Articles

Social Determinants of Health and Hirschsprung-associated Enterocolitis[1]. Knaus ME, et al. J Pediatr Surg. 2022 Sep 30;S0022-3468(22)00632-7. Online ahead of print.

Hirschsprung-associated enterocolitis (HAEC) is the most common cause of morbidity and mortality in patients with Hirschsprung disease. Previous studies have sought to identified risk factors for HAEC to drive prevention efforts. Often cited risk factors include trisomy 21, long segment disease, and postoperative obstruction although conflicting studies exist.

In their retrospective review of 100 patients with Hirschsprung’s disease, Knaus et al., assessed clinical, surgical, and social factors contributing to HAEC. 29% of their patients had at least one episode with 42 episodes occurring over a median follow-up period of 31 months. There was 1 death in a post-operative child with a delayed presentation of HAEC. All patients had Swenson pull-throughs. Segment length did not appear to be factor. Sociodemographic factors not found to be associated with HAEC were: sex, race/ethnicity, language, need for interpreter, urbanicity, distance traveled, household income, and insurance type. Social or environmental factors that were associated with increased risk of HAEC were: use of public transportation, missed appointments, safety concerns in the home or neighborhood, crowded housing, involvement of child protective services, absent prenatal care, and maternal drug used. Their findings suggests that HAEC has a strong social component. The authors postulate that this may be due to high levels of household chaos. Household chaos is an emerging concept in the public health literature. It reflects the level of disorganization, hurriedness, or environmental confusion in a family home. It has been associated with adverse child health outcomes. It is unknown if household chaos leads to poor health comes as a result of lack of education, poor health literacy, or a delay in the recognition of complications or if there is a biological phenomenon occurring similar to toxic stress. This study suggest that a child’s environment may play an important role in the development of HAEC. Given this, pediatric surgeons should have an understanding of their patients’ home environments prior to discharge to ensure caregivers are appropriately educated about the risks of HAEC and have the necessary supports in place.

Children from Disadvantaged Neighborhoods Experience Disproportionate Injury from Interpersonal Violence[2]. Trinidad S, et al. J Pediatr Surg. 2022 Jun 9;S0022-3468(22)00384-0. Online ahead of print.

Injury from interpersonal violence in childhood is associated with significant morbidity and mortality at the time of injury, while also profoundly effecting children’s long-term physical and mental health and thus their ability to grow and thrive. Risk of interpersonal violence is known to be associated with a child’s age, race, and insurance status. Understanding how these factors interplay with a child’s environment and lead to injury can help us focus injury prevention efforts to minimize future trauma.

Using neighborhood census tracts, Trinidad et al. conducted a retrospective review of injured children, 0-16 years, admitted to their level 1 trauma center over a 9-year periods (2010-2019). During this time 6.2% (394) children were admitted as a result of interpersonal violence. The most common mechanisms of injury were abuse, being struck by an object, and firearms. They found that the type of injury suffered by a patient was strongly associated with the patient’s neighborhood level socioeconomic deprivation. Such that children living in neighborhoods with the highest levels of deprivation were 3.8x more likely to suffer an injury as a result of interpersonal violence than children living in areas with the lowest levels of deprivation (9.92% vs 2.56%, p< 0.001). They also found that age, race and insurance status effected the likelihood that children were injured as a result of interpersonal violence with age < 5 yrs and > 11 yr being a risk factors, as well as, Black race and public insurance. As noted by the authors, systemic racism plays a large role in the interaction between race, insurance status, and neighborhood deprivation and how these factors effect a child’s risk of injury. Given this, upstream factors that address systemic racism and target the environment in which children live need to be a focus of injury prevention programs for meaningful change to occur.

Evaluating the Thematic Nature of Microaggression among Racial and Ethnic Minority Surgeons [3]. Appah-Sampong A, et al. J Am Coll Surg. Aug 1:235(2):210-216. Epub 2022 Apr 28.

