Disparities.2 This collaborative effort that began with the National Medical Association (NMA) and the American Medical Association (AMA) now has over 60 member organizations working to develop action plans to address issues leading to disparate health. Another example is partnerships between physician organizations and community-based organizations (CBOs) to form consortia such as the NMA’s “We Stand with You” program to improve health and combat disparities.3 Partnering with CBOs allows for the grassroots exchange of ideas and education through formal programs and mentoring. Although these programs are promising, both will need more time to determine their outcomes in terms of reducing health disparities.
These examples, however, are not typical for most physician organizations. This raises an important question: What role should physician organizations play in addressing social justice issues? Health disparities are a social justice issue that has been a recurrent theme in American medical history. After Reconstruction, the need for adequate medical treatment for the freed slaves led to institutions such as Meharry Medical College and Howard University Medical College. As Byrd and Clayton4 report in their seminal book, An American Health Dilemma: Race, Medicine, and Health Care in the United States, 1900–2000, the burden of the African American health status in the 20th century was directly related to the number of African American physicians available to treat African American patients. It is interesting to note that there were more African American physicians per capita in the 1920s than there are today, despite the integration of our American medical colleges.4
Disparities in a Historical Context
Under a social justice construct, one must examine how historical and institutional biases have led to increasing health disparities and a dearth of minority physicians. The Flexner Report5 of 1910 essentially standardized the four-year curriculum of modern-day medical schools, but in his report Flexner denigrated African American medical schools of the day such that the number of these schools was reduced from 12 to 2, Howard and Meharry.4 Flexner asserts that if a student cannot pay for medical education, then he or she ought not to be able to become a physician,5 which introduced further barriers for minority students, who often came from low-socioeconomic-status backgrounds. Another example of institutional bias that impacted African American physicians was that the AMA in 1870 passed a formal resolution for the exclusion of African American physicians and women physicians. The NMA was founded in 1895 so that physicians of color could have a professional home, because they could not become AMA members. Because of these exclusions and Jim Crow laws that plagued American society into the 1960s, African American physicians had extreme difficulty integrating hospitals, which affected their ability to care for their patients. In June 2008, the AMA issued an official apology in JAMA for their part in the past disenfranchisement of African American physicians.
In 1968 in his inaugural speech, NMA President Dr. James Whittico6 explained the presence of differences in health outcomes for African Americans compared with whites. Since his speech, the NMA has advocated for a health system that would cover the elderly and most vulnerable. The NMA supported the Medicare and Medicaid system, signed into law in 1965, even though it was opposed by the AMA and other organized medical groups.
In 1985, then Secretary of Health and Human Services Margaret Heckler further validated the disparate health conditions in the United States with her report on the health status of minorities, known as the Heckler Report.7 In 1999, Schulman et al8 reported biases among physicians in the care for African Americans as related to cardiovascular interventions. In 2003, the Institute of Medicine released the report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,9 which further categorized the depth and breadth of health disparities in our country. More recently, in 2009 LaVeist et al10 showed that our zip codes were the greatest determinant of health status and health outcomes—more so even than our educational status, financial status, and access status. Later, in 2011, the Joint Center for Political and Economic Studies, under the direction of Dr. Brian Smedley, released figures to show that health disparities cost our health system $1.24 trillion over a three-year time frame.11
Seizing an Opportunity for Innovation, Improvement, and Growth
I believe that physician organizations have a golden opportunity to flex our muscles to address social injustice. We have the opportunity to change the paradigm of medicine from being a reactive industry to becoming a proactive industry. There are collaborative opportunities to increase advocacy for more effective standards to direct our health system as cuts threaten the survival of small and solo physician practices. We must also remember small and solo practices when we are generating accountable care organizations and patient-centered medical homes—we cannot afford to let these practices that often serve our underserved become extinct. We can advocate for changes to the sustained growth rate formula used to place value and determine reimbursement rates. We can appeal for the continued funding of pipeline programs that increase the diversity of the workforce. We can advocate for diversity in all clinical trials to enable us to practice evidence-based medicine for all our populations. We can carry forward the same inclusiveness as it relates to comparative effectiveness research and the awarding of grant funding from private and public sectors, understanding that diversity of investment promotes diversity in innovation. We can come together to educate the public and future generations about a new perception of health: “We want you to stay healthy longer rather than to get well soon.”
