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Promoting racial/ethnic diversity within the physician workforce is a national priority. However, the extent of racial/ethnic discrimination reported by physicians from diverse backgrounds in today’s health-care workplace is unknown.
To determine the prevalence of physician experiences of perceived racial/ethnic discrimination at work and to explore physician views about race and discussions regarding race/ethnicity in the workplace.
Cross-sectional, national survey conducted in 2006–2007.
Practicing physicians (total n=529) from diverse racial/ethnic backgrounds in the United States.
We examined physicians’ experience of racial/ethnic discrimination over their career course, their experience of discrimination in their current work setting, and their views about race/ethnicity and discrimination at work. The proportion of physicians who reported that they had experienced racial/ethnic discrimination “sometimes, often, or very often” during their medical career was substantial among non-majority physicians (71% of black physicians, 45% of Asian physicians, 63% of “other” race physicians, and 27% of Hispanic/Latino(a) physicians, compared with 7% of white physicians, all p<0.05). Similarly, the proportion of non-majority physicians who reported that they experienced discrimination in their current work setting was substantial (59% of black, 39% of Asian, 35% of “other” race, 24% of Hispanic/Latino(a) physicians, and 21% of white physicians). Physician views about the role of race/ethnicity at work varied significantly by respondent race/ethnicity.
Many non-majority physicians report experiencing racial/ethnic discrimination in the workplace. Opportunities exist for health-care organizations and diverse physicians to work together to improve the climate of perceived discrimination where they work.
Physician surveys conducted in the 1990s established that racial/ethnic discrimination was common in the health-care workplace. A 1995 national study among academic physicians found nearly half of non-majority physicians had experienced racial/ethnic discrimination in the workplace.1 Another national study, conducted in 1993–1994 among female physicians, found that approximately 60% of non-majority respondents reported racial/ethnic discrimination at work.2 Further, physicians from non-majority backgrounds are generally less satisfied with their careers1,3 and less likely to be promoted than their majority colleagues with similar academic productivity.4,5
Since the 1990s, however, achieving racial/ethnic diversity within the physician workforce has been a national priority.6–8 A number of high profile efforts have sought to increase the number of medical trainees from non-majority backgrounds and to improve the climate for diversity within the medical profession.9–16 Today, it is unclear whether these efforts have lessened the prevalence of reported experiences of racial/ethnic discrimination among physicians that was reported more than a decade ago. A 2005 Massachusetts study17 found that one-third of responding physicians thought racial/ethnic discrimination experienced by physicians was “somewhat” or “very significant,” but no recent national studies have been conducted. As a result, the prevalence of racial/ethnic discrimination reported by physicians from diverse backgrounds in today’s health-care workplace remains unknown. Determining the prevalence of physician experiences of racial/ethnic discrimination is of critical importance as the US strives to foster physician workforce diversity and eliminate disparities of all kinds from the health-care setting.
In this national survey of physicians conducted in 2006–2007, we examined self-reported physician experiences of perceived racial/ethnic discrimination over their career course. We also assessed physician experiences of perceived discrimination of any type in their current work setting. Lastly, we explored physician views about race and discussions regarding race in the workplace. Based on previous qualitative work,18 we hypothesized that physician race/ethnicity would be associated with reports of workplace discrimination and with views about race at work. We also tested our hypotheses that other physician characteristics, such as physician age or work setting, would be associated with workplace discrimination outcomes.
We conducted a cross-sectional, national survey of physicians in the United States, completed between October 2006 and February 2007, oversampling for physicians of African descent. Physicians in current practice but not in clinical training were eligible. Our sampling frame included 1,500 physicians obtained via simple random sampling from the American Medical Association (AMA) Physician Masterfile, augmented with 250 physicians also obtained via simple random sampling from the National Medical Association (NMA) membership roster. The AMA Physician Masterfile is a database designed to record basic data on all recognized physicians in the US and territories. The AMA Physician Masterfile contains information on all physicians in the US, regardless of whether they are members of the AMA.19 The NMA is a professional group that aims to promote the collective interests of physicians of African descent, and its membership roster includes active and inactive members of the NMA.20
After an initial mailing to the 1,500 physicians from the AMA Masterfile, 15 inquiries were returned because the respondents were deceased. We attempted to verify the contact information of the 1,485 remaining physicians before subsequent mailings, and 601 physicians were eliminated because of incorrect or unverifiable contact information. Of the remaining 884 physicians, 469 completed the survey after three mailing waves, yielding a AMA Masterfile response rate of 53.1% (469/884). There were no statistically significant differences between AMA Masterfile respondents and non-respondents regarding physician specialty, age, or geographic location. Data on physician race/ethnicity were not available through the AMA Masterfile. Among the NMA sample, 60 physicians responded after the first wave; all self-identified as black. Because the NMA required that mailings to their members be coordinated through a third-party vendor, we could not identify how many non-responses were due to inaccurate contact information. Including NMA respondents and non-respondents in response rate calculations yields a conservative overall response rate of 46.6% (529/1,134). There were no statistically significant differences between the survey responses of the 60 black respondents identified through the NMA compared with the 27 black respondents identified through the AMA Masterfile regarding reported experiences of discrimination or their views about race/ethnicity. We, therefore, combined the two samples for our analyses, resulting in a final sample of 529 physician respondents: 469 from the Masterfile and 60 from the NMA membership roster. The study was approved by the Yale School of Medicine Human Investigations Committee.