Black, Hispanic, Latino(a), and Asian American surgeons face discrimination in the workplace. The most common form of discrimination experienced are microaggressions. Microaggressions are brief, commonplace verbal, behavioral, and environmental slights that work to make the recipient feel ‘othered’ or like they do not belong. Microaggressions are associated with burnout among minoritized surgeons. Microaggressions take on many themes including the assumptions of criminality, low intelligence, foreign status, and invisibility. Environmental microaggressions are common and relate to the presence of environmental cues that signal belonging.

Using survey data this study found that the types of microaggressions experienced by minoritized groups varies depending on their group identity. Although all groups reported high levels of environmental microaggressions, Black surgeons were more likely to report experiencing microaggressions with the theme of criminality, invisibility, and undesirability than Asian American and Hispanic/Latino(a) surgeons. In contrast, Asian American and Hispanic/Latino(a) surgeons were more likely to experience microaggressions with the theme of being a foreigner or not belonging. This study reminds us that stereotypes lead to biases that inform our interactions with others and lead to microaggressions. Understanding and confronting how our biases manifest as microaggressions helps us to mitigate them.

Evaluating the Thematic Nature of Microaggressions

The Use of Race, Ethnicity and Social Determinants of Health in Three Pediatrics Journals [4]. Williams W, et al. J Pediatric. 2022:247:81-6.

The reporting of race, ethnicity and social determinants of health (SDOH) parameters is common in the medical literature; however, the data is rarely used to study patient outcomes in a meaningful way. In 1997, all NIH studies were required to collect race and ethnicity data the reporting of which was left to investigators. While other groups pushed for a more thoughtful interpretation of how such parameters effect patient outcomes in terms of the sociocultural implications of race and ethnicity. The racial reckoning of 2020 brought this issue to light again with a call for meaningful study into how race and ethnicity, as social constructs, drive health inequities and a cessation of the reporting of race and ethnicity as a biological construct.

A review of 317 research studies published in 3 top pediatrics journals between in 2021 revealed that race reporting is still common in US studies with 83% reporting on participant race, while only 46% reported on a non-race related SDOH. Despite high race reporting only ¼ of these studies interpreted their significance and linked race to their study findings, with far fewer doing so for SDOH. Although it is true that we cannot fix what we do not measure, the persistent failure to link study findings to the sociocultural underpinnings of race, ethnicity, and/or SDOH risks perpetuating the notion that disparate outcomes are biologically driven and adversely impacts efforts to achieve health equity.

Association of Race and Family Socioeconomic Status with Pediatric Postoperative Mortality [5]. Willer BL, et al. JAMA Network Open. 2022;5(3):e22289.

Low socioeconomic status (SES) has been associated with a higher risk of postoperative morbidity and mortality in the pediatric population, as has race. The intersection of racism and SES in childhood is complex. Children of minoritized races disproportionately experience poverty and inequality; however, the degree to which racism drives health outcomes across socioeconomic strata remains ill-defined. Understanding the multifactorial causes of health disparities is critical for improving equity in the provision of pediatric surgical care.

Using zip code-based parental income quartile as a proxy for SES, Willer, et al. performed a retrospective cohort study of 1,378,111 children who underwent inpatient surgical procedures over a 17-year period. They reported that pediatric postoperative mortality rates declined as SES increased, consistent with prior studies. They then stratified by self-reported race and found that race was an independent predictor of postoperative mortality across all income levels. (Figure 1) Furthermore, the difference in the mortality rate between the highest and lowest income quartiles was significantly smaller for Black children than white children, indicating that the survival advantage of belonging to higher SES quartiles was greater for white children. This is consistent with previous data in adults showing more rapid improvement in self-rated health among white adults than Black adults with increasing income levels. The authors conclude that interventions addressing socioeconomic disparities alone may not be sufficient in addressing persistent racial inequities in pediatric surgery patients. They call for a multifaceted approach which considers equitable access to personalized, high quality, comprehensive surgical care for children of all races.

