Finding The Best Doctor For You Generations of Americans have struggled against segregation. Most of us believe in the ideal of a colorblind society. But what happens when that ideal come up against research that finds colorblindness sometimes leads to worse outcomes?

People Like Us: How Our Identities Shape Health And Educational Success

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This is HIDDEN BRAIN. I'm Shankar Vedantam. There is comfort in the familiar. That's why Marlon Wade (ph) likes to head over to his local barbershop, Wrist Action.

MARLON WADE: I just stop in.

VEDANTAM: It's on MacArthur Boulevard in Oakland, Calif. He doesn't come for a cut.

WADE: No hair, no hair. I just wear the bald head.

VEDANTAM: He comes to shoot the breeze.

WADE: (Laughter).


VEDANTAM: He points to one of the barbers, who's a friend.

WADE: That's my son's godfather. That's one of my old school teammates. We played baseball together.

VEDANTAM: Basically, Marlon likes to hang with people who know and understand him, people he grew up with.

WADE: (Laughter).

VEDANTAM: Some years ago, when Marlon was in the market for a new doctor, he looked for that same feeling of connection.

WADE: I have various choices. I had, like - I had over 20 doctors to choose from.

VEDANTAM: But one stood out. She was, like him, black and, like him, a practicing Muslim.

WADE: She gets me. I get her. We talk about life. We talk about our religion. You know, if something wrong with me, she going to let me know.

VEDANTAM: It's the kind of trusting relationship Marlon doesn't believe he'd find in a doctor of a different race.

WADE: I don't think a lot of these doctors relate to people of my skin color. Like, when it comes to heart disease, diabetes, like, a lot of these diseases can be researched and medically something done for it. But at the end of the day, my community not getting that service.

VEDANTAM: A variety of studies do suggest that black men in America often receive inferior care compared to white patients. They have the lowest life expectancy of any major demographic group. Many of the diseases they're dying from are chronic or preventable.


VEDANTAM: Now a growing body of research suggests Marlon Wade might be onto something in his choice of doctor.

OWEN GARRICK: The black doctors were able to convince more effectively the patients to take more of the preventative services compared to the nonblack doctors.


VEDANTAM: This week on HIDDEN BRAIN, we considered a simple but controversial way to improve outcomes in medicine, education and other fields. And we ask, what happens when the ideal of a colorblind society runs into hard evidence that you may get better outcomes by not being colorblind?


VEDANTAM: Where Owen Garrick was a kid growing up in the South Bronx, he lived across the street from a bunch of relatives, including his Uncle Bobby.

GARRICK: So he was the one that you could always hang out with, to the mall or to the store or to some friend's house. You can go swimming with him. He's a guy you can just jump in his car, come back at all hours of the evening, and he was your excuse, right? You know, Mom, Uncle Bobby let - you know, had me staying out all night.

VEDANTAM: But when he was 66 years old, Uncle Bobby found out he was dying of prostate cancer.

GARRICK: So he started having bone pain due to the metastases to his bone, and that brought him - and the pain brought him in. And so then he was diagnosed. He probably died a few months after he was diagnosed.

VEDANTAM: In Owen's opinion, it was a preventable death. Prostate cancer is usually slow growing. It's easy to detect.

GARRICK: He could still be very much alive and still very much active in his community and with his family but unfortunately wouldn't go in for his preventative services.

VEDANTAM: Owen says many of the older men in his family were the same way. They didn't trust doctors. They didn't get preventative care. This is the kind of story told over and over again in black America. And it's a story reflected in a grim statistic. The average life expectancy of black men is 72 years - about four years shorter than the average for white men.

GARRICK: It's not just prostate cancer. It's cardiovascular disease, stroke. It's diabetes. Most of the death is due to preventable or chronic conditions.


VEDANTAM: This is something Owen wants to change. He's a doctor and researcher. He runs Bridge Clinical Research, a company whose mission is to make the medical system work better for black Americans. Owen is tired of the bad news about black men and health care in America. He's tired of talking about the disparity in health outcomes. What Owen wants is a fix, a way to get black men, particularly low-income black men, to go to the doctor for preventative care. He wants doctors who will listen to patients and patients who will listen to doctors.


