Minority Doctors Skeptical of Health Reforms : Medicine: Black doctor says he has been target of bias in peer reviews. He and others fear expansion of managed care plans run primarily by Anglos would harm minority physicians and patients.
Dr. Patrick Chavis, a Compton obstetrician and gynecologist who delivers about 1,000 babies a year, has this fantasy: He puts on a suit of armor and goes into the delivery room clad in metal from head to toe.
“I would do my deliveries in armor, so they wouldn’t know I was a black man. I’d be a hell of a doctor. They would say: ‘Look at Dr. Chavis, coming in here every day and kicking butt. What a man!”’ said Chavis, 40.
But there is no suit of armor to shield Chavis.
Instead, Chavis and other African-American and Latino physicians in California--the two largest underrepresented minority groups in medicine--must battle on a daily basis the vexing problems of being minorities among the mostly white ranks of medical doctors.
For Chavis, this has meant disciplinary actions taken against him by panels of all-white physicians and the humiliating experience of having another physician look over his shoulder while he treated his patients. It meant being singled out for criticism on procedures that white physicians performed without a question being raised, he said. And it also meant watching angrily as his patients, most of whom are receiving public assistance under the Medi-Cal program, were ushered into a room, known as “the Medi-Cal room,” that was separated from private patients.
Chavis said his experience as a black physician in a white world went something like this: “If you say anything, you become a troublemaker. If you sue anyone, then you become litigious. If you aren’t always smiling, then something is wrong with you. Then, if you are always smiling, they say: ‘Dr. Chavis must be overstretched. He deals with all these patients and he is still happy. Something must be wrong.’ ”
All this led to headaches, loss of sleep and, ultimately, the filing of a lawsuit alleging racial discrimination against Long Beach Memorial Medical Center.
Chavis won the lawsuit in September, and a jury awarded him damages of $1.1 million. Since then, a judge overturned the jury’s verdict, appeals have been filed and there could be another trial.
Beyond the immediate issues raised by his problems at Long Beach Memorial, the Compton physician’s experiences underscore some of the key problems health officials are wrestling with as they attempt to overhaul public and private health care delivery systems.
Many health care professionals believe that African-American and Latino physicians, along with their patients, will be especially vulnerable if there is a wholesale shift of public patients away from the traditional fee-for-service system into “managed care” plans, as is being contemplated in Washington, Sacramento and around the country.
The fears spring from the kind of experience related by Chavis and the historical problems of exclusion and inequality in the health industry that skew along racial and ethnic lines, such things as who gets health insurance and how much health care executives earn.
A recent nationwide study published in the Journal of the American Medical Assn. found that 39% of Latinos under age 65--or 7.2 million people--were uninsured in 1989. That rate is three times higher than the rate of uninsured Anglos and nearly twice that of uninsured African-Americans.
Another recent study, sponsored by the American College of Healthcare Executives and the National Assn. of Health Services Executives, found that African-American health executives did not rise as far as their white counterparts and earned substantially less, a median of $53,000 annually, compared to the $67,000 a year for their Anglo counterparts.
Nationally, medicine still remains a heavily white male-dominated profession. Although some groups, such as Asian-Americans and Anglo women, have been growing in numbers, the ranks of African-American and Latino physicians remain low. During the 1950s and ‘60s, when 10% of the population was black, only 2.2% of all physicians in the United States were black, according to the Assn. of American Medical Colleges. There were similarly low rates of Latinos and American Indians.
Hoping to counter what one association official called “unequal opportunity in medicine,” the association in 1970 started a program to increase the first-year medical school enrollments of the underrepresented groups to 12% of all students. Last year it finally reached that goal.
In the tangle of today’s emerging managed care systems, the concern of health officials is concentrated in two areas: finding a place for the low numbers of African-American and Latino physicians, and structuring a delivery system that will meet the needs of underserved neighborhoods shunned by mainstream medicine.
Though these problems are common enough, they are expected to become even more troublesome with a greater shift to managed care. Black physicians today practice in areas that have been shunned by many HMOs, and many of their patients, lacking insurance or enough money to pay for medical services, have been turned away by corporate medical practices.
African-American Dr. Jessie L. Sherrod, an epidemiologist and director of infection control at Martin Luther King Jr./Drew Medical Center, told a state hearing recently that “if we are excluded (from state-financed managed care systems)--and that’s what we fear most--it’s going to make for a system that is not going to work.”
Supporters of managed care believe these fears are groundless. They argue that managed care systems will not only provide better opportunities for minority physicians, but will also be better for their patients, particularly those on public assistance programs such as Medi-Cal.
Mark Davis, an administrator with the federal Health Care Financing Administration, which oversees the Medi-Cal program, said the current system is flawed because many physicians refuse to put up with the low reimbursement fees and mountains of paperwork required by the state. Many patients cannot find care. “With managed care what you are doing is buying guaranteed access,” he said. “The plan finds someone a doctor. It gives them a phone number to call 24 hours a day.”
But some minority physicians say new managed care systems will not be immune to well-established attitudes and practices, such as the peer review system that have been steeped in mainstream American medicine for years.
Built around the notion that doctors are the best judges of other doctors, peer review is supposed to be objective, based on science and what is best for the patient. It can come into play in a doctor’s life in a number of ways, from all-important patient referrals from other physicians, to acceptance of research papers in medical journals, to decisions on whether they will be granted practicing privileges at hospitals.