Figure 1:Adjusted Incidence of Inpatient Death Across Increasing Levels of Household Income by Zip Code

Based on data from Black and White children recorded in the Children’s Hospital Association Pediatric Health Information System who received inpatient surgical procedures between January 1, 2004, and December 31, 2020. Adjusted mortality rates were controlled for sex, Hispanic ethnicity, age, insurance status, complex chronic conditions, and procedural group. OR indicates odds ratio.

Race, Postoperative Complications, and Death in Apparently Healthy Children [6]. Nafiu O, et al. Pediatr 2020 Aug;146(2);e20194113.

Disparate surgical outcomes between African American patients and their white peers have been demonstrated in the adult population and are often attributed to higher rates of preoperative comorbidities. Racial difference in surgical outcomes have not previously been demonstrated in the pediatric patients, who tend to have fewer preoperative comorbidities.

Nafiu et al. analyzed 172 549 children, ASA class of 1 or 2, who underwent inpatient surgical procedures during a 5-year period captured by the NSQIP database. They reported that the African American children had 3.43 higher odds of dying than their white counterparts, as well as an 18% relative higher risk of postoperative complications and 7% relative higher odds of serious adverse events. By including only ASA Class 1 and 2 patients in their analysis, the authors were able to show that differences in baseline health status are insufficient in explaining disparate surgical outcomes between African American and white children. The authors purposed physician-patient communication, provider bias, resource allocation, household income, and a lack access to specialized care as reason for these differential outcomes. The authors call for future investigations to evaluate the root causes of surgical complications and how they affect mortality across and within groups. Equal access to high-quality care is a critical step in reducing inequities. Efforts to combat racism in medicine require multi-pronged approaches, taking into consideration the interface between individual patient and family factors, their social context, the systems in which they live and receive care.

Police Exposures and the Health and Well-being of Black Youth in the US: A Systematic Review [7]. Jindal M, et al. JAMA Pediatr. 2022;176(1):78–88.

By age 24 years, Black youth have nearly 9-fold the number of encounters with police as do their White counterparts. These encounters are more likely to involve the use of force by police and five-fold as likely to result in injury to the youth. This disproportionate contact and differential treatment are forms of structural racism. Little is known about the impact of policing on the well-being of Black children.

The authors conducted a systematic review to examine existing literature documenting the association between police exposures and health for Black youth. They found 29 studies published between 1980 and 2020 including data from nearly 20,000 participants ages 9 to 26 years old. Most studies were of moderate or strong quality based on the Quality Assessment Tool from the Effective Public Health Practice Project. Overall, this review found a positive association between police exposure and adverse health outcomes for Black youth including mental health outcomes such as sadness, anger, and stress and risk behaviors such as sexual risk behaviors and substance abuse. The findings in this study emphasize the detrimental impact that seemingly trivial police contact can have on Black youth, particularly given the wide range of settings – grade schools, historically White colleges, neighborhoods, and parks – in which they occur. The study suggests the importance of considering the influence that policing has on Black youth, and the authors recommend use of a standardized approach to screening youth for exposure to police and for associated health manifestations. Pediatric clinicians can also support community and legislative reforms that focus on mitigating the health impact of police exposures on youth.

Race, Postoperative Complications, and Death in Apparently Healthy Children [6]. Nafiu OO, et al. Pediatrics. 2020 Aug;146(2):e20194113. Epub 2020 Jul 20.

It is generally understood that African American patients have higher rates of postoperative morbidity and mortality compared with their White peers. This has largely been attributed to greater preoperative comorbidity burden among African American patients. The objective of this study was to characterize the racial differences in postoperative mortality and complications among apparently healthy children.