VEDANTAM: So Owen and his fellow researchers, Marcella Alsan and Grant Graziani, designed a field study to try to answer one simple question.

GARRICK: Will black men take more preventative care services if they're randomly assigned to a black doctor?

VEDANTAM: Is it possible that the race of your physician matters in terms of your own health?


VEDANTAM: To find out, Owen and his colleagues rented a medical clinic in Oakland. They recruited 14 black and nonblack doctors to staff the clinic during the study. For patients, they turned to flea markets and barbershops in and around the East Bay, places like Wrist Action where Marlon Wade likes to hang out.

GARRICK: And if you go to a black barbershop, you will have all sorts of black men in the barbershop.

WADE: Not much, but how you doin'?

GARRICK: You'll have folks who - like me. You'll have my kids at that barbershop. You'll have folks who didn't graduate from high school and their kids.

VEDANTAM: The first step was asking patrons in these places if they'd answer some basic questions. Some 1,300 men agreed to fill out a short survey about their socioeconomic status, health history and level of trust in the medical system. For these efforts, they received cash or a voucher for a free haircut plus a coupon for a free health screening. About half the men showed up at the clinic for that screening. Before their checkup, the clinic staff showed the men a picture of the doctor they'd been randomly assigned. They also asked them to select from a list of preventative care services that they'd be willing to receive.

GARRICK: Height and weight to check body mass index, blood pressure, cholesterol, which was total cholesterol and a diabetes screen, which is hemoglobin A1c.

VEDANTAM: At first, the men made similar choices.

GARRICK: They all accepted generally the same level of preventative services.

VEDANTAM: In other words, seeing the photos of the doctors did not change patients' decisions about what services to accept. Typically, the men would choose some of the services but not all. They might agree to get their body mass index and blood pressure checked but forgo the tests for diabetes and cholesterol that come with a needle stick. But what happened next changed their choices.

GARRICK: The doctor then comes in and says, OK, Mr. Smith, you've only selected these three. You know, you've only selected height and weight and blood pressure. We really recommend that you take all five because they're all recommended. They're all good for your health.

VEDANTAM: As I said, some of the black patients were randomized to receive this advice from a black doctor, some from a nonblack doctor. Did the race of the physician affect what patients did?

GARRICK: The black doctors were able to convince more effectively of the patients to take more of the preventative services.

VEDANTAM: And not just by a little - by a lot. The black doctors were about 20% more successful than nonblack doctors at getting patients to have their blood pressure and body mass measured. They were even more effective at persuading their patients to have invasive tests. For diabetes and the flu shot, the black doctors were about 50% more successful than nonblack doctors. And then came the cholesterol results.

GARRICK: There was a 72% difference in the ability of the black doctor to recommend and have the black male patient take cholesterol screening compared to the nonblack doctor.

VEDANTAM: Seventy-two percent. Now, the real-life implications of these results might be significant. High cholesterol, for instance, can lead to heart attacks, strokes. What if black patients in the real world responded to their physicians like their counterparts in the study? Owen Garrick says the gap in the United States between blacks and whites in cardiovascular disease outcomes might shrink by nearly 20%.

GARRICK: That could be 20% of the people living to see their grandkids graduate from college and high school, right? That's how I think about it.


VEDANTAM: These results suggest they might be an easy, low-cost way to save the lives of black men. Owen and his colleagues wanted to understand what was going on. Why were the black doctors so much more effective? The researchers didn't think prejudice was at play because the patients rated all the physicians, black and nonblack, as equally good. But then they discovered a clue. It was in the notes the doctors had written about their patients.

GARRICK: We found that the black doctors actually wrote more notes compared to the nonblack doctors about their patients. And often, those notes talked about their non-health care issues - a wedding is coming up; will the Warriors repeat as NBA champions? Like, so nonmedical issues.

