Pandemic solutions: COVID-19 sheds light on systemic biases Black physicians face

Is the United States prepared for the next pandemic? Bird flu cases are on the rise, newly elected President Donald Trump recently removed the United States from the World Health Organization, and Robert F. Kennedy, who has a history of propagating vaccine misinformation, and attempted to suppress COVID-19 vaccine authorizations during the pandemic, is now running the Department of Health and Human Services.

If another pandemic should come our way — and experts say it will — it will be imperative to learn from the systemic consequences of the COVID-19 pandemic, such as the undue hardships endured by Black doctors.

While COVID-19-driven physician burnout increased tremendously during the pandemic, the stressors contributing to this burnout were not experienced equally among all physician populations. Minority as well as marginalized physicians were disproportionately impacted early in the pandemic compared to other physicians, with Black doctors being especially affected, according to an American Medical Association (AMA) report from 2020.  The outcomes of this reinforce the legacy of health inequities and structural racism experienced by Black Americans.

Diana Lemos, one of the authors of the AMA report, told the AmNews that she and her team decided to conduct this study after seeing many reports and articles in the media emphasizing the specific ways physicians of color were impacted by the pandemic. Through a web-based survey, she and her team examined “the specific ways that the COVID-19 epidemic affected minoritized and marginalized physicians more negatively than their non-minoritized, non-marginalized counterparts.”

The report showed that Black physicians were among those who expressed the “highest rates of burnout onset or increase due to COVID-19.” Other findings from the AMA report found that Black physicians experienced an increase in “racist treatment from colleagues or patients” and that they were among those more likely to have a lack of resources to provide COVID-19 testing and treatment. 

The lack of Black doctors

These findings are concerning given the shortage of Black doctors. Data from the AAMC’s 2023 Physician Workforce Data Dashboard shows that Black physicians represented 5.2% of the medical workforce in 2023, while United States Census data from the same year shows that Black individuals comprise 13.7% of the population. 

In addition to the lack of Black physicians, many doctors overall are leaving the medical field. A report from Definitive Healthcare said that 71,309 physicians left the workforce between 2021 and 2022, in part due to pandemic factors relating to physician burnout, as well as scarcity of staff and resources.

HIV doctor Dr. Stella Safo said that because Black and Brown physicians already experience baseline discrimination, the lack of protection and appreciation during the pandemic impacted them more intensely. 

Immediate past president of the National Medical Association, Dr. Yolanda Lawson, told the AmNews physician burnout was a national crisis that was brewing pre-pandemic, and that burnout symptoms were aggravated by the stress of COVID-19.

“I think the pandemic was just the tip of the iceberg,” Lawson said. “There’s been consolidation in health care. We know that there are more administrative tasks physicians are responsible for, and some of those factors have contributed to burnout. And then you take something like the COVID-19 pandemic and it definitely exacerbated it due to increased work hours, personal illness, [and]  personal loss — these are all still emotional impacts.”

Lawson added that Black physicians may not have “equal footing” when it comes to resources for example, compared with white doctors, contributing to heightened stress. In addition, Lawson said seeing a disproportionate amount of Black patients die emotionally affected Black doctors. She experienced these effects herself working as a physician in Dallas.

“I can personally say I had never seen that many of my patients die as I did during that time. I have never gone through something like that through such a short period of time,” said Lawson. 

An invited commentary published in 2020 signaled alarm that the COVID-19 pandemic could cause reductions in Black doctors due to various disparities experienced by the population, including the lack medical resources Black physicians had when caring for Black patients who were “overrepresented among cases of COVID-19” and because they had “more comorbid chronic conditions that increase their own susceptibility to mortality from COVID-19.”

It also noted the negative mental health impacts that Black physicians may have experienced during the pandemic, suggesting that “being responsible for providing care to a disproportionate number of patients with COVID-19 — especially at sites with inadequate resources — also places Black physicians at greater risk for developing the mental health issues seen in health care workers dealing with the pandemic, including anxiety, depression, and posttraumatic stress disorder as well as imposter syndrome, loneliness, and survivor guilt.”

The Pandemic’s impact

Dr. Janeen Marshall experienced first hand the difficulties with having a lack of resources during the pandemic, and like Lawson, saw many of her patients die from COVID-19. In November 2019, Marshall was working as a medical director at a nursing and rehabilitation center in the Bronx, which primarily served patients of color. By December, Marshall saw her patients getting sick and dying suddenly.

“People [were] coming out of the hospital and they [were] fine. And then the next day they [were] not. And then the next day they [were] dead,” Marshall said.

