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Structural Racism as a Fundamental Cause of U.S. Health Disparities: A Critical Examination of Race in Orthopaedic Total Joint Replacement Surgery

By Aliya G. Feroe, MPH

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Citation

Feroe, A.G. Structural racism as a fundamental cause of U.S. health disparities: a critical examination of race in orthopaedic total joint replacement surgery. HPHR. Surgery and Public Health, 2021; 30. 

Abstract

Structural racism has long been and continues to be a fundamental cause of health and health care disparities in the United States. Many tragedies of this past year only reinforce this truth—from the police murders of Breonna Taylor and George Floyd to the disproportionate burden of the COVID-19 pandemic on Black communities. There are multiple avenues through which structural racism deepens racial health disparities; racial inequities in healthcare quality and access are just one. The purpose of this review is to describe structural racism, alongside the other forms of racism, such as internalized racism, interpersonal racism, and institutional racism, within the context of the well-described racial disparities in total joint replacements within the field of orthopaedic surgery.

Structural Racism and Racial Disparities in Total Joint Arthroplasty

In the wake of the Chauvin trial for the murder of George Floyd, as COVID-19 continues to disproportionately devastate communities along color lines, the link between structural racism and health inequities has never been clearer. Structural racism refers to “the totality of ways in which societies foster racial discrimination, through mutually reinforcing inequitable systems in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, and so on. These systems in turn reinforce discriminatory beliefs, values, and distribution of resources. Altogether, they affect the risk of adverse health outcomes.”1-3 Structural racism deepens health inequities, in part, through healthcare quality and access.1,3 Other dimensions of racism can be mapped to the patient’s healthcare outcomes as follows: the patient themselves (internalized); the patient-provider dynamic (interpersonal); and the patient-within-the-broader healthcare system (institutional).8
 
Racial health disparities are well-documented across the broad range medical specialties. Having been consistently identified as the least diverse and slowest to progress in the ways of diversity, equity, and inclusion, Orthopaedic Surgery is a particularly ripe case study in which to explore structural racism.While Black-White health inequities cut deeply across all orthopaedic subspecialties, from sports medicine to trauma, those in total joint arthroplasty (i.e., total hip replacement or total knee replacement) have undergone the most study and will be the subject here.10-21
 

Black-White racial disparities in total joint arthroplasty typically fall within one of three categories: lower utilization rates,22-26 worse perioperative metrics (e.g., time to surgery, operative time, and length of hospital stay),27,28 and increased post-operative poor physical function, complications, and mortality.29-33 Despite various efforts to combat these disparities in total joint arthroplasty, they persist and, in some cases, have worsened over recent decades.22-26,34

The following sections will focus on examples of the various forms of racism as fundamental causes of the persistent racial disparities in total joint arthroplasty and orthopaedic surgery evident today.

Internalized and Interpersonal Racism

The history of discrimination and injustice experienced by Black Americans within U.S. health care is horrific, but this knowledge is critical to understanding the roots of racial health disparities today. Harriet Washington’s “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present” details the course of mistreatment of Black Americans since the earliest slaves in the U.S. to the present—from the unconsented use of Black bodies for dissections in medical education, to the unethical treatment of Black men in the infamous Tuskegee syphilis study, to the surgical experimentation of gynecologic procedures on enslaved Black women by the once revered Dr. J. Marion Sims.35

 

This deep history of devaluing Black bodies in healthcare has—consciously and/or subconsciously—instilled a sense of contemporary racial superiority in many white providers, as one form of internalized racism.41,42 Rapidly mounting studies around implicit bias in health care have demonstrated the impact of implicit bias on health care quality and outcomes, and the exacerbation of racial disparities.43 Implicit bias within the context of total joint replacements may include suboptimal postoperative pain management secondary to the unconscious misbelief that Black patients have lower pain thresholds—though, it must also be called out here that a concerning number of health care providers, including medical students, still consciously believe this dangerous myth.44 Similarly, implicit bias may involve a surgeon subconsciously taking more care in the operating room when performing surgery on a patient that resembles that surgeon—whether in regards race, ethnicity, sexual orientation, age, or other identity.

