Where does equity start? An American surgeon’s northern exposure

In the wake of the death of George Floyd at the hands of police last year and as a response to the racial awakening that engulfed the country, the American College of Surgeons (ACS) issued a call to action on racism as a public health crisis.1 My professional society, the American Pediatric Surgical Association, took a similar stance.2 In doing so, they joined virtually every professional medical society in the U.S. and beyond in denouncing racism and discrimination.

The ACS cannot quickly erase implicit bias or end systemic racism, but it can take a giant step by endorsing a universal system of equitable health care for all.

The ACS Board of Governors established a Diversity Pillar and recently sent a primer on the vocabulary of diversity, equity, and inclusion to all members.3 Throughout the nation, we saw thousands of physicians kneeling in their white coats as part of the White Coats for Black Lives movement. All of these actions are commendable.

But please indulge me for a few moments. As I watched the Democratic primaries unfold and Bernie Sanders win in several of them, I was fascinated to see single-payor health care, or Medicare for all, move from the extreme to the mainstream. I did not believe it would happen in my lifetime. In response to this seismic shift, then-President Donald Trump, in his last State of the Union address, declared this movement an attempt to socialize medicine and vowed to do everything he could to stop this “socialist” takeover of health care.

In this speech, he followed a sacred political conservative tradition of vilifying a Medicare system for all Americans, a tradition shared by the medical establishment. In fact, the American medical-industrial complex—including professional medical societies, hospitals, insurance companies, and pharmaceutical companies—have touted the same line for decades. The American Medical Association, for example, waged a fierce, albeit unsuccessful, fight in the 1960s regarding the establishment of Medicare.4 Organizations that have tripped over themselves recently to issue anti-racism statements have for decades tolerated and even supported an American health care nonsystem that institutionalizes discrimination against minorities and low-income citizens.

Regardless of our political affiliation (and I consider myself a conservative), I believe we can agree on one thing: Our health care system is intrinsically unjust. It has given rise to an entire field of research on disparities in health care access and outcomes, from pediatric appendicitis to virtually all adult cancers.5,6 An overwhelming disproportion of patients who suffer from these disparities are minorities and low-income individuals.

Gross inequity and social injustice in the way we provide health care in the U.S. is an evidence-based conclusion, supported by decades of research and publications.

Our commodity-modeled health care system—which considers health care a privilege, not a right—institutionalizes racism, discrimination, exclusion, and lack of equity in distributing our most fundamental societal resource—health care. We also know, at least in the field of pediatric surgery, that when we even the playing field of health coverage, racial disparities disappear.7,8 Gross inequity and social injustice in the way we provide health care in the U.S. is an evidence-based conclusion, supported by decades of research and publications.9

And so, let me pose a simple question: Does anyone believe that a market-based solution can produce equity in health care? Does anyone believe that America’s insurance companies are interested in transforming our health care environment to a socially just, needs-driven system?

I am an American pediatric surgeon who has practiced in Canada for the last 13 years. Before this move, I had completed my residency training in California and practiced there for nearly a decade. I had a wonderful practice in California. I enjoyed the collegiality of members of superb surgical and pediatric departments and attended to and advocated for a wonderful population of grateful patients and their families. But I became increasingly disillusioned with the financial politics of practicing medicine. Competition for contracts and hospital affiliations created an atmosphere of animosity and distrust between physicians. It resulted in itinerant surgical practices. Surgeons covered multiple hospitals that had no business taking care of children to fulfill their obligations under these contracts.

Subsidization of surgical practices by hospital administrations created complex, circuitous, and sometimes, frankly, corrupt relationships between hospitals and physicians. These relationships frequently led to unnecessary procedures and interventions that resulted in more unnecessary procedures and interventions that benefited the hospital and the practitioner—not the patient. Thousands of patients were trapped in health care plans that treated them as widgets and manipulated them for financial gain, rather than as human beings in their most vulnerable state. I increasingly encountered patients presenting with late-stage disease, the types of conditions I see on medical mission trips to Africa.

