As Usha Lee McFarling has pointed out, the orthopedic surgeon specialty suffers from a gross underrepresentation of minorities and women, more severe than in other medical specialties. There are various reasons for this and a variety of possible paths toward improvement, but the “critical first step,” as American Academy of Orthopedic Surgeons former president Kristy Weber, MD, told Ms. McFarling, “is changing the culture.”
“Changing the culture” is a large, diffuse aspiration. The AAOS has taken a number of steps toward that end, but they have not had much success. The two of us have identified others, which may help to move the needle.
Viewed from this perspective, the cultural barriers to inclusivity are similar to those that perpetuate inequitable health care. Both are driven by ingroup/outgroup prejudices that operate below the level of consciousness and are largely unseen.In our book Seeing Patients, we examined health disparities in six “non-mainstream” groups: African Americans, Hispanic Americans, women, gays and lesbians, and the elderly. We based our work initially on the Institute of Medicine’s breakthrough 2003 compendium, Unequal Treatment, which brought together a large number of studies on health care inequities that had appeared in a variety of journals over many years, but had never generated the critical mass necessary to create a call for action or even attract serious attention.
Unequal Treatment allowed us to understand that each medical specialty, right down the line – orthopedics, cardiology, gynecology, oncology, psychiatry, to name just a few – has its own grim history of discrimination. Our sense of the medical community in the 21st century led us away from the idea that overt bias is a significant cause of these still ongoing inequities. Most physicians, we believed, consider themselves to be, and strive to be, humane, compassionate, and egalitarian caregivers. The answer then seemed to be in subconscious rather than conscious bias.
As we reviewed the literature and strove to understand the primary drivers of the discrimination that systematically affects medical care, our attention was drawn to two critical and complementary mechanisms hard-wired into our systems for parsing and responding to our environment. The first was “stereotyping,” so often used as a pejorative, but which is, in fact, a primary and essential mental function.
“We all make stereotypic judgments,” says Rice University emeritus professor of psychology David Schneider in The Psychology of Stereotyping (page 419). “It happens with race. It happens with disability. It happens ... with gender, age, and physical appearance. ... That’s just the way it is: Our mental apparatus was designed to facilitate quick decisions based on category membership.”
Differentiation – social stereotyping in our case – is a given, then; it’s innate. The content of stereotyping – of Blacks, gays, women, and others – is not innate, but it is deeply ingrained by living in a given milieu and just as impossible to ignore.
The second mechanism we focused on was the neurobiology that underlies the impact of hidden emotion on rational thought. In his seminal book Descartes’ Error, neuroscientist Antonio Damasio spells out how the mind with its cognitive functions has evolved from the body and its emotional systems, and how they function together through neuro-networks that connect the mechanisms of feeling with the brain’s decision-making centers.
“Feelings,” Dr. Damasio tells us, “come first in [brain] development and retain a primacy that pervades our mental life.” The limbic system, the part of the brain that controls our emotional responses, constitutes a “frame of reference and has “a say on how the rest of the brain and cognition go about their business. [Its] influence is immense.” (Page 185)
Dr. Damasio was not focusing on medical decisions, but his insights, we felt, had great relevance for the question of unconscious bias in health care. Various studies by physicians and medical scientists do speak directly to the issue of how affective bias influences diagnosis and treatment. Pat Croskerry, director of Dalhousie University’s Clinical Research Center, argues that “cognitive and affective biases are known to compromise the decision-making” and that commonly “these are largely unconscious mistakes.”
Harvard’s Jerome Groopman, in his book How Doctors Think (page 40), writes that most incorrect diagnoses and treatments are “mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we ... often don’t even recognize.” Cognition and emotion, Dr. Groopman insists, are inseparable. The emotional landscape sets the ground for decision-making.
The underlying mechanisms that enable health care prejudice are the same that enable interpersonal prejudice generally. Unseen and largely unrecognized, they affect ingroup/outgroup relations in every field of interaction, from bias in policing, to bias in housing, to bias in employment – “powerful and universal,” in Dr. Croskerry’s words, “affecting all walks of life.”
Decision-making about acceptance into orthopedic residencies is no exception. As Prof. Schneider says, “That’s just the way it is.”