VEDANTAM: The black doctors and black patients were connecting as human beings. They were talking about family, sports, life. It's the kind of chitchat that says, I know where you're coming from. I hear you. Marlon Wade from the barbershop made the very same point about his doctor.

WADE: She gets me. I get her. We talk about life. We talk about our religion. You know, if something wrong with me, she going to let me know.

VEDANTAM: Owen's research is part of a growing body of work that suggests matching patients and doctors by race can make a difference in health outcomes. In another study, researchers found that Florida patients assigned to physicians of their own race were 13% less likely to die while in the hospital. These results were driven almost entirely by black patients matched with black physicians.


VEDANTAM: The research raises difficult questions about our medical system, our society and our biases. The clearest takeaway from the research is that warm and empathetic communication matters. Owen Garrick believes that doctors might be taught to bridge some of the differences he observed in his study.

GARRICK: Because if communication is the mechanism, you can train - or you should be able to train nonblack doctors to more effectively communicate with their patients.


VEDANTAM: There is a more daunting takeaway. If you want better outcomes in health care, especially among the most vulnerable patients, having a more diverse pool of physicians is crucial. Owen says what he wants is for patients to have a choice. If they want to see a black doctor, they can choose one. But right now, that's often not possible.

GARRICK: Four percent of physicians are black. Blacks represent 13% of the U.S. population. So an underrepresentation.


VEDANTAM: It's important to note that choice is not just something blacks might prefer. In a follow-up survey, Owen and his team found that both black and white respondents indicated a same-race preference. Sixty-five percent of blacks surveyed said a black doctor would better understand their concerns. Seventy percent of whites said a white doctor would better understand them.

There is a third implication of Owen's research, and it feels radioactive. Given the results, I asked him, should hospitals and medical centers match patients and doctors by race, particularly when it comes to black men? Owen challenged the notion that this needed to be a radioactive idea.

GARRICK: Fraternities and sororities self-select by gender. You could argue that that's segregation. I wouldn't argue that that's segregation. But, you know, someone might. You know, a pessimist might. And I think in - the pessimists of the world might argue that recommending black physicians for black patients is segregation. I don't see it that way.

VEDANTAM: Still, Owen acknowledges he would be uncomfortable with the idea that hospitals would deliberately steer black patients to black doctors and white patients to white doctors. After all, we struggled as a nation for decades to overcome segregation. How would patients react if they were told when they showed up at a clinic, you're black so we're sending you to the black doctor?

There is some tension here, right? Because there are two values, I think, that are in conflict with one another here. I mean, there is one value that basically says, you know, we should all essentially treat one another the same. We should all get along well. We should all, you know, as Dr. King would say, look at each other's character and abilities and not the color of our skin or our gender. I mean, so that is an ideal. And the other ideal is we should trust the data, and we should trust the evidence and we should follow where the evidence leads.

And it feels like those two values, following the evidence and the data and following this norm that we have about how we'd like our society to be, these two values are in conflict.

GARRICK: Right. And they're partly in conflict because we don't live in an ideal world. And some might argue, skeptics of the world might argue, that we profess to live in an ideal world when we know absolutely the world is not ideal. So given that, given the cards you're dealt, the life you live, the world we exist in, how do you best, in our case, accomplish, improve health outcomes for all populations - and specifically in our research study, the black male population? And this issue of the race of the doctor seems to work.


VEDANTAM: And it isn't just in medicine. When we come back, the results of matching people by their identities from education, to retail, to banking.


VEDANTAM: In 1985, researchers in Tennessee launched a massive experiment to see if class sizes affected learning. There was plenty of anecdotal evidence at the time suggesting that kids did better in smaller classes, but there was no hard data to prove it. Project STAR changed that.


VEDANTAM: More than 11,000 students from kindergarten through third grade were randomly assigned to one of three class-size groups. Researchers tracked their performance over time. The experiment is now considered one of the most important education studies ever conducted. It showed that smaller class sizes led to substantial improvements in early learning, especially for minority students. In the decades since, researchers have also come to realize the random placement of kids in Project STAR could be used to study something else.

