Race Disparities in U.S. Nephrology Fellowship Training

Discussion

Disparities continue to exist between the racial background of ESRD patients and that of the physicians who care for them. African Americans account for 13% of the U.S. population yet only comprise 6.5% to 7.1% of U.S. medical school graduates, 5.5% of internal medicine residents, and a mere 3.8% of all nephrology fellows (31 trainees). This change in nephrology fellows is not due to a reduction in the number of nephrology trainees because the overall number has increased 19.8% nationwide between 1999 and 2008. Furthermore, there has been a 4.5% decrease in African-American nephrology faculty between 1998 and 2008 with only 28 (3.3%) academic nephrology faculty being African American (20). There are no available data on the racial makeup of nephrologists in private practice.

It has been well established that the growing burden of renal disease disproportionately affects African Americans in the United States (2,21–25). Mechanisms accounting for African Americans' predilection toward ESRD are not clearly understood. Socioeconomic status, including poverty and lower education, has been implicated. Personal health behaviors and the presence of other comorbidities may also contribute to the disparities regarding kidney disease. Clinical factors such as diabetes and hypertension have been found to account for the largest degree of excess risk from modifiable risk factors. Familial clustering of renal disease has been reported, and with the identification of several candidate genes such as MYH9, the role of genetic factors is increasingly being recognized (26,27). Access to medical care is another key factor. There is evidence that African Americans are evaluated later in the disease course and tend to have more rapid progression of their kidney disease (23).

Trust can play an integral role in patient-physician relationships. A patient's trust in his or her physician may help improve clinical outcomes (6,28–32). Distrust in health care is often cited as a major contributing factor in racial disparities because it may interfere with access to medical care and adherence to medical advice given by health care providers (30). This distrust can translate to decreased access to and knowledge of medical treatments as well as lack of willingness to adhere to medical advice and to participate in clinical trials and studies. In addition, distrust in one's health care provider is associated with decreased use of recommended preventive services (29,31,32). Perceived discrimination may be associated with stress and maladaptive health behaviors that could pose barriers to success in delivering care and adherence to recommendations (33–35). The degree to which racial discordance plays a role in the care relationship in nephrology is uncertain. Furthermore, there is no evidence that trust cannot develop between racially discordant patients and providers.

Low numbers of African-American nephrology trainees and consequently low numbers of new African-American nephrologists, both academic and nonacademic, in the midst of increasing numbers of African-American ESRD patients has important implications for ESRD care. Specific data regarding nephrologist-patient relationships and quality of care when race is concordant and trends in African-American nephrologists' practice locations are lacking and are potential subjects for future study. Nevertheless, with the most recent data showing a decrease in the number and percentage of African-American nephrology fellows in the last year, the importance of increasing minority recruitment in nephrology is magnified. However, increasing minority nephrologists will not alone solve health care disparities in ESRD. It has been recommended that movement toward culturally competent care systems be implemented nationally to address racial disparities in health care (36). In the meantime, health care providers and institutions need to strive for accessible and quality care according to the Healthy People 2010 charge (3).

Although methods for increasing cultural competence, improving equality of health care, and expanding access to care are being explored nationally, simultaneous efforts are needed to increase minority recruitment to more closely balance the race of trainees and patients (2). Such initiatives could be associated with improved patient outcomes in the ESRD program but may also have an effect on other areas of health care. Multiple strategies are needed to increase minority recruitment to the health care workforce. As suggested by the Sullivan Commission on Diversity in the Healthcare Workforce (37), the culture of health professions schools must change with new and nontraditional paths to the health professions explored. The report stressed that commitments to workforce diversity must be at the highest levels.

A greater emphasis on medical school recruitment efforts must provide the foundation for diversifying the physician workforce. Because of continued disparity in primary and secondary education among minorities, there have been initiatives to strengthen the educational pipeline by partnering academic medical centers with local school districts and colleges (38). Patterson and colleagues emphasize the great necessity for health profession-public school partnerships to increase minority access to health careers and provide a framework for the development and sustainment of such collaborations (39). Continued and, in some cases, expansion of funding of such initiatives to strengthen the educational pipeline are vital components in the effort to increase minority physicians. Partnering with minority medical student organizations such as the Student National Medical Association (SNMA) may also prove beneficial (40). Working with SNMA on local and national levels would promote earlier minority exposure to the field and provide a gateway to valuable mentoring relationships.

Other valuable resources are diversity councils. Nephrology fellowship program directors should work closely with already existing diversity councils at their institutions or work toward the development of diversity councils to identify specific challenges to minority medical student, resident, and fellow recruitment and minority faculty development (41). It is critical that minorities are recruited to stay in academics and are represented on medical school faculties and key institutional committees particularly in specialties such as nephrology in which racial disparities exist between patients and physicians. Nephrology fellows should be encouraged and supported to enter academics as clinicians, educators, or researchers.

In conclusion, continued racial disparities in CKD exist with a disproportionate number of African-American patients having kidney disease. Given the integral role of patient and physician race concordance in the therapeutic relationship, efforts to increase the number of African-American nephrology trainees may help to optimize patient care and improve outcomes.