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A Community and its Doctors in Need of a Cure

by A. Black, M. D.

The history of provision of medical services during slavery reveals a non-altruistic intent on the part of the slave-holding class. Rather, the primary goals were to maintain commercial productivity and protect the slave owners from contagion. The post-Civil War and Reconstruction eras were similarly driven, in large measure, by a desire to protect the white community from contagion. The history of Black institutions of health care service and training is one of under-capitalization and under-recognition for their very real accomplishments, as well as outright opposition and resistance to the right of such entities to exist.

Professional career experience for Blacks in medicine has been mixed, with segregated hospital staffing patterns and segregated medical society memberships occurring as impediments. Practices have been unevenly capitalized and, therefore, have tended to fall further behind in a post-segregation period of broad societal competition for the same patients by doctors of all ethnic, national and religious origins. Specifically, group practice affiliation, technologic advances and corporate advertising of services have by-passed the Black professional community to a significant degree.

The current status of Black institutionally-sponsored training programs is precarious at best and continually subject to a hostile, undermining influence from the "majority" community regulatory and accreditation apparatus.

The Black hospital is a nearly extinct species.

The status of available training outside of Black institutionally sponsored environments is not promising from a macroeconomic perspective. Although enrollments and the awarding of degrees have increased by several fold relative to, for example, a 1950's time frame, this staggering improvement in the national production of minority providers leaves us with a pitifully diminutive misrepresentation relative to population. Currently, national medical school enrollment for Blacks is approaching 6% of the student body, neatly halving our per capita representation in the society. That this situation measures a several fold increase in medical school matriculation also measures the depth and degree of societal resistance to credentialing Blacks as health care providers. This only gives scale of order to the original problem of segregation-based refusal to provide training to Blacks because they were Black. The traditionally Black medical schools, once almost the universe of available training slots for Blacks, have expanded from Howard and Meharry to include 1970's progeny King-Drew and Morehouse. These four schools collectively now constitute approximately 25% of the Black undergraduate medical student body nationally.

Career attrition is disproportionately rapid for Black providers.

The issue of society memberships has been incompletely resolved. Blanket denial of admission based on race is no longer publicly defended, but covert, subtle delays and ultimate defeat of many Black applications is more the rule than the exception. Our own house is not in good order in that our internal or public discussions of such matters have been nonexistent, untimely or lacking in frankness. Specifically, the old segregation-era paradigm of Blacks seeking white-provided services has not died. Lack of discussion helps it flourish, albeit somewhat quietly. But our problems are not confined to the Black public. Our professionals themselves are ambivalent about the stigmatization of Black training programs and even services provided by themselves.

Patterns of practice are covertly discriminatory. Black medical students, especially in "majority" programs and at the Morehouse School of Medicine (which has successfully dedicated itself to the production of primary care practitioners) are disproportionately counseled into "primary care", or psychiatry and away from high-tech, invasive diagnostic or therapeutic specialties (heretofore and currently the more highly remunerated specialties). They also are not allowed to pursue these specialties freely; facing lots of resistance, some of it arbitrary and unreasonable, to the post-graduate admissions process as well as early termination after cursory evaluation. Again, dramatic progress in this area only underscores the magnitude of the earlier exclusion.

Black practitioners face a disproportionate degree of indigent patients in their practice experience. The degree of this problem makes independent practice frankly impossible for a high proportion of our community. At the same time, salaried positions have been unevenly available in this economic sector (as well as others).

The new phenomenon of managed care has already established a poor legacy. Full-time salaried positions have been hard to come by. This is especially ironic given the origins of our oldest HMO (Health Maintenance Organization), Kaiser-Permanente, in meeting the needs of an under-served community of Black port and rail workers in the Oakland Bay. The original Kaiser hospital, located in Richmond, Ca. which to this very day is solidly Black, was taken off-line as an inpatient facility less than a decade ago.