We adhered to several principles of questionnaire development in order to enhance the validity of our findings.21,22 We specifically focused on physician self-reported perceptions of discrimination at work. In general, researchers have found that self-reports of discrimination are accurate and reliable when cross-validated against other data sources.23,24 After a review of published workplace discrimination instruments, we concluded that existing questionnaires were not appropriate for use in this project.25 Therefore, we combined analysis of our previous qualitative work 18 and a review of questionnaires used in prior physician workplace discrimination studies1,2 to inform development of a new questionnaire. We explicitly defined discrimination on the questionnaire as “the unfavorable or unfair treatment of a person or group of persons in comparison to others who are not members of that group.” Once the questionnaire was drafted, we pilot tested it with 20 physicians-in-training to identify challenges with comprehension and clarity. The final questionnaire included 35 items.
To assess physicians’ experience of racial/ethnic discrimination over their career course, we used an item adapted from two prior physician surveys1,2: “Since completing medical training, how often have you personally experienced discrimination because of your race or ethnicity?” We dichotomized Likert responses for analysis (0= never, rarely and 1= sometimes, often, very often) because of small numbers in the often and very often categories. Five participants selected an available “N/A” option and were removed from data analysis. To assess discrimination of any type that physicians experienced in their current work setting, we used an item adapted from a prior single-state physician survey17: “Have you personally experienced discrimination in your current workplace?” with a yes/no response option. We measured physicians’ views about race with a series of statements with response options of strongly agree, agree, neutral, disagree, or strongly disagree (specific items are detailed in Table 4).
We measured respondents’ personal and professional characteristics including race (black, Asian, white, other), Hispanic/Latino(a) ethnicity (yes, no), age, nativity (whether born in the US), gender, relationship status, medical school location (US/Canada or international medical graduate), board certification status, annual individual income, primary work setting, self-rated health, sexual orientation, and religious affiliation. We categorized self-identified race/ethnicity for analysis as: white (non-Hispanic white), black (non-Hispanic black), Asian (non-Hispanic Asian), “other” (non-Hispanic other race), and Hispanic/Latino(a) (which included individuals who self-identified as Hispanic/Latino(a) regardless of race). We measured years in practice, time at current work setting, and hours worked per week as continuous variables. Physician specialties were categorized into primary care specialties (including general internal medicine, general pediatrics, family medicine), internal medicine subspecialties, pediatric subspecialties, general surgery, surgical subspecialties, obstetrics and gynecology or obstetrics and gynecology subspecialties, or other (i.e., specialties for which we received fewer than ten respondents). Respondents were also asked to provide the zip codes of their primary work sites, which were collapsed into four US geographic regions (Northeast, Midwest, South, and West).
We used standard frequency analyses to describe the characteristics of the sample; the proportion of physicians reporting that they experienced racial/ethnic discrimination in the workplace sometimes, often, or very often during their careers; the proportion of physicians reporting that they experienced discrimination at their current work setting; and views of physicians regarding race/ethnicity at work. We estimated the bivariate associations and their statistical significance using odds ratios and chi-square statistics. Non-Hispanic white race/ethnicity was used as the reference group. We used multivariable logistic regression modeling to estimate adjusted associations. For multivariable models, we included independent variables that we hypothesized a priori to be associated with experienced discrimination (i.e., gender, race/ethnicity) and independent variables that were significantly associated (p≤0.05) with reported discrimination in bivariate analyses. Additionally, we included longevity at the current work setting in the model in which “discrimination at their current work setting” was the outcome. We tested for interactions between race and the other covariates in multivariable models including gender, but none were significant (p>0.05); thus, interaction terms were dropped from the final models. The Hosmer-Lemeshow technique26 was used to test goodness of fit for the final models. We used a modified Bonferroni correction to adjust for multiple comparisons.27 SAS statistical software, version 9.2 (SAS Institute Inc., Cary, NC) was used for all analyses.
