Racial fatigue: Minority doctors feeling the pressure

The parents of a pediatric resident's patient asked that she be taken off their child's case. It was not because of her capabilities. They didn't like the color of her skin. The resident, now a practicing physician, still tears up when she revisits the incident.

Marcella Nunez-Smith, MD, MHS, recounts this story and others she heard from black physicians while researching their workplace experiences in 2005. A black physician herself -- and a general internal medicine instructor at Yale University School of Medicine in New Haven, Conn. -- Dr. Nunez-Smith began her investigation after the topic arose repeatedly over coffee with friends.

In her initial research, published in the Jan. 2 Annals of Internal Medicine, she found that the racism black physicians face is often more subtle than being called the "n" word. As she expands this study, Dr. Nunez-Smith is finding that black physicians nationwide experience a general stress related to being black and being a doctor, such as an elusive promotion or a lack of referrals from other physicians.

Call it racism, negative experiences, or, like Dr. Nunez-Smith, call it "racial fatigue." Regardless of the terminology, it undermines careers and erodes job satisfaction, diversity experts said.

"You make it in your career based on how you fit in. When people get disenchanted trying to make that career, they go do something else. It's a tremendous loss," said Daniel J. Wooten, MD, a black physician who has been teaching and researching health care disparities as executive associate dean of academic and faculty affairs at James H. Quillen College of Medicine, East Tennessee State University at Johnson City.

Frustrated by a lack of traction in academic medicine, some black physicians pursue careers in areas such as the pharmaceutical industry, said anecdotal reports. Others discover that their specialty isn't welcoming and switch fields. The common theme is the way they were treated because of their race, not higher pay, Dr. Nunez-Smith said.

"This is something physicians of color are talking about in private, and it is clearly influencing career paths of people I know," she said.

At the same time black physicians are growing disillusioned, research on racial disparities in health care underscores the importance of a diverse physician work force. Blacks make up 3.7% of the physician work force, according to the American Medical Association. They represent 12.9% of the overall population, U.S. Census Bureau data show. Ideally, 12.9% of all physicians would be black, too, work force experts said. The idea is that with more minority physicians in practice, racial disparities will decline.

The medical profession is working on the issue. In November 2006, the AMA announced that it would seek to broaden representation of racial and ethnic minorities, women, the poor, people with disabilities, and gays, lesbians and transgender individuals in the physician work force. That same month, the Assn. for American Medical Colleges rolled out a marketing campaign to increase minority medical school applicants.

But the racial climate within the medical profession gets little attention, diversity experts say.

"We don't look at each other and ask, 'Is everything OK here? Is this an environment that can sustain a diverse work force?' If it can't, then we'll never have a chance to see if an increase in diversity will help outcomes," Dr. Nunez-Smith said.

Dr. Nunez-Smith hopes her work will clarify what contributes to black doctors' sense of isolation as a first step toward seeking a solution. From what she's seen, the answer may be simple: Make race an open conversation in the workplace. Not having a safe place to discuss race was the chief source of stress among the 25 black physicians she interviewed for her study. This sense of unease also emerged in her initial findings from a survey of 2,000 black physicians she is conducting.

Silence can be as loud as words

Creating a safe space to talk about race is not as simple as it sounds. "You bring up race, and the room gets quiet. What people hear is 'racism,' and everybody gets defensive," said Dr. Wooten, speaking from his 40 years of experience. People typically want to deny that racism exists, he said.

There is also a tendency to deny the impact of race on individuals, Dr. Nunez-Smith said. "The presumption is that you and I are the same, because we are both physicians, but that doesn't reflect reality."

For example, how many white doctors are mistaken for the janitor? A black physician she spoke with was.

Most doctors consider themselves color-blind, and this includes to whom they refer their patients, said Albert W. Morris Jr., MD, president of the National Medical Assn.

Evidence says otherwise. "When you look at referral patterns of physicians, you find African-American physicians refer to white specialists, but very few white physicians refer to African-American specialists," said Dr. Morris, a diagnostic radiologist in Memphis, Tenn.

Doctors, busy with patient schedules and office demands, may not consider checking out minority alternatives, but Dr. Morris said it could be in the patient's best interest. Referring a patient to a physician of his or her same race may help the patient achieve a better outcome. A black patient's conversation with a black physician is likely to be more open, he said.

