Diversity, equity, and inclusion: Leveling the playing field for surgical patients

I couldn’t help sitting there reflecting on how sometimes when you’re in the middle of a crisis, like we are now with the coronavirus, it really does [sic], ultimately, shine a very bright light on some of the real weaknesses and foibles in our society.

–Anthony Fauci, MD, April 7, 2020¹

The coronavirus 2019 (COVID-19) pandemic has transformed every aspect of American life and, perhaps unsurprisingly, has unveiled some of the fault lines in the U.S. health care system.² It long has been recognized that minority populations in the U.S. bear a disproportionate burden of disease compared with Caucasians.^3,4 However, what COVID-19 has convincingly illustrated is the inextricable cost of being economically disadvantaged while suffering health care inequities and how this dangerous combination portends to disrupt everyday life, with the culmination of a disturbance to our societal infrastructure.

In this article, members of the Associate Fellow Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) describe how COVID-19 has raised awareness regarding disparities in surgical care, explain how surgeons are positioned to play a leadership role in reducing these inequities, and how involvement in ACS programs enables surgeons to serve as advocates for all surgical patients. Many of these individuals are susceptible because they live in densely populated urban centers and often they live in close contact with many family members in multigenerational households. Additionally, people of lower socioeconomic status have less access to health care resources.

Along with these health care disparities, COVID-19 has poignantly illustrated how health care inequities translate into threats to our nation’s economic stability and overall public health. When predominantly minority workers became infected with the coronavirus in pork plants in Black Hawk County, IA, and Sioux Falls, SD, it threatened the food supply chain. Soon after the Navajo Nation became a COVID-19 hotspot and local rural hospitals were overwhelmed, hospitals in Phoenix, AZ, and Albuquerque, NM, became center points of the pandemic, shifting the public health disaster from these rural communities to an already stressed health care system, with little capacity to compensate for a crisis.

Surgeons as leaders in improving access to equitable care

Unfortunately, the health care disparities brought to light by the COVID-19 crisis are not new, nor have surgeons been unaware of their existence. Racial, ethnic, and socioeconomic differences in surgical outcomes, attributable to a combination of patient, provider, and systemic issues, are known. Underinsured patients, individuals with lower incomes, and groups with a higher burden of comorbidities all are more likely to experience worse surgical outcomes.⁵ Access to surgical care itself is not equitable, as insurance plans vary in terms of coverage for specialty care.⁵ In some areas of the U.S., nonwhite patients are less likely to have an operation by a high-volume surgeon than their white counterparts.⁶ Although surgeons are not directly in control of these surgical disparities, we are positioned to effect change through the ACS.

The College is poised to take a leadership role in our nation’s recovery from the COVID-19 pandemic with a primary objective to reduce inequalities in surgical access. Established research and quality programs, such as the ACS National Surgical Quality Improvement Program (ACS NSQIP^®), are designed to improve the quality of surgical care through objective validated metrics. Participants in these programs experience opportunities to improve access for patients and to have fewer complications and better outcomes. More importantly, ACS NSQIP provides a platform to build on and capture other social determinants of health, such as socioeconomic status, education, neighborhood and physical environment, employment, social support networks, and access to health care, to more comprehensively understand and tackle inequities in surgical care for the underserved.

As we begin to recover from the restrictions and obstacles that COVID-19 has imposed on our profession, it is incumbent on surgeons to take leadership roles within their own health care systems to address disparities that will inevitably widen because of the pandemic. Systems-based practice guidelines on access, timeliness, and appropriateness of surgical care can serve as a logistical model to measure inequities to surgical care and, perhaps most importantly, to address them. For instance, a multidisciplinary approach to increase the timeliness to surgical care for vulnerable populations is an ideal example of local advocacy.⁶ Using hospital-level measures to identify opportunities for quality improvement could ultimately reduce costs and enhance resources devoted to treating complications, performing reoperations, and readmitting patients for care.

Fellows of the ACS pledge to work to establish the just, effective, and efficient distribution of health care resources to provide surgical care to everyone, irrespective of gender, race, disability, religion, social status, or ability to pay.⁷ Albeit difficult to navigate in the present, the COVID-19 pandemic will be viewed in the history books as both a defining point and an opportunity. As a defining point, it will teach us how vulnerable the most marginalized populations are; as an opportunity, it will give us a chance to improve access to surgical care for the well-being of our communities and to partner with government to advocate for these populations.

