Achieving Equity and Parity in Otolaryngology Care

NEW ORLEANS—Third-generation African American physician Dana M. Thompson, MD, MS, professor and division head of otolaryngology–head and neck surgery at the Ann and Robert H. Lurie Children’s Hospital of Chicago and Northwestern Fienberg School of Medicine, said she faces racial discordance on an ongoing basis with most of her patients, colleagues, students, mentors, sponsors, and all of her bosses.

Her John Conley, MD Lecture on Medical Ethics, “Achieving Parity in Otolaryngology Care: The Ethical Obligation Beyond Care Access,” presented September 15, 2019, at the American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS) Annual Meeting in New Orleans, showed how her African American patients and those in other underrepresented groups also face this type of discordance in the American healthcare system every day.

“If we are anthro-culturally different from our patients and we see our patients through the lenses of our biases, we risk not understanding their values, expectations of their care, and their needs,” Dr. Thompson said. “This partnership is our ethical responsibility to our patients to help them live healthier lives and achieve health equity.”

Dr. Thompson’s presentation also covered how the effects of American slavery, segregation, capitalism, and individual biases interfere with equity and parity in medicine and otolaryngology. She offered a way forward for physicians based on an examination of personal values and advocacy efforts that can have an impact on equity and parity.

Medicine’s Dilemma: Cost, Access, and Quality

Access to healthcare, Dr. Thompson said, is a function of several factors, including the availability of personnel and supplies close to where a prospective patient lives or easily accessible by transportation. It also means care that is timely, affordable, understandable, and respectful of the patient’s culture. According to Dr. Thompson, healthcare expectations of Americans are those anthro-cultural beliefs and values espoused by the middle class, who value advanced technology, expedited care, and access to the highest possible form of care delivery, despite the diagnosis.

“That leads us to medicine’s dilemma: infinite needs versus finite resources,” Dr. Thompson said, citing the work of the medical economist William Kissick, MD, who was active in drafting Medicare and authored Medicine’s Dilemmas (Yale University Press, 1994). Dr. Kissick coined the phrase “Iron Triangle of Cost, Access, and Quality” to explain that if there were a triangle where cost, access, and quality each represented an angle, expansion of any one of the angles would almost always compromise one or both of the other two.

If we are anthro-culturally different from our patients and we see our patients through the lenses of our biases, we risk not understanding their values, expectations of their care, and their needs. —Dana M. Thompson, MD, MS

Quoting Dr. Kissick, Dr. Thompson said, “Tradeoffs are inevitable regardless of the size of the triangle, and they’re all choices that society must make.” She added, “When we look at how we view healthcare as Americans, are we okay with this concept?” She pointed to unsustainable costs, quality that lags behind other comparable countries, and the inequitable distribution of healthcare access. “Populations who are going to be at greatest risk are those that we have biases against based on race, ethnicity, sex, sexual identification, age, disability, socioeconomic status, and where we live,” she said.

Market Justice vs. Social Justice

Dr. Thompson pointed out that the guiding principles of care access can fall under market justice (the belief that healthcare access and allocation is a reward based on personal effort and achievement, akin to private insurance) or social justice (the belief that access and allocation is a social resource and ability to pay is inconsequential for receiving care, akin to publicly funded insurance). “The reality of the United States is our payment system is a combination of both,” she said. “We have to recognize that the outcomes are not always equitable and ask, is there parity in the value of care when comparing payment systems?”

Impacts on Health Equity

For African Americans, the long history of inequity and healthcare inequity stretches back to slavery. “The transport itself from Africa to the New World remains one of the best examples of the ability of one center of humanity to destroy the health of another,” she said. “So the fact that the African American population is the least healthy ethnic group in the United States is not due to chance alone. We have to remember our history.”

That history continued with segregation, including “separate but equal” hospitals for African Americans and segregated medical schools, and it continues today with a deeply rooted distrust of the healthcare system based on cases that include that of Henrietta Lacks, whose cervical cancer cells were used without her knowledge or consent to become one of the most important cancer cell lines in the history of medical research.

Capitalism has also been a long-time deterrent to parity and equity in healthcare. “To really understand the brutality of American capitalism, you have to start on the plantation. While cotton may have been king and helped our economic development as a country, it was done on the backs of slaves,” Dr. Thompson said.

Race and socioeconomic status comprise the social determinants of health in American healthcare delivery models, and other factors play a part too. One of the strongest predictors of life expectancy, Dr. Thompson said, is whether a person graduated high school, which varies dramatically among class, race, and other ethnic divisions. It also determines who goes to college or vocational school, ultimately becomes employed, and lives a healthy life.

Ethnicity and culture, she said, can affect a patient’s attitude toward the idea of even visiting a physician at all. Lack of reliable transportation in urban areas, and long-distance transportation challenges in rural areas, can delay care, while lack of financial resources can limit access to healthy food and lead to poor nutrition and limited healing. “If we look in the city that we’re in right now, New Orleans,” she said, “you will see that there is more than a 25-year difference between life expectancy depending on which area of the city that you live.”

She pointed out that Black infants and children in poor rural communities have a three times higher mortality rate compared with those in affluent areas. Uninsured, underinsured, and rural patients tend to present late with head and neck cancer. Children from lower socioeconomic backgrounds are more likely to present with more severe complications of bacterial sinusitis. And children with hearing loss from certain geographic regions or ethnic backgrounds are significantly delayed in diagnosis and treatment for hearing. “Roots of inequity are driven by the socioeconomic factors that impact marginalized populations and our biases and our attitudes toward them,” she said.

How to Make a Difference

There are several ways physicians can help close the gap on healthcare outcomes. Dr. Thompson said that it starts with acknowledging the problem and the historical factors behind disparities, understanding the impact of the social determinants of health on outcomes, and actively integrating resources to help patients overcome their negative influence on health and well-being.

Dr. Thompson recommends physicians take the Harvard implicit bias online test (implicit.harvard.edu/implicit/takeatest.html) to become aware of biases they may not even consciously know they have, and work to overcome these biases to better understand patients. This growth leads to building trust and more effective relationships with patients, and becoming true partners in care, she said.

Creating a diverse workforce is also part of the solution. Dr. Thompson said working in diverse groups not only helps physicians see their biases, but also allows people from disparate backgrounds to educate each other about how their perceptions and biases may impact their interactions with patients. Additionally, they can also point out how social determinants of health impact specific communities and share possible solutions.

“Educating the next generation of diverse physicians is essential to achieving parity,” Dr. Thompson said. “Minority patients are more likely to seek care from and trust a racially concordant physician. Minority physicians are more likely to return to their communities and serve vulnerable populations. And diverse physicians will ask relevant scientific questions about how race and other social determinants of health impact outcomes.”

Unfortunately, according to an ACGME report, otolaryngology is behind other specialties when it comes to diversity (JAMA Intern Med. 2015;175:1706–1708). “We still have a gap that can be filled through awareness, mentoring, sponsorship, pipeline programs, and advocacy,” Dr. Thompson said.

Dr. Thompson acknowledged her many mentors in the audience for supporting her in her path and acknowledged the recent passing of Thomas McDonald, MD, who was her chair at the Mayo Clinic when she was a resident and who made Dr. Thompson her first job offer. As an Irish Catholic immigrant from Northern Ireland, she said, he had his own pathway with discrimination and, as such, could empathize with her and understand some of her challenges. “What has helped me along the way has been mentors, sponsors, and colleagues who have either been color blind or gender blind or able to see potential beyond a bias,” she said.   

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Renée Bacher is a freelance medical writer based in Louisiana.