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The Role of Pediatric Surgeons in Advancing Public Health

By Oluwatomilayo Daodu, MD, MPH, FRCSC and
Shahrzad Joharifard, MD MPH FRCSC ​

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Citation

Daodu O, Joharifard S. The role of pediatric surgeons in advancing public health. HPHR. 2021; 32.

Pediatric surgery is a decidedly niche specialty comprised of a small but mighty group of professionals who manage both common and extraordinarily rare surgical diseases affecting patients ranging from premature neonates to adolescents. While pediatric surgeons proudly bear the responsibility of improving patient’s and their families’ health, addressing public health challenges is tied to that responsibility.  Surgical care plays an essential role in preventing disability and death worldwide.1

 

 Pediatric surgery, more specifically, is critical for treating congenital anomalies, life-threatening injuries, and many childhood cancers. Yet, while there has been increasing recognition of pediatric surgery’s essential role in mitigating disparities in global child health,1,2 the role of pediatric surgeons in addressing public health concerns has often been neglected. 

 

Given the numerous public health disparities affecting children and youth, pediatric surgeons must lead and advocate for equity in child health.3,4

 

Morbidity and mortality due to firearms, non-accidental trauma, motor vehicle accidents, and all-terrain vehicles (ATVs)  require urgent attention from public health systems. This article, however, will not focus on trauma. This is because pediatric surgeons have long engaged in advocacy to prevent unnecessary injury and death due to trauma in children. Instead, we will focus on two critical public health issues requiring urgent attention: disparities due to systemic and structural racism and decreased access to quality care for children living in remote and rural areas. In fact, the American Pediatric Surgery Association (APSA) has endorsed several initiatives to help address these critical inequities.5-7

 

The ways in which our social infrastructure, health systems, and educational networks perpetuate racism are well documented. A legacy of systemic racism in healthcare disproportionately disadvantages patients who identify as Black, Indigenous, and People of Colour (BIPOC).  Pediatric surgeons commonly treat patients in their most vulnerable moments when systemic racism can have its most devastating impact. In outpatient settings, however, these impacts may be more subtle. Racial disparities in child health outcomes are striking and particularly relevant to pediatric surgery. A recent landmark study identified higher rates of both postoperative complications and mortality in otherwise healthy Black children compared to Caucasian children in the United States.8 This study is only the most recent in a long line of published research detailing inferior surgical outcomes, differential access to healthcare services, and substandard experiences within the health system.9-13 Finally, healthcare workers’ biases have been shown to lead to diagnostic delays and/or errors, differential treatment of pain for BIPOC children, and a breakdown in communication between health practitioners and BIPOC families.14

 

Merely acknowledging the harmful effects of systemic racism on BIPOC children is grossly insufficient. Instead, as pediatric surgeons, our professional responsibility includes working to transform our societies and health systems to prevent these harms from occurring actively. Changing individual behaviour or surgical practices is not enough. By embracing concrete solutions that help to end injustice, pediatric surgeons can better care for patients and their families and contribute to dismantling the systemic biases that are entrenched in our institutions and governments. Pediatric surgeons can do this by developing strategies to address structural and systematic barriers to providing optimal care for BIPOC patients and other marginalized and underserved patients. They must become active advocates within their hospitals, organizations, and local and national governments. Doing so will allow pediatric surgeons to influence strategies that enhance diversity, inclusion, and equity in medicine and society at large. 

 

Access to healthcare is essential for pediatric patients and their families. Children living in rural and remote settings face challenges in accessing subspecialist care. Geographic barriers to accessing subspecialty care result in poorer quality of care, morbidity, and even mortality, not to mention undue financial and personal stress for families.15  Compared to children living in urban settings, children living in rural settings have worse outcomes following admission to tertiary hospitals. This disparity is explained in part by the fact that rural children are frequently more medically complex and also have multiple socio-economic barriers to accessing care.15 In a large and sparsely populated country such as Canada, the impact of living far away from a tertiary pediatric hospital is stark.16 Nearly one-quarter of all Canadian children live more than 100km away from the closest pediatric surgeon, and these children predictably have decreased access to healthcare and inferior outcomes. 

