Diversity

We just added two new cardiologists to our practice.  Drs. Ann Narmi and Ruby Satpathy recently completed their cardiology training and made the decision to become members of the CHI Health Heart and Vascular Specialists (either that or it was part of their parole negotiations—that’s how I ended up here).  If you were to review their curricula vitae you would come to two conclusions:

1. Both are highly qualified, impeccably educated and eminently talented cardiologists.
2. Both are women.

I highlight the latter point mainly because the addition of two women to our group, along with the two we already have, gives us far more X chromosomes than you'd find in almost any other cardiology practice.  As I’ve pointed out in a previous blog post, the field of cardiology (and in particular the subspecialty of interventional cardiology, in which both of our new doctors are trained) has traditionally been dominated by men.  Given the fact that more than half the medical students in our country are women we’re bound to see more and more female cardiologists in the future.

I really enjoy the diversity in my group and in the field of medicine in general.  Not only do we see more women in medicine but we are also fortunate to have doctors of various nationalities and backgrounds.  When I first came to Omaha I was part of a group that included doctors from nearly all seven continents (despite our best efforts we failed to recruit anyone from the Antarctica School of Medicine) and group meetings felt a little like diplomatic gatherings at the United Nations.

As a patient I don’t think I’d care what gender, nationality, religion, color, texture or flavor my doctor is—the metrics I’d employ would have more to do with competency and communication.  I wrote about this topic in another blog post last year:

Here’s my list of what I think patients value most in doctors:

1. Bedside manner, interpersonal relationship, and communication skills.  According to a survey from the United Kingdom cited on WebMD http://www.webmd.com/news/20080310/what-do-patients-want-from-doctors the most sought-after physician attributes are a “warm, friendly manner” and “a doctor who knows me well.”

2. Accessibility.  The same study cited “short waiting time” and “flexibility in selecting appointment times.”

3. Clinical competence.

Somewhere down the list falls “a diploma on the wall with an Ivy League school emblem,” probably right below “ruggedly handsome good looks” and just above “pleasant waiting room feng shui.”

I guess the list I made last year failed to take one particular thing into account: birthplace.

An interesting article was printed last week in the New York Times called “When The Doctor Doesn’t Look Like You” that addressed the issue of doctors who hail from foreign countries (currently, roughly one-quarter of all practicing physicians).  The story highlighted the bias some patients have against doctors whose skin color and accents are not typical of the local community.  I have seen this on many occasions.  I know of patients who request that they see only doctors who are from the US and other patients who have switched from doctors simply because they speak with accents that are un-Nebraskan.

The bias, by the way, relating to doctors and their provenance extends also to other factors.  Just last month I had a patient choose me as his doctor simply because I come from Utah.  He had spent many years there and wanted someone he could relate to.  I’ve had patients who refuse to see female doctors and those who want to see only female doctors.  A patient I saw last week was sent by one of our Alegent Health Clinic doctors whom he had only recently met.  I mentioned that I hadn’t met his new doctor but that I’d heard that she is quite good.  His response: “I don’t know but she’s really hot.”  (Contrary to what you might think I didn’t immediately go look her picture up on the Alegent website.  Not immediately.)

The most common bias I have encountered relates to physicians from other countries, the so-called foreign medical graduates.  I've put some thought into this bias and have concluded that there are four possible reasons a patient may object to having a foreign doctor serve as their caregiver:

1. Patients may not feel comfortable with a doctor who they perceive may have different cultural background or values than they have.  They may believe that a physician born and trained in Nebraska is far more likely to be able to relate to the problems Mid-westerners face than someone born in South America or India.
2. While all foreign medical graduates speak English they may still have accents that make it hard for some people—particularly older patients with hearing difficulties—to understand.
3. Patients may have the perception that foreign doctors are not as well trained or as capable as their domestic counterparts.
4. Finally, ethnocentricity and racism may play a role.

I sincerely hope that point number 4 constitutes only a negligible portion of this bias but I can't tell.  I've heard patients casually relate extremely discriminatory remarks to me as they describe doctors or nurses, obviously believing that I hold the same view.  Still, I have to think that the cultural and language elements (points number 1 and 2 above) are the biggest culprits among patients who don't feel comfortable with foreign doctors.

Point number 3—the assumption that doctors from outside our borders are poorly trained—can be easily debunked with empirical evidence.  In a study published this year in Health Affairs, researchers combed the records of 244,000 patients admitted to hospitals in the United States who came under the care of primary physicians.  The authors correlated the outcomes of these patients with the nationality of their doctors.  The verdict?  Doctors from other countries outperformed locally grown MDs when it came to patient survival and complications.  The authors attempted an explanation for this discrepancy in a commentary published in the Times:

“John J. Norcini, lead author of the study and president of the foundation, postulates that the differences may stem from the fact that as primary care has become less attractive for graduates of American medical schools, it has also become less competitive. ‘The foreign international medical graduates are some of the smartest kids from around the world,’ he said. ‘When they come over, they tend to fill in where the U.S. medical school graduates don’t necessarily go.’ ”

I can tell you that we are very fortunate to have extremely high-quality doctors in Omaha (who, at one point, must have also been some of the smartest kids around) and many of them are foreign medical graduates.  We have doctors of all nationalities, backgrounds, languages, genders, religious persuasions—even former Utahns—and their competency lies in their training, intelligence and dedication and not birthplace or skin color.

We now live in an age where our Surgeon General is an African-American woman, where the most trusted medical voice on television is Dr. Sanjay Gupta (of Indian descent), and where fewer and fewer doctors look like Marcus Welby, MD or Dr. Kildare.  In my group we have two cardiologists who hail from countries outside the U.S. and who happen to be two of the most talented and capable cardiologists I've met.  In an increasingly flat world it is clear that patients will serve themselves best by judging their caregivers on merit rather than by appearance.