Trust — or a lack of it — can become a barrier when it comes to health care.

Black patients sometimes get less effective treatment than similar white patients, and sometimes that’s because they don’t trust doctors of a different race as much as they do doctors who look like them.

And yet, there are relatively few Black doctors in the U.S. The Association of American Medical Colleges reported that, in 2018, there were about 807,400 active physicians in the country and only 45,534 of them were black. Experts see it as a problem.

“Black Americans make up more than 13% of the U.S. population, yet only 5% of physicians are black,” wrote National Public Radio’s Yuki Noguchi in a story that appeared July 1. “That lack of representation isn’t just a problem within medicine … but it perpetuates a sense that medical and mental health care is not of — or for — the Black community.”

The example and insight of people such as Dr. Raegan Durant point to what can be done about that.

Durant is the medical director at Cooper Green Mercy Health Services and associate professor in the UAB Division of Preventive Medicine. He studies health disparities, among other things. His background is exceptional for black Alabamians; both his parents were lawyers, his mother eventually a federal judge, and his maternal grandparents both had master’s degrees. But Durant’s experiences as a doctor and an have given him an up-close look at what it will take to increase the numbers of Black doctors.

As Durant points out, the reasons there are so few black doctors are both long-standing and ongoing.

“I think the relatively low numbers of African Americans in the physician workforce are due to many of the same reasons that we see African Americans underrepresented in other areas. And this is an underrepresentation that has existed for decades now,” Durant said.

Noting that the AAMC shows that the number of black medical school students is just 7% of the total med school enrollment, Durant described that as “falling woefully short.”

“This has been traced to a number of things. Part of it, quite frankly is just exposure, the extent to which African American young people, when they are deciding what they want to do for a living, have exposure to African American doctors,” Durant said. “I think most of us would agree oftentimes you can only emulate what you see or what you’re aware of. If you don’t have role models or persons that you can see and who in many ways you can identify with, in terms of a racial, or probably more importantly, a similar cultural background, the career goal may seem a little bit less tangible for you.”

Beyond lack of exposure, Durant said, the cost of medical school is a barrier for black students. “I think the estimated cost of a medical school education now is just shy of a quarter of a million dollars; I think it’s $240,000 on average,” he said. “And because a disproportionate share of African Americans live with limited financial means and even in poverty, just inherently, there are fewer among the African American population who can afford either to pay out of pocket for those costs or even take out loans to cover those costs.”

Time is also a factor, Durant said.

“In order to practice, you’ve got to do residency and then in residency you’re paid like a trainee. You’re not paid like a full-fledged doctor even though you have a medical license and are practicing under the supervision of other doctors. … Time equals money,” he said. “If you are from a background already with limited financial means, you may be less inclined to spend a protracted amount of time after you’ve already invested eight years — you know, four years of undergrad, four years of medical school — then another, anywhere from three to seven years depending on your specialty choice, still working below your earning power to get more training.”  Factors tied to limited household income make becoming a doctor a more daunting pathway for African Americans, Durant said.

African American households are, on average, much poorer than those of white Americans.

A Little History

In a 2016 article in the Atlantic, Los Angeles-based reporter Karen Jordan chronicled the history of her great grandfather, one of the first Black doctors in Georgia. In the article, Jordan also outlined the struggles faced by Black doctors and how those struggles relate to the current underrepresentation of black physicians today.

She said doctors at the end of the 19th century had to be members of the American Medical Association to practice in hospitals. But membership decisions were left up to the local chapters, “which made an African American doctor hard-pressed to find a chapter that would accept him, particularly in the South,” she wrote.

Thomas Ward wrote in “Black Physicians in the Jim Crow South” that Black doctors were caught in a “self-fulfilling prophecy.”

“Black physicians were usually excluded from being able to practice at any of the hospitals in the South,” he said. “So if you’ve got a doctor who can’t practice at the hospital, and you think he’s inferior anyway, that seems to prove he’s inferior.”

