Houston we have a problem: Diversity, equity, and inclusion in Anesthesiology Part 2
Myron Yaster MD and Lynne G. Maxwell MD
The June issue of Anesthesia and Analgesia had 3 original articles and an editorial on the diversity, equity, and inclusion failures of our profession and of our training programs. They provide insights into opportunities for improvement, potential solutions, and evidence for why this matters. To do justice to these overlapping papers, we’ve split the PAAD reviews into 2 parts; the 1st was posted yesterday, the 2nd today. As always, your thoughts and opinions on this (and other PAADs) are important to us. So please send your thoughts to me (myasterster@gmail.com) or John Fiadjoe (john.fiadjoe@childrens.harvard.edu ) Myron Yaster MD
PS: Happy 4th of July, the PAAD will return next week
Editorial
Toledo P. Expanding Horizons: How Anesthesiologists Can Improve Health Equity. Anesth Analg. 2022 Jun 1;134(6):1164-1165. PMID: 35595690 1
Original article
Nwokolo OO, Coombs AAT, Eltzschig HK, Butterworth JF 4th. Diversity and Inclusion in Anesthesiology. Anesth Analg. 2022 Jun 1;134(6):1166-1174. PMID: 35130194 2
Original article
Diallo MS, Tan JM, Heitmiller ES, Vetter TR. Achieving Greater Health Equity: An Opportunity for Anesthesiology. Anesth Analg. 2022 Jun 1;134(6):1175-1184. PMID: 35110516 3
Original article
Wixson MC, Mitchell AD, Markowitz SD, Malicke KM, Avidan MS, Mashour GA. Raising Anesthesiology Diversity and Antiracism: Launching a National Initiative. Anesth Analg. 2022 Jun 1;134(6):1185-1188. PMID: 355956914
“In the United States, racial and ethnic minorities, inner-city, rural, low-income, and less-educated populations continue to experience suboptimal health and inadequate access to high-quality health care. The need to eliminate these health disparities has been recognized for decades. However, many health care interventions designed to eliminate health disparities and to achieve greater health equity have fallen short due to gaps in knowledge and translation. Eliminating health disparity and achieving health equity require: a greater understanding of these topics among anesthesiologists; an intentional commitment from anesthesiologists; a strategic and well-organized approach by our specialty; and the identification and application of the different needed tools. Health disparity and health care disparities are distinct. According to the US Centers for Disease Control and Prevention (CDC), health disparities are “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. In contrast, health care disparities are differences in access to health insurance, use of health care resources, and in the quality of care received by socially disadvantaged groups”.3
Dr. Olubukola Nafiu and his colleagues have published several landmark papers on racial disparity and postoperative morbidity and mortality that we’ve previously discussed in the PAAD.5-11 Many of these articles are based on data collected from Electronic Health Records, Anesthesia Information management systems (AIMS), and data registries like the National Anesthesia Clinical Outcomes Registry (NACOR), the Multicenter Perioperative Outcomes Group (MPOG), the Pediatric Regional Anesthesia Network (PRAN), Wake Up Safe, and the Society for Thoracic Surgery Cardiac Anesthesia Module, among others. “However, a major limitation exists regarding the use of these large registries for understanding race and ethnic disparities because of the lack of available and accurate data on race and ethnicity in large-scale datasets”.3 Thus, “studying, improving, and addressing the comprehensiveness and accuracy of data collection across the health system will be critical in any initiatives designed to advance health equity in anesthesiology”.3 This is an obvious target for SPA’s Biomedical Informatics Special Interest Group to tackle.
Two other targets identified by Diallo et al. are the roles of professional societies and medical journals in this battle. “Professional societies can have a major influence on health care delivery by informing health policy and health care reform decisions, as well as developing and revising clinical practice guidelines, consensus statements, and position statements.”3 Our primary subspecialty society, the Society for Pediatric Anesthesia (the PAAD is now under SPA’s umbrella) has recently formed a Committee on Diversity, Equity and Inclusion and has become responsible for part of the educational program at the Society’s future annual meetings. The committee is chaired by Dr. Nathalia Jimenez of Seattle Children’s Hospital (nathallia.jimenez@seattlechildrens.org ). As with all SPA committees and SIGs, these are open to all members to join. You do not need to be appointed or recommended to join this or any other SPA committee. Sooo, as Woody Allan said, ‘Showing up is 80 percent of life.’ We would urge you to consider joining and actively participating.
