General surgery textbooks and surgical disparities.

INTRODUCTION: Some academic textbooks have previously disseminated simplistic or even incorrect conceptions of race. Propagation of such ideas in General Surgery could contribute to gaps in quality of care received by minority patients. This study aims to determine whether General Surgery textbooks provide a thorough understanding of racial disparities. METHODS: General Surgery texts were drawn from Doody's list, an industry-standard list of textbooks for medical education. Technical guides, atlases, and books for non-General Surgery professionals were excluded. Passages mentioning medical differences amongst racial and ethnic groups were extracted. Six binary classifications were made, based on whether passages (a) described interventions to alleviate difference; (b) addressed environmental mediators of difference; (c) described the contribution of racism or discrimination; (d) used causal language to connect race to difference; (e) referred to known, heritable genetic mechanisms; and (f) directly provided a reference. Types of intervention were also extracted. A heuristic scale was calculated granting one point each for classifications a-c and losing one point for classification d. Three authors performed classifications, and raw agreement and Cohen's kappa were used to assess inter-rater reliability. RESULTS: Thirteen textbooks from Doody's list contained 511 passages discussing medical differences among racial/ethnic groups. Among passages, 25% discussed white people, 22% Black people/African Americans, 19% Asians, 9% Latinos, 4% Jewish/Ashkenazi people, 3% Native Americans, and 18% other. Fifteen passages (2.9%) used language indicating race was the cause of medical difference, and only two explicitly discussed racism or discrimination. Most passages (370, 72.3%) received a scale of 0. 120 (23.5%) received a scale of 1, eight (1.2%) received a scale of 2, and zero received a scale of 3. The mean passage scale was 0.24 and is not changing with time (regression coefficient -0.006/year, p = 0.538). Agreement was 91.2% across all categories and overall Kappa was 0.62. CONCLUSIONS: General Surgery textbooks do not provide readers with scientifically thorough understanding of health disparities. Teaching more comprehensive conceptions, including systemic causes and the role of racism, may prevent reflexive association of minority patients with poor outcomes. Future editions should include these details where disparities are discussed in an independent, comprehensive section.

Increases in adolescent firearm injuries were associated with school closures during COVID-19.

BACKGROUND: Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic. METHODS: Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes. RESULTS: There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city. CONCLUSION: AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

What do Trauma Surgery Textbooks Teach About Racial Disparities and the Roots of Violence?

This study presents a formal text analysis of trauma surgery textbooks. We examine passages that describe disparities or mechanisms of injury, and we report types of underlying causes and preventative interventions discussed. Trauma textbooks were drawn from an industry-standard list used by medical libraries. Chi-square testing was used to determine whether different types of underlying causes or preventative interventions were discussed by disparity type (those affecting racial minorities vs rural populations) and injury mechanism (accidental injuries vs intentional interpersonal injury). 146 passages were extracted from 7 textbooks, totaling 5576 pages of text. Passages discussing rural disadvantages or unintentional injury were substantially more likely to describe structural risk factors or governmental interventions than those discussing racial disadvantages or intentional injury, respectively. Textbook authors should consider enriching discussion of violence prevention or racial disparities to emphasize structural causes and interventions.

Inefficiency in Delivery of General Surgery to Black Patients: A National Inpatient Sample Study.

Background Racial disparities in outcomes among patients in the United States are widely recognized, but disparities in treatment are less commonly understood. This study is intended to identify treatment disparities in delivery of surgery and time to surgery for diagnoses managed by general surgeons-appendicitis, cholecystitis, gallstone pancreatitis, abdominal wall hernias, intestinal obstructions, and viscus perforations. Methods The National Inpatient Sample (NIS) was used to estimate and analyze disparities in delivery of surgery, type of surgery received, and timing of surgery. Age-adjusted means were compared by race/ethnicity and trends in treatment disparities were evaluated from 1993 to 2017. Linear modeling was used to measure trends in treatment and outcome disparities over time. Mediation analysis was performed to estimate contributions of all available factors to treatment differences. Relationships between treatment disparities and disparities in mortality and length of stay were similarly evaluated. Results Black patients were less likely to receive surgery for appendicitis, cholecystitis, pancreatitis, and hernias, and more likely to receive surgery for obstructions and perforations. Black patients experienced longer wait times prior to surgery, by 0.15 to 1.9 days, depending on the diagnosis. Mediation analysis demonstrated that these disparities are not attributable to the patient factors available in the NIS, and provided some insight into potential contributors to the observed disparities, such as hospital factors and socioeconomic factors. Conclusion Treatment disparities are present even with common indications for surgery, such as appendicitis, cholecystitis, and gallstone pancreatitis. Black patients are less likely to receive surgery with these diagnoses and must wait longer for surgery if it is performed. Surgeons should plan institution-level interventions to measure, explain, and potentially correct treatment disparities.

Ethical Care of the Traumatized: Conceptual Introduction to Trauma-Informed Care for Surgeons and Surgical Residents.

Trauma-informed care (TIC) is a set of principles and practices designed to improve the ways professionals treat people who have been traumatized. This study reviews fundamental concepts of TIC and applies them to the work of surgeons. TIC is described in relation to fundamental medical ethical concepts, and evidence for TIC-based intervention is reviewed. Implementation of TIC in medical education is also described, and recommendations for practice changes are made.

Understanding Racial Disparities in Gastrointestinal Cancer Outcomes: Lack of Surgery Contributes to Lower Survival in African American Patients.

BACKGROUND: Race/ethnicity-related differences in rates of cancer surgery and cancer mortality have been observed for gastrointestinal (GI) cancers. This study aims to estimate the extent to which differences in receipt of surgery explain racial/ethnic disparities in cancer survival. METHODS: The National Cancer Database was used to obtain data for patients diagnosed with stage I-III mid-esophageal, distal esophagus/gastric cardia (DEGC), noncardia gastric, pancreatic, and colorectal cancer in years 2004-2015. Mediation analysis was used to identify variables influencing the relationship between race/ethnicity and mortality, including surgery. RESULTS: A total of 600,063 patients were included in the study: 3.5% mid-esophageal, 12.4% DEGC, 4.9% noncardia gastric, 17.0% pancreatic, 40.1% colon, and 22.0% rectal cancers. The operative rates for Black patients were low relative to White patients, with absolute differences of 21.0%, 19.9%, 2.3%, 8.3%, 1.6%, and 7.7%. Adjustment for age, stage, and comorbidities revealed even lower odds of receiving surgery for Black patients compared with White patients. The observed HRs for Black patients compared with White patients ranged from 1.01 to 1.42. Mediation analysis showed that receipt of surgery and socioeconomic factors had greatest influence on the survival disparity. CONCLUSIONS: The results of this study indicate that Black patients appear to be undertreated compared with White patients for GI cancers. The disproportionately low operative rates contribute to the known survival disparity between Black and White patients. IMPACT: Interventions to reduce barriers to surgery for Black patients should be promoted to reduce disparities in GI cancer outcomes.See related commentary by Hébert, p. 438.