Debate about whether and when to accommodate patient requests for concordant clinicians should consider evidence. This article examines how existing evidence could be used to interpret or inform ethical arguments about whether to accommodate such requests. Studies on patient-clinician concordance yield mixed and inconclusive results. Concordance might contribute to increased patient satisfaction and trust, but these results are not consistent and could be the result of clinicians’ communication skills. Given this evidence and the risk of social harm in honoring concordance requests, this article argues that patients’ concordance requests should be honored only when health care services would be denied to a patient, such as in a case of a clinician’s conscientious objection to providing a service. All other requests should be scrutinized for a reasonable ethical justification.
In this article, we review evidence about patient-clinician concordance—that is, shared characteristics like gender, race, or socioeconomic status—and discuss how it bears on the debate about whether to accommodate patients’ requests for clinicians with specific characteristics. Patients may request a clinician with a specific characteristic for a variety of reasons, including personal preference, religious values, or assumptions about who provides the best care. Some might argue that patients, as the vulnerable party, ought to have their requests accommodated but draw a line when preferences are based on socially unacceptable reasons grounded in prejudice, sexism, or racism.
To approach these ethically tricky questions, we examine evidence of the effects of patient-clinician concordance and whether it justifies accommodation. While the evidence does not resolve the ethical questions about when or why to accommodate patient requests, it can help distinguish types of cases and limit the kinds of arguments to accept to support accommodation. We start with 2 counterfactual evidence scenarios and describe commitments that would follow. Next, we discuss evidence of the effects of patient-clinician concordance, which suggests that reasons to accommodate a patient’s request for a clinician with a specific trait are limited. Finally, we examine cases in which a lack of concordance might imply that health care services would be denied to a patient. Such cases arise when patients and clinicians hold different views about what constitutes health care. We suggest a reasonableness requirement for assessing patients’ concordance requests, a higher standard than mere preference.
Accommodating Concordance Requests
We begin by proposing 2 hypothetical cases about evidence for concordance.
First, suppose there is strong evidence demonstrating that patient-clinician concordance directly improves patient outcomes. We could improve health simply by matching patients to clinicians who are “like them.” Patient requests for concordant clinicians would be justified as choices for more effective care. We could even go so far as to argue that there is a moral obligation to arrange concordance since to not do so would deny patients an effective intervention.
In this first hypothetical case, there could be negative consequences of intentionally arranging concordance despite its appearing justified. It would stretch the health system past capacity because there are not enough clinicians of a certain race or ethnicity (hereafter, “race”) and gender, like black male physicians.1 Instead of reducing health disparities between social and racial groups, in this scenario it would exacerbate them due to the lack of minority clinicians. Classifying patients by characteristics they are seeking in clinicians could also lead to increased stereotyping, social segregation, and xenophobia—intrinsically harmful social outcomes. Patients could be stratified into groups that reinforce separate but equal treatment, a harmful social paradigm (albeit one not eliminated in our own day). Another possible outcome of purposeful concordance is that it could reinforce negative patient views of clinicians as biased, views borne of social and political inequities manifest in black patients historically not being treated by white physicians.2 Even given the putative clinical benefits of concordance, such deleterious social consequences would argue against it.
In the second hypothetical case, suppose there is strong evidence that patient-clinician concordance has no effect on patient care or outcomes. In this case, accommodating patient requests for a concordant clinician would not benefit patients. Since there would not be a medical reason for concordance, the justification would rest on the value of respecting patient preferences and choice. The importance of this case is to illustrate that if there is no evidence of effects of concordance, the possible justifications for accommodation narrow.
The medical system allows patients to make many choices based on their preferences, but requesting clinicians based on their identity characteristics is different since it is founded on personal, not professional, characteristics and can harm clinicians by exposing them to discrimination. (We acknowledge that personal and professional characteristics are often closely bound up since the exercise of a profession is not a “view from nowhere”3 but of necessity subjective. We adopt this division, however, as a first approximation. For example, a clinician who is white and foreign born—both personal characteristics—may prescribe antibiotics less frequently because of her Dutch medical training, a professional characteristic.4) If there were no evidence demonstrating effects of concordance, patient requests would need to be scrutinized because of the potential harm to clinicians.