But Dr. Richard Butcher, a black San Diego physician and president of the National Medical Assn., an African-American physician group, said elements of peer review resembled “a good old boy system.”
“You have people in established practices, pushing and promoting and moving people they are associated with, who they have their coffee and tea with,” he said. The problem, he said, is that “the African-American, the Hispanic, the Native American just doesn’t have those kind of contacts.”
One white health industry executive agreed. After requesting that he not be identified because of possible professional repercussions, the executive said that the peer system at some hospitals is “very clubby,” almost like being admitted to an exclusive country club, a comparison made by several others in the health industry.
“It can be very prejudicial. It can be racist. . . . If you get blackballed by one of the docs on a panel (which dispense hospital privileges), you can be out of the game,” he said.
It is widely believed that the peer review process will become even more of a factor as greater numbers of doctors and patients are brought into the managed care system. The system relies to an even greater degree on physician referrals, in-house disciplinary committees and the corporate medical culture than today’s more fractionated system.
In defense of their profession, even critics of the system refuse to condemn it with broad charges of racism. Many minority physicians say that medicine is no different than other American institutions where racism exists.
They say access and advancement opportunities for minority physicians generally have improved, pointing to minority-owned firms, such as Medical Centers and the Watts-based United Health Plan, that have been thriving by treating public patients.
Dr. Clyde W. Oden Jr., president and chief executive officer of United Health Plan, an arm of the Watts Health Foundation, called fears about the role of minorities in managed care medicine “a false issue” and argues that the system is wide open.
Chavis, for one, remains unconvinced about managed care.
As a physician in private practice, Chavis makes all the decisions on medical policy for his practice. Among the key decisions he made on his own were locating his practice in Compton, deciding to treat Medi-Cal patients and stressing natural childbirth over Cesarean sections, a surgical procedure often used to extract a fetus.
Were he to join a health maintenance organization, Chavis would become an employee and would have to work where he was sent. Because mainstream corporate medical practices shun impoverished areas such as Compton, Chavis figures he probably would have to leave the area and if his employer refused Medi-Cal patients, he would have to go along with that policy as well. Though most babies these days are born naturally, many hospitals are known to have unusually high Cesarean rates, and Chavis believes that, depending on where he ended up, he would face pressure to change that approach, too.
As an African-American, Chavis has overcome long odds to become a doctor.
According to the best estimates, African-American and Latino physicians in Los Angeles County represent just more than 6% of the county’s 26,940 physicians, even though the two groups represent 48% of the population.
Chavis said that as a young man growing up in South-Central Los Angeles, where he attended Washington High School, he felt peer pressure to become an athlete or musician.
Instead, he attended Albion College in Michigan, took a degree in biology and enrolled in medical school at UC Davis. Chavis attended Davis during the period that Alan Bakke, a white student, was challenging the school’s admission practices in a landmark reverse discrimination suit. Eventually, Bakke won admission. And Chavis became something of a minor celebrity from his interviews on public television defending his right to be at the school.
“People still say: ‘Hey, I saw you on Channel 28 being interviewed,’ ” Chavis said.
After getting his degree, Chavis did his residency at the Women’s Hospital at the Los Angeles County-USC Medical Center and ranked near the top of his class of residents. He also picked up a master’s degree in public health at UCLA.
At one point, the young physician got privileges to deliver babies at three hospitals--Long Beach Memorial, St. Francis Medical Center in Lynwood and Dominguez Valley, near Long Beach and Compton.
The Compton physician said his problems did not begin until he sought to bring his nearly all minority, public assistance dependent patients to the Women’s Hospital at Long Beach Memorial, a hospital with white management and a mostly white medical staff.
The problems that developed, which Chavis contends were racially motivated but which the hospital argues stemmed from Chavis’ professional shortcomings, went on for years.
Hospital spokesman Ron Yukelson said Memorial “vigorously” disputes Chavis’ charges or racism. Yukelson contended that Memorial has “an extremely racially balanced staff.” But when asked for a racial breakdown of those given privileges at the hospital, Yukelson said he could not provide one. “Why would we want to know how many African-American doctors are on the staff? We don’t count people on the basis of race,” he said.
Chavis said he had expected the practice of medicine at Long Beach Memorial would be much the way it was at County-USC. He said he was often challenged at County-USC, but he understood the rules. “The questions were always things like: ‘What is the mechanism of this antibiotic? . . . or that hormone? . . . Why did you do this and this to that patient?’ It was technique, it was procedure, it was literature,” he said.
At Long Beach, he felt “they were screwing with me.”
Chavis seems to take much of the ups and downs in his life in medicine in stride, although there have been pressures and tensions, including a failed marriage, many sleepless nights, and a dramatic loss of weight during the trial.
He has a thriving private practice now, with a usually full waiting room and a busy schedule.
Chavis said he remembers that while studying for his master’s degree at UCLA he and other students used to analyze Compton, awed by its problems: heavily minority, low income, high crime, welfare, unemployment.
“It’s difficult to practice where I practice.” he said. To succeed on his own, he said, he works “day and night, seeing patients and doing work that a lot of people wouldn’t touch.”
Still, he said he is happy. He shrugs off the problems he encountered when he got involved with corporate medical practices.
“I developed a practice on my own without them,” he said.