In one striking example, a Latino teenage boy with achalasia had lost 40 pounds and could not lie flat because of constant aspiration. His parents, both working adults, had been trying to negotiate the health care maze for more than a year. Most victims of this health care fiasco were Black and Latino. The worst part was that it was accepted as the norm. It did not seem to bother most of my colleagues much. Gradually, medical students also became acclimated to this reality. A study I conducted shortly after leaving California showed that whereas 87 percent of Ontario medical students (n = 1,354) supported the principle of universal health care, only 51 percent of California students (n = 887) did.10 In one of the most politically liberal states in the nation, half of the future doctors did not support health care equity.

In Canada, I can see any patient and any patient can see me. Micromanagement of daily practice is nonexistent. There are no contracts, authorizations, denials, appeals, reviews, forms to complete, or managed care. If referring physicians like the quality of care I provide, they can refer more patients to me. If they don’t, they are free to refer them to any other pediatric surgeon in town. Patients have the same freedom. My relationship with the hospital administration is defined by professional, not financial, standards. I have no allegiance to any corporate or governmental entity. I am happy with my income, and even happier that it is not subject to the whims of a hospital or plan administrator.

The phrase “surgical productivity,” a euphemism for “find any patient to operate on,” is nonexistent. I pay high taxes, but these taxes help insure 100 percent of my patients and allow them to see me whenever necessary. They allow the child of the new refugee to get the same care as the child of the corporate executive. They help provide prescription drug coverage to the entire population and guarantee long-term care for the elderly. They help subsidize the education of the medical students I train and allow them to graduate with minimal debt, retaining a sense of idealism.

All advanced pediatric surgical care in Canada is centralized and occurs only in academic children’s hospitals, optimizing quality. Referring hospitals and physicians have no incentive to deny patients the highest standards of care, and patients may go to any hospital they choose. My patients’ parents have peace of mind regarding their and their children’s health. If they change jobs or lose their job altogether in a bad economy, as we are experiencing during the coronavirus 2019 pandemic, they and their children will still get the same care and see the same physicians.

Contrary to what is often peddled in some U.S. media outlets, no government bureaucrat, or any bureaucrat for that matter, comes between my patient and me.

Contrary to what is often peddled in some U.S. media outlets, no government bureaucrat, or any bureaucrat for that matter, comes between my patient and me. This environment of “socialized medicine” allows for more patient autonomy and choice than was available to most of my patients in California.

The Canada Health Act is built on a foundation of five basic principles: public administration, comprehensiveness, universality, portability, and accessibility. These principles have produced a more efficient health care delivery system and have served Canadians well, preserving their health security for many decades and eliminating the risks of financial devastation because of medical bills.

It is true that some Canadians seek medical care in the U.S. Although these patients make for great media sound bites, they do not contribute seriously to health care policy debates, as their numbers are infinitesimally small.11 Meanwhile, droves of Americans leave the U.S. every year to seek less expensive, essential medical care overseas.12

An imperfect system

Is the Canadian health care system perfect? No. The complete absence of any financial contribution by the patient can lead to overuse. Hospitals are typically funded by annual budgets that do not always incentivize patient care, creating some resource limitations. Waiting times for surgery do exist. In our practice, this condition is always one that can be delayed.

Because operating time is more restricted than in the U.S., we do find ourselves frequently replacing patients on our operating lists with more urgent patients—a state I refer to as constant triage. The waiting list problem is more severe in adult medicine and has become a national priority. Although I have access to the same technology I had in California, my hospital lags in other areas, such as electronic health records. Despite universal access, significant health care disparities still exist among Canada’s indigenous populations and First Nations communities. We should remember that Canada spends half as much per capita as the U.S. on health care.

No perfect health care system has been developed—at least not yet. Canada also is looking to reform its system and is studying different models; however, one model Canada resolutely does not intend or desire to emulate is that of the U.S.

How are we going to realize our aspirations for equity and social justice? One of my favorite Martin Luther King, Jr., quotes is, “Of all the forms of inequality, injustice in health care is the most shocking and the most inhuman.” We can issue statements. We can make commitments. We can create vocabulary. We can even kneel in our white coats. But if we truly believe that we need to transform our society, then we must be willing to transform our health care system. And yet, in this area, I believe little has changed. In a recent town hall meeting of our professional society, I asked the president whether our organization is ready to endorse “Medicare for all who want it.” The moderator did not feel comfortable repeating the question as I wrote it in the chat box and rephrased it into a generic version. I often feel that our talk of social justice parallels fear of the same.