Surgeons as policy leaders

At present, patients face a multitude of challenges when diagnosed with chronic conditions that will require weeks or even months of treatment, rehabilitation, and support; this scenario is especially true for patients in underserved populations who often present to surgeons with a newly diagnosed malignancy.⁸ Compared with the rest of the population, underserved patients are more likely to first present with a symptomatic malignancy rather than one identified during routine screening.⁹ Educational and psychological barriers may contribute to symptomatic presentation, which may include a general lack of knowledge of symptoms, as well as a fear of actually finding a cancer diagnosis; these intangible barriers have been shown to prolong symptom presentation among lower socioeconomic groups.⁹ Consequently, underserved populations generally present at later stages of cancer.^10-12

In 2010, the Patient Protection and Affordable Care Act served to increase insurance coverage among underserved populations with the goal of providing care to lower-income families and increasing the number of people in the U.S. with health insurance coverage. Unfortunately, the prevalence of early- and late-stage diagnoses has not changed because of implementation of this legislation.¹³ This outcome is likely attributable to a multitude of factors, including decreased availability or access to cancer screening, educational disparities, socioeconomic differences, environmental exposure risks, and access to transportation, among others.^14-19 Moreover, outside of basic access to primary care, underserved populations have less access to newer, potentially more effective drugs and clinical trials.²⁰

With a complex, ever-changing treatment landscape, surgeons often are at the forefront of conversations with patients and families in understanding the best strategy to access long-term care. Strong advocates are needed for our patients to seek care, which can last for months, if not years in some cases. As general and specialty surgeons routinely are involved in the care of patients not immediately limited to surgical treatment, coordinating multidisciplinary care by other treatment teams can become burdensome. While an uninsured patient who presents with an urgent surgical catastrophe may be treated with an operation due to the acuity, much of the long-term outcome on such a patient is determined by the ability to achieve adequate recovery and additional treatment if needed.²¹ Patients may need access to skilled nursing facilities, home health care, physical therapists, nutritionists, and specialty care by other physicians. Surgeons should feel empowered to advocate for these patients after they have recovered from an operation, regardless of the need for future surgical intervention. Often these decisions and higher-level conversations need to happen before discharge.

Finally, surgeons must be on the forefront of policy change, particularly for underserved populations. As the cost of medical care has risen over the last three decades,²² it is imperative that surgeons participate in legislation and policy efforts aimed at removing barriers to high-level care, which would ultimately prove less costly and more efficient. As physicians and surgeons, we need to be involved in decisions made in Washington, DC, regarding the right to receive medical care for our underserved patients. The ACS establishes relationships with policymakers via the ACS Professional Association Political Action Committee (ACSPA-SurgeonsPAC) and encourages all members to become involved in these efforts.

Associate Fellows and Residents as agents for change

All surgeons should work toward these changes, but Resident Members and Associate Fellows of the ACS, as well as young faculty, are uniquely positioned to lead this charge. This generation of trainees was raised in an era when information and technology crossed paths to yield a more educated and pliable surgeon workforce. The methodology for learning the practice of surgery and the explosion in surgical approaches to tackle a problem has changed the paradigm for surgeons and their capabilities. Fellows, Associate Fellows, and Resident Members also are more diverse groups than those of previous generations.²³ Surgeons who more accurately represent the composition of society are more effectively positioned to advocate for their patients.

Each day we see a variety of patients from different ethnic and cultural backgrounds who speak a multitude of languages; we work side-by-side with colleagues from different cultures; and we live in communities that are far more diverse than those of our forebearers. Training future generations of surgeons in cultural competency should be a priority, with a focus on the inequities in our medical system that perpetuate societal inequities.

We live in a time of rapidly growing technology and the ability to amass data quickly. With the technology to analyze data on populations and outcomes, resident and faculty researchers are poised to test and find solutions to the exposed gaps in surgical care. The acquisition of data and putative changes to improve care, combined with political advocacy toward these changes, are an essential part of our surgical practice and the activities of the ACS.

References

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