Race, Racism, and Respiratory Health.

The study and practice of pulmonary medicine have been profoundly influenced by race theory, which was ascendant at the time of key developments within the specialty. We explore how, as a social determinant of health, race remains a powerful driver of present-day health disparities in respiratory diseases. Both legacy and contemporary inequities are identified through Dr DR Williams's model of cultural, structural, and interpersonal racism.

Towards a Race-Neutral System of Pulmonary Function Test Results Interpretation.

It has been observed widely that, on average, Black individuals in the United States have lower FVC than White individuals, which is thought to reflect a combination of genetic, environmental, and socioeconomic factors that are difficult to disentangle. Debate therefore persists even after the American Thoracic Society's 2023 guidelines recommending race-neutral pulmonary function test (PFT) result interpretation strategies. Advocates of race-based PFT results interpretation argue that it allows for more precise measurement and will minimize disease misclassification. In contrast, recent studies have shown that low lung function in Black patients has clinical consequences. Furthermore, the use of race-based algorithms in medicine in general is increasingly being questioned for its risk of perpetuating structural health care disparities. Given these concerns, we believe it is time to adopt a race-neutral approach, but note that more research is urgently needed to understand how race-neutral approaches impact PFT results interpretation, clinical decision-making, and patient outcomes. In this brief case-based discussion, we offer a few examples of how a race-neutral PFT results interpretation strategy will impact individuals from racial and ethnic minority groups at different scenarios and stages of life.

Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement.

Current American Thoracic Society (ATS) standards promote the use of race and ethnicity-specific reference equations for pulmonary function test (PFT) interpretation. There is rising concern that the use of race and ethnicity in PFT interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race and ethnicity in PFT interpretation. Review of evidence published since then that challenges current practice and continued discussion concluded with a recommendation to replace race and ethnicity-specific equations with race-neutral average reference equations, which must be accompanied with a broader re-evaluation of how PFTs are used to make clinical, employment, and insurance decisions. There was also a call to engage key stakeholders not represented in this workshop and a statement of caution regarding the uncertain effects and potential harms of this change. Other recommendations include continued research and education to understand the impact of the change, to improve the evidence for the use of PFTs in general, and to identify modifiable risk factors for reduced pulmonary function.

How Financial Aid Policy Shortchanges American Healthcare.

Issue: Medical school debt is increasing. This trend may reduce access to medical school at a time of historic recognition of the need for greater openness and diversity in medical education by disadvantaging candidates who are underrepresented in medicine. The effects of high education-related debt for medical school needs greater consideration. Evidence: The implementation staircase model is employed as lens for understanding the impact of debt on trainees who are underrepresented in medicine and the healthcare system overall. Higher debt burdens are associated with worse mental health outcomes and increased odds of attrition in medical school. Trainees cite debt as a concern in considering primary care careers. Those with greater debt are less likely to pursue or remain in academic careers. Implications: The current financial aid system's reliance on high debt burden undermines goals to improve the representation of underrepresented candidates in primary care and academic medicine. Alternative models requiring less debt could facilitate the creation of a more diverse workforce in healthcare.

The Role of the Chief Resident in Promoting Health Equity.

Drawing on recent experiences as a Chief Resident, the author proposes several strategies for promoting health equity. Challenges to this task are highlighted. The Chief Resident's ability to bypass these obstacles and construct experiences that promote long-term change is explored through the framework of the formal, informal, and hidden curricula. The strategic use of didactic conferences, role-modeling, and personnel decisions are emphasized.

Contribution of Individual and Neighborhood Factors to Racial Disparities in Respiratory Outcomes.

Rationale: Black adults have worse health outcomes compared with white adults in certain chronic diseases, including chronic obstructive pulmonary disease (COPD).Objectives: To determine to what degree disadvantage by individual and neighborhood socioeconomic status (SES) may contribute to racial disparities in COPD outcomes.Methods: Individual and neighborhood-scale sociodemographic characteristics were determined in 2,649 current or former adult smokers with and without COPD at recruitment into SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study). We assessed whether racial differences in symptom, functional, and imaging outcomes (St. George's Respiratory Questionnaire, COPD Assessment Test score, modified Medical Research Council dyspnea scale, 6-minute-walk test distance, and computed tomography [CT] scan metrics) and severe exacerbation risk were explained by individual or neighborhood SES. Using generalized linear mixed model regression, we compared respiratory outcomes by race, adjusting for confounders and individual-level and neighborhood-level descriptors of SES both separately and sequentially.Measurements and Main Results: After adjusting for COPD risk factors, Black participants had significantly worse respiratory symptoms and quality of life (modified Medical Research Council scale, COPD Assessment Test, and St. George's Respiratory Questionnaire), higher risk of severe exacerbations and higher percentage of emphysema, thicker airways (internal perimeter of 10 mm), and more air trapping on CT metrics compared with white participants. In addition, the association between Black race and respiratory outcomes was attenuated but remained statistically significant after adjusting for individual-level SES, which explained up to 12-35% of racial disparities. Further adjustment showed that neighborhood-level SES explained another 26-54% of the racial disparities in respiratory outcomes. Even after accounting for both individual and neighborhood SES factors, Black individuals continued to have increased severe exacerbation risk and persistently worse CT outcomes (emphysema, air trapping, and airway wall thickness).Conclusions: Disadvantages by individual- and neighborhood-level SES each partly explain disparities in respiratory outcomes between Black individuals and white individuals. Strategies to narrow the gap in SES disadvantages may help to reduce race-related health disparities in COPD; however, further work is needed to identify additional risk factors contributing to persistent disparities.

