The Great Migration and Healthcare to Black America.

The Great Migration, the movement of 6,000,000 black Americans from the South to the great urban centers of the eastern seaboard, the industrial Midwest, and West Coast port cities from roughly 1915-1970, was one of the defining demographic events in American history. It dwarfed the 100,000 49ers who swarmed westward in search of gold, the incarceration of 110,000 Japanese to concentration camps in the American interior during World War II, and the 300,000 Okies who escaped the Dust Bowl to California. In the words of writer Isabel Wilkerson, "[It] swept a good portion of all the black people alive in the United States at the time into a river that carried them to all points north and west."Blacks crammed into urban districts rife with crime and communicable disease, subjecting them to risks of death far higher than their proportion of the population. Without access to adequate inpatient hospital facilities, they received care in public hospitals run by hospital staffs that excluded black physicians from their membership and medical schools that refused admission to black students. The untenable health station of Black America was one of the leading causes of the civil rights movement of the 1950s and 1960s, activism that succeeded in integrating the hospitals and medical schools by federal acts passed in 1964 and 1965 that transformed American medicine.

The Immigrant Backstories of Asian American Surgeons.

The stories of Asian immigrants have both shared themes and ones that are unique to the histories of their homelands. Their labor was essential to the settlement and economic development of America, yet their presence incited riots and official restrictions to their rights to immigration and citizenship. Chinese laborers mined the Gold Country, built the transcontinental railroad, and reclaimed tillable land in the Central Valley. Yet they were denied the immense bounty they created, and their immigration was blocked by the Chinese Exclusion Act of 1882.Japanese, Asian Indians, and Filipinos replaced them on farms as migrant laborers. As foreign nationals they were not allowed to own land, but they thrived as independent farmers on leased plots. Their success attracted discrimination and racist violence. They, too, were barred from immigration and citizenship (Johnson-Reed Act, 1924).World War II was a watershed event for Asians in America. Japanese Americans, ethnically identical to the enemy, were imprisoned in concentration camps in the American interior. China, the Philippines, and India, all allies of the US, were rewarded with naturalization rights for their nationals. In 1965 Congress liberalized immigration quotas and reversed the 1924 restrictions, with priority given to those with advanced technical ability in science, including medicine. Asians from Taiwan and India took advantage of the new regulations and predominated among the newcomers. After the fall of Saigon in 1975, America accommodated yet another Asian population in the country, the tens of thousands of refugees from Southeast Asia.

Injury Patterns, Imaging Usage, and Disparities Associated With Car Restraint Use in Children.

BACKGROUND: Motor vehicle collision (MVC) is a leading cause of accidental death in children. Despite effective forms of child safety restraint (eg, car seat and booster seat), studies demonstrate poor compliance with guidelines. The goal of this study was to delineate injury patterns, imaging usage, and potential demographic disparities associated with child restraint use following MVC. METHODS: A retrospective review of the North Carolina Trauma Registry was performed to determine demographic factors and outcomes associated with improper restraint of children (0-8 years) involved in MVC from 2013 to 2018. Bivariate analysis was performed by the appropriateness of restraint. Multivariable Poisson regression identified demographic factors for the relative risk of inappropriate restraint. RESULTS: Inappropriately restrained patients were older (5.1 years v. 3.6 yrs, P < .001) and weighed more (44.1 lbs v. 35.3 lbs, P < .001). A higher proportion of African American (56.9% v. 39.3%, P < .001) and Medicaid (52.2% v. 39.0%, P < .001) patients were inappropriately restrained. Multivariable Poisson regression showed that African American patients (RR 1.43), Asian patients (RR 1.51), and Medicaid payor status (RR 1.25) were associated with a higher risk of inappropriate restraint. Inappropriately restrained patients had a longer length of stay, but injury severity score and mortality were no different. DISCUSSION: African American children, Asian children, and Medicaid insurance payor status patients had an increased risk of inappropriate restraint use in MVC. This study describes unequal restraint patterns in children, which suggests opportunity for targeted patient education and necessitates research to further delineate the underlying etiology of these differences.

Medicine and History: a Surgical Model for National Integration.