The authors conducted a retrospective study by analyzing the American College of Surgeons National Surgical Quality Improvement Program – Pediatric (NSQIP-P) database using 2012-2017 data. Patients ages 17 years or under with ASA Class I or II undergoing inpatient procedures were included. The primary outcome was overall 30-day in-hospital postoperative mortality, and the secondary outcomes were overall 30-day postoperative complications and serious adverse events. Among over 170,000 patients, 11.4% of the children were African American and 70.1% were White. The authors found that even among these apparently healthy children, African American children had a higher risk of postoperative mortality and several other postoperative complications (including bleeding requiring transfusion and sepsis) compared to their White peers. These findings have serious implications for the perioperative care of African American children because they suggest that factors other than baseline comorbidity burden may contribute to differential postoperative outcomes.

The Reporting of Race and Ethnicity in Medical and Science Journals: Comments Invited [8]. Flanagin A, et al. JAMA. 2021 Mar 16;325(11):1049-1052.

Terminology, usage, and word choice are critically important in scientific literature, especially when describing people and when discussing race and ethnicity. The indistinct construct of racial and ethnic categories has been increasingly acknowledged, and the AMA Manual of Style: A Guide for Authors and Editors provides guidance to authors and editors, including regarding usage and reporting of race and ethnicity.

The AMA Style Committee has recently revised the entire subsection on race/ethnicity, and the revised section on inclusive language addresses correct and preferred usage of terms related to race and ethnicity, sex and gender, sexual orientation, age, socioeconomic status, and persons with diseases, disorders, or disabilities. Flanagin et al here provide the revised subsection on race/ethnicity and invite comments on ways this guidance could be improved.

Pediatric Social Risk Screening: Leveraging Research to Ensure Equity [9]. Cullen D, et al. Acad Pediatr. 2021 Sep 24:S1876-2859(21)00452-6. Epub ahead of print.

The Covid-19 pandemic and concurrent economic recession have exacerbated the effects of poverty on child health. There is additional pressure to implement screening protocols for social risk factors within pediatric health care. The effect of standardized social risk screening on resource engagement is unknown.

Cullen and coauthors describe three potential sources of inequity related to screening for social risk interventions. First, there is a discordance between screening results and the desire for services. This discordance occurs in both directions, with some participants screening positive but not reporting a specific “need” for services, and other participants having social needs but screening negative. Second, there is a discomfort with screening present across many participants but highest in those who report social risk due largely to fear of judgment and involvement of child protective services. Finally, screening discrimination at the healthcare level occurs as social risk screening practices are more commonly implemented in clinical settings with a majority of non-white clientele. Black and Brown children are more likely to be referred to child protective services and less likely to either stay with their parents or be reunified with them after foster care. The authors close with a recommendation for ethical, patient-centered approaches to implementing social needs interventions.

Promoting Equity for Women in Medicine - Seizing a Disruptive Opportunity[10]. Jagsi R. N Engl J Med. 2021 Jun 17;384(24):2265-2267.

Women are underrepresented in the science, technology, engineering, mathematics, and medical (STEMM) fields, particularly in leadership positions. Disruptions associated with the Covid-19 pandemic have had a disproportionate effect on women’s personal and professional lives.

In 2020, the National Academies of Sciences, Engineering, and Medicine (NASEM) published a report containing ideas for addressing long-standing issues of underrepresentation in the STEMM fields. Examining these practices is particularly important in light of changing responsibilities and a workplace culture that has accompanied the Covid-19 pandemic. Since the onset of the pandemic, women have played an outsized role in adapting to the changing needs of family members, patients, students, and colleagues, and there is growing evidence that these changes may result in lasting, negative consequences for career trajectories. Specific challenges include increased workload, reduced academic productivity, changes in interpersonal interactions, and difficulties associated with remote work. Institutional response to the pandemic has varied, but many organizations have missed opportunities to apply equity-minded leadership principles in the rush to manage the crisis. The authors in this Perspective piece published in the New England Journal of Medicine urge those of us in the academic medicine community to combat bias in selection and promotion processes, seek input from diverse stakeholders, and consider the long-term consequences of their decisions.

COVID-19 medical papers have fewer women first authors than expected[11]. Andersen JP. Elife. 2020 Jun 15;9:e58807.

