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The changing face of the physician

Medical Economics JournalMedical Economics October 2023
Volume 100
Issue 10

The physician workforce is more diverse than it ever has been, and the diversity is only increasing.

© stock.adobe.com

© stock.adobe.com

Listen to an audio version of this article:

The stereotype of an American physician is an older White man, well-dressed, with a dignified bearing. Think of the famous paintings by Norman Rockwell. His 1947 painting “The Family Doctor” shows a physician in a suit, leaning forward with a stethoscope between his hands, listening attentively to a worried mother holding a baby, presumably the patient, while the father looks on. The office is well-appointed with thick red carpet.

Was this stereotype historically accurate? Largely, yes. According to data from the 1920 census, more than 97% of physicians were White and 95% were men. In the century since, the demographics of U.S. physicians have undergone significant changes in terms of race, gender, and other characteristics, even if White men remain the largest class of practicing doctors today. Today’s physician workforce is more gender balanced with greater racial diversity, but much work remains to get the ranks to match the diversity of the U.S. population, experts say.

Chase Mussard, M.D. Photo by Kathryn Elsesser

Third-year family medicine resident Chase Mussard, M.D. Photo by Kathryn Elsesser

Learn more about Dr. Mussard.

“The good news is that it’s much more diverse than it used to be, and different voices are entering the medical field, which I think is important,” says Yalda Jabbarpour, M.D., a family physician and director of the American Academy of Family Physicians’ (AAFP) Robert Graham Center for Policy Studies in Washington, D.C. “But we still have room to grow.”

Diversity and stagnation

Although there has been a gradual increase in racial and ethnic diversity among physicians over the years, physician numbers have stagnated compared with population growth for many racial groups. The plight of the Black physician represents a stark example. A 2021 paper from researchers at UCLA found that the proportion of Black physicians has increased by 4 percentage points over the past 120 years. The share of U.S. Black doctors remains unchanged since 1940.

“These findings demonstrate how slow progress has been, and how far and fast we have to go,” wrote Dan Ly, M.D., assistant professor in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA, and the study’s author.

Discriminatory practices and limited access to medical education and training opportunities over the decades had hindered progress in achieving proportional representation. A 1987 article published in the Bulletin of the History of Medicine titled “Entering a White profession: Black physicians in the New South, 1880-1920” included first-person accounts of Black physicians and the way White physicians reacted.

First, the article excerpts a letter from an unnamed young Black physician in Kentucky to famed sociologist and civil-rights pioneer W.E.B. Du Bois: “I am well received by my White professional brother,” he writes. “We ride in the same buggy; consult together and read each other’s books. I have a few White patients…”

This hopeful description of physician fraternity across racial lines was not universal. As a counterpoint, the same article references a 1914 letter to the editor for the journal The Medical World from a White physician, asking how to repress Black physician growth: “I notice in some places they seams (sic) to be making more money than the White physicians. What is the best thing we can do to keep them down?”

The American Medical Association has acknowledged its role in historic bias against Black physicians, releasing a study that outlined the systemic discrimination and, in 2008, issuing an official apology and promising to do better. The key lies in the next generation of physicians.

Aerial Petty, D.O., is a third-year family medicine resident serving as chief resident at NewYork Presbyterian-
Columbia University in New York City.

“There are plenty of people who grow up in underserved neighborhoods — whether that’s rural or inner city, and ethnic and minority populations who never saw a doctor growing up — who think that being a doctor is a goal that was never in the cards for them, because they were never exposed to it or thought that this is a possibility,” Petty says. “It’s a matter of going to where people are and not just expecting them to come to you. Ultimately, that’s going to be the first steps to increasing diversity.

Diversity is important not just for physicians; it matters for patients too, especially vulnerable populations in underserved areas, Jabbarpour says. The leading research, suggests that racial and language concordance between physicians and patients is a key variable that leads to better outcomes for vulnerable patients. Black and Hispanic doctors are more likely to work in these communities, which improves access and outcomes for these patients.

