AMHE Newsletter winter 2020 February 24 Haitian Medical Association Abroad Association Medicale Haïtienne à l'Étranger Newsletter # 273 AMHE NEWSLETTER Editor in Chief: Maxime J-M Coles, MD Editorial Board: Rony Jean Mary, MD Reynald Altema, MD Technical Adviser: Jacques Arpin Disparities in Orthopedics Maxime Coles MD One look at healthcare nowadays, brings us to a realty showing how profoundly affected we are with the socio-economic issues as well as the race/ethnicity issues. The effects of these factors on the quality of care provided to the patient is certainly felt when we are looking at disparities in Orthopedics. Disparity is seen when one is assessing care and more with the quality of care received around the recovery from surgical interventions. Total joint replacements, treatment of hip fractures or spinal surgery have shown striking revelations. It is important for the one delivering care to understand well the effects of such factors on the patients they care for and the outcome after surgical treatments. Other has to certainly minimize such effects on the patient’s health or the health system itself. It remains unclear why the disparities exist in patients with Diabetes or Cardiovascular disease as well as in patient undergoing total joint arthroplasty. Others have discussed inequities in orthopedics but could racism explain disparities in Orthopedics? Medicine is a highly homogenous field deserving diverse population. Diversity in In this number - Words of the Editor, Maxime Coles,MD - Décès - La chronique de Rony Jean-Mary,M.D. - Students Resident Corner - La chronique de Reynald Altéma,M.D. - Telepathology device (AIDA2) - Chronicle of Slave rebellions in the Americas. - Upcoming Events - GOOD BYE MARLENE RIGAUD APOLLON - And more... 2 healthcare goes beyond the language in the United States are Christians, 14% barrier. We need to understand the mindset are Jewish, 7% are unaffiliated, 5% are of the patient with a larger context about Hindu and 3% are Muslim. their culture, sexual orientation, gender, We need to evaluate a little more, sexual religious beliefs and socio-economic minorities although a study at the conditions. University of Stanford found that about In the past, the American medical 1/3 of sexual minorities students chose not profession used exclusively white male to divulge information fearing physicians in dominance while white discrimination. Many universities have women were also allowed to enter medical encouraged them to come forward. school. It is now a contrast when diversity African American women with breast dictates that anyone can dream to choose cancer are more likely to have a higher from a wide variety of male or female rate of mortality than white women. doctors with different nationalities, races African American patients in a need for a colors or creeds and even sexual kidney transplants are more likely to wait orientations. The homogeneity of the past twice the amount of time it takes for a has eroded with more medical school white patient to have the same transplant. accepting more female applicants or more Hispanic and African American women racial and ethnic minority applicants. are more likely to die from Diabetes than Diversity in Healthcare starts in medical white patients. school. The more the class are diverse the more the classmates benefit from different Increasing diversity in healthcare, renders perspectives. This can improve knowledge the field of Medicine to be more accessible and learning outcome for all students to the underserved patients: African improving intellectual engagement, social American, Hispanic, Native American and skills, racial understanding and active poor communities with underserved thinking. This will become the Whites. The patients also are more likely armamentarium of a physician in practice. to choose a physician of similar background when given an option. African American, Hispanic and Native American Although three-quarters of physicians and physicians also are more likely to see surgeons are white, 20% are Asians, less patients with Medicaid because it is almost than 5% are Black or Hispanic and less are always the medical insurance of the Native American. Two Third of practicing Underprivileged. surgeons are still male in spite of a change in the male: female ratio in the last decade. Physicians will need also to show their In the medical schools, students from low competence in taking care of those economic status are underrepresented and patients in caring for different disease more likely to abandon their medical burdens and socio-economic realities. studies within the first two years. More They need to understand the diversity of students in Medical school come from the population they serve. affluent families with higher social economic status. I will always remember my own The field of Medicine remains largely a experience when I gained a training spot Christian profession and 2/3 of physicians 3 on the surgical program at Howard patient in his office. It was already 12 University Hospital. I have to say that it hours after the injury. I refused to accept was the first time I felt discrimination in the patient. I did not appreciate it and my life. This was exactly the 80’s. Coming reported him. The conception of a patient from our homeland, I was unaware of the being poor and without insurance pushed competition between residents or students him to neglect him. I did not assume the to help their advancement in the same care and he was forced to delegate one of program and I found myself for a while his partners to deal with it. The attitude of unaware of different rules and activities, such physicians in the 90’s was such that because my older residents will not “place the color of the skin of the patient was me in the “loop”. I found out that I dictating the kind of treatment they were represented for them a foreigner in the receiving. I Kept my ground. program trying to get a position which We know already that many orthopedic belong to an African American. I became procedures are seldom performed in aware of the reason and soon their attitude certain racial and ethnic minorities as changed toward me. I confronted also an seen around the country. By example, Attending who accused me of not providing Blacks are less commonly offered a joint proper care to a patient and I have to prove replacement than a Caucasian for the him wrong. This confrontation valued me same condition. Worse, even after the later his esteem and he became a good procedure is done, attention given in the friend allowing me to write one scientific post-operative period for physical therapy paper with him, paper we published in a by example may be reduced famous Orthopedic journal. considerably, rendering the rate of One may uncover in recent studies that complications higher among Blacks and racial prejudices among physicians in other minorities with more re-admission, America dating from the early 90’s and and complications including death. even earlier, was rampant. When you heard Hispanics have been found to have a patients described as Blacks, Negroes, significantly higher rate of infection after Chinese, Reggae, Hispanic etc., you may total joint replacement (64%) when see the way the clinicians could be compared to Blacks. Other studies have developing an unconscious bias in shown that they were also less likely to participating in their treatment. Orthopedic receive pain medication following their care provided to minorities is growing and surgical treatment compared to Whites. those attitudes need to be avoided. There are so much data around to observe While I was chief of Orthopedic Trauma at such facts in any type of surgical Bridgeport Yale Health, an attending on treatment. Women and Children, Lesbian call did not come to see a patient who was and Gays, Transgender, Underprivileged victim of a Gun Shot Wound to the knee and Handicapped patients, Prisoners and joint. He needed to come and do a washout even some religious group have felt the via arthroscopy during the evening, but did same lack of attention when they are not bother coming to do it. The next cared for. morning, he tells me that there was a “low In 2002, the congress has started to look Life” patient with a gunshot wound and he at these issues forcing the Institute of would have to leave to see his high paying 4 Medicine (IOM) to publish a report on outcome on surgical treatment of possible solutions to those problems. osteoarthritis by example. 24% of Blacks Insurance coverage has also played a role in disparity. Patients with Medicaid or have low expectation with Knee Medicare alone are less likely to have a arthroplasty compared to 15% in Whites. total joint replacement, perhaps because of In other areas of the country, this the low re-imbursement rate. Blacks with perception is not the same which may Medicare and Medicaid combined may bring in the equation different factors like benefit more often from a Knee or a shoulder replacement. the patient preference or even the physician bias. Others state that Blacks A study performed at Boston University found disparity around the country in may have less access to accurate relation to age, income, comorbidities, information or simply be more skeptical employment, education and even the way about the surgical treatment even before they look for insurance coverage. As noted meeting the surgeon. above a combination of Medicare and Medicaid is better than Medicaid or It may be true that we are seeing great Medicare alone. strides in welcoming a broader spectrum It is possible that disparity between white of physicians but a lack of diversity in women and Hispanic women or between Healthcare can have detrimental effect on white and black women has been almost eliminated but in black men disparity, little patients by example in the transgender has changed compared to white men.