CONSTANCE LINDSAY: If you are randomizing by class size, you are also randomizing by teacher race.

VEDANTAM: This is Constance Lindsay. She is an education professor at the University of North Carolina in Chapel Hill. She said this insight led to a new research question. Do children who have a teacher of the same race do better than children who don't? Education researcher Thomas Dee was the first to analyze the Project STAR data in this new way. Did students do better if they were matched with a teacher of the same race? In 2004, he published his findings. Constance says they were striking.

LINDSAY: If you're a black student and you have a black teacher, on average, you're going to have a higher test score than a black student who has a white teacher.

VEDANTAM: The findings weren't just specific to black kids. They also held true for white students. Both black and white kids did better on math and reading achievement tests if they had a teacher of the same race.


VEDANTAM: Thomas Dee worried that his results might cause people to call for increased racial segregation in schools. He felt that would be a mistake. He first noted that his results only apply to how kids were doing during the four-year experiment. The results did not predict achievement over longer time periods. Second, he felt the best takeaway would be more study. He urged researchers to continue exploring why race dynamics matter in the classroom.


VEDANTAM: Fourteen years later, Constance Lindsay and her colleagues did just that.

LINDSAY: Basically, what we did is we said let's use the fact that we can follow the students over many, many years and see what happens to them in terms of high school dropout, whether they take a college entrance exam, and then whether they enroll in college.

VEDANTAM: In other words, they tried to answer the open question Thomas Dee had raised, do black children who are randomly assigned to black teachers perform better over the long term? What they found is those early interactions had a lasting effect.

LINDSAY: Black students in our sample who were matched to a black teacher were less likely to drop out of high school, more likely to sit for a college entrance exam - so think, you know, SAT, ACT - and then more likely to enroll in college.

VEDANTAM: The success of black students increased with every year they were matched with black teachers. Black students who spent more time with black teachers did better than black students who spent less time. These results could have huge implications. They suggest that race matching might be one way to get more at-risk black kids to stay in school and go on to higher education. Of course, Tennessee is just one state, and researchers wanted to make sure they weren't looking at a one-state phenomenon. So they turned to North Carolina. This state has a huge public school database. It contains all kinds of information about students, including their demographics, the classes they've taken and the race of various teachers over the years.

Again, the researchers looked at kids in elementary school and then tracked them over time. Now, these kids weren't randomly matched like they were in Tennessee, but still, they had exposure to black and nonblack teachers. Constance says the results told the same story. Black kids who had had black teachers were less likely to drop out of high school.

LINDSAY: And then when you finish high school in North Carolina, there's a survey you fill out that says, I will attend college, I will not attend college. It's basically, like, an intent-to-attend-college measure. And we find that more black students who are matched to black teachers report wanting to attend college.

VEDANTAM: Students who benefited the most from having a black teacher were those most at risk of dropping out, low-income black boys. The North Carolina data showed that these boys were 39% less likely to drop out of high school if they had a black teacher in elementary school - 39%. What Constance and her colleagues were seeing in education is what Owen Garrick saw in medicine - race matters.

Now, we don't know why these black teachers were making such a difference in the lives of their black students, but the researchers think a variety of forces might be at work. One could be implicit bias. Teachers may hold unconscious prejudices that negatively affect black students.

LINDSAY: That prevent them from, you know, maybe identifying kids for things like gifted programs or enacting harsher discipline punishments.

VEDANTAM: Constance says black teachers also serve as powerful role models for black students.

LINDSAY: The presence of, you know, a college-educated adult in your life makes a difference.

VEDANTAM: And then there's what's called cultural competence.

LINDSAY: Which is that teachers are able to read behavior better if you sort of share - you know, if you have cultural things that you share in common.


VEDANTAM: This seems especially true in the area of discipline. In another research project, Constance and her colleagues have found that one reason black boys sometimes get into trouble at school is because of something researchers call willful defiance.

LINDSAY: Willful defiance is, I get into an argument with the teacher and, you know, maybe I talk back, or something along those lines, and then you have to go to the principal's office.