The role of medical journals and their editorial priorities are also paramount because they are the primary conduit for disseminating new research findings and knowledge. “The editors of JAMA and the JAMA Network journals described and acknowledged these requisite, guiding principles for implementing a pragmatic roadmap toward meaningful and sustained DEI: leadership, inclusion, accountability, transparency, and opportunity. Operationally, the efforts include promoting fairness, equity, consistency, and clarity in use and reporting of race and ethnicity by clinical researchers, as well as a major research emphasis on addressing inequities and resulting disparities in health, treatment, and outcomes”.3
“Doing the same thing over and over again and expecting different results”, is as Albert Einstein allegedly said, “the definition of insanity”. Clearly a new approach is required. Wixson et al. 4 provide a potential solution of fixing the pipeline through their Raising Anesthesiology Diversity and Antiracism (RADAR) NIH funded program. “RADAR’s intention is collaboration, innovation, education, and mentorship—to elevate the diversity and inclusivity of our specialty for the benefit of our patients, trainees, colleagues, and greater community. It has been well described that diverse teams are more creative, innovative, and successful.” “Since anesthesiology exposure is often late in medical school curricula, engaging with high school, college, and early-stage medical students can help establish anesthesiology as a viable option before medical students are typically exposed to anesthesiology in their training, when they might already have committed to another specialty.”4 Establishing these connections with under-represented minority students early, particularly at the high school and college level, may “inspire students to consider medicine as an exciting and fulfilling path on which to embark. This exposure also produces a feeling of belonging through the creation of networking, mentoring, and sponsorship opportunities”.4
Another aim of the RADAR program is to focus on residents, fellows, and early-career faculty. “By (1) engaging underrepresented and historically marginalized populations, and (2) equipping the next generation of leaders within the field to develop an antiracist mindset that values diversity as a core pillar of the mission, we [the RADAR program] can begin the arc toward a more inclusive specialty”.4 The final aim of RADAR is to focus on our leaders within Anesthesiology. “By reimagining how ‘business gets done’ within our field, leaders can create long-lasting change that outlives the current moment”.4
NIH funding through the RADAR program is not the only way this can be done. I think as a group we can creatively come up with many solutions, a process in which we “let a thousand flowers bloom”. For example, when I (MY) was at Hopkins, I used some of my endowed chair money to sponsor 4-6 Baltimore city high school students from a local public high school to shadow me and my colleagues during summer break. I provided a stipend ($100/week plus funds for breakfast and lunch) to each of them and can say that almost all went on to college. A more formal collaboration developed by the Diversity Council of the Johns Hopkins Children’s Center and the Baltimore public school system is the MERIT (Medical Education Resources Initiative for Teens) scholars program. Through workshops, shadowing, and other experiences a pipeline is being created. Could we replicate these scholar programs using the resources, expertise, and can do attitude of the SPA membership? Could we sponsor collaborations between our practices and local public schools to help create the next generation of physicians and nurses? We are sure there are many other innovative solutions. Can you think of any, can you share your thoughts?
References
1. Toledo P: Expanding Horizons: How Anesthesiologists Can Improve Health Equity. Anesth Analg 2022; 134: 1164-1165
2. Nwokolo OO, Coombs AAT, Eltzschig HK, Butterworth JFt: Diversity and Inclusion in Anesthesiology. Anesth Analg 2022; 134: 1166-1174
3. Diallo MS, Tan JM, Heitmiller ES, Vetter TR: Achieving Greater Health Equity: An Opportunity for Anesthesiology. Anesth Analg 2022; 134: 1175-1184
4. Wixson MC, Mitchell AD, Markowitz SD, Malicke KM, Avidan MS, Mashour GA: Raising Anesthesiology Diversity and Antiracism: Launching a National Initiative. Anesth Analg 2022; 134: 1185-1188
5. Willer BL, Mpody C, Thakkar RK, Tobias JD, Nafiu OO: Association of Race With Postoperative Mortality Following Major Abdominopelvic Trauma in Children. J Surg Res 2022; 269: 178-188
6. Willer BL, Nafiu OO: Racial and Ethnic Disparities in NICU Care Practices. Pediatrics 2021; 148
7. Willer BL, Mpody C, Tobias JD, Nafiu OO: Racial Disparities in Failure to Rescue Following Unplanned Reoperation in Pediatric Surgery. Anesth Analg 2021; 132: 679-685
8. Sivak E, Mpody C, Willer BL, Tobias J, Nafiu OO: Race and major pulmonary complications following inpatient pediatric otolaryngology surgery. Paediatr Anaesth 2021; 31: 444-451
9. Nafiu OO, Mpody C, Michalsky MP, Tobias JD: Unequal rates of postoperative complications in relatively healthy bariatric surgical patients of white and black race. Surg Obes Relat Dis 2021; 17: 1249-1255
10. Mpody C, Willer BL, Minneci PC, Tobias JD, Nafiu OO: Moderating Effects of Race and Preoperative Comorbidity on Surgical Mortality in Infants. J Surg Res 2021; 264: 435-443
11. Mpody C, Willer B, Owusu-Bediako E, Kemper AR, Tobias JD, Nafiu OO: Economic Trends of Racial Disparities in Pediatric Postappendectomy Complications. Pediatrics 2021; 148