Furthermore, alliance-based managed care patterns such as IPA (independent physician association), PPO (preferred provider organization), HMO without walls, PHO (physician-hospital organization), etc., have discriminated in various ways, including initial denial of membership and systematic under-utilization or total non-utilization of available, credentialed minority service providers. This has been especially galling in situations where the served population was significantly or even predominantly composed of minority communities.

The net impact of managed care in the Black and minority professional communities to date has been one of methodical exclusion. The cumulative impact of these circumstances on the provision of professional health services to our national community provides prima facie evidence of complicity in an extensive, systematic, ongoing malrepresentation of our best interests, and contributes to a disproportionate burden of disease and early death in the Black community. A chilling and ominous warning has been sounded by Dr. Delutha King, a leading Black urologist who practices in Atlanta, Georgia. He has correlated our discouraging public health statistics with an observation that the bulk of our care is provided by non-Blacks.

This is not a trite observation. Documenting uneven availability of diagnostic and therapeutic modalities by class, race and gender is a new and promising discipline. See, for example:

  1. Ayanian J.Z., et. al., "Racial differences in the use of revascularization procedures after coronary angiography" Journal of the American Medical Association, 1993:269:2642-2646, and
  2. Whittle J.W., et. al., "Racial differences in the use of invasive cardiovascular procedures in the Dept. of Veterans Affairs medical system," New England Journal of Medicine, 1993:329:621-627.

Let us consider as one case in point, the deployment of the new important Laparoscopic modalities in American society.

Laparoscopy, which is to look inside the abdominal cavity with an endoscope, a telescope like instrument, was first developed by general surgeons, but embraced by gynecologists. Laparoscopic (fallopian) tubal ligation, a sterilization operation performed on women is commonly done and familiar to the public.

In this procedure, surgeons insert the laparoscope, about 1/2 inch in diameter, into the patient's abdomen through the umbilicus, or belly button. Only a 1/2 inch incision is required, representing a major technologic advance because that small incision replaces the much more invasive full laparotomy incision (an "operation" in the previous paradigm). Gynecologists progressively attempted more ambitious medical procedures with this modality, including laparoscopic removal of fallopian tube and ovary, then hysterectomy (removal of the uterus) or myomectomy (removal of a benign fibroid tumor of the uterus), and even laparoscopically-assisted vaginal hysterectomy (uterus removed through the opened vagina).

Eventually, digestive tract surgeons reclaimed their innovation. Laparoscopic surgery on the gall bladder was popularized, then laparoscopic appendectomy. By the date of this writing (1995), virtually every abdominal operation has been demonstrated, safely and effectively by a laparoscopic approach. This is true even of the most difficult and infrequently performed operations.

The power of laparoscopic intervention in contrast to old-fashioned laparotomy, or operation, rests in lessened pain and post-operative "complications", radically reduced inpatient hospital stays and reduced disability and recovery time. In point of fact, cholecystectomy (removal of gallbladder) has been reduced to an outpatient procedure.

Analogous developments in related fields have produced similar results, including video-endoscopy of the joint (arthroscopy) and a subsequent experience in video-endoscopy of the chest (thoracoscopy).

What has been the Black experience as this technology has revolutionized surgical practice in the abdomen? Black practitioners overall again failed to lead the way in the deployment of these important new technologies. However there were some exceptional performances at the individual level.  Note  An important publication in the evolution of laparoscopy was a multi-institution report on experience with the laparoscopic gall bladder operation. Fully 25 percent of 1518 cases reported by 59 surgeons from 20 hospital groups in 11 states were performed by one Black surgeon, Dr. Titus Duncan, reporting from Georgia Baptist Medical Center in Atlanta. But Dr. Duncan was not a member of the organization that reported these results and therefore his experience was reported by another (non-operating) surgeon. ["The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies," New England Journal of Medicine, 1991:324:1073-1078.]

Dr. James Rosser has contributed much innovation in this field, having reported pediatric laparoscopic gall bladder surgery and pediatric laparoscopic hernia repair. He has also reported an early sizable experience with adult laparoscopic hernia repair with enduring, quality results. Dr. Rosser has left a position recently as Director of Laparoscopic Surgery at Northeastern Ohio College of Medicine, where he underwent his surgical specialty training to assume the post of Director of Laparoscopy and Endoscopy at Yale University.

