The REPAIR Project was invited by the UCSF Department of Surgery to present at their weekly Grand Rounds. We are grateful for the opportunity to introduce our second year's theme, and we encourage you to read more about the topics discussed in our presentation and have provided links to resources discussed in our presentation below.
Medicine's role in the Prison-Industrial Complex
- Uncontrollable Blackness: African American Men and Criminality in Jim Crow New York, Douglas J. Flowe, UC Press, 2020
- The Condemnation of Blackness: Race, Crime, and the Making of Modern Urban America, Khalil Gibran Muhammad, Harvard University Press, 2019
- From Asylum to Prisons: Deinstitutionalization And the Rise of Mass Incarceration After 1945, Anne E. Parsons, UC Press, 2018
- The Protest Psychosis: How Schizophrenia Became a Black Disease, Jonathan M. Metzl, Penguin Random House, 2011
Medical Abolition and Surgery
Medical Abolition recognizes that historical associations between Blackness, pathology, and criminality are key in the ongoing anti-Blackness we witness in medical spaces. In our Grand Rounds presentation, we explored how this plays out in surgical spaces specifically.
Penetrating Trauma and Violent Injury
Penetrating trauma disproportionately affects Black communities:
- Severely injured Black and Hispanic trauma patients more likely to be undertriaged (Alber DA, Journal of Surgical Research 2021; 257:486-492. DOI: 10.1016/j.jss.2020.08.031)
- Pediatric penetrating trauma in the Bay area increased during the last decade, with Black and Hispanic children experiencing the greatest proportion of traumas (Schecter S, J Trauma Acute Care Surg 2012:73(3):721-5. DOI:10.1097/TA.0b013e318265cdce)
Black patients have worse outcomes for penetrating trauma, which can only partially be attributed to findings that show Black patients are more likely to be treated at lower-resourced hospitals.
- Race and insurance status each independently predicts outcome disparities after trauma (Haider AH, Chang DC, Efron DT et al, JAMA Surg 2008;143(10):945-949)
- Trauma patients admitted to hospitals with >20% Black patients had 45% higher odds of death (OR 1.45) and 73% higher odds of death or major complication (Glance LG et al, Health Services Research 2013; 48(5):1684-1703).
Potential directions for action:
- Universal insurance and equaly access healthcare system eliminates disparities for Black patients after traumatic injury (Chaudhary MA, et al. Surgery 2018;163(4):651-656.)
- Gun Violence Research and the Profession of Trauma Surgery (Peetz AB, et al. AMA Journal of Ethics. 2018;20(5):475-482.)
- How Doctors Can Help Prevent Gun Violence (Ranney ML and Betz ME, Harvard Business Review. 2019 Oct 24.)
Pain Management
- Racial bias in pain assessment and treatment recommendations and false beliefs about biological differences between Blacks and Whites (Hoffman KM et al, PNAS, 2016; 113(16):3296-4301.
Black patients experience more pain for the same conditions
- 5761 Lung and Colorectal Cancer patients: among those reporting pain, both blacks and multiracial individuals reported higher pain severity than whites. (Martinez KA, et al. Journal of Pain and Symptom Management 2014;48(6):1050-1059).
Black patients receive less pain management
- 2298 Pediatric patients with abdominal pain: black patients were less likely to receive any analgesic (OR 0.61) or a narcotic analgesic (OR 0.38) than white patients (Johnson TJ et al, Pediatrics 2013, 132 (4) e851-e858).
- Black patients with isolated long-bone fractures less likely than white patients (57% versus 74%, P =.01) to receive analgesics in this ED and more likely to receive no analgesic at all. (Todd KH et al 2000 Annals of Emerg Med)
- Racial Inequality in Prescription Opioid Receipt (36% lower mean annual dose among Black patients compared to White patients) and Role of Individual Health Systems (Morden NE et al, NEJM 2021; 385(4):342-351.)
Post operative pain control
- Black children less likely to fill opioid prescriptions after cholecystectomy (Lawrence AE et al, J Surg Research 2020;245:309-314).
- White patients receive more total post-operative narcotic analgesic than ethnic minority patients (McDonald DD, Res Nurs Health 1994;17(1):45-9.)
- Black and Latinx patients receive significantly less opioid analgesia than White patients following open reduction and internal fixation of a limb fracture in a national study of racial differences in pain screening in the VA health care system (Burgess DJ, et al. Clin J Pain. 2013 Feb; 29(2):118-23.)
- Black women are less likely to receive opioid analgesics postpartum compared to White women (Johnson JD, et al. Obstet Gynecol. 2019 Dec; 134(6):1155-1162; Badreldin N, et al. Obstet Gynecol. 2019 Dec; 134(6):1147-1153.)
Black patients perceived to be at greater risk for future misuse/abuse of prescription opioids
- Black patients perceived to be at greater risk for future misuse/abuse of prescription opioids. (Hirsh AT, et al. American Psychologist 2020;75(6), 784–795.)
- Black patients receiving opioid analgesia are more likely to be subjected to urine drug testing and restricted early refills (Becker WC, et al. Ann Fam Med. 2011; 9(3):219-25)
- Amongst stable chronic pain patients, Black patients are more likely to have their dosages reduced than are White patients (Buonora M, et al. Pain Med. 2019 Aug 1; 20(8):1519-1527)
Kidney Transplantation
Disparities in Living Donor Kidney Transplantation
- Black patients less likely to receive education regarding kidney transplant and less likely to consider living donor kidney transplant an option (Young CJ, Kew C. Med Clin North Am 2005; 89: 1003-1031.)
- Black patients were less likely to receive a LDKT compared with White patients, and this disparity increased with higher social vulnerability index (Killian AC et al. JAMA 2021; Purnell TS et al. JAMA 2018; 319:49–61.)
- Black patients less likely than whites to be referred for evaluation, to be placed on a waiting list (71.0% vs. 86.7%), or to undergo transplantation (16.9% vs. 52.0%) (Epstein AM et al NEJM 2000;343:1537-1544).
Transplantation and Pathologization of Race
Transplant waitlist eligibility criteria affects time to referral and transplant: reliance on GFR <20 → racial coefficients increase GFR for Black patients, raising the threshold for requiring (and being eligible) for kidney transplant
- Race-corrected GFR calculations are associated with delays in kidney transplant eligibility; if excluded, 35% higher instantaneous risk of achieving eligible GFR for transplant referral (Zelnick LR et al JAMA Network Open 2021;4:e2034004-e).
Transplant criteria often includes “social support” criteria which disproportionately excludes under-resourced and Black communities
- 9.6% of patients evaluated are excluded due to inadequate support, 67.3% of transplant providers believe this criteria disproportionately impacts low SES patients (Laden K et al Am J Transplant. 2019 Jan; 19(1): 193–203.)
- Neither social support nor marital status was predictive of medication adherence or post-transplant outcomes (Laden K et al. Transplant Rev. 2018 Jan;32(1):16-28.)