By Lloyda Broomes Williamson, M.D.
When considering the overall health of the Black population in the U.S., there is a clear critical need. Currently, 13 percent of the U.S. population is Black. However, only 4 percent of U.S. physicians are Black. There have been changes regarding the gender of Black physicians graduating from medical school. In most medical schools, greater than 50 percent of the class are women. This is the case for Black students. Second, there has been a disproportionate decrease in Black men graduating from medical school. In 1986, 57 percent of Black medical school graduates were men. However, this percentage decreased to 35 percent by 2015.
What factors contribute to this significant decrease?
In the past, public attention led to success to increase Black students’ acceptance into medical school and subsequent graduation. However, over time, this success led to the belief that the problem of Black student recruitment was solved. Subsequent decisions in multiple arenas have contributed to the reversal of these successes. For example, legal decisions limit institutional ability to address those problems through specialized recruitment strategies and quotas. Additionally, multiple professional barriers exist for underrepresented minority students who seek medical school admission. Reasons include:
• A lack of exposure to diverse physicians in clinical and research settings,
• A lack of mentorship by Black physicians,
• The high cost of education,
• The high cost of supplemental experiences such as test preparation for the Medical College Admissions Test (MCAT), and
• The lack of appropriate undergraduate advising and support, and
• Supplemental activities in areas of research and shadowing experiences.
We can look to history to understand some factors contributing to our critical need to increase the number of Black physicians. No centralized health care system was in place for millions of slaves during slavery in the U.S. or for millions of Black individuals after slavery ended in 1865. During the post-Civil War period, in spite of the tremendous odds against them, 12 Black medical schools were established. These schools existed without financial support by extensive endowments and other resources.
Prior to the Flexner report of 1910, approximately 155 medical schools existed in the U.S. The Flexner report is historically praised for several recommendations including the recommendations to increase the prerequisites for medical school and to focus on scientific methods of practicing medicine. These recommendations crushed the Black medical education community, resulting in the closure of all but two of the seven Black medical schools that existed by the time of his report: Howard University and Meharry Medical College. There were no recommendations to enhance or support those institutions, which had been created to develop a medical workforce to serve millions of Black Americans.
Obstacles were pervasive for Blacks physicians. Southern medical schools refused to admit Black students. Segregation in the American Medical Association led to the formation of the National Medical Association, established to serve as a “collective voice for Black patients and the patients they serve.” Years later, the Black Psychiatrists of America (BPA) was formed to serve the same purpose for psychiatrists in their field. The BPA will celebrate its 50th anniversary this spring. This celebration occurs after the American Psychiatric Association elected its first Black president in 2018, Altha Stewart, M.D., and the American Medical Association elected its first Black President, Patrice Harris, M.D., also a psychiatrist, to take office in 2019.
While we have made advances in these professional societies, a significant lack of progress exists in other areas. Many academic health centers which train physicians, express a commitment to diversity. However, an obvious lack of diversity exists in leadership in many health organizations. Resources need to be developed and implemented, with sufficient financial support for perpetual success. Instruction regarding implicit and explicit bias needs to occur during training in medical school in order to address the health disparities in clinical practice and research.
Let’s get back to the issue of mental health, specifically for individuals within the Black community. In the U.S., only 2,000 of the estimated 28,000 psychiatrists are Black, and the total number of psychiatrists is rapidly decreasing since three out of five psychiatrists are over 55-years-old. There are also significant areas within the U.S. that lack health equity. Black people are over represented in public mental health facilities, including community mental health centers and state hospitals. They are more likely to be involuntarily committed to treatment, they are evaluated as more hostile and suspicious, and they are more likely to be diagnosed with schizophrenia. Misdiagnoses may lead to treatment with inappropriate medications. Higher doses of medications may lead to side effects, which discourage Black patients from being compliant with medications and mental health appointments. Often, institutional biases are present. Loose criteria exists, which allows for provider bias to negatively affect the treatment outcome of Black individuals.
We must also consider another area with alarming statistics – the U.S. prison system. According to the U.S. Bureau of Justice, in 2013, 37 percent of the total male population was Black. In order to understand this area of health inequity, we must consider several historical facts and decisions regarding the approach to mental health treatment and substance abuse treatment, which negatively impact the Black population. Individuals present in U.S. jails and prisons are significantly more likely to have mental illness, a substance use disorder, or both. Not only does this significantly impact the lives of those individuals during incarceration, but there are serious health, social and economic consequences to their families during incarceration and after their release.
What factors led to this disproportionate presence of incarcerated individuals? Two significant periods can be identified:
• First, this is partially a consequence of the closing of most of the country’s state mental health hospital systems. Inadequate establishment and funding of community resources for those with chronic mental illness resulted in what some individuals describe as “transinstituitionalism,” transferring the chronic mentally ill from state hospitals to prisons. A recent study indicated that 16 percent of the correctional population, in some states, was incarcerated due to the lack of an appropriate state hospital bed for treatment. Incarcerated individuals with mental illness are more likely to commit suicide. Thus, the costs of incarceration are extremely high.
• Second, the War on Drugs is a significant factor. Black and Latino individuals who used crack cocaine, were described as “crackheads” and were portrayed as dangerous criminals. The policy of mandatory sentencing of drug possession is a clear and frequently cited example of racially informed drug enforcement. The amount of drug possession needed to meet the mandatory minimum requirement sentence differed greatly in that the amount of powder cocaine required was 100 times the amount of crack cocaine required. This racial inequity led to 80 percent of individuals with convictions for crack cocaine being Black while less than 33 percent of individuals with convictions for powered cocaine were Black.
One must also consider our current “opiate crisis,” which recently caused more deaths to white Americans. Yet, overdose deaths due to heroin have been present in the Black community for decades prior to this current crisis. The public outcry for those lives was not present.
Some people may ask, “Is it really necessary increase the number of Black physicians?” The answer is an absolute, unequivocal yes! Studies show that Black men are more likely to agree to and follow through with preventative health recommendations when they receive treatment from Black doctors, compared to when they receive treatment by white or Asian physicians.
Others may ask, “Is it really necessary to increase the number of Black psychiatrists?” Again, the answer is an absolute, unequivocal yes! Bias against mental illness is prominent in the U.S. – especially in the Black community. A mental illness is often not understood as a true medical problem. Myths exist including mental illness descriptions as a lack of faith, weak character, or an inability to “pull yourself up by your boot straps” and push through the hard times. Some incorrectly believe that Black people do not have psychiatric disorders including Bipolar Disorder or eating disorders. Others believe that children and teenagers do not become depressed or have Attention Deficit Hyperactivity Disorder. Many believe that Black people do not commit suicide. In fact, all of these disorders are present in the Black community.
Black psychiatrists often practice in underserved settings, but they are also present in academic health centers, community mental health centers, private practice and prisons. Many psychiatry subspecialties exist outside of General Psychiatry including Child and Adolescent, Addiction, Consultation/ Liaison, Forensic, Geriatric and Public Psychiatry. Psychiatrists work in research centers, mental health settings or integrated into primary care settings. Telepsychiatry is a growing tool used by psychiatrists to provide confidential services to individuals remotely who may not otherwise have access to psychiatric care.
It is critically important that we work to address the racial, societal, educational, institutional and political factors which negatively impact our ability to recruit Black students, especially Black males, into medical school and into specialties such as psychiatry.