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This conversation about patient-physician concordance (matching by race, specifically) is making me think about the continued importance of social & political factors as contributors to overall health & well-being.
Here's what we know:
- The 1910 Flexner Report recommended the closure of all but 2 medical schools that trained Black doctors
- 99% (396/400) of Black-serving hospitals were closed or converted in the 20 years after Medicare's implementation (Smith 2010; Wesley; 2010)
- The 1910 Flexner Report recommended the closure of all but 2 medical schools that trained Black doctors
- 99% (396/400) of Black-serving hospitals were closed or converted in the 20 years after Medicare's implementation (Smith 2010; Wesley; 2010)
It wasn't the Flexner Report itself that closed all but 2 of the medical schools that trained Black physicians, FYI. We can attribute that to the institutional power of the American Medical Association amid a push to "standardize" #MedEd (which preceded the Flexner report)
That said, we also have to understand that the medical schools that trained Black physicians had fewer resources and were dependent on white philanthropy for their survival, while their graduates did not generally have intergenerational wealth that would enable them to be donors.
Black physicians were among the most affluent in their communities, but they had far less resources and capital compared with their white counterparts. This had implications for the survival of medical schools and the hospitals they trained in.
And later, healthcare policies, such as the Hill-Burton Act, which "underwrote the creation of a modern health care infrastructure with $3.7 billion in federal funding & $9.1 billion in matches from state and local gov'ts" (Thomas, 2006), left Black-serving hospitals behind.
The socio-spatial disparities in who gets care where, the quality of care received can be understood in the context of facility-level segregation. Hospitals that serve Black patients- where the majority of Black folx are born- have less capital resources. https://twitter.com/Arrianna_Planey/status/1295814602337464322?s=20
We know from health services research that facility-level segregation is associated with worse health outcomes for a range of conditions (severe maternal morbidity, myocardial infarction), and outcomes (30- and 60-day readmissions among longterm care recipients in seg n'hoods)
This makes sense if we consider the nested and entangled contexts of concentrated disadvantage, which disproportionately exposes Black folks to environmental hazards, risks, and stressors, while making it harder to access resources essential for coping or mitigating harm.
Segregation- area-level and facility-level- is a proxy.
Just as patient-physician concordance is a proxy.
We know that white physicians are less likely to participate in Medicaid in service areas where the "poor" = majority non-white. The opposite is true for Black physicians.
Just as patient-physician concordance is a proxy.
We know that white physicians are less likely to participate in Medicaid in service areas where the "poor" = majority non-white. The opposite is true for Black physicians.
So there's the nested contexts of concentrated disadvantage. On top of health systems' decision-making about facility locations, there are provider-level decisions about participation in public insurance in majority-Black/Latinx-serving facilities- facilities with less resources.
In my work, I foreground the community impacts of hospital closures. However, it is also important to note that the closure of hospitals that serve Black communities is also a lost opportunity for trainees who would practice in these communities.
Since 2011, the # of hospitals that have closed exceeds the # of new hospitals. Every hospital closure has broader implications for #MedEd.
In these figures (based on NCHS data), we see that there has been an overall decline in the number of hospitals in the US since 1975.
In these figures (based on NCHS data), we see that there has been an overall decline in the number of hospitals in the US since 1975.
I want to emphasize this: while Hill-Burton funds were used as a 
to incentivize hospital desegregation, hospitals constructed w/ those funds overwhelmingly served white communities, while Black-serving hospitals closed and continued to close after Medicare's implementation.
to incentivize hospital desegregation, hospitals constructed w/ those funds overwhelmingly served white communities, while Black-serving hospitals closed and continued to close after Medicare's implementation.
As with education, we see that desegregation in health care was coincidental with the loss of Black institutions.
This isn't an argument against desegregation, but an argument that the underlying racist socio-spatial inequities baked in the social fabric remain salient.
This isn't an argument against desegregation, but an argument that the underlying racist socio-spatial inequities baked in the social fabric remain salient.
Desegregation did not address the enduring problems of "separate but UNequal" resource allocation. You can argue that desegregation was a nominal win- more substantive for some (admitting privileges for Black docs, while Black nurses & midwives were still systematically excluded)
I'm going to end by noting that we can't just look at the number of medical schools when we estimate lost potential supply of Black physicians, we need to look at hospitals (residency slots), too (this has implications for Black rural communities too!) https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2769573
Previous threads related to this topic: https://twitter.com/Arrianna_Planey/status/1203822071878475776?s=20
And we absolutely should pay attention to rural hospital closures, & their impacts on Black rural communities https://twitter.com/Arrianna_Planey/status/1205158273525198849?s=20
