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.
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.
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%.9 In fact, orthopaedic surgery is the least diverse specialty—on many measures, including race—across medical specialties.54
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.
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.