Disparities in Orthopedics
One look at healthcare nowadays, brings us to a realty showing how profoundly affected we are with the socio-economic issues as well as the race/ethnicity issues. The effects of these factors on the quality of care provided to the patient is certainly felt when we are looking at disparities in Orthopedics. Disparity is seen when one is assessing care and more with the quality of care received around the recovery from surgical interventions.
Total joint replacements, treatment of hip fractures or spinal surgery have shown striking revelations. It is important for the one delivering care to understand well the effects of such factors on the patients they care for and the outcome after surgical treatments. Other has to certainly minimize such effects on the patient’s health or the health system itself.
It remains unclear why the disparities exist in patients with Diabetes or Cardiovascular disease as well as in patient undergoing total joint arthroplasty. Others have discussed inequities in orthopedics but could racism explain disparities in Orthopedics?
Medicine is a highly homogenous field deserving diverse population. Diversity in healthcare goes beyond the language barrier. We need to understand the mindset of the patient with a larger context about their culture, sexual orientation, gender, religious beliefs and socio-economic conditions.
In the past, the American medical profession used exclusively white male physicians in dominance while white women were also allowed to enter medical school. It is now a contrast when diversity dictates that anyone can dream to choose from a wide variety of male or female doctors with different nationalities, races colors or creeds and even sexual orientations. The homogeneity of the past has eroded with more medical school accepting more female applicants or more racial and ethnic minority applicants.
Diversity in Healthcare starts in medical school. The more the class are diverse the more the classmates benefit from different perspectives. This can improve knowledge and learning outcome for all students improving intellectual engagement, social skills, racial understanding and active thinking. This will become the armamentarium of a physician in practice.
Although three-quarters of physicians and surgeons are white, 20% are Asians, less than 5% are Black or Hispanic and less are Native American. Two Third of practicing surgeons are still male in spite of a change in the male: female ratio in the last decade. In the medical schools, students from low economic status are underrepresented and more likely to abandon their medical studies within the first two years. More students in Medical school come from affluent families with higher social economic status.
The field of Medicine remains largely a Christian profession and 2/3 of physicians in the United States are Christians, 14% are Jewish, 7% are unaffiliated, 5% are Hindu and 3% are Muslim.
We need to evaluate a little more, sexual minorities although a study at the University of Stanford found that about 1/3 of sexual minorities students chose not to divulge information fearing discrimination. Many universities have encouraged them to come forward.
African American women with breast cancer are more likely to have a higher rate of mortality than white women. African American patients in a need for a kidney transplants are more likely to wait twice the amount of time it takes for a white patient to have the same transplant. Hispanic and African American women are more likely to die from Diabetes than white patients.
Increasing diversity in healthcare, renders the field of Medicine to be more accessible to the underserved patients: African American, Hispanic, Native American and poor communities with underserved Whites. The patients also are more likely to choose a physician of similar background when given an option. African American, Hispanic and Native American physicians also are more likely to see patients with Medicaid because it is almost always the medical insurance of the Underprivileged.
Physicians will need also to show their competence in taking care of those patients in caring for different disease burdens and socio-economic realities. They need to understand the diversity of the population they serve.
I will always remember my own experience when I gained a training spot on the surgical program at Howard University Hospital. I have to say that it was the first time I felt discrimination in my life. This was exactly the 80’s. Coming from our homeland, I was unaware of the competition between residents or students to help their advancement in the same program and I found myself for a while unaware of different rules and activities, because my older residents will not “place me in the “loop”. I found out that I represented for them a foreigner in the program trying to get a position which belong to an African American. I became aware of the reason and soon their attitude changed toward me. I confronted also an Attending who accused me of not providing proper care to a patient and I have to prove him wrong. This confrontation valued me later his esteem and he became a good friend allowing me to write one scientific paper with him, paper we published in a famous Orthopedic journal.
One may uncover in recent studies that racial prejudices among physicians in America dating from the early 90’s and even earlier, was rampant. When you heard patients described as Blacks, Negroes, Chinese, Reggae, Hispanic etc., you may see the way the clinicians could be developing an unconscious bias in participating in their treatment. Orthopedic care provided to minorities is growing and those attitudes need to be avoided.
While I was chief of Orthopedic Trauma at Bridgeport Yale Health, an attending on call did not come to see a patient who was victim of a Gun Shot Wound to the knee joint. He needed to come and do a washout via arthroscopy during the evening, but did not bother coming to do it. The next morning, he tells me that there was a “low Life” patient with a gunshot wound and he would have to leave to see his high paying patient in his office. It was already 12 hours after the injury. I refused to accept the patient. I did not appreciate it and reported him. The conception of a patient being poor and without insurance pushed him to neglect him. I did not assume the care and he was forced to delegate one of his partners to deal with it. The attitude of such physicians in the 90’s was such that the color of the skin of the patient was dictating the kind of treatment they were receiving. I Kept my ground.