What conclusions can be drawn from understanding the deep origins of subconscious bias that might improve the inclusion of minorities and women in orthopedics? A growing interest in “debiasing” in both the medical and cognitive psychology literature has identified or suggested methods of counteracting the prejudices we all harbor. (See Bhatti’s “Cognitive Bias in Clinical Practice,” Wilson and Brekke’s “Mental Contamination and Mental Correction: Unwanted Influences on Judgments and Evaluations,” and De Neys and colleagues’ “Feeling We’re Biased: Autonomic Arousal and Reasoning Conflict.”)
Many of these debiasing techniques have to do with education regarding cognitive functions, from training in decision-making processes to “time outs,” to checklists à la Atul Gawande, to other methods of metacognition.
But the two key prerequisites to all of these approaches are more or less self-evident. “For biases to be successfully addressed,” says Dr. Croskerry, “there needs to be ... awareness as well as the motivation for change.”
In a previous article we discussed the need to heighten awareness over and above current levels, and we have suggested steps toward that end. But awareness is only the first prerequisite; the second is motivation, and the depth of motivation necessary to create change in the business of orthopedic inclusion is, for all the AAOS’s efforts, simply inadequate – the result being that the culture does not change, or it changes so glacially as to be hardly noticeable.
Ms. McFarling noted in her interviews with orthopedic leaders, clinicians, residents, and medical students simmering feelings of frustration and perplexity. We would suggest that the frustration is because of the fact that, while there is a general awareness of the problem, there has simply not been the sufficiently determined motivation to fix it. “It is not neglected truths,” as religious scholar Gregory Dix put it, “but those that are at once fully acknowledged and frustrated of their proper expression, which take the most drastic psychological revenge.”
All of this leads back to the original problem posed by Prof. Weber, the former AAOS president: changing the orthopedic culture. The question of how cultures undergo transformation has been addressed by scholars across widely diverse fields (see, for example, Thomas Kuhn’s The Structure of Scientific Revolutions, Francis Fukuyama›s The End of History and the Last Man, and many others). But we are addressing here a narrow, well-defined slice of that problem. And our own explorations have led to the conclusion that the answer here lies in the issue of motivation – namely, how can a community that is aware of a problem be sufficiently motivated to fix it?
In Seeing Patients we argued that doctoring is the paradigmatic humanitarian profession, that physicians’ whole business is to care for and alleviate the suffering of other human beings. In this sense, doctors are the carriers of the humane ideal, which is congruent also with the noblest egalitarian principles of our life as a nation. We argued also that humanitarian medicine with its egalitarian mandate is a win-win-win proposition. The patient wins, the doctor wins, the society wins.
We think arguments like these should provide plenty of motivation for change. But in reality they are not sufficient. Our arguments and those of others along the same lines (see Louis Sullivan’s Breaking Ground and David McBride’s Caring for Equality) are directed for the most part at the better angels of our nature. They appeal to personal and political values: compassion, fairness, equality – powerful yet set against custom, habituation, and the daily pressures of practice, such arguments can and do easily come up short.
But when looked at straight on, with unblinking eyes, health care disparities should provoke other more forceful emotions: anger, to begin with; chagrin, consternation. Women receive fewer heart catheterizations and reperfusions than men. (See R. Di Cecco and colleagues’ “Is There a Clinically Significant Gender Bias in Post-Myocardial Infarction Pharmacological Management in the Older Population of a Primary Care Practice?” and Jneid and coworkers’ “Sex Difference in Medical Care and Early Death after Acute Myocardial Infarction.”) Because of this, more women die.
Blacks and Hispanics receive fewer analgesics for the excruciating pain of broken bones, and they are amputated more frequently than whites for identical peripheral arterial disease. (See Knox and colleagues’ “Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia,” Bonham’s “Race, Ethnicity and Pain Treatments: Striving to Understand the Causes and Solutions to the Disparities in Pain Treatments,” and Feinglass and coworkers’ “Racial Differences in Primary and Repeat Lower Extremity Amputation: Results From a Multihospital Study.”) They suffer accordingly.
The statistical accounting of these disparities masks the faces of pain and desperation – of disabilities, often of mortality. These are hard visceral truths that derive in part from the underrepresentation of minorities in various specialties, most pronounced in orthopedics. These are the truths that, when actually absorbed rather than just registered, have the capacity to transform awareness into motivation and in so doing can begin reshaping a culture that restricts minorities and women and makes orthopedics, as Ms. McFarling calls it, “the whitest specialty.”
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