Jordan’s article said the barriers didn’t end there. “The Flexner Report, a study of medical education in North America issued in 1910, dealt a devastating blow by imposing a new standard on medical colleges the majority of African American schools could not meet. It required all medical schools to be affiliated with a university as well as a hospital and stressed the importance of clinical training and having a full-time faculty.”

She wrote that at least four Black medical schools closed. “How would black doctors be educated now if they had so few schools to choose from?” she wrote.

Things improved for black doctors when formerly whites-only medical schools began to integrate in 1948, she said, but even as restrictions eased somewhat, old attitudes remained.

“When a black person walks in, whether this person is really a physician, they walk into a hospital not being perceived as a physician, but as a member of the housekeeping staff,” Vanessa Northington Gamble wrote in Making a Place For Ourselves. “So there are those biases I think black doctors still face, not the exclusion of the past but implicit biases. … Some people believe black physicians are there because of affirmative action, and they’re not as qualified as a white physician.”

In 2008, the American Medical Association issued an apology of sorts, taking ownership of its historical role in hindering the development of black doctors: “For more than 100 years, many state and local medical societies openly discriminated against black physicians, barring them from membership and from professional support and advancement. The American Medical Association was early and persistent in countenancing this racial segregation.”

 Mentors Needed

Although Black doctors aren’t barred from medical associations and Black students are allowed into medical schools today, they still face challenges their white counterparts don’t face. For example, Black med students don’t have the same level of access to mentoring, Durant said.

One reason is the scarcity of Black faculty members in medical schools, he said. “The number in the AAMC report that I was mentioning is 3% of all med school faculty is African American. So it’s an abysmally low number —lower than even the number of matriculants, which is at 7%. So if you were thinking about med school or trying to even get an experience as an undergrad in a medical school or perhaps trying to get an experience with another African American faculty member, those opportunities are just fewer and farther between,” Durant said.

That matters because many professionals benefit from mentorship and guidance from those who have already achieved what they hope to accomplish. Having a faculty mentor can significantly impact the experience of a medical student, he said.

“It’s not that white faculty can’t be perfectly effective and meaningful mentors for black students and vice versa for that matter,” Durant said. “I think the difference comes when African American students look for someone who, again, shares a cultural framework, and those folks just simply are not there or (are) there in limited numbers.

“The shared cultural framework comes into play when there are shared experiences. So maybe an African American faculty member had a similar experience or experiences as a minority in a larger class of majority students and that can be a source of encouragement. Perhaps that shared cultural framework can come into play just in, quite frankly, decompressing — helping the student at times to understand that there are others that have had the experience that the student is experiencing and have made it through with flying colors in many cases.”

That’s not just true when the shared experience is a negative one — such as encountering racist attitudes — but also true in positive cases as well, Durant said. “Some of it could just be very reaffirming,” he said.

“If I’m an African American man… who went to Howard, it might be gratifying to be able to talk to a faculty member that also went to Howard — as I watch majority faculty members do all the time with students and residents,” he said. “I listen to people reminisce about their days at Auburn, Alabama and lots of other majority institutions and they share that in common.”

Durant has experienced the value of those relationships from both sides —most recently as a faculty member. “It can be a chance encounter. It can be a one-off. But oftentimes that can be so meaningful to a student … it doesn’t have to be a longitudinal mentoring relationship. It can simply be a simple conversation,” he said.

As an example, Durant used to co-lead a course on health disparities for first-year medical students at UAB. The last time he did was a couple of years ago, he said. “Those first-year medical students are now third-year students, and some of them are even fourth-year students and still students come up to me today … and tell me how much they enjoyed the lecture and how much it meant to them that I gave the lecture.”

“It’s meaningful for them, particularly at the outset of their medical education — it literally is the first two weeks of school for them — to have an African American faculty member, quite frankly  talking about issues of race,” Durant said. “So perhaps my speaking about it, in their minds … . I probably bring more credibility in their perception. And I think while it can be a touchy subject, it’s less touchy for them to have me lecturing on it as opposed to someone else. And then I think also, for them it’s an acknowledgement that this is a learning environment where we can talk about these issues and there’s actually an African American faculty member who’s coming to talk about this — who’s been entrusted to talk about these issues. I think that goes a long way.”