Concordance and Health Outcomes
The challenge is that the evidence of the effects of concordance lies somewhere between these 2 hypothetical cases, perhaps closer to the second: it is inconclusive whether concordance improves health outcomes. Few studies have shown any direct correlation between these 2 variables. The exception is evidence of better outcomes with language concordance between non-English-speaking pairs,5-8 although other studies discussed below have reported effects of concordance.
One argument for concordance is grounded in evidence that racial minorities receive worse quality care than their white counterparts2; concordance requests could be justified by a motivation to try to remedy this disparity. However, evidence is mixed on whether concordance alone will reduce health care disparities. Some studies found no relationship between racial concordance and improved outcomes, communication, or patient satisfaction.9-11 Other studies found that both quality and type of treatment and communication are influenced not (or not strongly) by concordance but by patients’ or clinicians’ race or gender.10,12-17 Conversely, 2 studies have reported that racially concordant patient-clinician pairs are associated with increased medication adherence8,18—presumably linked to better patient outcomes—and another study reported an association between concordance and reduced cardiovascular events.19 It is worth noting that all 3 of these studies examined racial concordance for black patients, with 2 of the studies including samples of Hispanic and Asian patients.8,18
More consistently, studies have reported that patients were more satisfied with communication and their visits and had greater trust in their clinicians when they saw either racially or socially (gender-, education-, or age-) concordant clincians.14,20-23 It seems reasonable to conclude that patients who have positive health care experiences and trust their clinicians will adhere to recommendations.24 It could also be the case that clinicians similar to patients in some respects make patients feel more justified in reporting their experience, thereby mitigating epistemic injustice that occurs if patients are not believed because of their race or gender, for example.25,26 However, here, too, the concordance evidence is mixed, since other studies have shown that it is not racial concordance but the clinicians’ interpersonal and patient-centered communication that affects satisfaction and trust.10,27-29 The evidence thus cuts 2 ways: concordant clinicians may increase patients’ trust and positive feelings about the health care encounter, but clinicians who are well trained in communication and cultural competency can also cultivate patient trust.
Without clear-cut evidence of health benefits of concordance, the reasons to accommodate a patient’s request for a certain type of clinician are limited. Although evidence about effects of certain shared characteristics is inconclusive, each patient-clinician relationship is unique, shaped by many preferences and values. In the next section, we examine the acceptability of accommodating some preferences through 2 examples. These examples form the basis of our argument that accommodating patient preferences for concordant clinicians should be dependent on reasonable justifications.
A Case for Accommodation, Sometimes
In this section, we examine 2 situations in which patient requests are motivated by evidence-based reasoning about outcomes and values. One leads to an absurd and unacceptable conclusion, and the other provides a reasonable justification for accommodation and concordance. Consider: several studies have found that, compared to male clinicians, female clinicians have better communication with patients and improved outcomes—from lower 30-day mortality rates and fewer emergency room visits to better detection rates of adenoma during colonoscopies.30-36 Assuming those studies capture true effects, which is similar to the first hypothetical case we proposed, it could be that when a patient—male or female—requests a female clinician, the reason is to receive better care. If a female patient requests a female clinician, is it because she feels more comfortable or wants to maximize the likelihood of a good outcome? Without probing the reasons, we lose these distinctions, which matter since clinicians tend to respect some requests but not others; female patients are more likely to be accommodated.37 If female clinicians do indeed have better outcomes, then all patients would be wise to request them. But this is an unacceptable conclusion since the result would be to diminish the role of an entire gender in patient care—a socially and ethically detrimental outcome. These 2 lines of argument thus suggest that the reason someone has for requesting a certain kind of clinician is relevant to decisions about whether to honor such requests—as are the implications of concordance for the health system overall.
Finally, we consider the case of a patient who asks for a specific clinician because of concerns about physician conscientious objection. Whether health care clinicians ought to be able to conscientiously object to providing certain treatments—that is, refusing to offer them on moral grounds—has been the topic of much debate.38 It is our argument that in cases in which patients would be denied a health care service because of conscientious objection, they should be accommodated if they request an alternative clinician. If a patient asks for a clinician who will perform an abortion, for example, then that request should be accommodated. Concordance of values in this instance determines whether a legitimate health care service is a priori available to a patient. Apart from ethical questions conscientious objection itself raises, we should view patient requests for a value-concordant clinician—one who will perform certain services—as reasonable.
