When a black men sees a black physician, he is more likely to agree to receive more invasive preventive care services than when he sees a nonblack physician, according to a study recently published in National Bureau for Economic Research (NBER).

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Study details

For the study, the researchers—Marcella Alsan of Stanford University, Owen Garrick of Bridge Clinical Research, and Grant Graziani of the University of California, Berkeley—examined whether a doctor's race has an effect on a black male patient's demand for preventive care.

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The researchers recruited 1,374 black men at 20 barbershops and two flea markets in Oakland, California, offering them:

• A voucher for a no-cost health screening to receive five optional preventive care services: a blood pressure reading, body mass index (BMI) calculation, cholesterol test, diabetes assessment, and flu shot;
• $25 to complete a baseline study with questions about health care, medical mistrust, and socio-demographics; and
• $50—and a ride as needed—to encourage them to visit the clinic for the no-cost health screening.

In all, 637 black men—most of whom were older, did not have a primary care provider, and reported relatively low levels of education, health, and income—participated in the study.

The researchers then randomly assigned the study participants to an Asian, black, or white male physician. Neither the patients nor the physicians knew the study's objective.

When researchers took participants to their private patient rooms, they showed them a photo of their randomly assigned doctor on a tablet, provided the doctor's name, and explained the services they could receive. Participants who opted to receive cholesterol and diabetes assessments would need to have their finger pricked for blood. The researchers also randomly assigned participants to receive a $5 or $10 incentive for opting to receive a flu shot.

The participants then selected the services they would receive. Afterward, they spoke with their physicians, whom researchers told to encourage patients to consent to receive all five preventive services.

During their consultations, the participants could decide to revise the services they selected. After their visits, the patients completed a feedback form, and the researchers compared the services patients selected before and after speaking with their assigned physician.

Findings

The researchers found participants initially chose the same number of services when researchers showed them a photo of their randomly assigned physician, regardless of the physician's race.

However, researchers found after participants spoke with their doctor, the number of services they chose differed. The participants who saw a black physician opted to receive more preventive services—particularly the more invasive services that require finger pricks or injections. That held true even after the researchers controlled for the duration of the visit and physicians' characteristics.

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In particular, the researchers found participants who saw a black physician were:

• 26 percentage points more likely to agree to a cholesterol screening than those who saw a nonblack physician;
• 20 percentage points more likely to agree to a diabetes screening than those who saw a nonblack physician;
• 10 percentage points more likely to agree to a flu shot than those who saw a nonblack physician; and
• 10 percentage points more likely to speak about health or personal issues than those who saw a nonblack physician.

Alsan said, "Even among men who had been offered the opportunity to get a $5 or $10 incentive to say yes to the flu shot, some of those men had turned that money down, saying, 'No, I really don't want a flu shot. I just don't want a flu shot,’" but "[t]he African-American doctors were able to convince some of those men who had turned down the money to obtain a flu shot."

The researchers found men who reported a greater medical distrust had initially been the most reluctant to receive services, but they ultimately were the most likely to opt to receive more services after consulting with a black doctor. They also found black physicians wrote longer notes than nonblack physicians did about their patients.

Discussion

Alsan said, "We can only speak to our study and our population. But it was a very striking and strong finding." She said, "We think [better communication] is a mechanism behind our results, and we have suggestive findings that support that interpretation. But it would be a great follow-on study to figure out what type of communication [mattered]. Seeing what can be taught and what one can learn would be a wonderful next-generation study."

Jonathan Skinner, a health care economist at Dartmouth College, said of the study's findings, "It changed the way I think. This study convinced me that the effects [of race] are real." He continued, "It doesn't seem so controversial if a woman requests a woman physician. If a black patient asks for a black doctor, it's understandable, especially given this study. But what if a white patient asks for a white doctor?”

ChaRandle Jordan, one of the black physicians who participated in the study, said black patients who visit his office in Oakland tend to be guarded. Jordan said, "When you go into the room, you have to ask them about themselves, establish a rapport with them." He added, "It's something they don't teach you in medical school—taking that extra step because you appreciate there have been barriers in the past" (Torres, Harvard Business Review, 8/10; Kolata, New York Times, 8/20; Alsan et al., NBER, June 2018).

How to address health inequity in your community

With the shift in health care to focus on optimizing the health of individuals and communities, health care organizations are creating new strategies to address health care disparities in access and patient outcomes.

Advisory Board has created the Health Disparities Initiative, which provides actionable resources on a series of strategic imperatives and special topics to achieve equity of care. Interested in seeing research or resources that address your biggest health equity problems?

Download our resource, "Building Community Partnerships to Reduce Disparities," which includes studies featuring providers who have successfully partnered with community organizations to address health disparities and social determinants of health. You'll also find tools that can guide your organization’s community partnership strategy.

Download the Resource