There is significant evidence demonstrating that women in academic medicine shoulder a larger burden of domestic labor within their households than do men. The shift in social responsibilities related to the Covid-19 pandemic may disproportionately affect the scholarly productivity of women medical researchers as compared to men.

This paper compares the gender distribution of the authors of 1893 medical papers related to the Covid-19 pandemic to papers published in the same journals in 2019. Analysis showed that the proportion of Covid-19 papers with a woman first author was 19% lower than that for papers published in the same journals in 2019. These findings give credence to the idea that restricted access to child-care and increased work-related service demands may have taken a greater toll on women researchers as compared to men. There is abundant literature supporting the importance of diverse teams for solving complex problems. The authors of this paper argue that social constraints which disproportionately affect one group (women, for example) over another (men) could have profound negative consequences for our national and global response to the Covid-19 pandemic.

Unequal effects of the COVID-19 pandemic on scientists[12]. Myers KR. Nat Hum Behav. 2020 Sep;4(9):880-883.

Workplace restrictions and personal duties have changed during the Covid-19 pandemic, particularly in the early months of the pandemic. Scientists have not been immune to these shifting responsibilities, and evidence is needed on the magnitude of the disruption scientists are experiencing.

The authors of this paper conducted a survey of US- and Europe-based scientists to determine the extent of disruptions scientists experienced due to the Covid-19 pandemic. This survey was conducted in April of 2020, approximately one month after the WHO declared Covid-19 a pandemic. Results of the survey showed a decline in total working hours (61 hours/week to 54), a larger effect in research time for bench scientists (researchers whose work relies on physical laboratories and time-sensitive experiments), and a larger effect on female scientists and scientists with young dependents. The authors suggest several specific remedies, including enhanced childcare programs and tenure clock extensions for junior faculty.

Combating Anti-Asian Sentiment — A Practical Guide for Clinicians[13]. Lee JH. N Engl J Med. Published online March 24, 2021. NEJMp2102656.

Commentators have attributed recent increases in anti-Asian discrimination and violence to the blame placed on China for causing the Covid-19 pandemic, further perpetuated by U.S. officials at the highest levels use terms like the “China Virus” and “Kung Flu”. But Asian discrimination against Asian communities far precedes the recent COVID-19 pandemic, and in fact, has occurred for decades even outside the context of infectious diseases. Nevertheless, racism in the U.S. has been largely characterized along a Black/White binary, which has contributed to the increasing recognition of anti-Black racism as deeply embedded within societal structure, while inadvertently leading to the under-recognition and under-reporting of Anti-Asian racism.

Dr. Lee, who is a psychiatrist in the University of Washington, Seattle, proposes a framework that can be employed by clinicians to combat Anti-Asian racism. This framework includes tips such as: creating a safe space in outpatient settings (e.g. hanging welcoming signage), creating a safe space in inpatient settings (e.g. separating patients who display discriminatory attitudes or make discriminatory remarks from patients of color), addressing racism both during history taking (by asking directly if the patient has been affected by it) and examination, augmenting cultural competency (e.g. bystander training, crisis de-escalation, etc.) training for staff and offering institutional support to those who experience hate crimes, and providing resources specifically addressing anti-Asian sentiment (e.g. https://stopaapihate.org/)

Prevalence and Nature of Sexist and Racial/Ethnic Microaggressions Against Surgeons and Anesthesiologists [14]. Sudol et al. JAMA Surg. Published online March 24, 2021.

Microaggressions are subtle, insulting, discriminatory comments or actions that communicate a demeaning or hostile message to non-dominant groups. Microaggressions are known to cause chronic, severe distress, and ultimately physician burnout.

This paper describes the results of a primary survey study, which included 588 respondents (80 anesthesiologists and the remaining surgeons of different specialties) and used the Racial Microaggression Scale, the Sexist Microaggression Experience and Stress Scale, and the Maslach Burnout Inventory to assess the prevalence of microaggressions among surgeons and anesthesiologists, as well as its relationship with burnout. The study found 94% of women respondents experienced sexist microaggressions and 81% of racial/ethnic minority respondents experienced racial/ethnic microaggressions, respectively. Burnout was higher among women and racial-ethnic minority physicians at baseline, but even higher among those who experienced either sexist or racial/ethnic microaggressions, and higher still among women physicians who experienced both.

