Will Losing Black Physicians Be a Consequence of the COVID-19 Pandemic?

Abstract

A compelling case exists that increasing the number of Black physicians trained and practicing in the United States is one effective intervention to promote health equity and reduce the persistent health disparities that have become glaringly evident during the COVID-19 pandemic. However, the U.S. physician workforce has relatively few Black physicians. Blacks comprise approximately 13% of the U.S. population but only 5% of practicing physicians. In this Invited Commentary, the authors caution that the COVID-19 pandemic may erode the meager progress that has been made in increasing the number of Black physicians. This loss of Black physicians may happen because Black patients are overrepresented among cases of COVID-19, Black physicians care for relatively more Black patients often in settings with less access to SARS-CoV-2 testing and personal protective equipment, and Black physicians have more comorbid chronic conditions that increase their own susceptibility to mortality from COVID-19. All organizations in which physicians train and practice must redouble their efforts to recruit, train, and retain Black physicians. If nothing else, the COVID-19 pandemic must make academic health centers and health care systems recognize Black physicians as the precious resource they are and protect and reward them accordingly.

Both the COVID-19 pandemic and glaring police brutality have forced discussions of racial inequities in the United States, especially for Blacks. From the public’s now inescapable awareness of racial gaps in access to quality health care and the disproportionate burden of chronic health conditions borne by Black communities come calls to address and redress health disparities. Increasing the number of Black physicians in the United States has been recommended as one means of advancing health equity.¹ Data support this recommendation. Compared with other physician groups, Black physicians exhibit the least implicit racial bias² and practice in communities with relatively more Black patients. Black patients cared for by Black physicians experience higher-quality care, lower hospital mortality rates, better communication, and more active involvement in health care decision making.³ However, the U.S. physician workforce has relatively few Black physicians. Blacks comprise approximately 13% of the U.S. population but only 5% of practicing physicians.^4,5 Despite the Association of American Medical Colleges’ commitment to training a physician workforce that reflects U.S. demographics, Blacks comprise only 7% of medical students.^4,6

In this Invited Commentary, we caution that the COVID-19 pandemic, as a further assault on the health of Blacks in this country, may erode the meager progress that has been made in increasing the number of Black physicians. This loss of Black physicians may happen because Blacks are overrepresented among cases of COVID-19, Black physicians care for relatively more Black patients often in settings with less access to SARS-CoV-2 testing and personal protective equipment (PPE), and Black physicians have more comorbid chronic conditions that increase their own susceptibility to mortality from COVID-19.

The COVID-19 Pandemic Disproportionately Affects Black Communities

Blacks make up 18% of the Centers for Disease Control and Prevention (CDC) COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) catchment area but have accounted for 33% of coronavirus-confirmed hospitalizations.⁷ In Milwaukee, Wisconsin, 26% of the population is Black, but approximately half of the COVID-19 cases and 81% of related deaths have been among Black patients, with similar trends reported in Michigan, Illinois, and North Carolina.⁸ Multiple factors contribute to these disparities. Compared with Whites, Blacks are more likely to engage in work that does not allow for social distancing (e.g., the service industry), live in housing that facilitates virus transmission, and have a greater prevalence of chronic conditions that predispose them to adverse outcomes once infected with SARS-CoV-2. A review of recent billing information by Rubix Life Sciences found that, in spite of being at a considerably higher risk of exposure, Blacks with COVID-19 symptoms such as cough and fever were less likely than others to be tested for SARS-CoV-2.⁹ In some cities, testing sites that were located in neighborhoods with relatively large numbers of Black residents were inactive for weeks due to insufficient testing supplies.⁹

Black Physicians Disproportionately Practice in Communities With Higher Rates of COVID-19

Like other health care workers, physicians are at risk of contracting COVID-19 through exposure to the virus while providing care to infected patients or interacting with potentially contagious colleagues. Black physicians’ exposure to SARS-CoV-2 and risk of contracting COVID-19 are proportionately greater than other physicians because they are more likely to practice in areas with a higher population of Black patients and in smaller institutions and community outpatient clinics that have been particularly under-resourced with PPE. This greater risk is borne out by data from the CDC, which found that Blacks accounted for 21% of the 9,282 health care workers who have contracted COVID-19 (including 184 intensive care unit admissions and 27 deaths), whereas Blacks account for only 12% of all health care workers in the United States.¹⁰ Being responsible for providing care to a disproportionate number of patients with COVID-19—especially at sites with inadequate resources—also places Black physicians at greater risk for developing the mental health issues seen in health care workers dealing with the pandemic, including anxiety, depression, and posttraumatic stress disorder as well as imposter syndrome, loneliness, and survivor guilt.^11,12

Black Physicians Are More Likely to Have Chronic Health Conditions That Predispose Them to Mortality From COVID-19

Although physicians overall are healthier than the general population, health disparities manifest even between White and Black physicians.¹³ According to the CDC’s National Occupational Mortality Surveillance program, Black physicians are far more likely than White physicians to have chronic health conditions such as hypertension, diabetes, chronic lung disease, and heart disease, which increase the mortality risk from COVID-19.^7,14 Many factors may contribute to this difference, but Black physicians also face systemic racism.¹⁵ Chronic exposure to the daily stressors of being Black in the United States undoubtedly contributes to the greater burden of chronic health conditions and shorter life expectancy for Black physicians compared with their White counterparts.¹⁶ Further, when Black physicians enter the health care system as patients, they are at greater risk than their White colleagues of receiving lower-quality care at every level of disease severity and every stage of diagnosis and treatment for diseases affecting every organ system.¹⁷ In addition to the influence of racial stereotypes on clinical decision making,² racial bias is built into many diagnostic criteria and clinical algorithms in ways that disadvantage Black patients.¹⁸

Going Forward

Most of the race-based prejudice targeted at Black physicians does not resemble the cruel acts of violence inflicted on George Floyd, Ahmaud Arbery, or Breonna Taylor. However, the explicit and implicit acts of stereotype-based bias targeted at Black physicians are acts of violence. Academic medical centers and health care systems must no longer ignore the daily indignities Black physicians suffer because of the color of their skin.¹⁵ These institutions must implement policies to protect their Black physicians from racist patients and from discriminatory evaluative practices. Individuals within these institutions must educate themselves about how the mere existence of cultural stereotypes perpetuates inequities. All individuals must accept that exposure over time to the prevailing negative stereotypes about Blacks can cause them to be unwittingly complicit in discrimination against all Blacks, including Black physicians. Individuals must humbly accept that this discrimination will happen no matter how much they aspire to be fair and no matter how strongly they view themselves as egalitarian. This awareness must be accompanied by the willingness to engage in the hard work it takes to break these bias habits.¹⁹ All organizations in which physicians train and practice must redouble their efforts to recruit, train, and retain Black physicians. If nothing else, the COVID-19 pandemic must make academic health centers and health care systems recognize Black physicians as the precious resource they are and protect and reward them accordingly.