It has long been argued that increasing the racial and ethnic diversity of the physician workforce would have significant positive implications for health care delivery.1 The racial and ethnic diversity of the U.S. population is growing at a more rapid pace than that of the physician workforce. Currently, approximately 13.5% of physicians are from underrepresented racial and ethnic minority backgrounds.1 Furthermore, there is a geographic maldistribution of the U.S. physician workforce that has important implications for patients to access for routine and specialty care. Prior research indicates that physicians who are underrepresented in medicine are important for the provision of primary care at medically underserved locations.2
A 2014 Association of American Medical Colleges (AAMC) Analysis in Brief report examined backgrounds of the physician workforce. Underrepresented minority physicians were found to more likely practice in primary care and in underserved areas. For this reason, future research was encouraged to explore the specialty choice of medical students who are underrepresented racial and ethnic minorities.3
How the racial and ethnic composition of obstetrician–gynecologists (ob-gyns) compares with the overall physician workforce is unknown. The objective of this study was to explore differences in racial and ethnic composition between ob-gyns and other specialists belonging to the largest groups of physicians from whom adults predominantly seek their care. A secondary objective was to estimate whether racial and ethnic diversity in the ob-gyn workforce is associated with practicing at underserved locations.
MATERIALS AND METHODS
This cross-sectional study included all physicians who graduated from U.S. medical schools between 1980 and 2013. The checklist of essential items pertaining to presentations of methods and results sections followed the STrengthening the Reporting of OBservational studies in Epidemiology format (http://www.strobe-statement.org/index.php?id=strobe-home). Data about physician gender, race and ethnicity, and their specialty were pulled from three national sources: AAMC Student Records System (as of December 31, 2014), 2014 AAMC Minority Physicians Database, and 2014 American Medical Association Physician Masterfile. Availability of the AAMC race and ethnic minority database provided the most complete, long-term evaluation of diversity of medical students. Data from those sources were merged to the American Medical Association Physician Masterfile to form a cohesive analytic data set. The Masterfile contained data about all currently practicing physicians who resided in the United States and met the educational and credentialing requirements to be recognized as physicians.4
A medical student's self-reported primary racial and ethnic background was classified as being white, black, Asian, Hispanic, or native (Native American, Alaska Natives, and Pacific Islanders) (AAMC Student Records System, AAMC , Washington, DC). Those who did not report their background in any category were recoded as “unknown,” whereas a small number marked “others.” Each student's racial and ethnicity information was retrieved from the AAMC Student Records System and the 2014 AAMC Minority Physicians Database, which are not publically available.
Associations were found between physician racial and ethical backgrounds and physician specialties in the following largest specialties in adult outpatient care: general obstetrics and gynecology (including gynecology only and obstetrics only), family medicine (including general practice), emergency medicine, general internal medicine, and general surgery.5 For purposes of a more equitable comparison, we excluded subspecialists in each of these fields. Physician addresses were georeferenced and linked to underserved locations. Underserved practice locations were identified as being rural (2013 Rural Urban Commuting Areas), areas with 20% or more of the population living in poverty (2013 American Community Survey Five-Year Estimate), or a federally designated 2014 Primary Care Health Professional Shortage Area or 2014 Medically Underserved Areas/Populations.6–9
The University of New Mexico institutional review board considered this project to be exempt, because there was no research conducted on humans and no identifiers were reported on these large national databases. Descriptive statistics from the complete population of physicians were used to assess associations between physician race and ethnicity and practice location. Bivariate measures of associations were performed to study this relation. The χ2 test of association and two-sample t test were used where appropriate. A P value <.05 was deemed to be statistically significant.
The 190,379 physicians in this investigation included 66,008 family physicians, 54,258 general internists, 29,050 emergency medicine physicians, 26,990 ob-gyns, and 14,073 general surgeons. Few physicians (368 [0.2%]) did not record their gender. Although less than half (78,533 [41.3%]) of all physicians were females, this percentage increased between 2010 and 2014. Ob-gyns were the only specialists studied who were predominantly female (58.1% in 2010 to 61.9% in 2014). Figure 1 displays the gender distribution by specialty in 2014. Significant differences in proportions of female physicians were found between obstetrics–gynecology and any other specialty (P<.001).
The racial and ethnic composition of physicians in each specialty is shown in Table 1 according to gender. A significant association was found between physician race and ethnicity and gender for each specialty (P<.001). Whites constituted the largest racial group (74.4%) and were more likely to be males. Asians constituted the next most common racial and ethnic group with the highest proportion being among the general internists. Asian physicians were more likely to be female regardless of specialty.
Black, Hispanic, and native physicians constitute the underrepresented minorities in medicine. Blacks were the most common underrepresented minorities, with more females than males in each of the five specialties. The numbers of either Hispanic or native physicians were lowest among all racial and ethnic groups, regardless of specialty. Males were equally represented as females in the Hispanic and native physicians.