 

17,18  Furthermore, research has shown that inferior outcomes for common pediatric procedures such as appendectomy are governed more by a patient’s geographic location than other socio-economic factors.19

 

While telemedicine and remote access clinics can improve access to subspecialty surgical care, the lack of access to quality internet and imposed insolation during the COVID-19 pandemic, have revealed these interventions’ limitations.20  These initiatives alone cannot address the many factors that impact access to care since most surgical interventions will ultimately require transfer to a tertiary pediatric hospital. Thus, interventions considered for children living in rural and remote communities should be developed with a comprehensive understanding of children and their families’ needs, with utmost attention paid to financial, social, and cultural barriers to accessing care.  

Practical solutions can be considered for pediatric surgeons to address concerns about equity. The first solution is personal and peer education. The APSA ExPERT (Exam-based Pediatric surgery Educational Reference Tool) now allows Pediatric Surgeons to gain continuing medical education (CME) credits for going through a custom pediatric surgery-specific literature review on diversity, equity, and inclusion. Major pediatric surgery meetings and conferences, including those of APSA, the Canadian Association of Pediatric Surgeons, have included sessions about equity, diversity, and inclusion as parts of their primary program. Further, APSA has committed to and has started to initiate strategies that increase diversity among pediatric surgical trainees.6

 

Pediatric surgeons are uniquely positioned to influence policies related to improving child health. This advocacy should not be limited to surgical patients alone. Disparities related to race, ethnicity, and geography affect all pediatric patients, not just those requiring surgical care. To date, only one association of pediatric surgeons, APSA, has formally published, developed, outlined, and begun the implementation of concrete solutions to address these critical issues in care.  While other organizations are undoubtedly considering statements and solutions of their own, it is imperative that this work is publicly declared and followed through.  Pediatric surgery associations must make this a priority because the care that we provide for children will directly impact our entire population’s health. As advocates for child health, we must think through a public health lens and address systemic inequities in children’s care. 

References

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  2. Ullrich S, Kisa P, Ozgediz D. Global children’s surgery: recent advances and future directions. Curr Opin Pediatr. 2019;31(3):399-408. doi:10.1097/MOP.0000000000000765.

  3. Chandran A, Hyder AA, reviews CP-AE, 2010. Global Burden of Unintentional Injuries and an Agenda for Progress | Epidemiologic Reviews | Oxford Academic. doi:10.1093/epirev/mxq009.

  4. Stewart BT, Abantanga FA. Pediatric Trauma: Epidemiology, Prevention, and Control. In: Pediatric Surgery. Springer, Cham; 2020:269-278. doi:10.1007/978-3-030-41724-6_25.

  5. Waldhausen J, Barksdale E, Vacanti J, Langham M, Arca M, Dillon P, Hayes-Jordan A, Reynolds E. The APSA Board of Governors enthusiastically endorses the position paper “Diversity, Equity, and Inclusion: A Strategic Priority for the American Pediatric Surgical Association”. J Pediatr Surg. 2020 Oct 31:S0022-3468(20)30777-6. doi: 10.1016/j.jpedsurg.2020.10.024.

  6. Morrison ZD, Reyes-Ferral C, Mansfield SA, et al. Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association. Journal of Pediatric Surgery. 2020;0(0). doi:10.1016/j.jpedsurg.2020.11.011.

  7. Alaish SM, Powell DM, Waldhausen JHT, Dunn SP. The Right Child/Right Surgeon initiative: A position statement on pediatric surgical training, sub-specialization, and continuous certification from the American Pediatric Surgical Association. Journal of Pediatric Surgery. 2020;55(12):2566-2574. doi:10.1016/j.jpedsurg.2020.08.001.

  8. Nafiu OO, Mpody C, Kim SS, Uffman JC, Tobias JD. Race, Postoperative Complications, and Death in Apparently Healthy Children. Pediatrics. 2020;146(2):e20194113. doi:10.1542/peds.2019-4113.

