Racial and Ethnic Disparities in Anesthesiology: History, Current State, and a Way Forward
Myron Yaster MD and Olubukola Nafiu MD
“No problem can be solved from the same level of consciousness that created it” – Albert Einstein.
To address the persistent issue of health and healthcare disparities, we must first focus on understanding the root causes. Medicine, as a microcosm of society, reflects the cultures and sub-cultures that compose it. Despite significant advancements in medicine and societal progress, health disparities remain prevalent in all racialized societies. These disparities are inevitable in any system that categorizes individuals and assigns social value based on arbitrary factors such as skin color, gender, and ability. The United States was built on such a hierarchical model, now commonly referred to as systemic racism.1
It's important to clarify that systemic racism is not synonymous with individual racism. The term doesn’t imply that everyone within the system is racist. In fact, for such a system to persist and evolve, it requires the “participation” of good people. However, even well-intentioned individuals working within a skewed system will inevitably produce outcomes that reflect the system’s design. It’s akin to attempting to perform a craniotomy after administering a caudal epidural and then being surprised when the patient feels pain—the system dictates the result.
The unacceptable reality of systemic racism leads to poorer health outcomes for minoritized patients. Numerous studies have exposed the shameful impact of implicit bias and systemic racism in healthcare. For instance, research shows that Black children receive less pain medication after injury or surgery and experience worse outcomes even after routine procedures like tonsillectomies and appendectomies.2-5
In today's PAAD, Mergler et al.6 explore the impact of structural racism and both implicit and explicit provider bias in ADULT perioperative care. The article aims to (1) summarize the scientific literature on racial and ethnic health disparities within anesthesiology and (2) propose potential solutions and recommendations for addressing these disparities. The analysis primarily reflects U.S. scholarship, which reveals unique patterns of health disparities tied to the country's historical and social constructs of race and ethnicity. It's important to note that this article does not address racial and ethnic inequities in pediatric anesthesia or palliative care subspecialties.
It is beyond the scope of the PAAD to dive deeply into all the issues raised in today’s article. And very specifically, we will not review inequities in OB care and in critical care medicine. Rather, we will concentrate on inequities in acute and chronic pain medicine and in the anesthesia core curriculum. For the rest, I’d recommend reading the article in its entirety. I’ve asked Dr. Olubukola (“Bukky”) Nafiu to assist and highlight his own research in this area. Myron Yaster MD
Original special article
Mergler BD, Toles AO, Alexander A, Mosquera DC, Lane-Fall MB, Ejiogu NI. Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward. Anesth Analg. 2024 Aug 1;139(2):420-431. doi: 10.1213/ANE.0000000000006716. Epub 2023 Dec 28. PMID: 38153872.
If we all agree that the strength of any society lies in how its most vulnerable segment is treated, then pediatric health disparities are particularly discomfiting. Children inevitably depend on their caregivers to advocate for them. However, a system that negatively impacts segments of the adult population will produce the same (if not worse) outcome in the children of such minoritized adults. Consequently, pediatric perioperative health inequity is a mirror that reflects the unfortunate ugliness of adult health inequities. It bears restating that, this does not mean that pediatric healthcare providers are “bad” people. The system is doing precisely what it was designed to do. To change the outcome, we must change the system. As simple and as daunting as this may sound, it is doable. Since it is a human system, it requires concerted human-centric will to change it. Unfortunately, we have all been socialized to accept these disparities as “inevitable”. Yet, we must be willing to constantly declare (and believe) that, whereas health variations may be normal, health inequities are not. To change the system, we cannot afford to be mired by an epidemic disengagement or the illusion of complexity.
Health disparities are driven by factors affecting specific populations, independent of healthcare utilization. These disparities are worsened by limited access to care and the quality of care received. Although pediatric perioperative disparities involve children who underwent surgery, disparities in postoperative outcomes may stem from upstream factors such as socioeconomic status, comorbidity burden, implicit biases, suboptimal preoperative care, and delayed surgical referrals. We are not going to discuss the unfortunate catalogue of pediatric perioperative disparities.
Addressing racial and ethnic disparities in pediatric perioperative outcomes require a multifaceted approach. Previous suggestions for adult surgical patients include pay-for-performance initiatives that reward hospitals for tangible efforts to reduce disparities. These should serve as incentives rather than punitive measures and could be applied to pediatric surgery. Additionally, sustained investment in universal access to high-quality healthcare could reduce disease burden and, in turn, lower postoperative mortality rates.