Research backs up Dr. Morris' experience. A study in the Journal of the American Medical Association in 1999 found that black patients who visit physicians of the same race rate their medical visits as more satisfying and more participatory than do those who see physicians of other races.

Getting ahead -- or not

Race also can slow career advancement or sidetrack it altogether, researchers said. Welby Winstead, MD, assistant professor of otolaryngology at the University of Louisville, Ky., believes this has happened to him.

"I've watched my peers climb the academic ladder while I did not," said Dr. Winstead, who has been practicing for 25 years. These peers have had fewer publications, less research and shorter tenure, he said.

"If you are able to achieve a certain landmark to make that step, interestingly the rules change," he said. "It's always a little bit further away."

He walked out of his annual review when the discussion moved on to his promotion requirements for 2007.

"It was a huge, long list" of requirements that they laid out for him, Dr. Winstead said. "Letters of recommendation from people around the country, all the people I went to school with. It would be embarrassing. I've been doing this for 25 years. I'm not going to play a game that I have absolutely no chance of winning."

He's seen others hit the same barriers. He's watched as black physicians are recruited, stay two or three years, then leave, frustrated by benign neglect and a lack of support.

Edward Halperin, MD, dean of the University of Louisville School of Medicine since Nov. 1, declined to respond to Dr. Winstead's comments. But Dr. Halperin acknowledged that the school has had waves of minority recruitment without good retention -- a situation he wants to address.

"There's no point of spending all that money to hire and then not have them stay," Dr. Halperin said. "I want to create a nurturing environment."

He plans to meet with the local NMA chapter and its student branch. He also plans to have periodic meetings with the school's junior minority faculty to develop an inclusive environment.

The NMA's Dr. Morris said Dr. Winstead's experience is not uncommon in academic or private practices. "They set a standard. Once you reach it, they find someone who has done more than you and say the standard is now higher," he said.

According to a study in the Journal of the American Medical Association in 2000, black doctors and other underrepresented minorities were promoted at a slower rate, despite productivity levels on par with their white counterparts.

The study looked at the promotions of 50,145 full-time faculty who were assistant or associate professors between 1980 and 1989. By 1997, 46% of white assistant professors had been promoted, and 50% of white associate professors. At the same time, 30% of underrepresented minority assistant professors were promoted, and 36% of associate professors from this group of black, Mexican American, Puerto Rican and Native American faculty were promoted.

And the corrosive impact of race can begin in medical school.

A survey of minority students found 58% felt they had to be twice as good to be regarded as equal to their white classmates, according to a 1998 study published in the Journal of the National Medical Assn.

The research sums up the experiences family physician Ada Stewart, MD, had as a student in the late 1990s. Though she had a pharmacy degree, medical school classmates felt free to question her qualifications. "I'd be asked, 'How did you get in? My brother had a 4.0 and didn't make it.' They just assumed it was due to my race," said Dr. Stewart, who practices at a community health center in Columbia, S.C.

During rotations while she trained, Dr. Stewart said she received evaluations that said "needs a better knowledge base," while her fellow medical students with less experience did not.

"I worked as a pharmacist during medical school and residency," Dr. Stewart said. "How can anyone even think I don't know enough? You wonder if it's because of your race. You try to not think about that, but it's always at the back of your mind."

Improving the climate

Despite these experiences, many black physicians are optimistic that the medical profession can change.

"Medicine is a great place to move a national discussion on race forward," Dr. Nunez-Smith said. "These are people who are thoughtful and don't hold deep-seated hostilities about race. It's mostly a sin of omission, not commission."

Dr. Nunez-Smith envisions leaders in the profession supporting open discussions on race. "I have many colleagues who are fearful to talk about race," she said. "They're afraid they'll say the wrong thing. Lots of people say the wrong thing, but saying nothing is doing the most damage."

Dr. Morris cited the Commission to End Health Care Disparities as an example of the profession taking action. One of the goals of this collaborative effort between the AMA, NMA and National Hispanic Medical Assn. is to improve diversity within the physician work force by encouraging minority students to pursue health care careers and raising physicians' awareness of racial disparities in health care.