Historians and physicians have struggled to incorporate history into American medical education for over a century. Most efforts focus on local initiatives targeting a narrow audience. We describe a novel method involving the American College of Surgeons, a national organization with tens of thousands of members. Capitalizing on its infrastructure and influence over the field, we have implemented a variety of ventures that include panel sessions at meetings, poster competitions, travel grants, themed breakfasts, online communities, and other such projects. This programming has reached thousands of participants, ranging from pre-medical students to retired physicians, and it has increased both the exposure to and production of surgical history. Our article describes the process of establishing this nationally coordinated enterprise in the hopes that other medical specialties can emulate it and further the study of and appreciation for medical history.

Cost of Pediatric Trauma: A Comparison of Non-Accidental and Accidental Trauma in Pediatric Patients.

BACKGROUND: Nonaccidental trauma (NAT) affects >100,000 children in the United States every year and is associated with significant mortality and morbidity. Little is known about the financial burden of NAT, particularly in comparison to accidental trauma (AT). We sought to compare hospital charges and outcomes between children presenting with NAT and AT. METHODS: Pediatric (<16 y) trauma hospitalizations from 2006 to 2018 were identified using the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and Kid's Inpatient Sample (KID) databases. Hospitalizations were identified as NAT or AT based on ICD codes. Discharge weights were used to obtain national estimates and standardize them across the different sampling structures. Outcomes (hospital charges, length of stay (LOS), and mortality) were compared, and multivariate regression analyses were used to assess independent predictors of hospital charges and mortality. RESULTS: Fifty-eight Thousand Two Hundred Seventy-five pediatric hospitalizations were included with 17,954 (0.3%) categorized as NAT. Children with NAT were younger, more female, less likely to identify as White, and more under public insurance than those with AT. Hospital charges were significantly higher in patients with NAT ($27,100 versus $19,900, P < 0.0001). Mortality (4.9% versus 0.0%, P < 0.0001) and LOS (3.2 d versus 1.5 d, P < 0.0001) were significantly higher among patients with NAT. Multivariable regression analyses identified NAT as a predictor of higher hospital charges, mortality, and LOS. CONCLUSIONS: Nonaccidental trauma in pediatric patients is associated with significantly higher hospital charges, mortality, and LOS than accidental trauma. Ongoing research focused on the relative impact of known risk factors and resource utilization is needed.

Thurgood Marshall, Hero of American Medicine.

One of the heroes in American history, Associate Supreme Court Justice Thurgood Marshall (1908-1993) sought legal remedies against racial discrimination in education and health care. As director of the Legal Defense Fund (LDF) of NAACP from 1940 to 1961, his success in integrating law schools in Texas led to the first black medical student admitted to a state medical school in the South. Representing doctors and dentists needing a facility to perform surgery, the LDF brought cases before the courts in North Carolina that moved the country toward justice in health care. His ultimate legal victory came in 1954, Brown v. Board of Education of Topeka, the decision that declared racial segregation in public schools unconstitutional. In 1964, the LDF under Jack Greenberg, Marshall's successor as director, won Simkins v. Moses H. Cone Memorial Hospital, a decision that held that hospitals accepting federal funds had to admit black patients. The two decisions laid the judicial foundation for the laws and administrative acts that changed America's racial history, the Civil Rights Act of 1964 and the Social Security Act Amendments of 1965 that established Medicare and Medicaid. His achievements came during the hottest period of the American civil rights movement of the 1950s and 1960s. Well past the middle of the twentieth century, black Americans were denied access to the full resources of American medicine, locked in a "separate-but-equal" system woefully inadequate in every respect. In abolishing segregation, Marshall initiated the long overdue remedy of the unjust legacies of slavery and Jim Crow.

How Technology Shaped Modern Surgery.

The history of endoscopy and minimally invasive surgery is the story of technological advances in illumination, optics, and imaging that allowed operations to be performed within the body. After invention of the incandescent bulb by Joseph Swan and Thomas Edison in 1879, the basic design of early cystoscopes remained unchanged during the first half of the 20th century. Three inventions made endoscopy and laparoscopy possible. Invented in the 1950s, the Hopkins glass rod lens system was so elegant and effective-it gave images 80 times better than traditional Galilean optics-that endoscopes of the same design remain in use today. Also, originating in the same decade, fiber optics had in turn two major contributions: Flexible endoscopy and the transfer of light from a high voltage source into the body to illuminate internal structures and organs. Solid-state camera technology, developed in the late 1970s and 1980s, gave images of exceptional detail from a camera chip at the eyepiece of an endoscope. The panorama of advances created by the same technologies-global telecommunications, cellphone cameras, images from interplanetary space probes-reveals endoscopy and laparoscopic surgery as two more examples of today's technological age.