Patient-clinician concordance when both patients and clinicians share similar values about the goals of health care and similar personal beliefs is likely to result in improved partnership in the patient-clinician relationship, and it has been linked to greater patient trust in clinicians.23 To justify a request for concordance, however, the patient should be able to provide a reasonable explanation of the need for concordance. What constitutes “reasonableness” is a difficult question, and it is in judging the reasonableness of the request as it moves from one extreme of the continuum (a clinician’s potential conscientious objection) to fuzzier areas that these requests become ethically challenging. What we have shown is that the grounds for justifying reasonableness on the basis of evidence is limited. The grounds of reasonableness and potential benefits from value-based partnership warrant further exploration. With any benefit of concordance, like communication, whether to accommodate a concordance request means thinking about value tradeoffs within health care—an important but not overriding consideration in deciding on a patient’s clinician and care pathway.
Our argument about whether to accommodate patient requests is based on evidence of clinical benefit. Given the limited evidence of clinical benefit, we should not simply accept reasons for concordance that are grounded in claims about improved health outcomes or reduced health disparities without further probing the basis of such claims. The limited evidence supports our conclusion that concordance for the sake of health outcomes should be accommodated in few circumstances, which depend on the ability of patients to access legitimate health care—as distinct from their preferences and values, which we have not explored. While concordance might be an apparent route to increasing trust, we should focus on the harder task of improving clinician communication and patient-clinician relationships.
National Academies of Sciences, Engineering, and Medicine, Medicine. An American Crisis: The Growing Absence of Black Men in Medicine and Science: Proceedings of a Joint Workshop between the National Academies of Sciences, Engineering, and Medicine and the W. Montague Cobb/NMA Health Institute. Washington, DC: National Academies Press; 2018.
Smedley BD, Stith AY, Nelson AR, eds; Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.
Nagel T. The View From Nowhere. New York, NY: Oxford University Press; 1986.
Nuffield Trust. Antibiotic prescribing. https://www.nuffieldtrust.org.uk/resource/antibiotic-prescribing. Updated July 30, 2018. Accessed February 2, 2019.
- Dunlap JL, Jaramillo JD, Koppolu R, Wright R, Mendoza F, Bruzoni M. The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients. J Pediatr Surg. 2015;50(9):1586-1589.
- Eamranond PP, Davis RB, Phillips RS, Wee CC. Patient-physician language concordance and lifestyle counseling among Spanish-speaking patients. J Immigr Minor Health. 2009;11(6):494-498.
- Fernandez A, Schillinger D, Warton EM, et al. Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med. 2011;26(2):170-176.
Traylor AH, Schmittdiel JA, Uratsu CS, Mangione CM, Subramanian U. Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter? J Gen Intern Med. 2010;25(11):1172-1177.
Meghani SH, Brooks JM, Gipson-Jones T, Waite R, Whitfield-Harris L, Deatrick JA. Patient-provider race-concordance: does it matter in improving minority patients’ health outcomes? Ethn Health. 2009;14(1):107-130.
- Phillips KL, Chiriboga DA, Jang Y. Satisfaction with care: the role of patient-provider racial/ethnic concordance and interpersonal sensitivity. J Aging Health. 2012;24(7):1079-1090.
- Schoenthaler A, Montague E, Baier Manwell L, Brown R, Schwartz MD, Linzer M. Patient-physician racial/ethnic concordance and blood pressure control: the role of trust and medication adherence. Ethn Health. 2014;19(5):565-578.
- Beach MC, Saha S, Korthuis PT, et al. Differences in patient-provider communication for Hispanic compared to non-Hispanic white patients in HIV care. J Gen Intern Med. 2010;25(7):682-687.
- Beach MC, Saha S, Korthuis PT, et al. Patient-provider communication differs for black compared to white HIV-infected patients. AIDS Behav. 2011;15(4):805-811.
- Berger JT. The influence of physicians’ demographic characteristics and their patients’ demographic characteristics on physician practice: implications for education and research. Acad Med. 2008;83(1):100-105.