We know already that many orthopedic procedures are seldom performed in certain racial and ethnic minorities as seen around the country. By example, Blacks are less commonly offered a joint replacement than a Caucasian for the same condition. Worse, even after the procedure is done, attention given in the post-operative period for physical therapy by example may be reduced considerably, rendering the rate of complications higher among Blacks and other minorities with more re-admission, and complications including death. Hispanics have been found to have a significantly higher rate of infection after total joint replacement (64%) when compared to Blacks. Other studies have shown that they were also less likely to receive pain medication following their surgical treatment compared to Whites.
There are so much data around to observe such facts in any type of surgical treatment. Women and Children, Lesbian and Gays, Transgender, Underprivileged and Handicapped patients, Prisoners and even some religious group have felt the same lack of attention when they are cared for.
In 2002, the congress has started to look at these issues forcing the Institute of Medicine (IOM) to publish a report on possible solutions to those problems. Insurance coverage has also played a role in disparity. Patients with Medicaid or Medicare alone are less likely to have a total joint replacement, perhaps because of the low re-imbursement rate. Blacks with Medicare and Medicaid combined may benefit more often from a Knee or a shoulder replacement.
A study performed at Boston University found disparity around the country in relation to age, income, comorbidities, employment, education and even the way they look for insurance coverage. As noted above a combination of Medicare and Medicaid is better than Medicaid or Medicare alone.
It is possible that disparity between white women and Hispanic women or between white and black women has been almost eliminated but in black men disparity, little has changed compared to white men. Many have voiced that perhaps orthopedic surgeons may discriminate. In a study in Virginia among primary care physicians, it was found that physicians more likely associated black men with “negative words” and white men with “positive words”. At the conclusion of the study the Primary care physician agreed with the findings and more found that white patients were more cooperative and reliable.
In the Veteran Administration, it was found that Orthopedic surgeons were less likely to refer black patients with Osteoarthritis than their counterpart white patients with the same pathology for any knee or hip replacement. Once adjustment on preferences were made in the institution, the disparity disappeared.
Blacks and Whites expect different outcome on surgical treatment of osteoarthritis by example. 24% of Blacks have low expectation with Knee arthroplasty compared to 15% in Whites. In other areas of the country, this perception is not the same which may bring in the equation different factors like the patient preference or even the physician bias. Others state that Blacks may have less access to accurate information or simply be more skeptical about the surgical treatment even before meeting the surgeon.
It may be true that we are seeing great strides in welcoming a broader spectrum of physicians but a lack of diversity in Healthcare can have detrimental effect on patients by example in the transgender patient. It is difficult for a transgender to access health care because of a lack of competence of physicians in the field.
There are certainly limitations in the fact that health care workers are missing proper skills to deal with different cultures and backgrounds. Patients brings diversity and if we can understand their belief, we can provide better care. They need to find physicians who ”resemble” them with the same beliefs and cultures.
It is always beneficial to know a little about the background of the patient. If I know by example that he/she is from Haiti, prior to examine him or her, I would place on the table all the options and let him think about it prior to take a definitive approach Many physicians can’t understand the need to develop a thrust between the patient and the physician.
Augustus White from Harvard Medical School has suggested public education to improve patient’s knowledge about accessing care and participate in the decision making while providers, hospital staff and healthcare insurance workers need also to undergo training to recognize cultural differences and adapt to the situations. We may have to spend more time into research to try to eliminate the causes of disparity.
It is important for a physician to understand also traditional medicine like it is implanted in our original land of Haiti or elsewhere. We are all called to provide care to our compatriots in the United States and often in our country during medical missions, we need to remember what we have learned in Medical school: “Approach a patient as a whole and allow him to participate in the treatment”. Listen to the medical and para-medical care, he looked for prior to visiting your office and avoid judging his approaches. He may tell you about the medications, and “medicine-feuille”, he has taken. He may tell you about the people who have offered him previous archaic or paramedical treatments, but at the end, he is in front of you because nothing has worked outside of the medical word. He is ready to accept a different approach to treat his condition, away from his “mystic” world.
Actually the failure of any previous treatment has forced him to seek medical care. I have seen the same in other African countries where I had the privilege to participate in healthcare medical missions like in Ethiopia and Egypt. The way to communicate with the “Healers” in Ethiopia is the same and I applied what I learned back home talking to a “Hougan” for helping a patient in distress. Each culture may require a different approach but it is primordial to learn about the patient’s background while providing care. The world of Disparity is complex and it can take so little to gain or lose the full confidence from the one you are offering medical care.
Disparity in diversity will be the theme of our next AMHE annual convention in Panama. I invite you all to participate and learn more about the topic during the last week of July 2020.
Maxime Coles MD (2-10-2020)
1- Nelson, CL: “Disparities in Orthopedics surgical intervention”: Journal American Academy of Orthopedic Surgeons; 2007. 15 Suppl. 1: S13-17. Orthopedic.
2- Medscape Orthopedics (2017 Web MD, LLC) Aug 17, 2017.