Communication training is inadequate: the role of deception, non-verbal communication, and cultural proficiency.

In this commentary, we argue that the limited experiential exposure of medical students to different cultures makes the instruction devoted to communication skills inadequate. The relationship of these dynamics to honesty in clinical encounters is explored. Absent significant experiential exposure to differing group cultures to counter the natural tendency to favor one's own, discrimination prevails. Knowledge or awareness of cultural differences does not necessarily equate to communication proficiency. Critically, interactions based on lived experience offer a deeper knowledge and understanding of culturally meaningful nuances than that imparted through other formats. Medical students' lack of experiential exposure to different cultures results in communication miscues. When the stakes are high, people detect those miscues diminishing trust in the doctor-patient relationship. Greater experiential cultural exposure will enhance the facility and use of culturally specific communication cues. At its core, the requisite transformation will require medical students to adapt to other cultures and greater representation by marginalized and stigmatized populations not only among the studentry but staff and faculty. The time is now to ensure that the physicians we produce can care for all Americans. What cannot be taught must be identified by the selection process. Competence with half the population is a failure for American medicine.

The dynamics of poverty, educational attainment, and the children of the disadvantaged entering medical school.

Approximately one-third of the US population lives at or near the poverty line; however, this group makes up less than 7% of the incoming medical students. In the United Kingdom, the ratio of those of the highest social stratum is 30 times greater than those of the lowest to receive admission to medical school. In an effort to address health disparities and improve patient care, the authors argue that significant barriers must be overcome for the children of the disadvantaged to gain admission to medical school. Poverty is intergenerational and multidimensional. Familial wealth affects opportunities and educational attainment, starting when children are young and compounding as they get older. In addition, structural and other barriers exist to these students pursuing higher education, such as the realities of financial aid and the shadow of debt. Yet the medical education community can take steps to better support the children of the disadvantaged throughout their education, so they are able to reach medical school. If educators value the viewpoints and life experiences of diverse students enriching the learning environment, they must acknowledge the unique contributions that the children of the disadvantaged bring and work to increase their representation in medical schools and the physician workforce. We describe who the disadvantaged are contrasted with the metrics used by medical school admissions to identify them. The consequences of multiple facets of poverty on educational attainment are explored, including its interaction with other social identities, inter-generational impacts, and the importance of wealth versus annual income. Structural barriers to admission are reviewed. Given the multi-dimensional and cumulative nature of poverty, we conclude that absent significant and sustained intervention, medical school applicants from disadvantaged backgrounds will remain few and workforce issues affecting the care patients receive will not be resolved. The role of physicians and medical schools and advocating for necessary societal changes to alleviate this dynamic are highlighted.

Relative value units and payer mix analysis of facial trauma coverage at a level 1 trauma center: is the current model sustainable?

PURPOSE: We aimed to approximate the annual clinical work that is performed during facial trauma coverage and analyze the economic incentives for subspecialty surgeons providing the coverage. METHODS: A retrospective, clinical productivity data analysis of 6 consecutive years of facial trauma coverage at an American College of Surgeons-verified Level I trauma center was performed by the use of a trauma database and relative value unit (RVU) data. A payer mix analysis also was completed. SPSS V19 was used for analysis. RESULTS: Between 2006 and 2011, 526 patients were treated for facial injuries. The annual nonoperative RVUs ranged from 371 to 539, whereas the annual operative RVUs range was 235-426. Trend analysis displayed that most of the annual RVUs were nonoperative until the year 2011, when the operative RVUs surpassed the nonoperative. Payer mix analysis revealed that commercial insurance coverage was the most common (range 21-54%, median 41%) followed by self-pay coverage (18-32%, median 29%). This finding was a consistent phenomenon except in the year 2009, when self-pay covered the majority of the RVUs (32%). Nasal bone fractures (24%) and mandibular fractures (16%) were the two most common diagnoses. Open reduction and internal fixation of mandibular fractures (17%), open reduction and internal fixation orbital bone fractures (15%), and complex facial repair (12%) constituted the most common operative procedures. Facial trauma consultations were obtained 22% (16-24%) of covered days. The percent of days requiring emergency procedures was (0.5-1%). CONCLUSION: The infrequency of subspecialty consultations and operative interventions, and significant payer mix differences between facial trauma patients relative to the current ambulatory surgery population of the covering subspecialties poses economical challenges for both the hospitals and providers that use the traditional coverage models.