The Daily Dose • Sunday, April 29

Investigating, Conceptualizing and Addressing Healthcare Disparity in Anesthesiology and Perioperative Medicine

By Dr. Nawal Ragheb-Mueller, from the IARS 2018 Annual Meeting*

Saturday’s late afternoon panel on health care disparities in anesthesia and perioperative medicine began by raising some provocative and compelling questions. Who is responsible for disparities in care? What can we, as a society, do about it? What is the evidence for the extent of disparities in the perioperative realm? What is the role of anesthesiologists, if any, to effect change?

Dr. Michael Andreae, panel moderator and practicing anesthesiologist, introduced the topic by referencing the work of Dr. Donald Berwick. Thirty years ago, Dr. Berwick, a physician and former director of Children’s Hospital Medical Center, published a thoughtful paper in NEJM describing the stages of denial, grief and acceptance of some responsibility for addressing the burden of improving care for all members of society.

Dr. Andreae’s introductory remarks were followed by the insights of Dr. Jay Kaufman, who proceeded to deconstruct the myth of race. Dr. Kaufman, a Canadian epidemiologist, noted that in Canada, unlike in the U.S., federal agencies do not routinely collect and analyze data using race as a variable. He observed that the scientific consensus is that human variation is continuous, not discrete and race is a rather faulty construct. The adverse consequence of using race as a variable in health research is that it leads to de-emphasizing, or failing to examine, more significant factors such as socioeconomic status or access to care.

In case anyone doubted that disparities in treatment are reflected in the perioperative setting, Dr. Kaufman pointed to a 2015 publication in JAMA Pediatrics, which reported on the analysis of the National Hospital Ambulatory Medical Care Survey data from 2003 to 2010. The authors concluded that appendicitis pain is undertreated in pediatrics and black children are significantly less likely to receive opioid analgesia than white children.

The panel’s focus then turned to the potential sources of disparity, as Dr. Renee Navarro, physician and Vice Chancellor at UCSF, described her institution’s efforts to effect change from the ground up. She noted that there are both patient and health systems-level factors which influence disparity. In addition, unconscious (implicit) provider bias may come into play, particularly when tired, distracted, or under pressure.

UCSF, under Navarro’s leadership, has undertaken several initiatives to promote a culture of equity and inclusion. The institution engages in active outreach, seeking minority applicants to the medical school and they have focused on “in-reach”, as well as outreach, by nurturing the internal pipeline of medical students. As well, they have pursued a graduate medical education focus with a GME committee to sustain a critical mass of diverse minorities. The institution also compensates faculty for their efforts to expand diversity and inclusion and have this count in the promotions process. Their efforts have been successful as the proportion of Hispanic, African-American and female faculty has significantly increased since 2010.

The panel’s concluding speaker, Amos Jones, JD, briefly touched on enforcing fair employment practices in the academic setting and remarked on the progress made since the Civil Rights Act of 1964. Today, there is no intentional, overt discrimination but he noted there are still barriers in hiring. Mr. Jones concluded that by equalizing hiring, we are not doing a favor to the marginalized group; we are doing a favor to society at large. In his final remarks, Jones observed that based on his research, our specialty is doing a commendable job, as it has been proactive, rather than reactive. In the anesthesiology community, the issue is the pipeline and promotion. Despite progress, this is, unfortunately, a scenario fairly common in many of the medical specialties.

*Coverage of the Panel, Investigating, Conceptualizing and Addressing Healthcare Disparity in Anesthesiology and Perioperative Medicine