Health disparities present to us in organized medicine a challenge that is cleverly disguised as an immovable object but that is truly a great opportunity for innovation, improvement, and growth. Physician organizations have a unique opportunity to provide avenues of innovation and accomplishment.
The Liaison Committee on Medical Education’s requirement12 that medical schools “have policies and practices to achieve appropriate diversity … and … engage in ongoing, systematic, and focused efforts to attract and retain students, faculty, staff, and others from demographically diverse backgrounds” is one example of organized medicine’s current efforts to make a difference regarding racial and ethnic disparities. In another example, a blueprint and a metric for improving patients’ health are offered through the decades of Healthy People (HP) initiatives.13 HP 2000 aimed to reduce health disparities, whereas HP 2010’s goal was to abolish them; HP 2020 seeks to improve health and eliminate health disparities. This evolution in achievable goals reflects an increasing knowledge that health is not the simple absence of overt disease, for there are people who are not ill but are also not healthy. Improving human health (HP 2020’s goal) is influenced by the social determinants of health. Organized medicine cannot address all of the social determinants but may be able to improve health by, for example, demonstrating cultural competence.
HP 2020 lists multiple social determinants of health that need to be addressed (e.g., access to health care services, public safety, social norms and attitudes),14 but one that can be addressed most appropriately by organized medicine is cultural competence. Cultural competence is more easily achieved by a diverse health care provider workforce—one that aligns with the patients’ differences in race, ethnicity, gender orientation, wealth, and other demographic characteristics. Therefore, if medical societies are to take some ownership of improving population health as per HP 2020, they can address social determinants of health through advocacy for workforce diversity and cultural competence.
Organized medicine has the opportunity to help eliminate health disparities through collaboration, education, advocacy, and research. In the words of Satcher and Higginbotham15: “To eliminate disparities in health we need leaders who care enough, know enough, will do enough, and are persistent enough.”
Other disclosures: Before beginning his term as president of the National Medical Association, Dr. Bright was a coauthor on the study by Peek and colleagues on which this commentary is based (see Peek ME, Wilson SC, Bussey-Jones J, et al. A study of national physician organizations’ efforts to reduce racial/ethnic health disparities in the United States. Acad Med. 2012;87: 694–700).
Ethical approval: Not applicable.
1. Peek ME, Wilson SC, Bussey-Jones J, et al. A study of national physician organizations’ efforts to reduce racial and ethnic health disparities in the United States. Acad Med. 2012;87:694–700
4. Byrd MW, Clayton LA. An American Health Dilemma: Race, Medicine, and Health Care in the United States, 1900–2000. 2002 New York, NY Routledge Press
5. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4.. 1910 Boston, Mass Updyke
6. Whittico JM. Close “the medical gap.” President’s inaugural address, National Medical Association. J Natl Med Assoc. 1968;60:427–431
7. U.S. Department of Health and Human Services. . Report of the Secretary’s Task Force on Black and Minority Health: Volume I: Executive Summary. 1985 Washington, DC U.S. Department of Health and Human Services
8. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–626
9. Smedley BD, Stith AY, Nelson AR Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.. 2003 Washington, DC National Academies Press
10. LaVeist TA, Gaskin D, Trujillo AJ. Segregated Spaces, Risky Places: The Effects of Racial Segregation on Health Inequalities. September 2011 Washington, DC Joint Center for Political and Economic Studies
11. LaViest TA, Gaskin DJ, Richard P. The Economic Burden of Health Inequalities in the United States. 2009 Washington, DC Joint Center for Political and Economic Studies
12. Liaison Committee on Medical Education. . Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. http://www.lcme.org/functions.pdf
Accessed March 1, 2012
15. Satcher D, Higginbotham EJ. The public health approach to eliminating disparities in health. Am J Public Health. 2008;98:400–403