In March 2020, when the pandemic was reaching its height, Marshall was petrified to go to work. The nursing and rehabilitation facility’s morgue had three beds, but patients were dying 20 at a time. 

 “And at that point, nursing homes weren’t given any additional supplies,” Marshall said. “We weren’t set up like an acute hospital at all.”

On top of the pressure she experienced at work, Marshall, a new mother, lived with her father who had dementia in an apartment in the Bronx. After returning from a stressful day at work, Marshall said she would remove all her clothing at the apartment door, put her clothes in the washer and dryer, and shower. 

“This was my life for weeks,” Marshall said. 

 Marshall had to grapple with keeping her patients, her family, and herself alive. It wasn’t just fear that she felt, it was also anger at the fact that the health outcomes and the lack of resources her facility had were unique to the Bronx.

“I came back to the Bronx to practice in the Bronx because that’s where I’m from,” Marshall said. “Those are my people. I think that was also hard because me and my staff, we all look alike, and we look like the patients in the beds.”

Lemos told the AmNews that when emergencies hit physicians of color, they are likely to be overburdened because they are more likely to already be serving a population with unmet needs. In addition, physicians of color may experience burnout from working in settings that lack access to essential resources, limiting the quality of care they can provide. Burnout can also stem from experiencing racism in the workplace. 

A lack of resources

During the pandemic, Dr. Oni Blackstock, an HIV physician, researcher, and founder and executive director of Health Justice, remembers feeling like she did not have the resources to support her patients holistically when she was working at a public hospital caring for patients with HIV. This left her frustrated and disheartened. 

Blackstock told the AmNews physicians of color were more impacted by pandemic burnout because they often work at under-resourced hospitals or community-based hospitals in communities of color.

“A disproportionate burden was placed on hospitals in Black and Brown communities, impacting the providers who work there, as well as the patient care they were able to provide, and thus the outcomes for patients,” Blackstock said. She added that the stress of being one of few physicians of color was intensified by caring for the sickest patients in places with limited resources. 

While working in these low-resource settings, Safo said Black physicians were often asked to choose between themselves and their patients. 

“The choice isn’t fair because at the end of the day, we should all be able to bring our full selves into the work versus sacrificing ourselves for the work,” said Safo. “And that’s what I think a lot of Black physicians feel like they’re asked to do.” 

Many Black physicians, Safo said, were deeply impacted by the death of Susan Moore, a Black physician who contracted COVID-19 and died after being ignored and mistreated by hospital staff. 

“There’s this sense and this sentiment that these institutions do not appreciate you,” said Safo. “And if you died, they would simply replace you with the next person.”

Difficulties in direct patient care continued for Marshall when she started working as the deputy chief of geriatrics and chief of palliative medicine at the James J. Peters VA Medical Center, in the Bronx in August 2020. 

“It was infuriating to practice in that part of the Bronx for patients who really should be getting better and not even the federal system is getting it right for us,” Marshall said. “That part really, I think angered me more than anything else.”

In September 2022, Marshall returned to Mount Sinai, where she had done her residency and fellowship, as founding medical director for the Rehabilitation at Home program for Mount Sinai at Home as well as for a mid-career palliative care fellowship.

Eventually, the stress and burnout of her workload became insurmountable. Marshall had to balance many roles and nonclinical tasks like wading through an unending inbox of messages, requests, and follow-ups that far exceeded what a clinician reasonably can accomplish in a day.

The burdens of the non-patient workload drove Marshall to leave direct patient care. She now works remotely as a medical director for Biofourmis, where she oversees medical care for patients in the post-acute phase in addition to supporting efforts to design novel programs, and strategizing ways to improve patient care and program improvement. 

Leaving medicine

Many of Lawson’s colleagues left clinical medicine altogether due to the pandemic, highlighting that their mental health was impacted by the disproportionate number of Black people who suffered or died of COVID-19. Many physicians she speaks to have some level of mental fatigue and burnout that lingers from the pandemic. 

Similarly, Blackstock’s colleagues worked at hospitals with sicker patients, which contributed to some physicians she knew leaving the health care field.  

“It was the moral injury of not being able to do all we can for our patients,” said Blackstock. “Not having enough ventilators, not having enough therapists to incubate patients, not having enough medications. If people were already thinking of leaving, if people already had doubts, this was that experience that cemented it for many people.”

It is anticipated that by 2034, the overall physician shortage could intensify, with losses ranging from 37,800 and 124,000, according to a report by the Association of American Medical Colleges (AAMC). 