VEDANTAM: And so what do you see with willful defiance?

LINDSAY: So we see that the drops in willful defiance are huge when you have a black teacher.


VEDANTAM: But just as there's a shortage of black doctors in America, there's also a shortage of black teachers. Nationwide, teachers in elementary and secondary schools are overwhelmingly white despite growing racial diversity among students.

LINDSAY: So for example, in the North Carolina data, both in the long-term study and in the discipline study that I have, over 50% of the black students never have a black teacher.


VEDANTAM: On a very personal level, Constance knows well the lasting impression a black teacher can leave on students.

LINDSAY: 'Cause my grandmother was a teacher here in D.C. public schools for a very long time.

VEDANTAM: Constance describes her as a warm demander.

LINDSAY: This is someone who is - you know, sort of holds you accountable for the things that you should be doing, but does it in a warm fashion.

VEDANTAM: Her name was Mae Wilson (ph).

DONALD WILLIAMS: Mae Wilson. Well, dealing with her, she was stern. She kept an orderly classroom. She was the boss, you know?

VEDANTAM: This is Donald Williams (ph). He's in his late 60s and has lived nearly all his life in Washington, D.C. In the early 1970s, Don was a student at a school that has educated generations of African-American students, Dunbar High School. This is where Mae Wilson taught.


WILLIAMS: Man, it's been a long time since I looked in this book.

VEDANTAM: From an old yearbook...


VEDANTAM: ...Don points to his younger self, a star football player at Dunbar.

WILLIAMS: Here, I was blocking. There, I was running with the football. There, I was running with the football. There, I got tackled.

VEDANTAM: Most of Don's memories from high school revolve around football. Except for that homeroom teacher, Mae Wilson, whom he's never forgotten.

WILLIAMS: She's, like, 5'5", 5'4", but her demeanor was bigger than that, you know? She didn't take a lot of, you know, nonsense. You knew it. You knew. She was like your mother away from home. But she didn't take any stuff. She didn't cut any corners.

VEDANTAM: Don says there was something about Mae Wilson that made you pay attention. Maybe it was the tailored skirt suit she wore, or her air of authority.

WILLIAMS: She always looked business. She always looked business. She never came in a nightclub dress, or something like that. She always looked professional. So that's another message that you saw in her, that she was - she'd stick to the rules of being on time, doing things that you need to do, not being rowdy, controlling yourself in public.

VEDANTAM: Her lessons ultimately stuck and became life lessons for Don. I asked him if it made a difference to him that Mae Wilson was black. He told me the question was a no-brainer - yes, of course, it made a difference.

WILLIAMS: As a black kid, you can relate better when you see someone in the position that you're in 'cause if you're not black, you can't understand what I'm saying. You can - yeah, you can say it 'cause it's the right thing - oh, I under - no. You don't. You couldn't possibly know. 'Cause you're not black.

VEDANTAM: Don has the same feeling about his football coaches. He says shared identity often led to trust.

WILLIAMS: Like I said, a kid needs to see someone who's been there. It's easy for you to talk it when you got it. It's easy for a rich man to tell you to save your money. He got money. How can a rich man tell a poor man what's going on, what life is about? It's got to be someone that knows the avenues to go to that someone that's black that's been through it. You know, you got to - and then, you know, that's his ticket. That's his motivation there to show you what's - how it can be done.

VEDANTAM: Giving students the feeling that they are understood by their teachers, who can say this is a bad idea? But if you zoom out, putting this idea into practice runs into all sorts of problems related to history, politics and optics. I asked Constance Lindsay about this.

Let's say you're the principal of a school, and you have one black teacher in second grade, and you have, let's say, 15 black students spread across five sections of second grade. Would you assign all those 15 students to the black teacher?

LINDSAY: I probably would not do that. If I had students that in that particular set of 15 that were particularly disadvantaged, I might. I might also explore ways in which teachers could co-teach so that, you know, all of those 15 students would have the opportunity to interact with that teacher. But I definitely wouldn't advocate sort of segregating them into one class.

