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Britton BV, Nagarajan N, Zogg CK, et al. US Surgeons’ Perceptions of Racial/Ethnic Disparities in Health Care: A Cross-sectional Study. JAMA Surg. 2016;151(6):582–584. doi:10.1001/jamasurg.2015.4901
Across the field of surgery, racial/ethnic minorities present with higher incidence and prevalence of surgical disease and worse postoperative outcomes.1-4 Even after adjusting for contributing factors, such as socioeconomic and insurance status, differences persist in the receipt and outcomes of care.1-4 Research suggests that racial/ethnic disparities in surgical care stem from a complex interplay of patient, provider, and systematic factors.1 As health care professionals, surgeons play a key role in patients’ outcomes. Surgeons’ lack of awareness of racial/ethnic disparities in surgical care may impede actions to alleviate gaps in care. The objective of this pilot study was to assess current US surgeons’ awareness of racial/ethnic disparities in surgical outcomes and processes of surgical care.
A 21-question anonymous online survey was sent from July 1, 2013, to March 31, 2014, to a randomly selected sample of 536 practicing general surgeon members of the American College of Surgeons. The questionnaire, described in detail elsewhere,5 was adapted from work conducted among cardiologists and cardiovascular surgeons in 2004 by Lurie et al6 and Taylor et al.7 The modified survey, designed to be completed in 10 to 15 minutes, was validated based on in-depth cognitive testing performed by 5 external surgeon reviewers. The Johns Hopkins University School of Medicine Institutional Review Board approved the study. Completion of the survey required provision of written informed consent.
Data analysis was conducted from April 1, 2014, to November 30, 2015. Analytical methods for the study have been previously described.5 In brief, descriptive statistics were tabulated for each question using Pearson χ2 tests, with 2-tailed P < .05 considered significant. Responses were weighted for nonresponse bias using demographic characteristics ascertained for both respondents and nonrespondents. To further account for potential confounding owing to sex, race/ethnicity, affiliation with an academic medical center, practice setting (rural, urban, or suburban), geographic location (West, Midwest, South, or Northeast), and year of graduation from medical school, multivariable logistic regressions weighted for nonresponse bias and adjusted for significant differences in demographic factors were performed.
As previously reported, of the 536 surgeons contacted, 172 (32.1%) completed the survey.5 Most respondents were male (118 [68.6%]) and self-identified with non-Hispanic white race/ethnicity (129 [75.0%]). Asian (16 [9.3%]), non-Hispanic black (7 [4.1%]), Hispanic (11 [6.4%]), and other (9 [5.2%]) races/ethnicities comprised the remainder of respondents. A slight majority of respondents (90 [52.3%]) graduated before 2000. Most respondents practiced in urban settings (110 [64.0%]), were affiliated with an academic medical center (137 [79.7%]), and had more than 5 surgeons in their practice (101 [58.7%]).5
Overall, reported surgeon awareness of racial/ethnic disparities was low: 63 surgeons (36.6%) agreed that racial/ethnic disparities exist in health care; 20 (11.6%) thought that racial/ethnic disparities were present in their hospital or clinic; and 8 (4.7%) reported disparities within their personal practice. The Table shows the results of a stratified comparison based on differences in the demographic factors of health care professionals. Whether male or female, white or nonwhite, urban or rural, affiliated with an academic medical center or not, or graduates of medical school before vs after 2000, all groups of health care professionals exhibited a relative reduction of 54.8% to 78.9% in the likelihood of reporting racial/ethnic disparities when the practice environment moved from health care in general to their hospital or clinic. The difference was even more pronounced when considered for health care in general relative to a surgeon’s personal practice, with a relative reduction of 71.0% to 97.0% in the likelihood of reporting racial/ethnic disparities in care.
As evidence documenting racial/ethnic disparities grows and the US population becomes increasingly diverse, urgent action is needed to reduce disparities in surgical care. Health care professionals, as leaders in their field, play an essential role, whether through support of related research or implementation of changes in clinical practice. Nevertheless, despite recognition of health care professionals as a contributing factor,1 the results of our study reveal that, among a national sample of general surgeons, only one-third openly acknowledge that racial/ethnic disparities in surgical care exist.
Careful consideration and further exploration of a larger sample of health care professionals, including surgeons and surgical staff, are warranted to understand what these results mean in terms of surgeon awareness and education regarding racial/ethnic disparities, health care professionals’ willingness and ability to acknowledge the reality of personal responsibility, and a lack of understanding as to why such disparities occur.
An important step will involve investment in purported interventions to increase awareness, including workforce diversification, educational initiatives aimed at improving cultural dexterity, and collaborative endeavors led by health care professionals, such as the American College of Surgeons Committee on Optimal Access. To move from awareness to acknowledgment to action, the involvement of health care professionals must not be ignored.
Corresponding Author: Adil H. Haider, MD, MPH, Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham & Women’s Hospital, 1620 Tremont St, One Brigham Circle, Fourth Floor, Ste 4-020, Boston, MA 02120 (email@example.com).
Published Online: January 27, 2016. doi:10.1001/jamasurg.2015.4901.
Author Contributions: Ms Britton and Dr Haider had full access to all the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis.
Study concept and design: Britton, Haider.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Britton, Nagarajan, Zogg.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Britton, Nagarajan, Zogg.
Administrative, technical, or material support: Britton, Zogg, Selvarajah, Salim, Haider.
Study supervision: Zogg, Haider.
Conflict of Interest Disclosures: Dr Haider is the principal investigator of a contract from the Patient-Centered Outcomes Research Institute entitled “Patient Centered Approaches to Collect Sexual Orientation/Gender Identity Information in the Emergency Department” and a Harvard Surgery Research Affinity Research Collaborative Program Grant entitled “Mitigating Disparities Through Enhancing Surgeons’ Ability To Provide Culturally Relevant Care.” Dr Haider is also a cofounder and equity shareholder of the company Patient Doctor Technologies, Inc, which owns and operates the website https://www.doctella.com. No other conflicts were reported.
Previous Presentation: This study was presented at the 86th Annual Meeting of the Pacific Coast Surgical Association; February 20, 2015; Monterey, California.
Additional Contributions: We thank Nicole Lurie, MD, MSPH, Allen Fremont, MD, PhD, Arvind K. Jain, MS, Stephanie L. Taylor, PhD, and Rebecca McLaughlin, BA, The RAND Corporation; Eric Peterson, MD, MPH, Duke University; B. Waine Kong, PhD, JD, Association of Black Cardiologists; and T. Bruce Ferguson Jr, MD, Louisiana State University, for allowing us to use a modified version of their survey for this research. Saifuddin Ahmed, PhD, Department of Population, Family, and Reproductive Health and Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, assisted with methods to analyze survey data. Alexander J. Schupper, BA, A. Gatebe Kironji, BS, Albert T. Lwin, BS, and Marcelo Cerullo, BA, Johns Hopkins University School of Medicine, provided input on the development and conduct of this research. None of the individuals were compensated for their contribution.