Racial bias in patient selection of an obstetrician.

Objective: The objective of this study was to determine racial bias in patient selection of an obstetrician.

Methods: Obstetrical patients referred for genetic counseling at a community hospital were included. Self-reported patient race/ethnicity were compared with obstetrician's race/ethnicity.

Results: The patient population (n = 1,519) was 27.8% white, 25% Hispanic, 22.5% black, 20.5% Asian, and 4.3% other. Physician race/ethnicity was 47.8% white, 28.8% Asian, 14.4% Hispanic, and 9% black. Patient race/ethnicity and physician race/ethnicity were correlated (contingency coefficient = 0.54, P < 0.001). White and Asian patients were more likely to select obstetricians of their own racial background (72.7% and 66.6%) than were Hispanic or black patients (36% and 24.6%, P < 0.001). Patients of all races were more likely to be under the care of a physician of their own race than of a different race.

Conclusions: In an urban community with a racially diverse population, there is a strong racial bias in patient selection of an obstetrician.

Key Words: bias, ethnicity, physician, race, selection

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Patient selection of a physician may be influenced by many factors, including accessibility, professional reputation, culture, socioeconomic factors, race, and sex. A recent study found that patients were more likely to choose a primary care physician on the basis of professional and practice characteristics, such as reputation, office appearance, or availability of appointments than on the physician's personal attributes, such as age, sex, or race. (1) Few studies have specifically evaluated racial bias in physician selection. (2,3) The 1987 National Medical Expenditure Survey found that patients belonging to a minority group were five times more likely to report that their primary doctor belonged to a racial minority than were white patients. (2) Several studies have examined the impact of physician sex in the selection of an obstetrician-gynecologist (4,5); however, no study has evaluated racial preference in the selection of an obstetrician. The objective of this study was to determine racial bias in patient selection of an obstetrician in a racially diverse urban population.

Materials and Methods

The records of 1,519 consecutive patients referred between 1999 and 2002 for genetic counseling to a single private community hospital that serves a racially diverse population in metropolitan Houston were reviewed. The self-reported patient's race/ethnicity was recorded and compared with the obstetrician's race/ethnicity. Statistical analysis was performed by means of contingency coefficient and [chi square] tests. Statistical significance was assumed at a value of P < 0.05.

Results

The study population (n = 1,519) was 27.8% white, 25% Hispanic, 22.5% black, 20.5% Asian, and 4.3% other. Non-English-speaking patients accounted for 10.6% of the population. Seventy percent of patients had private insurance, 25.8% had Medicaid, and 2.1% were self-pay. Of the 136 referring physicians, 47.8% were white, 28.8% Asian, 14.4% Hispanic, and 9% black. There was significant correlation between patient race/ethnicity and physician race/ethnicity (contingency coefficient = 0.54, P < 0.001). White and Asian patients were significantly more likely to select obstetricians of their own racial background (72.7% and 66.6%, respectively) than were Hispanic or black patients (36% and 24.6%, respectively, P < 0.001). However, this may reflect the decreased availability of Hispanic and black physicians, since Hispanic and black obstetricians were more likely to have patients of their own race in their practice (62.6% and 61.7%, respectively) than were white and Asian doctors (42.2% and 47.3%, respectively, P < 0.001). Patients of all races were significantly more likely to be under the care of a physician of their own race than a different race [white patients: odds ratio (OR) = 4.3 (95% CI, 3.4 to 5.5, P < 0.001); Hispanic patients: OR = 7.3 (95% CI, 5.3 to 9.9, P < 0.001); black patients: OR = 7.4 (95% CI, 5.1 to 10.7, P < 0.001); and Asian patients: OR = 8.4 (95% CI, 6.4 to 11.1, P < 0.001)].

Discussion

The US population is becoming increasingly multicultural. Data from the 2000 census indicate that 69% of the population is white (non-Hispanic), 12.5% are of Hispanic/Latino origin, 12.3% are black or African American, and 3.6% are Asian. (6) Recent medical school enrollment figures reflect this diversity. In 2001, first-year medical school enrollees were 65.4% non-Hispanic white, 19.4% Asian, 7.9% black, and 6.5% Hispanic (including Puerto Rican). (7) The influence of physician race/ethnicity inpatient selection of obstetrician-gynecologist has not previously been studied. Our results indicate that in an urban multiethnic community with a racially diverse population of obstetrician-gynecologists, there is a strong racial bias in patient selection of an obstetrician. This bias exists across all racial/ethnic groups.

We did not investigate specific reasons for a patient's choice of physician. However, communication skills and cultural beliefs have previously been shown to play a significant role in physician selection. (8) The Commonwealth Fund 1994 National Comparative Survey of Minority Health Care found that minorities choose primary care physicians of their own race/ethnicity because of language and personal preference and not because of location. (3) It is unlikely that language was the main factor in our population because only 10.6% of the population was non-English-speaking in this primarily privately insured population. Other factors such as a physician's reputation, skills, and insurance carrier may have played a role and will be investigated in future studies in this racially diverse patient population.

The effect of physician race/ethnicity on use of health care resources by minority populations has not been extensively investigated. One study that described perceived quality of health care noted that patients whose doctor was of the same race reported greater satisfaction with health care than patients with a physician of a different race. (9) It is possible that increased diversity in the medical profession may alleviate obstacles to health care in minority populations and increase patient satisfaction.

Conclusion

There is a high likelihood that patients will seek obstetricians of their own race/ethnicity and that obstetricians will see patients of their own race/ethnicity if practicing in a racially diverse community. This previously unreported association could be important in counseling residents in obstetrics and gynecology about practice opportunities.

Accepted May 4, 2004.

References

1. Bornstein BH, Marcus D, Cassidy W. Choosing a doctor: an exploratory study of factors influencing patient's choice of a primary care doctor. J Eval Clin Pract 2000;6:255-262.

2. Gray B, Stoddard JJ. Patient-physician pairing: does racial and ethnic congruity influence selection of a regular physician? J Community Health 1997;22:247-259.

3. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Aff (Millwood) 2000;19:76-83.

4. Plunkett BA, Kohli P, Milad MP. The importance of physician gender in the selection of an obstetrician or a gynecologist. Am J Obstet Gynecol 2002;186:926-928.

5. Chandler PJ, Chandler C, Dabbs ML. Provider gender preference in obstetrics and gynecology: a military population. Mil Med 2000;165:938-940.

6. USA Statistics in Brief-Population and Vital Statistics, 2000. www.census.gov/statab/www/poppart.html.

7. Barzansky B, Etzel SI. Educational programs in US medical school, 2001-2002;288:1067-72. www.ama-assn.org/ama/pub/article/168-192.html.

8. Rothschild SK. Cross-cultural issues in primary care medicine. Dis Mon 1998;44:293-319.

9. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med 1999;159:997-1004.

RELATED ARTICLE: Key Points

* A significant correlation between patient race/ethnicity and physician race/ethnicity was found.

* White and Asian patients were more likely to be under the care of physicians of their own race compared with Hispanic and black patients.

* Overall, patients of all races were significantly more likely to be under the care of a physician of their own race than a different race/ethnicity.

Karen M. Schneider, MD, Michelle N. Strecker, MS, Pamela A. Promecene, MD, and Manju Monga, MD

From the University of Texas Medical School Houston, Houston, TX.

This study was approved by the Committee for the Protection of Human Subjects at the University of Texas Health Science Center-Houston, Houston, TX.

Reprint requests to Karen M. Schneider, MD, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Medical School Houston, 6431 Fannin 3.604, Houston, TX 77030. Email: [e-mail]