As doctors, the routine is familiar to us. The format of the initial visit is strongly imprinted from our medical school days. We walk into a patient’s space, be it clinic, trauma bay, or hospital room. After introductions, the visit starts out with the physician recording the chief complaint and obtaining a history of present illness. Then comes the past, family, and social history—if we ever get to that. Rushed and pressed for time, we often interrupt the patient long before the complete story emerges . Although we were taught to form differential diagnoses and be open to alternative explanations, we race to a diagnosis and form a treatment plan. We may even start to think about what we’re going to tell the patient before we achieve diagnostic certainty. In all this hurry, how often do we consider that implicit bias may have influenced the whole interaction, including our very ability to understand the patient’s underlying concern ?
We encounter the patient with our eyes and ears. Age, gender, ethnicity and race, language proficiency—these things present themselves right away. A perception of socioeconomic status may jump out at us. Right or wrong, often wrong, much of this assessment happens before the first blink.
Often hidden is where the patient comes from; only rarely do we think about the neighborhood where a patient lives, but perhaps we should. Using statistical modeling from census data (demographic, socioeconomic, and geographic characteristics), the U.S. Small-area Life Expectancy Estimates Project highlights substantial gaps in life expectancy associated with one census tract . As highlighted in this online tool made available by the Robert Wood Johnson Foundation, people living blocks apart may have vastly different opportunities to live a long life . Enter your address to see your census tract’s life expectancy. Try it. In my area, I found a 9-year difference between neighboring communities.
The idea of place—of neighborhoods, their structure, resources, and atmosphere—and how it affects health is increasingly recognized as being independent from sex and gender, race and ethnicity . For instance, even after controlling for individual characteristics, place of residence was found to be associated with disparities in asthma treatment in children . A study from my own institution (Loma Linda University) found that place-related stressors (feeling unsafe walking, community noise, sense of community trust) play into the social-environmental context, and place may eclipse other commonly used socioeconomic factors .
Is it place, socioeconomic status, health insurance plan, race, or sex that affects the patient with an orthopaedic problem?
Shyam Brahmabhatt MD and his team from the Rothman Orthopaedic Institute and Drexel University College of Medicine in Philadelphia, PA, USA, seek to answer this question by looking at a well-defined orthopaedic condition—prosthetic joint infection (PJI) of the knee—and a life-altering outcome—above-knee amputation (AKA) . Which patients are at a higher risk of having their infection treated by amputation? Not surprisingly, they found that patients with comorbidities were more likely to undergo AKA. His team went further, however, and statistically adjusted their data to account for differences in comorbidities and dissected down to the ZIP Code™ level. Surprising to me, race and sex were not associated, but public health insurance (Medicare and Medicaid) emerged as factors associated with AKA after PJI .
Their work also highlighted the importance of place. Their ZIP Code™ level analysis revealed that patients in the lowest income quartile by location were more likely to undergo AKA after PJI, independent of comorbidities. Discerning readers will see that ZIP Code™ is not necessarily a direct proxy for socioeconomic status; while this can be considered to be a limitation, the team’s findings bring place-related health disparities to the forefront. Perhaps the bigger picture includes not only social determinants, but also physical determinants of health.
Please join me as we explore what compelled Dr. Brahmabhatt to take up this challenging and timely topic. Discover what surprised him and his team, how place and social context affects health, and how we as physicians can put this knowledge to use as we work with our patients.
Take 5 Interview with Shyam Brahmabhatt, MD, author of “Socioeconomic Status Is Associated with Risk of Above-knee Amputation After Periprosthetic Joint Infection of the Knee”
M. Daniel Wongworawat MD:Congratulations on your work highlighting health disparities. What drew you to study inequalities in care?
Shyam Brahmabhatt MD: While attending medical school and residency in Philadelphia, PA, USA, I had always been struck by the stark contrast of income levels and resources available to people living in different areas of the city. At Temple University Hospital, the majority of patients we treated were from lower income backgrounds. Even now at Abington Hospital in Abington, PA USA, which is about 15 miles north of Philadelphia, I still encounter many disadvantaged patients on a regular basis. While I am confident that we provide outstanding surgical care, a variety of factors including poor followup, inability to afford medication, and lack of access to primary care leads to worse outcomes for these patients. I was then, and still am today, interested in exploring which specific factors were associated with poor outcomes in orthopaedic surgeries in order to better target interventions to improve patient care.
Dr. Wongworawat:Many readers might have an idea about how social factors may affect access to care and health status. I was surprised to read that race and sex were not contributing factors. What findings surprised you?
Dr. Brahmabhatt: The finding that race and sex were not contributing factors to AKA after TKA was also surprising to us, especially given previous research that has indicated that black patients are more likely to undergo AKA secondary to peripheral vascular disease or PJI of the knee. Also surprising to us was the fact that patients with Medicare or Medicaid insurance were associated with a greater risk of AKA. We did not intuitively expect Medicare insurance to be an associated risk factor, especially given the similar risks of AKA for patients ages 50 to 64, 64 to 80, and older than 80.
Dr. Wongworawat: You used ZIP Code™ as a measure of socioeconomic status. Going beyond social determinants, ZIP Code™ also might reflect physical determinants (barriers, sidewalks, lanes, green space). Might these environmental issues have a compounding effect on patients after AKA?
Dr. Brahmabhatt MD: Absolutely. While ZIP Code™ may not be a perfect measure of socioeconomic status, it is associated with the level of resources that may be available to people living in that area. Patients living in low-income urban areas lacking access to public transportation, grocery stores, and buildings accessible to persons with disabilities are going to struggle both before and especially after an AKA. Undoubtedly, we would expect a patient living in a more-affluent suburb with more resources to have an easier recovery and rehabilitation. The difficulty as physicians is trying to consider a patient’s social determinants while making the best clinical decisions for him or her, especially when certain social factors are particularly unmalleable.
Dr. Wongworawat:ZIP Code™ and insurance type may give an idea about health care access. You found an association with risk of receiving AKA after PJI. On an individual level, what do you think nudged the selection towards favoring AKA? Is it worse control, delayed presentation, or something else?
Dr. Brahmabhatt: I think it’s difficult to say since from our study we were unable to directly look at each factor individually. However, I would speculate that it’s likely a combination of factors. Patients from lower-income backgrounds or Medicaid health insurance are generally going to have worse access to medical care. This could lead to delayed and more-severe presentation of PJI, perhaps resulting in a greater risk of AKA for treatment. Furthermore, even after patients are successfully treated for PJI, if patients lack access to medication, they would conceivably be more likely to develop recurrent PJI of the knee and eventual AKA.
Dr. Wongworawat:The solution for bringing health equity might start on the individual level. What words to you have for the practicing orthopaedic surgeon on how to make an immediate difference, and what message is important as we train the next generation of doctors?
Dr. Brahmabhatt: I would say that it begins with treating every patient as if (s)he was your own family member. This can certainly be challenging with some patients because of inherent confirmation biases within the physician themselves, but it’s important to remember why we became doctors in the first place and serve every patient with full dedication and commitment, no matter what background or difficulties he or she brings. The message that I would impart is that upholding the principles of equity, social justice, and ensuring community health are important for all physicians. Regardless of whether you are an internist, psychiatrist, or orthopaedic surgeon, we all must play a role in ensuring that all members of our community receive quality health care. It’s important to remember that all specialties work together as a team to fulfill vital roles in helping our patients towards that goal.
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