- Hampton SB, Cavalier J, Langford R. The influence of race and gender on pain management: a systematic literature review. Pain Manag Nurs. 2015;16(6):968-977.
- Strumpf EC. Racial/ethnic disparities in primary care: the role of physician-patient concordance. Med Care. 2011;49(5):496-503.
- Traylor AH, Subramanian U, Uratsu CS, Mangione CM, Selby JV, Schmittdiel JA. Patient race/ethnicity and patient-physician race/ethnicity concordance in the management of cardiovascular disease risk factors for patients with diabetes. Diabetes Care. 2010;33(3):520-525.
- Adamson AS, Glass DA, Suarez EA. Patient-provider race and sex concordance and the risk for medication primary nonadherence. J Am Acad Dermatol. 2017;76(6):1193-1195.
Alsan M, Garrick O, Graziani G. Does diversity matter for health? Experimental evidence from Oakland. https://www.nber.org/mwg-internal/de5fs23hu73ds/progress?id=DFHwSs0dW6IkfsAFdGJXqrXSRhJalbkbyuOzprJwEpA,&dl. National Bureau of Economic Research working paper 24787. Published June 2018. Updated October 2018. Accessed April 12, 2019.
- Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915.
- Earl TR, Saha S, Lombe M, et al. Race, relationships, and trust in providers among black patients with HIV/AIDS. Soc Work Res. 2013;37(3):219-226.
- Persky S, Kaphingst KA, Allen VC Jr, Senay I. Effects of patient-provider race concordance and smoking status on lung cancer risk perception accuracy among African-Americans. Ann Behav Med. 2013;45(3):308-317.
- Street RL Jr, O’Malley KJ, Cooper LA, Haidet P. Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity. Ann Fam Med. 2008;6(3):198-205.
Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(4):e94207.
- Kidd IJ, Carel H. Epistemic injustice and illness. J Appl Philos. 2017;34(2):172-190.
Fricker M. Epistemic Injustice: Power and the Ethics of Knowing. Oxford, UK: Oxford University Press; 2007.
- Adams A, Realpe A, Vail L, Buckingham CD, Erby LH, Roter D. How doctors’ communication style and race concordance influence African-Caribbean patients when disclosing depression. Patient Educ Couns. 2015;98(10):1266-1273.
- Martin KD, Roter DL, Beach MC, Carson KA, Cooper LA. Physician communication behaviors and trust among black and white patients with hypertension. Med Care. 2013;51(2):151-157.
- Thornton RL, Powe NR, Roter D, Cooper LA. Patient-physician social concordance, medical visit communication and patients’ perceptions of health care quality. Patient Educ Couns. 2011;85(3):e201-e208.
- Baumhäkel M, Müller U, Böhm M. Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. Eur J Heart Fail. 2009;11(3):299-303.
- Berthold HK, Gouni-Berthold I, Bestehorn KP, Böhm M, Krone W. Physician gender is associated with the quality of type 2 diabetes care. J Intern Med. 2008;264(4):340-350.
- Dahrouge S, Seale E, Hogg W, et al. A comprehensive assessment of family physician gender and quality of care: a cross-sectional analysis in Ontario, Canada. Med Care. 2016;54(3):277-286.
- Mehrotra A, Morris M, Gourevitch RA, et al. Physician characteristics associated with higher adenoma detection rate. Gastrointest Endosc. 2018;87(3):778-786.e775.
- Ramirez AG, Wildes KA, Nápoles-Springer A, Pérez-Stable E, Talavera G, Rios E. Physician gender differences in general and cancer-specific prevention attitudes and practices. J Cancer Educ. 2009;24(2):85-93.
- Tsugawa Y, Jena AB, Figueroa JF, Orav E, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-213.
Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ. 2017;359:j4366.
- Padela AI, Schneider SM, He H, Ali Z, Richardson TM. Patient choice of provider type in the emergency department: perceptions and factors relating to accommodation of requests for care providers. Emerg Med J. 2010;27(6):465-469.
- Schuklenk U. Conscientious objection in medicine: accommodation versus professionalism and the public good. Br Med Bull. 2018;126(1):47-56.