Expanding Equity in Anesthetic Care and Professional Advancement

Jane S. Moon, MD

A full century after the creation of Anesthesia & Analgesia (A&A), the longest-running physician anesthesiology journal in the world, we celebrate the tremendous gains made in the quality and safety of anesthetic care. However, research in recent decades has revealed persisting disparities in professional opportunity and in the delivery of anesthesia. Moderated by Thomas Vetter, MD, MPH, A&A Deputy Editor-in-Chief, the A&A Journal Symposium, “Moving the Needle: Strategies for Reducing Healthcare Disparities,” on Friday, April 14, at the IARS 2023 Annual Meeting tackled the issue of inequity at the individual, department and systems levels.

Romana Hasnain-Wynia, PhD, Chief of Academic Affairs and Public Health at Denver Health, spoke on “Why Patient and Stakeholder Engagement is Important to Advance Equity.” She described her personal experience as Past Director of the Addressing Disparities program at the Patient Centered Outcomes Research Institute (PCORI) to emphasize the importance of engaging all key stakeholders in any research endeavor aimed at expanding healthcare equity. These stakeholders include not only clinicians, caregivers, health system leaders, advocacy organizations, and payors, but also the patients themselves.

Dr. Hasnain-Wynia then pointed to Denver Health as a model “learning health system” in which all stakeholders are engaged, and internal data and experiences are systematically integrated with external evidence to advance equity in tangible ways.

Mofya Diallo, MD, MPH, Clinical Associate Professor at Children’s Hospital of Los Angeles, then spoke on “The Future of Quality and Safety Includes Health Equity: What the Anesthesiologist Needs to Know.” Dr. Diallo shared her personal journey to health equity research via a negative peripartum experience five years ago. After that difficulty, she became more attuned to the vast literature on disparities in anesthetic care leading to suboptimal patient outcomes. Some examples include differential pulse oximeter readings (Crooks 2023), disparate pediatric postoperative trajectories (Nafiu 2020), and unequal access to regional and obstetric anesthesia (Beletsky 2021, Butwick 2016).

At the same time, Dr. Diallo concluded her talk with a message of hope. Anesthesiologists, who have pioneered so many advancements in patient safety over the years, are uniquely positioned to be healthcare leaders. With our expertise in problem-solving, quality improvement, perioperative medicine, and multispecialty collaboration, there is incredible opportunity for anesthesiologists to chart the future of perioperative medicine (Gottumukkala 2023). In addition, the new Center for Medicare and Medicaid Services (CMS) requirement to meet health equity metrics for payment qualification may incentivize more physicians to do our part.

Dr. Diallo provided compelling evidence that implementing clinical care pathways like Enhanced Recovery After Surgery (ERAS) protocols has successfully reduced disparities in patient outcomes (Wahl 2018, Dela Merced 2022). She urged anesthesiologists to leverage our essential role as perioperative physicians to implement care pathways that will improve outcomes for all patients, including those from socially disadvantaged groups.

Olubukola Nafiu, MD, MS, Associate Professor at Nationwide Children’s Hospital, Ohio State University, then presented, “A Case for Personalized Mentoring” to discuss the power of effective one-on-one mentoring to promote the careers of underrepresented minorities in medicine (URiM). According to Dr. Nafiu, URiM physicians are more likely to leave academic medicine, less likely to receive grants, less likely to be promoted quickly, and less likely to seek mentorship. He confessed his own mistaken assumption early in his career that he could simply outwork everyone, stating that “genius without opportunity” is useless. He also emphasized mentorship as the “greatest act of leadership.” “Success without succession equals failure!” he said.

Dr. Nafiu proposed the acronym “RADICAL-Trust” to represent the essential attributes of an effective mentor-mentee dyad: Receptivity to discomfort, Accessibility, Durability, Inspiration, Challenge, Altruism, leaving a Legacy. He encouraged potential mentors to get to know junior URiM faculty members on a personal level and to invest meaningfully in their careers. He also encouraged potential URiM mentees to put their best foot forward and do their absolute best to facilitate the mentor-mentee relationship.

Paloma Toledo, MD, MPH, A&A Executive Editor for Diversity, Equity, and Inclusion (DEI) and Chief, Division of Obstetric Anesthesia at University of Miami, Miller School of Medicine, gave the final presentation of the session on “Creating the Framework for Medical Journals to Improve Health Outcomes.” First, Dr. Toledo congratulated A&A on its recent centennial and celebrated the vast improvements in maternal mortality and obstetric anesthesia over the past 100 years (Toledo 2022). At the same time, she noted that maternal mortality in the United States has increased in recent decades (GBD Study 2016), a tragic phenomenon that has affected socially disadvantaged races the most.

Dr. Toledo discussed the power of modern medical journals to disseminate completed research on healthcare disparities with rapid speed across the world. By mere virtue of the fact that A&A is one of the first medical journals to have a dedicated section on Healthcare Disparities, it is in a unique position to collect and share research in an effective and organized way. For example, anesthesiologists have played an essential role in developing safety bundles to reduce maternal morbidity and mortality, and journals play a crucial role in sharing this knowledge with the aim of improving clinical outcomes (Howell 2018).

After discussing the role of the medical journal in alleviating healthcare system disparities, Dr. Toledo outlined A&A’s three-pronged approach to addressing DEI issues in anesthesiology: (1) measurement of the demographics of the editorial board (and eventually reviewers and authors as well), (2) ensuring fair editorial processes, and (3) outreach and education.

A recent survey of A&A editorial board members found that 94% are in academic practice. Forty-six percent were born or raised outside of the United States. Sixty-eight percent are men, and 29% are women. Forty-nine percent identify as White, 11% as Asian, 3% as Black, and 3% as Hispanic. Age was evenly distributed. Increasing diversity among its editors, authors, and reviewers remains a high priority for the journal.

In addition, A&A seeks to ensure fair editorial processes by minimizing bias during peer review, using inclusive language, and developing DEI-related guidelines on reporting content related to diverse groups. The journal also believes in the mission of the Anesthesia Research Council to advance research activities within the specialty (Culley 2020). To that end, it is committed to mentoring early-career physician scientists in the review process and in strengthening writing and presentation skills.

Finally, Dr. Toledo warmly welcomed submissions for A&A’s upcoming October 2023 DEI-themed issue, for which she is serving as guest editor with Dr. Vetter and Crystal Wright, MD. The deadline for submissions is May 1, 2023.

Dr. Vetter concluded the session by moderating a Q&A discussion that covered a variety of topics: the wisdom and value of asking for help; the power of quality improvement projects to generate meaningful clinical research; ways that nonacademic anesthesiologists can promote health equity; and the need for more structured opportunities for research training during our residency and fellowship years.