True reform in U.S. health care will come only when we consider health care a fundamental right of every citizen, when patients are set free and allowed to choose their physicians and hospitals, and when physicians rid themselves of competing corporate interests.

Finally, this is not just about our patients or the society we serve. This also is about equity, inclusion, and ethics in our profession. The corporatization of U.S. medicine, in many instances, has led to the erosion of professionalism, as increasing numbers of physicians shift their allegiance from their patients to their corporate employers and payors. Most of our past debates have not been about health care reform but rather about expanded coverage. True reform in U.S. health care will come only when we consider health care a fundamental right of every citizen, when patients are set free and allowed to choose their physicians and hospitals, and when physicians rid themselves of competing corporate interests. Medical practice will always have a business component, but we have to transform health care into a fundamental service, not a fundamental business.

The ACS cannot quickly erase implicit bias or end systemic racism, but it can take a giant step by endorsing a universal system of equitable health care for all. And if it does, that will resonate much louder than any statement, any commitment, or any vocabulary we create.

Disclaimer

The thoughts and opinions expressed in this column are solely those of Dr. Emil and do not necessarily reflect those of  the American College of Surgeons.


References

  1. American College of Surgeons. American College of Surgeons call to action on racism as a public health crisis: An ethical imperative. June 9, 2020. Available at: https://www.facs.org/about-acs/responses/racism-as-a-public-health-crisis. Accessed August 26, 2021.
  2. American Pediatric Surgical Association. Statement on equity and social justice. June 17, 2020. Available at: https://apsapedsurg.org/apsa-news/statement-on-equity-and-social-justice/. Accessed August 26, 2021.
  3. American College of Surgeons. From the Board of Governors Diversity Pillar: An introduction to common terms of diversity, equity and inclusion. Bulletin Brief. May 4, 2021. Available at: https://www.facs.org/publications/bulletin brief/050421/clinical?utm_medium=email&utm_source=rasa_io#top_bog_dei. Accessed August 26, 2021.
  4. DeBakey ME. The role of government in health care: A societal issue. Am J Surg. 2006;191(2):145-157.
  5. Goyal MK, Chamberlain JM, Webb M, et al. Racial and ethnic disparities in the delayed diagnosis of appendicitis among children. Acad Emerg Med. September 29, 2020 [Online ahead of print].
  6. Zavala VA, Bracci PM, Carethers JM, et al. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer. 2021;124(2):315-332.
  7. Lee SL, Shekherdimian S, Chiu VY, et al. Perforated appendicitis in children: Equal access to care eliminates racial and socioeconomic disparities. J Pediatr Surg. 2010;45(6):1203-1207.
  8. Cheong LH, Emil S. Determinants of appendicitis outcomes in Canadian children. J Pediatr Surg. 2014;49(5):777-781.
  9. De Jager E, Levine AA, Udyavar NR, et al. Disparities in surgical access: A systematic literature review, conceptual model, and evidence map. J Am Coll Surg. 2019;228(3):276-298.
  10. Emil S, Nagurney JM, Mok E, Prislin MD. Attitudes and knowledge regarding health care policy and systems: A survey of medical students in Ontario and California. CMAJ Open. 2014;2(4):E288-E294.
  11. Katz SJ, Cardiff K, Pascali M, et al. Phantoms in the snow: Canadians’ use of health care services in the United States. Health Affairs. 2002;21(3):19-31.
  12. Milstein A, Smith M. America’s new refugees—seeking affordable surgery offshore. NEJM. 2006;3(16):1637-1640.

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Sherif Emil
Sherif Emil
19 days ago

Thank you American College of Surgeons for allowing all points of view to be shared and all voices to be heard.

Sherif Emil
Sherif Emil
13 days ago

Thank you American College of Surgeons for granting me the privilege to share my perspective in The Bulletin. Inclusion starts by including all voices and viewpoints.

Bruce Murray
Bruce Murray
13 days ago

Very well said Dr. Emil. I was particularly struck by the comment that on a per capita basis Canada spends only about half the amount on health care are the USA does. However, the entire Canadian population is covered and the health outcomes in Canada are about the same as in the USA. However, twice as much is spent in the USA to achieve the same health outcomes as are achieved in Canada. That means that in terms of financial efficiency the USA model is very financially inefficient.

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