Inequity in Acute and Chronic Pain
“The notion that Black people are less sensitive to pain can be traced back to slavery. In a study involving White laypersons and physician trainees, a significant portion said that Black people had thicker skin than White people (58% for laypersons, 22%–40% for trainees). Holding such beliefs was correlated with giving lower pain ratings to Black people in 18 hypothetical scenarios.7”6 “Much of the literature on racial disparities in acute pain management focuses on care in the emergency department. Specifically, research has shown that Black and Latinx patients’ acute pain is consistently and significantly undertreated when they present to the emergency department for a myriad of medical complaints.”6
“There is a large body of literature on the topic of racial disparities in chronic pain care; a comprehensive review by Morales and colleagues8 found that patients of color, and especially Black patients, were more likely to have their pain undertreated despite experiencing a higher severity of chronic noncancer and cancer pain. Additionally, Black patients with chronic pain were more likely to be subjected to closer monitoring for possible opioid misuse9 despite research that shows that Black patients are less likely than White patients to misuse prescription opioids.10”6
Incorporating Inequities/Disparities and Antiracism into the Core Curriculum for Anesthesiology
Based on the maxim that “knowledge is power”, education is a powerful tool to combat systemic racism. Education feeds our imagination, and it is only through imagination that we can build empathy. A uniquely human ability, empathy is the ability to imagine yourself in someone’s shoes. Unfortunately, we cannot empathize with what we don’t know or don’t see. Recent data suggests that a substantial proportion of persons in contemporary colleges and higher institutions have never had formal instructions about race and systemic racism in the U.S. Thus, it is possible for many to pass through the educational system without learning about the vagaries of slavery and systemic racism. This critical gap in knowledge has created a crisis of obliviousness which allows health inequities to flourish. While it may be too far downstream, we can begin by educating our trainees and ourselves about health disparities.
Incorporating education on inequities, disparities, and antiracism into the core curriculum for anesthesiology is essential for addressing the systemic biases that impact perioperative healthcare. Anesthesiologists play pivotal roles in patient care, often interacting with diverse populations who experience varying degrees of access to and quality of medical services. Despite this, traditional medical training has largely overlooked the critical impact of social determinants of health and systemic racism on patient outcomes. The current medical and residency training curricula inadvertently tell our trainees that certain problems are critically important, and others are not. Failure to include health disparity training as a foundational building block of our training system is an unfortunate missed opportunity.
To close this gap, a change in curriculum that include comprehensive education on the historical context of racial inequities in healthcare, the identification and mitigation of implicit biases, and strategies to ensure equitable care in the clinical setting is needed. We should also emphasize the importance of culturally competent communication and provide tools for recognizing and addressing disparities in healthcare delivery.
By integrating these topics into anesthesiology training, the curriculum will prepare future anesthesiologists to recognize and combat perioperative health disparities. This approach is not only vital for fostering an inclusive healthcare environment but also for improving patient outcomes, particularly among marginalized groups. As the field of anesthesiology continues to evolve, such a curriculum will be crucial in ensuring that practitioners are equipped to provide equitable and compassionate care to all patients.
Finally, as human beings, our imagination and limitless capacity for empathy is our superpower. We must be willing to deploy this power to say that these disparities are unconscionable and that we are paying too high a price with the current system. We need to change the consciousness that created the current system we are in. If we stick with the same assumptions, nothing is going to change and that will be a tragedy.
References
1. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet (London, England) 2017;389(10077):1453-1463. (In eng). DOI: 10.1016/s0140-6736(17)30569-x.
2. Hansen EE, Chiem JL, Low DK, Rampersad SE, Martin LD. Enhancing Outcomes in Clinical Practice: Lessons Learned in the Quality Improvement Trenches. Anesthesia and analgesia 2024 (In eng). DOI: 10.1213/ane.0000000000006713.
3. 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. (In eng). DOI: 10.1016/j.jss.2021.07.034.
4. Sivak E, Mpody C, Willer BL, Tobias J, Nafiu OO. Race and major pulmonary complications following inpatient pediatric otolaryngology surgery. Paediatric anaesthesia 2021;31(4):444-451. (In eng). DOI: 10.1111/pan.14142.
5. Nafiu OO, Owusu-Bediako K, Chimbira WT. Unequal Rates of Serious Perioperative Respiratory Adverse Events Between Black and White Children. J Natl Med Assoc 2019;111(5):481-489. (In eng). DOI: 10.1016/j.jnma.2019.03.006.
6. Mergler BD, Toles AO, Alexander A, Mosquera DC, Lane-Fall MB, Ejiogu NI. Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward. Anesthesia and analgesia 2024;139(2):420-431. (In eng). DOI: 10.1213/ane.0000000000006716.
7. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A 2016;113(16):4296-301. (In eng). DOI: 10.1073/pnas.1516047113.
8. Morales ME, Yong RJ. Racial and Ethnic Disparities in the Treatment of Chronic Pain. Pain medicine (Malden, Mass) 2021;22(1):75-90. (In eng). DOI: 10.1093/pm/pnaa427.
9. Gaither JR, Gordon K, Crystal S, et al. Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients. Drug and alcohol dependence 2018;192:371-376. (In eng). DOI: 10.1016/j.drugalcdep.2018.05.033.
10. Schuler MS, Schell TL, Wong EC. Racial/ethnic differences in prescription opioid misuse and heroin use among a national sample, 1999-2018. Drug and alcohol dependence 2021;221:108588. (In eng). DOI: 10.1016/j.drugalcdep.2021.108588.