Without Sanctuary [15]. Ogunwole SM. N Engl J Med. 2021;384(9):791–3.

The impact of racism and racial discrimination on physicians, as well as patients, has been well described. But the intersection of both, and their impact on patient care has been less explored.

In this candid yet powerful perspective, Dr. Ogunwole, a Black Internal Medicine physician at the Johns Hopkins University, describes an experience during her residency that affected her strongly. She recalls Ms. A, a young Black woman with sickle cell anemia, being the victim of racial profiling by her nurse and ultimately by hospital security staff. She was accused of taking opioid pain medication not prescribed to her during her admission, physically restrained, and violently pinned to the ground despite having critically low platelets and a high risk of bleeding. In the words of Dr. Ogunwole, “In quiet moments, I often reflect on how our society decides who deserves punishment and who deserves redemption. I think about grace, and how Black people get so little. I think about trust, and how Black people get so little. I think about the benefit of the doubt, and how Black people get so little. And I think about the varied manifestations of Ms. A.’s pain — how no one, me included, offered her a sanctuary.”

Physician-Patient Racial Concordance and Disparities in Birthing Mortality for Newborns [16], Greenwood et al. Proc Natl Acad Sci U S A. 2020 Sep 1;117(35):21194-21200.

Recent work has shown evidence of the effect of patient-physician gender and racial concordance in medicine. Concordance can reduce outgroup biases, boost communication, and increase trust. Limited evidence exists that these benefits translate into material health benefits.

This work investigates the potential for patient-physician racial concordance to ameliorate healthcare disparities experienced by Black newborns, who die at three times the rate of White newborns in the United States. Investigators examined 1.8 million births in Florida hospitals from 1992-2015. The primary interest was whether the Black-White newborn mortality risk differs depending on physician race. Researchers found a robust racial concordance benefit for Black newborns being cared for by Black physicians as compared to Black newborns being cared for by White physicians. In the simplest model, this amounted to a difference of 257 deaths per 100,000 births, a 58% reduction in the racial mortality difference. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. This work gives strength to the call for hospitals, medical schools, and other healthcare organizations to build robust pipelines and pathways for Black students in medicine, reduce biases, and dismantle institutional racism.

Disability and Diversity studies as a professional basis for diversity-aware education and training in medicine [17]. Dungs et al. GMS J Med Educ 2020; 37(2)

People with disabilities who have negative experiences in the health care system, such as lack of sensitivity, disrespect, and devaluation, often choose to not seek professional medical care. An inability to distinguish symptoms from the disability or other diseases, limited knowledge of the disabled person’s life, and communication problems result in suboptimal patient-doctor relationships and treatment plans.

Disability and Diversity Studies (DDS) aim to move away from the medical model to the social model of disability. The medical model emphasizes the physical illness or disability, whereas the social model focuses on social disadvantages and barriers. In the DDS program, affected persons define their needs and request support, as opposed to predefined institutional patient care plans that are often biased and based on categorical assumptions. “The focus is on assistance models that enable those affected to lead a self-determined and supported life according to their needs.” The principle “Nothing about us, without us!” is recommended in the training of all health care professionals. The DDS Bachelor’s program curriculum at the Carinthia University of Applied Sciences is outlined in this paper. Inclusion of people with disabilities in medical education is deemed essential to acquire the following six fields of competence for respectful, patient-centered care.

1. Contextual and conceptual framework for disabilities
2. Professionalism and patient-centered care
3. Legal obligations and responsibilities for the care of patients with disabilities
4. Teams and system-based practice
5. Clinical evaluation
6. Clinical care over the life span and during changes.These principles should be applied in the treatment of people with any disability (i.e. physical, mental, addiction, economic, social, etc.).

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