In 1992, the Johnson and Johnson laparoscopic subsidiary, Ethicon, sponsored a free symposium and animal practicum on the subject of laparoscopic hernia repair. This event was supervised by Dr. Rosser and Black surgeons from around the country were invited. At this event, corporate representatives observed that Black practitioners were not in the vanguard of deployment of the important new laparoscopic modalities. The fact that these surgeons were not in the leadership of accountability for new product sales at the hospital or free standing surgery level made the company slow to invite them to the Ethicon headquarters and laboratory in Cincinnati. Eventually, however, Black surgeons were allowed to attend such an event, and it was a very "special" weekend in the sense that it was attended by minority doctors only.

What opportunity exists to improve these circumstances?

Some, I hope.

Increasing attention to solo practice opportunities and hospital acquisition or management would appear, on the surface, to be out of step with the times. Private practice, in some sense may survive this passage but solo practice is seemingly already obsolete, frequently noncompetitive, or financially nonviable. The future of private sector practice is already manifest as single specialty or multi-specialty group practice. Reimbursement methods are changing rapidly and radically, disfavoring the former "fee-for-service" (indemnity insurance), and favoring newer flat rate, prepayment for cachement and "discounted fee-for-service in lieu of volume" arrangements. We have also seen a few examples of aggregate flat rate reimbursement to doctors and hospitals collectively, with the split between hospital services and professional services to be negotiated between those two factions. The stick driving this carrot is that the award can be made to another, competitively bidding group at a different hospital.

Similarly, hospital in-patient capacity is being reduced nationally, in both the macro sense and in many localities. Capitalization costs in the hospital industry are extremely high, running into the dozens of millions of dollars, and occasionally the hundreds of millions, per site. The industry is very competitive, with hospital failures, attrition and forced acquisitions increasingly commonplace. The most viable ownership/management entities at the present time appear to be large national consortia or hospital chains, operated on a for profit basis. Teaching hospitals are particularly endangered and that sector is turning to the large, national chains for management contracts and outright acquisition. Black hospital management or ownership, short of billion dollar capitalization and national stature, would seem to be particularly flawed given today's circumstances.

Managed care offers some potential relief. This sector is large, growing rapidly and will not go away soon. HMO's are subject to Federal enabling legislation and will not prove to have unlimited immunity in discriminatory retention practices affecting Black professionals. Also, as the proportion of the population covered through managed care arrangements increases, the absolute number and proportion of the insured group present as minorities will increase, acutely in some localities. Sensitivity to ethnic mix in the work force will become a minimal assumption in award granting by corporations and municipalities because, in part, the served and the provider communities are beginning to demand it.

Academic life offers a productive outlet for trained specialists. Employment opportunities for surgeons in the discipline of trauma seem to be available. Meanwhile, traditional private practice should be viable for Black practitioners in group settings which will likely be increasingly multi-ethnic in mix without reference to the origination of the group. This means successful situations for Blacks will entail joining established groups which cannot be characterized as Black, or expanding successful Black originated practices to include non-Black providers.


Please note that our practitioners do not enjoy a level playing field as regards new techniques. By way of constructive response to a harshly judgmental practice environment which exercises disproportionately punitive initiatives in privileging and licensure against Black practitioners, we have evolved an extremely conservative pattern of practice. This has been good to the extent that Black clientele do not frequently seek Black provided professional services only to ultimately experience victimization vis-a-vis early societal experience with a new modality. Obviously this has been bad to the extent that Black professional life is characterized by less than leadership performance.

Both our practice and our training patterns are "conservative" and "safe" such that imperviousness to disparaging assault by the majority community based on caricature of incompetency is intended. Our style of practice is extremely orthodox, and mainstream, in intention, but paradoxically behind the mainstream. I am certain this paradigm overlaps disciplines other than medicine.

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Meanderings 2.06 -- June 1995