Workforce Issues in Pediatric Surgery.

High salaries indicate a demand for pediatric surgeons in excess of the supply, despite only a slight growth in the pediatric-age population and a sharp increase in numbers of trainees. Top-level neonatal intensive care units require 24-hour-7-day pediatric surgical availability, so hospitals are willing to pay surgeons a premium and engage high-priced locum tenens surgeons to fill vacancies in coverage. With increased supply comes an erosion of the numbers of cases performed by trainees and surgeons in practice. Caseloads may be inadequate to gain expertise and maintain skills. A quality initiative sponsored by the American College of Surgeons and the American Pediatric Surgical Association will discourage underresourced community facilities and surgeons without specialty training from performing operations on children, mostly common conditions such as appendicitis. This will further increase demand for specialty-trained practitioners. Receiving less attention are considerations of value, the ratio of quality per dollar cost. Cost concerns, paramount among buyers of health care (businesses, insurance companies, and governmental health agencies), will prefer community hospitals that have lower cost structures than specialty children's facilities. Less recognized are the costs to families, who for a myriad of reasons would prefer closer alternatives. Cost considerations support providing pediatric surgical services in local facilities. Quality considerations may be addressed by a tiered system where top centers would care for conditions that require technical expertise and advanced modalities. Evidence indicates that pediatric surgeons already direct such cases to more specialized centers.

Quality and extent of locum tenens coverage in pediatric surgical practices.

The prevalence and quality of locum tenens coverage in pediatric surgery have not been determined. An Internet-based survey of American Pediatric Surgical Association members was conducted: 1) practice description; 2) use and frequency of locum tenens coverage; 4) whether the surgeon provided such coverage; and 5) Likert scale responses (strongly disagree, disagree, neutral, agree, strongly agree) to statements addressing its acceptability and quality (two × five contingency table and χ(2) analyses, significance at P < 0.05). Three hundred sixteen of 1163 members (27.2% response rate) responded. One-fourth (24.1%) used a locum tenens regularly. Reasons were long-term inability to recruit a full-time surgeon (35.2%) and short-term vacancies (32.4%). One-fifth (20.4%) did locum tenens work; one-fourth (27.0%) plan to do so in the future. Two-thirds (64.2%) believe that surgical care in a locum tenens situation does not provide the same level of care as a full-time community-based surgeon. Most support locum tenens for short-term coverage (87.3%) and recruitment problems (72.1%), but not long-term vacancies (38.8%; P < 0.001) or permanent coverage (27.0%; P < 0.001). locum tenens coverage is an established feature of pediatric surgery. Most view it as a stopgap solution to the surgical workforce shortage.

Employment and hospital support among pediatric surgeons.

Employment, either by an academic entity or a hospital, is increasingly becoming a feature of surgical practice. Independent practices receive indirect subsidies to support their revenue. A survey of the extent of employment and the forms of indirect subsidies by which hospitals support independent practices, not previously done, would be of interest to all clinicians. A 2012 Internet survey of pediatric surgeons, asking practice description, hospital support, governance and management, conditions of compensation, selected contractual obligations, and arrangements for part-time coverage was conducted. Response rate was 21.8 per cent (253 of 1,163). Employed surgeons comprised 80 per cent: 60 per cent academic (152 of 253) and 20 per cent nonacademic (51). Only eight per cent (19) were in private practice. Half (47% [106 of 226]) had administrative tasks. One-fifth (20% [45 of 223]) was in a system without physician input in governance. The rest were in practices with physicians involved in management: on boards of directors (35% [78]), in management positions (31% [69]), and entirely physician-run (14% [31]). Most salaries were independent of external benchmarks. Productivity measures, when applied to compensation (54% [117 of 218]), used relative value units (71% [83 of 117]) more often than revenue production (29% [34]). Patient contact minimums (4% [nine of 217]) and penalties were less common (20% [43 of 218]) than bonus provisions (53% [116 of 218]). Most surgeons in private practice (75% [14 of 19]) received nonsalary hospital support. Pediatric surgery reflects the current trend of physician employment and hospital subsidies. Surgeon participation in governance and strategic system decisions will be necessary as healthcare systems evolve.

