February 2004 Bulletin

AAOS looks at racial, ethnic, gender disparities in orthopaedics

AHRQ/AAOS conference seeks to reduce disparities in musculoskeletal care

By Carolyn Rogers

The prevalence of racial, ethnic and gender disparities in the treatment and outcomes of musculoskeletal medicine was the focus of a Nov. 21, 2003, workshop conducted by the Academy, in cooperation with the Agency for Healthcare Research and Quality (AHRQ).

Washington, D.C., was the site of the one-day conference, which brought together a broad spectrum of participants that included researchers from diverse disciplines, representatives of government agencies and institutions responsible for physician training, and primary care physicians and orthopaedic surgeons who occupy academic positions as well as those in clinical practice.

Representatives of the sponsoring organizations—Vernon T. Tolo, MD, past president of the AAOS; James N. Weinstein, DO, MS, former member of the AAOS Board of Directors; AAOS President James H. Herndon, MD; and AHRQ Director Carolyn Clancy, MD—called upon participants to use the conference as an opportunity for collaboration among physicians and researchers, leading to a reduction in disparities in musculoskeletal medicine.
Topics such as the epidemiology of musculoskeletal disease, patient-physician communication challenges, diversity issues and education/workforce matters all were addressed in panels and discussion sessions throughout the day.

White men three times more likely to undergo TKA
Research examining gender and racial differences in the rates of knee/hip joint replacements and arthroplasty were presented during the “Epidemiology of Musculoskeletal Disease” session. Factors contributing to differences in musculoskeletal disease and treatment include race, ethnicity, gender, income and a lack of consensus about indications for patient referral and the “right” rate for arthroplastic procedures.

For instance, Said A. Ibrahim, MD, MPH, assistant professor at the University of Pittsburgh School of Medicine, presented research showing that white men are three to five times more likely than African-American men to undergo total knee arthroplasty (TKA), and that significant differences in favor of whites have also been reported for hip joint replacement.

Women have three times greater “unmet need” for TJR
Results of research by James G. Wright, MD, MPH, of the University of Toronto indicates that although women in the United States and Canada receive more hip and knee replacements than men, the unmet need for this service is more than three times greater in women than in men.

Wright believes that the reasons for this differential in unmet need probably originate in the differences in doctor-physician communication. He concluded that there is a need for more studies, possibly using standardized patients, to analyze patient-physician communication in these encounters.

The causes of the many racial, ethnic and gender disparities presented in the epidemiology session were the focus of the “Diversity Issues” panel discussion. Participants discussed the relationship between disparities and physician and patient factors, e.g., caregivers’ and providers’ biases, and between disparities and the patient-provider interaction.

Research by C. Kent Kwoh, MD, University of Pittsburgh Medical Center, found that ethnic and racial variations in the utilization of total joint replacement (TJR) may be due to variations in the patient’s perceptions of the efficacy of various treatment options and/or the patient’s expectations of the outcomes of TJR.

Based on his study of musculoskeletal diseases among Hispanics, Augustin Escalante, MD, of the University of Texas Health Science Center at San Antonio, concluded that 1) there is no indication of major differences between Hispanics and non-Hispanic whites in the prevalence of arthritis, but Hispanics under-use surgical procedures for arthritis; 2) there is evidence that Hispanics receive TJR at more advanced stages of osteoarthritis than do non-Hispanic whites; and 3) under-representation of Hispanics is more pronounced among recipients of total hip replacements than among TKA recipients.

Physician workforce issues
In the “Education and Workforce Issues” session, panelists responded to the question, “What sort of workforce will we need to serve our population?”
Dartmouth Medical School researcher Jon Lurie, MD, MS, presented research showing a substantial gap between the proportion of African-American and Hispanic physicians relative to the population—particularly in orthopaedics.

However, “The direct effect of the under-representation of African Americans and Hispanics among physicians caring for patients with musculoskeletal problems is unclear,” he said.

In terms of the relationship between the physician workforce and the population its serves, Dr. Lurie emphasized that “the absolute number of physicians probably has less consequences for the delivery of quality health care than do the issues of who the physicians are, where they are practicing, and what they are doing in their practices.”

More women needed in orthopaedics

With women now making up 50 percent of entering medical school classes, most medical specialties have been the recipient of a “downstream” effect, with increasing numbers of women in training programs and medical school faculties. However, orthopaedic surgery lags far behind other surgical specialties, with women comprising just 8.9 percent of orthopaedic residents in 2001, compared to 23.7 percent for general surgery in the same year, explained J. Sybil Biermann, MD, of the University of Michigan Medical Center.

Dr. Biermann maintains that, given the aging of the population, an increase in the number of women in orthopaedics will be necessary to meet projected workforce needs.

To see an increase in women entering orthopaedics, a strategy for improvements in mentoring, training, practice and lifestyle, will have to be developed and implemented, she said.

During the “Communication: Bridging the Disparities Gap” session, presenters discussed how communications among health care institutions, patients and physicians affect racial disparities and, conversely, how the communications process itself is affected by racial disparities.

Cultural beliefs, biases affect communication
Institutional factors that contribute to racial and ethnic disparities in communication during the patient-provider encounter include the cultural sensitivity of the staff and the availability of interpreter services, according to Wendy Levinson, MD, of the University of Toronto.

Communication is also affected by patients who “bring different pre-existing sets of health beliefs and varying levels of trust in doctors and in health care to the encounter,” Dr. Levinson said.

Physician factors include the physician’s beliefs about the patient and predictions about patient adherence to treatment; interpretations of the patient’s symptoms; interaction with the patient; and clinical decision-making.
John R. Tongue, MD, chair of the AAOS Communications Skills Mentoring Project Team, stressed that physicians need to be aware of their own cultures and how their biases affect the physician-patient interaction. In addition, physicians need to develop cross-cultural communications skills to understand the biases held by others and to reduce disparities.

Diversity necessary “to get at the bigger truth”
The role of diversity in medical school and residency training, its value to the public and to medicine, and how diversity can be brought to these programs was the focus of the final panel session, “Bringing Diversity into Medical Education.”

Charles Terrell, EdD, vice president, Association of American Medical Colleges (AAMC), division of community and minority programs, said, “Diversity in the classroom helps students understand how different cultures and belief systems influence the way people experience illness and respond to medical advice and treatment.”

David C. Leach, MD, executive director of the Accreditation Council for Graduate Medical Education (ACGME), discussed the importance of the residency experience in the formation of physicians. Dr. Leach reminded the audience that good clinical judgments depend on diversity in physicians. He likened good clinical judgment to vision—vision being a “physiological hallucination,” in that we “see” some things only by ignoring other things.

“To get at the bigger truth, we need others who are different from us so that we can ‘see’ the things that we ignore,” he said.

Next steps

Conference presenters, panelists and attendees were asked to develop the “next steps” for the AAOS to take—alone and in tandem with other entities—to reduce racial, gender and ethnic disparities in musculoskeletal disease.

The group developed numerous recommendations for additional studies of the causes of the disparities and for interventions to reduce disparities and improve outcomes. These programs were categorized as interventions or modifications to be directed to 1) the public (patients, family and community), 2) orthopaedists, and 3) primary care physicians.

In addition, participants strongly recommended that the AAOS work collaboratively with primary care physician organizations and other specialty organizations in these efforts.

AHRQ, AAMC and ACGME also expressed their support of the Academy’s efforts and indicated that they would work cooperatively with AAOS to further the diversity agenda.

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