“That’s really interesting, and I don’t know if we have any guesses about what it means for the future,” Jabbarpour says. “It does not mean that White, English-speaking people should not go into medicine. The data, I think, is trying to say that we need the physician population to mirror the population of the United States.”

How women will take over medicine

Although work is needed to make medicine more racially diverse, the gender balance has been shifting dramatically as more women enter medical school. Gender proportions vary between specialties but, in family medicine, women will take over most of the workforce by 2026 if current trends hold, Jabbarpour says.

Third year family medicine resident Aerial Petty, D.O. Photo by Agne Sopyte

Third year family medicine resident Aerial Petty, D.O. Photo by Agne Sopyte

Learn more about Dr. Petty.

However, more female physicians are coming into a health care system that is not necessarily set up for their success. Women in family medicine, particularly young physicians, are facing greater levels of burnout than male and older physicians. “A lot of that does have to do with how the health care system is set up (and) does not really support how women traditionally want to practice,” Jabbarpour says.

Although no individual physicians are alike and many of the same gender have different priorities and concerns, female physicians generally tend to practice in a manner that makes administrative burden more difficult, especially in the fee-for-service reimbursement world, Jabbarpour says. For example, female physicians tend to want to deal with all a patient’s issues at once. “So, what happens then is that because they’re dealing with all the issues in one visit, they’re actually getting paid less,” she says. “So, they are often overworked (and) underpaid and the system is not set up the way that women naturally tend to work.”

Burned-out physicians tend to reduce clinic time, which exacerbates the primary care shortage and the wage gap between male and female physicians, which has remained stubbornly large in recent years. For example, the Medical Economics Physician Report, an annual survey of U.S. primary care physicians, puts the annual wage gap between male and female physicians at about $80,000.

Jabbarpour cautioned that typical reasons people give for the wage gap are not as clear-cut as many think. Jabbarpour says the AAFP’s research has looked at the wage gap and controlled for a host of leading variables, including seniority, hours worked and number of patients seen — and the wage gap has remained.

“People often say it’s the choices that women make: they go into the lower-paying specialties, they choose to have less clinical time, they spend longer with their patients in a fee-for-service system,” Jabbarpour says. “But there’s still a wage gap when you control for all of that, and I think that just must go back to the fact that there’s bias in the system.”

Will the power of numbers help reverse this? Will more women serving in leading roles at hospital systems help? Only time will tell.

The mission of young physicians

What of the next generation? Although it can be risky to generalize differences between generations, those who work with residents and younger physicians — and younger physicians themselves — do see differences between the way they approach medicine and how their older colleagues do so.

“They really do seem to be very mission driven,” Jabbarpour says. “They seem less concerned about ‘How do I add more money to my pocketbook,’ and more like, ‘How do we help this patient with their social determinants of health,’ or ‘How do we fight for our patients against the insurance companies?’ They are much more vocal in order to advocate for their patients.”

They do not only advocate for patients, in Jabbarpour’s view. They also advocate for themselves when it comes to work-life balance.

“I think we are seeing that across every industry, and medicine is not immune to that,” she says. “It’s always a joke about how when we were residents, we would never dare ask to go home, even if it was the end of the day. We would literally just sit there until someone dismissed us to go home, and we were adults. It’s not like that anymore. Now it’s, ‘You know what, I need to be home, I have a hard stop at 5:30.’ They really do protect themselves and try to have a life outside of medicine.”

That does not mean they are not ambitious and driven. Medical Economics got a chance to speak with two third-year family medicine residents — Chase Mussard, M.D., and Petty — about kicking off their careers.

Mussard wants to embark on a career of full comprehensive family care, whereas Petty wants to focus on minority health policy and advocacy an addition to caring for patients.

“I want to do full comprehensive scope of care,” Mussard says. “I want to take care of my patients in the clinic and in the hospital. Maternity care is a big priority for me — newborn care, specifically substance use in pregnancy care. I think family medicine is very uniquely suited in this realm and that’s a passion of mine.”

Says Petty: “If there’s a problem, you can either just complain about it or you can do something about it. Ifeel lucky that I’m impassioned by being a person who tries to do something about it.”