Characteristics of hospitals with lowest costs in management of pediatric appendicitis.

BACKGROUND: A primary determinant of value in treating appendicitis is inpatient cost. The purpose of this study was to identify hospital-level factors that drive costs associated with the treatment of appendicitis. METHODS: Cost-to-charge ratios from the 2009 Kids' Inpatient Database gave average all-payer costs by hospital for uncomplicated appendicitis (without peritonitis, ICD-9-CM 540.9) and complicated appendicitis (generalized peritonitis, 540.0; peritoneal abscess, 540.1). The 10% of hospitals with the lowest costs were defined as low cost; the remaining 90% were defined non-low cost. Bivariate and multivariate analyses compared hospital characteristics between the two groups. RESULTS: Threshold cost dividing low cost from non-low cost for uncomplicated appendicitis was $4626; for complicated appendicitis, it was $6,026. For both conditions teaching status, lower percentage of pediatric discharges, and fewer registered nurses (RN) per 1000 adjusted patient-days predicted a hospital to be low cost. A cost benefit for medium and large hospitals and higher inpatient volume was found only for uncomplicated appendicitis. Regional effects were noted. CONCLUSIONS: The findings show the high-cost structure of hospitals that care for high volumes of children, emphasizing the need to constrain cost. There is some benefit of economies of scale, and careful attention to the numbers of nursing personnel.

Professionalism behind barbed wire: health care in World War II Japanese-American concentration camps.

Physicians and nurses of Japanese ancestry provided health care to 110000 persons incarcerated by the US government during World War II. They faced immense public health challenges created by overcrowding and inadequate resources. Their extraordinary service to their community reflected their professional devotion to their patients and the values of their Japanese homeland.

Single payer health insurance in pediatric surgery: US impressions and Canadian experience.

CONTEXT: Some advocate single payer national health insurance, present in Canada, as a solution to problems in US health care. METHOD: Pediatric surgeons in the US and Canada were surveyed regarding their attitudes (US) and experience (Canada) under a single payer by electronic mail regarding features of a single payer using a Likert scale (1-strongly disagree to 5-strongly agree) on quality, administration, organization, and economics. RESULTS: Overall response rate of 22% (175/835), 153 US, 22 Canadian. US and Canadian respondents predicted a higher quality of care for both emergency (66 and 36%, respectively) and elective conditions (47 and 9%) under a single payer. Both groups recognized delays for elective surgery. Better access to surgical care under a single payer, seen by most Canadians (81%), was not predicted among Americans (44%, p = 0.00012). Americans (68%) did not believe a single payer would address workforce shortages, while Canadians (68%) disagreed (p = 0.00001). Both groups agree (p = 0.7) that personal income is decreased. CONCLUSIONS: US surgeons anticipate benefits and problems that Canadian surgeons with direct experience with a single payer do not experience. This discrepancy must be recognized during the ongoing debate over the future of US health care.

In defense of industry-physician relationships.

The objective was to examine the economic, ethical, and legal foundations for conflict of interest restrictions between physicians and pharmaceutical and medical device industries ("industry"). Recently academic medical centers and professional organizations have adopted policies that restrict permissible interactions between industry and physicians. The motive is to avoid financial conflicts of interest that compromise core values of altruism and fiduciary relationships. Productive relationships between industry and physicians provide novel drugs and devices of immense benefit to society. The issues are opposing views of medical economics, profit motives, medical professionalism, and extent to which interactions should be lawfully restricted. Industry goals are congruent with those of physicians: patient welfare, safety, and running a profitable business. Profits are necessary to develop drugs and devices. Physician collaborators invent products, refine them, and provide feedback and so are appropriately paid. Marketing is necessary to bring approved products to patients. Economic realities limit the extent to which physicians treat their patients altruistically and as fiduciaries. Providing excellent service to patients may be a more realistic standard. Statements from industry and the American College of Surgeons appropriately guide professional behavior. Preservation of industry-physician relationships is vital to maintain medical innovation and progress.

Pediatric surgery workforce: supply and demand.