The proportion of physicians in each specialty who were underrepresented minorities increased slightly each year between 2010 and 2014 (Fig. 2). This 5-year trend was statistically significant for all five specialties (P<.001 for obstetrics–gynecology; family medicine; P<.01 for emergency medicine; P<.05 for general surgery). Ob-gyns had consistently the largest proportion of physicians who were underrepresented (18.4%). This primarily involved the highest percentage the specialists who were black (11.1%) and Hispanic (6.7%).
Significant associations were found between obstetrician–gynecology practice location and their racial and ethnic composition. Table 2 contrasts the race and ethnicity of ob-gyns according to the type of underserved practice location. When compared with the white and Asian ob-gyns, those identified as being underrepresented minorities were more likely to practice in areas that either were federally designated as being medically underserved (P<.001) or having a population that was 20% or more in poverty (P<.001). Native Americans, Alaska Natives, and Pacific Islanders were the racial group of ob-gyns with the highest proportion practicing in rural areas (17.7% native compared with 9.3% nonnative; P<.01).
Understanding racial and ethnic diversity among health care providers will gain in importance as the number of adult women in the United States continues to grow and be more diverse.10 Findings from this study are of particular importance in light of a potential physician shortage, the well-known maldistribution of the physician workforce, and the Affordable Care Act mandate that promises to deliver care to 32 million additional Americans. Results in the present study demonstrate that, when compared with other ob-gyns, underrepresented racial and ethnic minorities are more likely to practice in underserved and higher poverty areas.
The AAMC race and ethnic minority databases permitted an in-depth understanding of diversity among physicians in different medical specialties. Ob-gyns were found to have the highest proportion of the studied physicians who are either black or Hispanic. The proportion of ob-gyns who were black females was nearly the same as the U.S adult black population (11.1% compared with 12.3%).11 Understanding the roles of black women in medicine is of particular importance given that their numbers among medical school applicants, matriculants, and graduates are on the rise.12
A probable explanation for this more diverse composition would be that ob-gyns have a larger proportion of females than in other specialties. As demonstrated in the current investigation, female ob-gyns are more likely than their male counterparts to be black or Asian. These two observations are supported by a study of faculty diversity, which demonstrated ob-gyns at academic health centers to consist of a higher proportion of females who were also more likely than male faculty to be black (Rayburn WF, Liu CQ, Elwell EC, Rogers RG. Diversity of physician faculty in obstetrics and gynecology. J Reprod Med 2015 [in press]). We anticipate that this diversity in race and ethnic composition will expand as more than 80% of the current obstetrics–gynecology residents are females.13 The higher diversity among ob-gyns could also be the result of the availability of more female mentors who could potentially serve as role models and provide guidance to incoming medical students.
Underserved women are at an increased risk of health problems related to limited access to timely quality health care in addition to elevated levels of poverty and geographic and social isolation.14 Ideally, patients should have access to a culturally competent health care provider workforce. Such a relation between the physician and patient is important when addressing gender-specific health disparities within racial and ethnic minority populations.15–17 Results from our investigation confirm that a higher proportion of underrepresented minority ob-gyns are more inclined to work in underserved areas.
Limitations of this investigation require acknowledgement. The study was limited to the largest groups of physicians to whom adult women predominantly seek their care. There were several other large groups of specialists not represented in this report, particularly psychiatrists and general pediatricians. We also did not include subspecialists in each medical group to permit a fairer comparison among the five specialties. Subspecialists represent a high proportion of internal medicine residency graduates and an increasing number of obstetrics–gynecology residency graduates.18 Physicians in this study were U.S medical school graduates and did not include those graduating from international medical schools. Doctors who were international medical graduates constitute a fair proportion of residents in family medicine (34.4%), internal medicine (41.4%), and obstetrics and gynecology (13.6%).13 Lastly, certain persons self-reported their racial and ethnic background as being either “other” or “unknown.” These two categories represented a very small percent (1.6–3.7%) of physicians in the study cohort, which, we believe, would not affect final conclusions from our findings.
In conclusion, results from this study provide useful information about diversity when comparing physicians in different large specialties serving adults. The findings presented in this study could be of significant importance to medical school recruitment and admissions efforts aimed at enhancing diversity. In addition, the greater racial and ethnic diversity in the obstetrics–gynecology workforce, especially with underrepresented minorities, may improve physician workforce distribution. Access to care in underserved practice locations, improvements in patient satisfaction, and less health disparity of underserved women may result from greater physician workforce diversity.18 Future studies should be conducted on the role of diversity of ob-gyns and access to, and quality of, patient care in underserved communities. In addition, studies that explore why women, and in particular black women, are attracted to the field of obstetrics–gynecology should be conducted. Understanding factors that were instrumental in their recruitment in obstetrics–gynecology could shed further insight on this topic and be potentially helpful for increasing diversity in other medical specialties. Lastly, similar studies about other medical specialties should be undertaken to better understand the role diversity plays in the physician workforce.
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