 

Studies have demonstrated the association between race-concordant clinical relationships and increased healthcare utilization,46 improved quality of care (e.g., more comprehensive histories and physical examinations47), improved medication adherence,48 and positive patient-reported health care experiences.49 Without race concordance in patient-provider relationships, interpersonal racism (conscious or unconscious) can occur. Thus, increasing minority race-concordance in patient-provider relationships helps to ensure that health care providers resemble their patient population.50-56

 

Optimizing minority race-concordance is a substantial challenge in the field of orthopedic surgery where white, cisgender, heterosexual men form the vast majority of orthopaedic surgeons, with little change in recent decades. From 2006 to 2016, the percentage of African-American or Black orthopaedic surgeons only inched up by 0.3%, from 1.6% to 1.9%.In fact, orthopaedic surgery is the least diverse specialty—on many measures, including race—across medical specialties.54

Structural and Institutional Racism

Structural racism comes into play when considering how and why this lack of diversity exists within orthopaedic surgery. First, there is a vicious-cycle in the proximal recruitment of medical students into orthopaedic surgery, given the racial bias that plagues the residency application process.53 As evidence, racial minority applicants had a lower odds of admission into orthopaedic surgery residency programs between 2005 and 2014 than their white peers, before and after controlling for various metrics of academic performance (e.g., USMLE Step [medical boards] scores and grades).53
 
Second, racial inequities in education and socioeconomic status have knocked many racial minorities out of the competitive pipeline to orthopaedic surgery at any of the countless checkpoints along the way (e.g., college admissions, medical school admissions, residency match, etc.).8,36 In fact, there are additional leaks which persist along the entire length of the educational pipeline within residency: underrepresented minority (URM) residents comprised 17.5% of all residents who resigned and/or were dismissed during the prior decade, despite the fact that they only comprised around 6% of all orthopaedic residents.50,57,58  This high attrition rate of Black orthopaedic residents is unparalleled across all other medical specialties.57
 
Institutional racism appears in orthopedic surgery in the existence of cost-containment strategies that use preexisting factors, such as body mass index, high hemoglobin A1c [marker for diabetes], and smoking status, as inflexible eligible criteria for lower extremity joint arthroplasty. Since there is an uneven distribution of such comorbidities in Black patients, 60 these near-universal institutional policies disproportionately bar Black patients from undergoing life-changing total joint replacement procedures.

Steps to Combatting Structural Racism

Given that these causes of racial health inequities are myriad and interrelated, effective interventions must be “interconnected, multi-sectoral, and across intervention levels”6—addressing the various manifestations of racism. Effective solutions of the sort include individual interventions combined with creating a sociocultural ecosystem that directly addresses the roots of structural racism. Or, considering former CDC Director Dr. Tom Frieden’s “Health Impact Pyramid,” the most effective interventions are those that improve socioeconomic factorsand build a context that enables healthy choices, supplemented by long-lasting protective interventions, clinical interventions, and education.” 61 Place-based approaches, like Purpose Build Communities, are one such example that address concentrated economic disadvantage with integrative strategies to build social, physical, and economic infrastructure. 62,63
 
Individual-level efforts—in conjunction with population-level interventions—are still important, actionable, and necessary, for all aspiring and practicing healthcare providers—including, but not limited to, orthopaedic surgeons. Following George Floyd’s murder, the Harvard’s Orthopaedic Residency Program Director Dr. George Dyer—one of too few Black orthopaedic surgeons—issued a call-to-action to orthopaedic surgeons to do their part to combat structural racism.56 He asked all surgeons to consider their role in America’s racist culture, to identify their biases within the context of their own privilege, and to determine concrete actions to engage in active anti-racism. 56 Extending this call-to-action across all medical specialties, I offer some examples of individual-level efforts to combat racism:
 
  • Internalized racism:
    • Seek opportunities (e.g., webinars, Grand Rounds) to learn and accept the racist roots of U.S. history
    • Identify, name, and reflect upon racism in one’s everyday medical practice
  • Interpersonal racism:
    • Actively mentor and recruit students from underrepresented groups in medicine to diversify healthcare to match the diversity of its patients
    • Advance diversity, equity, and inclusion (DEI) efforts through involvement with one’s own hospital- or residency-based DEI groups
  • Institutional racism:
    • Challenge and eliminate policies that uphold structural barriers (e.g., inequitable cost containment strategies)
    • Support curricula inclusion efforts in undergraduate and graduate medical education (e.g., implicit bias training)

While tackling structural racism in healthcare is a bold mission, the advancement of health equity is at the very core of our commitment to the alleviation of human suffering and disease. We all can and need to do our part.

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About the Author

Aliya G. Feroe

Aliya G. Feroe, MPH is a fourth-year medical student at Harvard Medical School and recent graduate of the Harvard Chan School of Public Health (Class of 2022) in the field of Health and Social Behavior. She is in pursuit of a career as an orthopaedic surgeon, with a commitment to curbing disparities in musculoskeletal health and improving diversity, equity, and inclusion in medicine.