Two decades of research have shown that patient–clinician concordance -- when patients are treated by doctors of similar race or ethnicity -- leads to increased communication and patient satisfaction, shared decision-making, and greater adherence to treatment plans. But few studies have measured clinical outcomes.
Researchers from UCLA examined a large dataset of older patients in California undergoing common surgical procedures. They focused on patients who are Black or Hispanic, “the largest minoritized and marginalized groups traditionally in American health care,” according to Evan Michael Shannon, MD, MPH, an assistant professor of medicine and clinician-investigator in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA.
Dr. Shannon is first author of the study, published in BMJ Open, which found improved metrics in a subset of patients. When Hispanic surgeons operated on Hispanic patients, it led to reduced length of stay, by half a day, and fewer readmissions to the hospital. No difference was observed for Black patients, likely a reflection of the low numbers of concordant pairs with Black surgeons.
“People question the benefits of diversity, so this paper gives us a little bit of insight that a diverse physician workforce can lead to meaningful outcomes for patients,” said Dr. Shannon, also a staff physician and hospitalist at the VA Greater Los Angeles Healthcare System.
The benefits are not just theoretical, Dr. Shannon continued. If Hispanic patients didn't understand post-discharge instructions, they may have to return to the hospital, leading to “real, reverberating effects,” and not just for the patients’ care. Surgeons are rated based on their clinical metrics. Hospitals are on the hook financially for the added costs of readmissions.
“Having diversity is good for patients and not just in improved communication and trust, but the most important kind of outcomes, like hospitalizations,” Dr. Shannon added.
But getting to patient–clinician concordance means parity with the population. Although Black people make up 13.7% of the population, an estimated 6.1% of general surgeons are Black. Similarly, only 5.8% of practicing physicians identify as Hispanic despite being 19% of the overall population.
The study noted that diversifying the workforce will take time. In the interim, training in cultural humility – respect, empathy, avoiding assumptions and generalizations -- can help physicians achieve greater understanding while treating all patients.
“Just because you're the same gender or from the same racial or ethnic group doesn't mean you have a similar life experience and connection with the patient you're seeing,” said Keith C. Norris, MD, PhD, a co-author of the study and executive vice chair of the UCLA Health Department of Medicine’s Office of Community Engagement and Inclusive Excellence. “Treating everybody as an individual and having a level of respect and sensitivity to the patient tends to lead to better outcomes.”
Those outcomes, Dr. Norris said, include less time in the hospital – freeing up beds for other patients – and reducing expenses for the health system: “If cultural sensitivity or cultural humility training can help improve patient outcomes and reduce costs, that's a good thing to put in place.”
Matching concordant pairs
The researchers analyzed two datasets in California. Medicare figures from 2016 to 2019 provided information on patients ages 65-99 who had undergone one of 14 common surgical procedures, such as appendectomy, hip replacement and hysterectomy.
Medicare classified 1,858 Black and 4,146 Hispanic patients. The race and ethnicity data trace back to Social Security information, which gave the researchers confidence in its accuracy.
The Medical Board of California database yielded information about surgeons. Here, the researchers were limited by those physicians who had self-reported their racial and ethnic makeup – only about 21% of all surgeons. This resulted in 67 Black, 98 Hispanic and 590 white surgeons.
Medicare data helped the researchers determine which surgeons had operated on which patients. Those with similar racial or ethnic makeup were concordant. These pairs also included those who reported multiple backgrounds and matched on at least one of them.
Dr. Shannon said the lack of findings for Black patients was not totally unexpected given the low numbers of concordant pairs. But more data may mean similar results to Hispanic patients – especially because, Dr. Shannon said, previous research showed that concordance results in Black patients having more trust and better communication. He also pointed to his personal experience as a Black physician and hearing things from Black patients “that I don't think they would say to a white physician.”
Accessing new datasets, including in other states, and expanding the numbers will be critical to further examine concordance. This study’s methodology could then be used to measure clinical outcomes for other types of physicians, for example hospitalists, who also “care deeply about similar metrics like mortality, readmission, complications, length of stay,” Dr. Shannon said.
“I think this is hopefully the beginning of a series of research that uses the data sets we have to answer these questions about concordance and clinical outcomes. So stay tuned.”