As intended, historically underrepresented racial/ethnic minority physicians were overrepresented in our sample (Table 1) compared with the general physician population; 16.4% versus 3.5% self-identified as non-Hispanic black, and 5.7% versus 5.0% self-identified as Hispanic/Latino(a).28 Approximately 70% of our sample was male, similar to the physician gender distribution (72% male) nationally. Almost one third of our sample was between 50–59 years of age, compared with the roughly one-third of active physicians nationally over age 55. Most respondents were born in the US, and most attended medical school in either the US or Canada. The sample was also diverse by specialty, practice setting, and geographic location.
As shown in Table 2, the proportion of physicians who reported that they experienced racial/ethnic discrimination sometimes, often, or very often during their medical career was substantial among non-majority physicians [71% of black physicians, 45% of Asian physicians, 63% of “other” race physicians, and 27% of Hispanic/Latino(a) physicians]. In contrast, 7% of white physicians reported having experienced racial/ethnic discrimination sometimes, often, or very often during their medical career.
In unadjusted analysis, race and ethnicity were significantly associated with the odds of experiencing racial/ethnic discrimination sometimes, often, or very often during the medical career (Table 2). Several other physician characteristics were also significantly associated with increased odds of reporting experiences of racial/ethnic discrimination, including being born outside of the US and Hinduism versus Protestantism. However, several other characteristics such as physician age, number of years in practice, and gender were not significantly associated with reported racial/ethnic discrimination in unadjusted analyses (p-values>0.05; data not shown).
In the multivariable analysis, the effect of race for non-Hispanic physicians remained significant (black versus white physicians adjusted OR=28.7, 95% CI 13.4, 61.6; Asian versus white physicians adjusted OR=6.0, 95% CI 2.5, 14.7; and “other” race versus white physicians adjusted OR=19.1, 95% CI 5.7, 64.2). Hispanic/Latino(a) ethnicity and the other physician characteristics were no longer statistically significant in adjusted analysis (Table 2).
Many non-majority physicians reported experiencing personal discrimination of any type at their current work setting [59% of black, 39% of Asian, 35% of “other” race, and 24% of Hispanic/Latino(a) physicians] compared with 21% of white physicians (Table 3).
In unadjusted analyses, race was significantly associated with reporting experiences of discrimination in the current work setting (Table 3). Being female, having been born outside of the US, in fair/poor versus excellent self-rated health, and working in certain work settings (solo practice, in a group/staff member HMO, or hospitalist versus private group practice) were also significantly associated with increased odds of reporting discrimination in their current workplace in unadjusted analysis (p-values<0.05).
In the multivariable analysis, black race remained significantly associated with increased odds of reporting discrimination in the current work setting (black versus white adjusted OR=3.9, 95% CI 1.7, 9.0) (Table 3). Female gender, being in fair/poor versus excellent self-rated health, and certain work settings also remained significantly associated with reporting current workplace discrimination in the adjusted analysis.
Views about the role of race at work varied significantly by respondent race/ethnicity, with particularly large differences noted between black and white physicians (Table 4). Compared with white physicians, black physicians were significantly more likely to agree/strongly agree that race influences relationships at work (p-value=0.0008). Physicians who identified as black, compared with physicians who identified as white, were significantly more likely to agree/strongly agree that they were under greater scrutiny than their colleagues (p-value=0.0001), that they were asked to take on certain responsibilities because of their race/ethnicity (p-value=0.0001), that patients refused their care (p-value=0.0008), and that it was difficult to find a mentor (p-value=0.0008). Additionally, black physicians were less likely to believe issues of discrimination were discussed at work (p-value=0.0008) and less likely to feel comfortable communicating about race/ethnicity at work (p-value=0.0007) when compared with white physicians. These patterns were also apparent, although less pronounced, among physicians who identified as Hispanic/Latino(a), Asian, and “other” race.
Despite recent efforts to foster racial/ethnic diversity within the physician workforce, a majority of non-Hispanic black physicians reported experiencing discrimination in their current workplace even after adjusting for years in practice, age, gender, specialty, region of the country and other factors. These findings are similar to those from national surveys conducted more than a decade ago,1,2 suggesting that significant numbers of non-majority physicians continue to experience discrimination at work. However, the experience of perceived discrimination does not appear to be static over the career course of individual physicians. Although most non-majority physicians in our sample reported having specifically experienced racial/ethnic discrimination at work at least sometimes during their careers, fewer non-majority physicians reported current workplace discrimination than reported career racial/ethnic discrimination. Notably, physician views on how race, ethnicity, and discrimination affect their current professional experiences varied significantly by the respondent’s self-identified race/ethnicity. The dramatic racial differences in physician responses suggest that many non-majority physicians encounter a work environment where they perceive specific, discrimination-related challenges.
