Author: Nneoma Ubah, MD, MPH Candidate
International Anesthesia Research Society
The Daily Dose April 21, 2023
The Scholars’ Day panel, “Expanding Inclusivity in Academia: Digging Deeper into Disparities in Medical Care, Research and Academia,” held Saturday, April 15, during the IARS 2023 Annual Meeting, delved into the inequalities in healthcare with great emphasis on anesthesiology practices.
Garrett Burnett, MD, Assistant Professor of Anesthesiology, Perioperative and Pain Medicine at Icahn School of Medicine at Mount Sinai, kicked off the panel by describing disparities in healthcare which, according to the CDC, are “preventable differences in the burden of disease, injury, or opportunities to achieve health that are experienced by socially disadvantaged people.” Subsequently, he mentioned the factors that affect disparity (race, gender, sexual orientation, income, etc.) and the types, which include disparities in health outcomes, access to care, the experience of care, and monitoring/technology. After briefly summarizing these categories, he supported his analogy with evidence.
According to the Heckler report, 60,000 excess deaths were recorded among the Black population compared to Whites every year. National Healthcare Quality and Disparities Reports from 2022 also recorded that about a third of the quality metrics in Blacks was worse than that of the Whites, particularly in sepsis, postoperative hemorrhage, and post-operative deep vein thrombosis, which anesthesiologists often manage. In obstetric anesthesiology, Black patients are more likely to receive general anesthesia, which is associated with more complications than the alternative. Pediatric specialty also recorded outcome disparities with more postoperative adverse events in Black children.
Dedicated to illuminating these health inequalities, Dr. Burnett shared with the audience his research, a retrospective cohort study that explored the relationship between self-reported race and intraoperative occult hypoxemia. He found that Blacks and Hispanics had higher rates of occult hypoxemia, leading to higher Sequential Organ Failure Assessment (SOFA) scores and mortality. This corresponded with a letter in the New England of Medicine which confirmed that the pulse oximeter was overestimating the oxygen saturation of Black patients. A study conducted by Masimo (the manufacturing company) also argued that disparities did not occur in healthy volunteers, although they were evident in the patient pool.
After highlighting these studies, Dr. Burnett made some recommendations for reducing health disparities. Quality data confirms the existence of the disparities and can then be shared with national databases and monitored. In clinical care, doctors must recognize their personal biases, educate their patients and advocate for equity in their communities, according to Dr. Burnett. On the system level, an equity culture should be embedded in the values of the programs.
At this point, Matthew Wixson, MD, Clinical Assistant Professor in Anesthesiology and Pain Medicine and Associate Chair for Diversity at University of Michigan, continued by introducing an initiative he is leading, Raising Anesthesiology Diversity and Anti-Racism (RADAR), which aims to recruit, connect, and develop a diverse community of academic anesthesiologists through outreach and address some of these issues. The program works to reach people as early as middle and high school, via mentorship and resource development for leaders to promote a culture of antiracism.
For clarity, Dr. Wixson explained inclusivity as “a set of social processes that influence an individual’s access to information, sense of belonging and job security as well as social support received from others.” For inclusivity to exist, there should be a common purpose in the group, trust, appreciation of individual attributes, a sense of belonging and cultural competence, and respect, among many others. This environment encourages productivity and willingness to contribute positively.
To promote inclusivity, he recommended various strategies. Speaking up is an important step, especially in a position of power. This can drive change in a gathering where the diversity culture is nonexistent. It is also important to look within and admit to personal biases while checking in and reaching out to those affected.
In conclusion, he cited a study conducted in Oakland, CA that highlighted the positive effect of racial concordance in care. In the study, Black people were paired with White and Black doctors. A pre-posttest survey revealed that the patients were more willing to undergo all the preventive services, including the invasive ones when there was racial concordance with their doctor. He also mentioned that children of color were less likely to receive adequate postoperative analgesia, which must be addressed immediately.
Maya Hastie, MD, EdD, Associate Professor of Anesthesiology, Vice Chair for Education, Associate Program Director, Adult Cardiothoracic Anesthesia Fellowship and Co-Director, Faculty Development and Career Advancement Program at Columbia University Vagelos College of Physicians and Surgeons, concluded the panel with a discourse emphasizing the difference between diversity and inclusivity. In simple terms, diversity is “being invited to the party,” while, more importantly, inclusivity is “being asked to dance.” To further delineate these differences, she provided various statistics on gender differences at different levels of health care.
According to Association of American Medicine Colleges (AAMC) reports, 51% of medical school applicants are women and 48% graduate, only 18% are department chairs, with as low as 13% in anesthesiology alone. In clinical care, 87% of women felt their clinical abilities were doubted because of their gender, compared to only 7% of men. In medical schools, 12.5% of men experienced at least one incident of sexual harassment, while 33.7% of women admitted that they had been sexually harassed at least once. In anesthesiology, one in four women felt disrespected in their work over the past year and also tops the list in workplace harassment – with one in two women and one in five men affected. Also, only 4% of anesthesiology residents are African Americans, but they make up 22% of those dismissed from the program. This confirms a need to advocate and lead for a change.
Dr. Hastie recommended some relevant practices for this initiative. As a leader, it is essential to understand what goes on behind the scenes and people’s reasons for resisting change which may be cognitive (fixed beliefs) or emotional (fear of loss). Another critical skill is the art of persuasion which comprises focusing on the future and providing acceptable alternatives while also knowing the right time to promote change.
She concluded the panel with the eight tactics for enacting change. The first three are gaining credibility (being trustworthy even in small tasks), focusing on facts (from data and people’s stories), and helping people identify what will be preserved. Others are connecting to a bigger purpose, finding allies, diagnosing before leaping into action, making hard choices, and leading with empathy, even with those that may not agree with the work.
This panel deftly explored the various aspects of diversity, its positive effect on health outcomes, and how to promote this culture in the workplace and beyond.