Durant’s own experience as a student 20 years ago also sheds light on the value for black med students in having black faculty. “I graduated from medical school in May 2000,” he said. “It was a different time but honestly, with events of late, in some respects it wasn’t so different.”

Durant graduated from Howard University before going to one of the most prestigious medical schools in the country — with a very limited number of other black students.

“I’d had four years of nurturing and reaffirming and all of those great things that come with attending an HBCU (historically black colleges and universities). I went to Johns Hopkins for medical school. In my med school class there were six African Americans out of 120,” he said. “We had a great class — I’m hard pressed to think of any member of the class that I didn’t get along with … . However, there was a special bond with my African American classmates and a bond with the African Americans in the classes ahead of us.

“And it really was a family atmosphere. They looked out for us. They made sure that we understood what was needed for each course. And they were available if we ran into problems. And it (was a) nurturing environment that was cultivated by a black faculty member, as it turns out, a native of Alabama — Dr. Levi Watkins.”

Watkins was born in Kansas, but his family moved to Montgomery, where he became a civil rights activist. At the age of 11, he took part in the Montgomery Bus Boycott. He went on to become the chief resident of cardiac surgery at Johns Hopkins in 1971, the first Black chief resident in the institution’s history. The first doctor to ever implant a defibrillator, Watkins was an associate dean of the Johns Hopkins School of Medicine when Durant attended.

“He did not have a specific institutional role for diversity or inclusion,” Durant said. But he made sure that environment was fostered among student, trainees and faculty and was something that happened organically, “And he sort of set the tone and then everyone followed suit,” Durant said.

Having mentors help those who already have made it to medical school, and recruiting students in the first place, requires outreach, Durant said.

More Students Wanted

Colleges can get more minority students with “pipeline programs,” he said, referring to initiatives to let medical schools connect with students even before they get to college. Such programs already exist, Durant said, pointing to UAB’s Minority Health & Health Disparities Research Center.

The programs UAB has, “really take kids from sometimes as early as high school and sometimes even earlier and begin to groom them or at the very least help them cultivate their interest in science and medicine,” Durant said.

For example, UAB’s Healthcare Opportunities in Pipeline Education Portal — also known as the Hope Portal — is designed to connect “students, scholars, and faculty members with information about UAB’s many training opportunities, the majority of which are healthcare-related,” the MHRC website noted. The Hope portal is a collaborative effort of the research center and UAB’s Office of Diversity and Multicultural Affairs, which has a number of programs focused on increasing diversity at the university.

A similar initiative, called Black Men in White Coats, started by Dr. Dale Okorodudu of the University of Texas Southwestern Medical Center, aims specifically at recruiting young black males into medicine with programs even reaching out to kids in elementary school and their parents.

Durant also said that young Black students need the chance to be exposed to medicine as a career, giving them experiences that will prepare them mentally for taking on a medical education, including assurance that they have everything they need to compete for medical school.

He used his own children, now pre-teens, as an example.

“My wife is a physician. If either one of our kids were interested in medicine, we would have virtually an unlimited number of people to call to help facilitate some experience for them in medicine to expose them. Most kids don’t have that. I think the pipeline programs give them some exposure so they may have a summer experience. Certainly I think it helps them. I think they have MCAT prep and there may be some other things to kind of help them to shore up grades, but then some of those intangibles — I’m not sure that the playing field ever gets leveled.”

Durant’s kids, even at a young age, benefit from hearing their parents talk about medical careers.  But with so few black kids having doctors as parents, that “lived experience” is hard to come by for most, he said.

“But I’m wondering, are there ways in which we can approximate it so that they have a leg up as well? Because when it comes to med school admissions, everybody has good grades … everybody has good MCAT scores. So then, it’s these intangibles that end up making the difference and unfortunately … the environment and the factors that help to cultivate the intangibles are not evenly distributed in our society.”