Lawson said if this exodus continues, the system will never stabilize and have adequate numbers to care for the population. 

Dr. Malika Fair, senior director of equity and social accountability at the AAMC, said as the population ages and medical needs become more complex, the demand for physicians is not going to be met by the current supply. With the shortage of Black physicians, there is concern that Black populations, who are more likely to be medically underserved, will have less access to health care. Physicians who come from historically marginalized racial ethnic groups, such as Black, Hispanic, Latino, and Native American populations, are more likely to serve patients who are medically underserved. 

“Physicians who represent the diversity of our nation are a key part of ensuring access to care for all Americans,” said Fair. 

In addition, when a health provider and patient share the same race, there are many associated positive health outcomes for Black patients. For example, patients are more likely to follow physician guidance. Areas where there are more Black physicians result in longer lifespans Black populations. 

“We need more Black physicians, but we also need all health care providers, regardless of race, to be able to provide care to Black patients and all patients too,” Blackstock said. “We want to work on increasing the number of Black physicians, but we also want to make sure that people are trained in a way where they are providing culturally and structurally responsive care to people.”

Finding solutions

There is no doubt that Black physicians are indispensable and integral to the medical workforce. Despite the challenges impacting this physician population, it’s not too late to retain Black doctors and grow the workforce. 

In changing these structures, Blackstock said that it is important to address and rectify the consequences of the systemic roadblocks that have prevented building the Black physician workforce. The historical roots of the shortage are multi-faceted, but can be attributed in part to the Flexner report — a 1910 study credited with dissolving a slew of medical schools, including five of seven Black medical colleges. The closure of these schools led to an estimated loss of 30,000 to 35,000 Black doctors. 

One reparation effort that Blackstock suggested includes alleviating the cost burden of medical school. Black physicians have been found to accrue higher amounts of anticipated debt from attending medical school, which has been suggested as a factor preventing future Black doctors from medical school enrollment. Blackstock said that because Black physicians tend to lack intergenerational wealth, they can be at a disadvantage when it comes to paying for medical school. 

This debt also impacts Black physicians from working in the primary care field. According to Blackstock, because Black physicians tend to work in underserved and under-resourced communities, their salaries tend to be lower, making it more challenging for Black physicians to pay off their high medical school debt. This may propel Black physicians to seek out jobs more lucrative than those in primary care, such as positions within the pharmaceutical or insurance industries. This holds true too for academia, said Blackstock, where salaries hang low compared to other health care fields. She said that loan repayments, and financial bonuses and incentives can support Black physicians pay off their high debt burden. 

Blackstock added that free tuition programs provided by historically Black medical schools can also serve to support future Black doctors. These institutions are “powerhouses for Black physicians,” according to Blackstock, turning out a large number of Black doctors and demonstrating how they make students feel supported. Medical school environments that lack strong support systems for Black students can result in them prematurely leaving their program — an occurrence Blackstock observed while attending Harvard Medical School. 

But the onus should not just be on historically Black medical colleges, as all medical schools can work towards cultivating a more diverse student population. Lawson said factors that are impacting the preservation of Black doctors include the Supreme Court decision putting an end to affirmative action and higher education being impacted by policies banning DEI. To address this, Lawson said that medical schools need to “develop broad policies that will allow for inclusiveness” which should be incorporated in the admissions process.

The admissions processes should also seek to take a holistic approach, considering all of a candidate’s talents and their background when determining whether they will be a good fit for an institution’s program, Blackstock said. Committees should also be diverse with themselves and have unified understanding regarding the importance of a diverse workforce. 

Early exposure to seeing Black physician representation is also crucial. It is imperative for young Black individuals to see that becoming a doctor is achievable and mentoring programs can support this effort. 

“You can’t be what you can’t see,” Blackstock said. 

To support under-resourced hospitals, Blackstock said that there needs to be an “equity centered funding for hospitals that bear a disproportionate burden in terms of taking care of people who are uninsured,” explaining how it’s important that these hospitals receive Medicaid Disproportionate Share Hospital Payments so that hospitals “can build up their capacity to be prepared when the next pandemic strikes.”

And while it is crucial to focus on the barriers faced by physicians of color, their experience is often the canary in the coal mine, according to Safo. The realities that impact doctors of color are still issues that affect all physicians, not just those who are marginalized. It is crucial to have conversations about the issues facing doctors of color in order to eliminate the systemic issues in health care — and to address these experiences before the next pandemic arrives.