VEDANTAM: Why not? That's what your data show works.

LINDSAY: That is what the data show that works. But I think we agreed that segregation is bad.

VEDANTAM: But I think this is what makes the paper really, really tricky, which is it's actually suggesting that's something that we thought was a good thing might have an outcome that is not such a good thing.

LINDSAY: That's right. That's right. So I guess if you held a gun to my head and you said I had to pick between segregating students and, you know, making sure that students had a black teacher, I would pick that they had a black teacher.

VEDANTAM: So you actually would put the students in the same class then?

LINDSAY: If you said I had to.


VEDANTAM: No, I guess what I'm asking you is not so much whether I have to but, you know, if you looked at the data and said that you are improving the odds of students by 10, 15, maybe 20%, and you did not do that thing that could improve their odds by 10, 15, 20%, I mean, that is immoral.

LINDSAY: You could say that. You could say that. I mean, if I were a parent of a black boy, and there was one black male teacher in the school, I would go tell the principal to assign my child to him.


VEDANTAM: There is some evidence the race-matching effects we see in medicine and education also show up in other spheres. At Temple University, Derek Avery and his colleagues found that customers at a retail store who interacted with sales agents of the same race had higher levels of satisfaction. This was especially true in areas where racial minorities were a larger share of the customer base.


VEDANTAM: Columbia University's Raymond Fisman found in a study conducted in India that ethnic and religious matching between bankers and customers increased the likelihood of loans being repaid. It also lowered the cost of loans because banks perceived there was a lower risk in lending money.


VEDANTAM: Other workers observed that gender can act in similar ways to racial or religious identification. Brad Greenwood at the University of Minnesota found that more women in Florida survived a heart attack when their doctor was a woman rather than a man.


VEDANTAM: At the University of Massachusetts, social psychologist Nilanjana Dasgupta has found that female students in calculus classes were more engaged in the subject when they had a female professor rather than a male professor.

NILANJANA DASGUPTA: Just having a female professor ends up making women feel they'll do better in the class or making them feel more confident, making them feel that they care more about math than when the same course material, same exam, same syllabus is taught by a male professor.


VEDANTAM: This is important because calculus is a gateway class to degrees in careers in math and science, where women are currently underrepresented.


VEDANTAM: There are three lessons from all these examples. The first is that we really need doctors and teachers and loan officers and store clerks from different races and different backgrounds. It can have tangible and measurable outcomes. The second lesson is that if we want to be understood by people who are different from us in some way, it's going to take work. You can't just assume that your job begins and ends with teaching a course or diagnosing the patient. You have to make a connection with the human being across from you.

The final lesson has to do with a seemingly contradictory effect of diversity. In an earlier episode of HIDDEN BRAIN, The Edge Effect, we talked about how diversity boosts creativity and innovation. By contrast, here we've seen how connecting with people who are like us can produce better outcomes. One explanation for this contradiction lies in what you are trying to achieve. You want novelty and creativity? Those flourish from bringing together different perspectives. But if you want trust and communication, those come easier when we have things in common.


VEDANTAM: This week's episode was produced by Jenny Schmidt and Parth Shah. It was edited by Tara Boyle and Rhaina Cohen. Our team includes Laura Kwerel and Thomas Lu.


VEDANTAM: Our Unsung Hero this week is Jeff Rogers. Jeff helps to run two of our sister NPR shows, the TED Radio Hour and How I Built This. He played an early role in helping get HIDDEN BRAIN off the ground. He's also the kind of person you want to have when things are changing quickly around you. Jeff can be coach, friend and taskmaster. He has an uncanny ability to stay calm, which is why so many people say whenever they have a problem, I'm sure Jeff can help with that.


VEDANTAM: For more HIDDEN BRAIN, you can find us on Facebook and Twitter. If this episode reminded you of someone who connected in a meaningful way with you, whether in the classroom, the doctor's office or at work, please share this episode with that person. Tell them the impact they had on your life.


VEDANTAM: I'm Shankar Vedantam, and this is NPR.

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