  9. Olsen J, Tjoeng YL, Friedland-Little J, Chan T. Racial Disparities in Hospital Mortality Among Pediatric Cardiomyopathy and Myocarditis Patients. Pediatr Cardiol. 2021;42(1):59-71. doi:10.1007/s00246-020-02454-4.

  10. Chavez LJ, Cooper JN, Deans KJ, et al. Evaluation of racial disparities in postoperative opioid prescription filling after common pediatric surgical procedures. Journal of Pediatric Surgery. 2020;55(12):2575-2583. doi:10.1016/j.jpedsurg.2020.07.024.

  11. Carlo WF, Floyd S, Pearce FB, et al. Examining racial and socio-economic disparity in the pediatric heart transplant evaluation. Pediatr Transplant. February 2021:e13979. doi:10.1111/petr.13979.

  12. King B, Fallon B, Boyd R, Black T, Antwi-Boasiako K, O’Connor C. Factors associated with racial differences in child welfare investigative decision-making in Ontario, Canada. Child Abuse Negl. 2017;73:89-105. doi:10.1016/j.chiabu.2017.09.027.

  13. Baetzel A, Brown DJ, Koppera P, Rentz A, Thompson A, Christensen R. Adultification of Black Children in Pediatric Anesthesia. Anesth Analg. 2019;129(4):1118-1123. doi:10.1213/ANE.0000000000004274.

  14. Chamberlain JM, Joseph JG, Patel KM, Pollack MM. Differences in severity-adjusted pediatric hospitalization rates are associated with race/ethnicity. Pediatrics. 2007;119(6):e1319-e1324. doi:10.1542/peds.2006-2309.

  15. Peltz A, Wu CL, White ML, et al. Characteristics of Rural Children Admitted to Pediatric Hospitals. Pediatrics. 2016;137(5):e20153156-e20153156. doi:10.1542/peds.2015-3156.

  16. Dean P, O’Donnell M, Zhou L, Skarsgard ED. Improving value and access to specialty medical care for families: a pediatric surgery telehealth program. Can J Surg. 2019;62(6):436-441. doi:10.1503/cjs.005918.

  17. Wilson, Kathleen and M. Rosenberg. “The geographies of crisis: exploring accessibility to health care in Canada.” Canadian Geographer46 (2002): 223-234. doi:10.1111/j.1541-0064.2002.tb00742.x.

  18. McEvoy CS, Ross-Li D, Norris EA, Ricca RL, Gow KW. From far and wide: Geographic distance to pediatric surgical care across Canada. Journal of Pediatric Surgery. 2020;55(5):908-912. doi:10.1016/j.jpedsurg.2020.01.036.

  19. Akhtar-Danesh G-G, Doumouras AG, Flageole H, Hong D. Geographic and socio-economic predictors of perforated appendicitis: A national Canadian cohort study. Journal of Pediatric Surgery. 2019;54(9):1804-1808. doi:10.1016/j.jpedsurg.2018.10.065.

  20. Kohler JE, Falcone RA, Fallat ME. Rural health, telemedicine and access for pediatric surgery. Curr Opin Pediatr. 2019;31(3):391-398. doi:10.1097/MOP.0000000000000763.

About the Authors

Oluwatomilayo Daodu, MD, MPH, FRCSC

Dr. Tito Daodu is a Pediatric Surgeon at Alberta Children’s Hospital in Calgary. She is currently completing a Masters in Public Health at the Harvard T.H. Chan School of Public Health. Dr. Daodu has a passion for promoting justice and equity in medicine and currently serves as a co-lead for Anti-Racism curriculum development at the University of Calgary.

Shahrzad Joharifard, MD MPH FRCSC

Dr. Shahrzad Joharifard is a Canadian surgeon with a passion for public health. She is a pediatric surgeon at British Columbia Children’s Hospital and the University of British Columbia. In addition, Dr. Joharifard spent a year building a surgery program with Partners in Health in Liberia and is an active staff with Médecins Sans Frontières.