INTRODUCTION: Recent studies report a shortage of pediatric surgeons in the United States. We surveyed members of the American Pediatric Surgical Association (APSA) to estimate current workforce and demand and to provide data for workforce planning. METHODS: We conducted a survey of 849 APSA members to provide workforce data on their communities as follows: the number of active, retired, or inactive APSA surgeons; non-APSA fellowship graduates; surgeons without accredited fellowship training; and the estimated demand for additional pediatric surgeons. Internet search engines identified surgeons and practices offering pediatric surgical services. The US Census Metropolitan Statistical Areas (MSAs) defined service areas with populations of 100,000 or more. RESULTS: Of 137 MSAs with APSA members in practice, we obtained data from 113 (83%), with 247 (29%) of 849 surgeons responding. We estimate that the current pediatric surgical workforce consists of 1150 surgeons, with APSA members in active practice (60%) forming the single largest group, followed by general surgeons (21%). The percentage of active APSA surgeons was greater than the percentage of general surgeons in the 50 largest MSAs (76% vs 2%, respectively), whereas the opposite was observed in the smaller MSA ranked more than 51 in population (37% vs 46%, respectively). American Pediatric Surgical Association respondents estimated a national demand for 280 additional pediatric surgeons. Active APSA surgeons plan to delay retirement (8% of respondents) because it would leave their group or community shorthanded; 2% reported that retirement would leave the community without a pediatric surgeon. DISCUSSION: Workforce shortage in pediatric surgery is a problem of number and distribution. Incentives to direct trainees to underserved areas are needed. General surgeons provide pediatric services in many communities. Surgical training should include additional training in pediatric surgery.

Clinical and financial characteristics of pediatric surgery practices.

UNLABELLED: Pediatric surgical practices face many challenges. We wanted to define the clinical practice and financial support among different types of practices as follows: academic, private practice, and employed. METHODS: This study involved an Internet survey of members of the American Pediatric Surgical Association (APSA), comparisons using chi(2) and paired t test analyses. RESULTS: The response rate was 28.7% (233/811), 145 academic, 48 private, and 40 employed. More than 90% received partial to full financial hospital support. Only 7.3% received no outside support, most frequently those in private practices (16.7%; P = .016). More than 90% had resident or fellow coverage. Nearly all practices covered newborn conditions and solid tumors, with differences in pediatric trauma, patent ductus arteriosus, and urologic condition. Transfer out of community was low but increased for specific conditions during the respondents' absence, from 0.4% to 5.2% to 3.4% to 6.9% (P = .001-0.003). A minority of respondents noted that nonpediatric surgeons treated selected pediatric conditions in their communities as follows: inguinal hernia (38.4%), umbilical hernia (42.6%), abscesses (37.5%), and trauma (36.6%). Pediatric surgeons shared call within their group in 86.3%, whereas 5.6% took call alone. Many restricted call by excluding trauma (37.2%), soft tissue infections or appendectomies (21.3% for both), and older children (>12 years, 23.8%). Nearly one fifth (18.9%) expressed interest in having an APSA surgeon serve as a locum tenens in their practices. DISCUSSION: Many pediatric surgeons receive both financial and in-kind subsidies. Although they cover a wide breadth of surgical conditions, many limit the conditions that they treat to reduce call responsibilities. The workforce shortage in pediatric surgery creates call coverage problems that may affect up to 8% of US practices.

Industry support of graduate medical education in surgery.

The role of pharmaceutical and medical device companies ("industry") in graduate medical education (GME) is under debate. We surveyed program directors in general surgery and surgical specialties to determine industry activities in surgical GME. We used an internet-based questionnaire regarding industry marketing and educational activities in surgical programs, and their effects on surgical education. We received 65 responses to 377 requests (17%). Nearly two-thirds reported industry-sponsored meals. Industry-supported travel was infrequent ("never" and "seldom" in 56% of device workshops, 69% of lectures, and 74% of conferences). More than one-half reported support for academic events: paid lecturers and exhibition fees (both 58%), and unrestricted grants (62%). More than one-half (54%) reported industry-sponsored research. One-fourth believed their programs to be dependent on industry for their educational missions. Most disagreed that industry support posed a problem, either in general (55%) or for their program (71%). One-fourth of respondents (25%) advocated profession-wide restrictions of industry involvement with GME. Equal numbers agreed (39%) and disagreed (35%) with the view that pharmaceutical and medical device industries have motivations that are in conflict with those of doctors and their patients. Industry activities are widespread in surgical residencies, with approval of many program directors.