Our findings are consistent with observations made in the business literature describing the challenges associated with increasing workplace or workforce diversity, such as intergroup conflict and strained communication, without concurrent strategies to counteract these challenges.29,30 The business literature further suggests that specific core elements characterize successful diversity initiatives including: (1) recruiting racial/ethnic minorities into the organization, (2) promoting racial/ethnic minorities within the organization, (3) capturing the perspectives of employees regarding the race-related climate, and (4) emphasizing the relevance of diversity to the mission of the organization.31 The United Kingdom’s response to physician-experienced discrimination may also provide the US medical profession with some guidance. The British Medical Association launched a national campaign to inform National Health System patients and providers that racial harassment would not be tolerated. They further trained all NHS employees, not just racial/ethnic minority providers, regarding the knowledge, new structures, and skills necessary to respond to workplace discrimination.32 Leadership engagement, the development of policies that support professional equity, and physician participation in decision-making are principles that can be generalized to the US medical profession. For example, additional research can focus on addressing differential experiences such as difficulty finding mentors, being asked to take on certain responsibilities because of race/ethnicity, and patient refusal of provider.
To place these findings in perspective, it is important to recognize that they do not set the medical profession apart from the rest of American society. They reflect the fact that racism and discrimination have created a broad-based legacy of vastly differing world views.33 As organizations aim to recruit and retain a racially/ethnically diverse health-care provider workforce, it is necessary that organization leadership explicitly recognizes that differences in employee experiences and perceptions will inevitably affect the conversations about race within health-care settings,34 and should inform the development of formal and informal mechanisms for communication and conflict resolution.
Our study extends prior work and augments our understanding of the physician workplace experience, but it also has some limitations. First, although our cross-sectional study design demonstrated statistically significant associations between race and reports of experienced discrimination, caution should be used when drawing conclusions regarding causality. We found trends toward increased reports of discrimination among Hispanic/Latino(a) physicians, but our sample size provided limited power to assess the statistical significance of these associations. Finally, survey non-respondents may have had different views from respondents. However, we found no differences between respondents and non-respondents on observable characteristics such as specialty, age, or geographical region. The inclusion of the NMA membership roster in our sampling frame potentially introduces bias towards increased reports of discrimination if current or former members are more likely than non-members to report discrimination. We did not, however, find that physicians of African descent identified via the NMA were more likely than those identified via the AMA Masterfile to report discrimination, so we believe this potential sampling bias is not substantial. Furthermore, previous data35 have identified a tendency for individuals of African descent to underreport workplace discrimination, suggesting bias towards the null in our sample. Given our research objectives, it was imperative to explicitly recruit practicing physicians of African descent; the NMA membership roster remains the most comprehensive repository of contact information for this group. Despite our inability to describe the NMA membership roster non-responders, our response rates (53.1% from the AMA Masterfile, at worst 46.6% overall) are consistent with other recent national surveys of physicians on potentially sensitive topics (43%–53%).36–41
Non-majority physicians in the US, regardless of specialty, geographic region, gender, years in practice, or age, continue to report high rates of workplace discrimination, comparable to rates reported over a decade ago. These findings suggest that efforts to address workplace discrimination have not been entirely successful, and new initiatives will be needed to achieve the goal of professional equity in medicine. Increasing and successfully supporting physician workforce diversity may reduce existing racial/ethnic health-care inequities and improve the quality of health-care for all patients. It may be cause for optimism that fewer respondents reported current workplace discrimination than reported career discrimination, although job turnover or other undesired factors may account for this finding. Still, opportunities exist for health-care organizations and diverse physicians to work together to improve the climate of racial discrimination where they work. Understanding the different experiences and perceptions of a diverse workforce is fundamental to creating health-care work environments that successfully support diversity.
Conception and design (MNS, EHB); data acquisition (MNS, NP, MW, CB); data analysis and interpretation (NP, MMD, MNS, EHB); manuscript drafting (MNS); manuscript revisions (MNS, NP, MW, MMD, CB, EHB, BJ, HMK). MNS had full access to all of the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis. Thank you to Emily Bucholz for her assistance in the data collection phase of this project for which she was reimbursed as a research assistant. EHB is supported by the Patrick and Catherine Weldon Donaghue Medical Research Foundation Investigator Award (grant no. 02–102). MNS was supported, in part, by a grant through the Yale Center for Clinical Investigation. The funders did not contribute to the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.
Conflict of Interest None of the authors have any conflicts of interest to disclose.