• Director's Message

    Ralph Didlake, MD, FACS
    Associate Vice Chancellor for Academic Affairs
    Director, Center for Bioethics and Medical Humanities

    Knots, Cognizance and Outcome Disparities

    In a UMMC Department of Surgery Symposium lecture, a highly respected surgeon, one deeply interested in outcome disparities in surgical disease, presented to his audience a polished presentation which clearly demonstrated that, even after accounting for confounding variables, people of color are in some way treated differently that consistently and negatively impacts outcome.

    The presentation, based on the best sources and delivered with authority and professionalism, really commanded the room and made a very compelling case for the surgeons present.  At its close, however, when the chair asked for questions from the audience, a few complied, but no serious probing or discussion of what had been reported ensued.  

    Either so solid a case had been made that it brooked no comment, or the information hadn't resonated within the group. I began asking myself, "Is this silence a function of where we are as a state? Does it represent silent submission by physicians to painful, even unwelcome information on the continuing effects of our racial history and practices, or are we simply out of responses when it comes to topics associated with racial disparities in health care and health outcomes?"  

    Then, after a few awkward answers to the thin questions being posed, an intermediate resident spoke up. "Okay," he said to the lecturer. "What do we do with this information?"  

    Here was a surprise: an intermediate resident was directly asking a mentor a far more ambitious question than any that had preceded it. This question, so point-blank, was not anticipated by the speaker.  He seemed taken aback by it and, even though he responded, the question lingered longer than the answer.    

    The resident's question stayed with me as a prototype challenge to all of us engaged in medical and health-care education.  "You've made your case, but now what do we do with its information?"  In health care, deliberations matter to the degree  they change practices and so improve health outcomes.

    Perhaps the question might be paraphrased for all of us engaged with health-care education as, "Given what we know about disparate conditions and practices in and surrounding health care, how can we change the practices that are under our own control so as to advocate for our patients, positively affect outcomes, reduce disparities and improve health among all the people and communities we serve?"

    Since that lecture, I have asked myself repeatedly, "What answer might I have given to that question?"  Not being an expert on health-care disparities, I tried to derive it by a different route, one available to any experienced surgeon. 

    I determined, in reflecting upon the resident's question, that the only rational response a practicing surgeon could make was to liken it to something we understand - knot tying! Learning to tie a knot requires working systematically with the fixed factors of two strands of suture, 10 fingers, and a structure to be ligated or a stitch to be secured. In acquiring this skill, we begin with a set of actions that are entirely cognitive and step-wise.  The more we practice these actions, the more automatic they become.  

    Therein resides the answer to the resident's excellent question regarding "what do we do" with disparities data in clinical practice.  

    We must start with a similar, step-wise cognitive approach to outcome disparities.  At each patient encounter, we must practice, teac and model a deliberate, intellectually engaged determination to evaluate and treat each individual without bias, preconception or assumption. This mindful start to every patient encounter coupled with a pro-active effort to avoid the socio-cultural determinants of health and health-care disparities can, just like knot tying, become an acquired skill practiced automatically.

    All analogies have their limits. Nevertheless, interventions intended to yield the hopeful patient outcomes that prompt students each year to seek medical, nursing and bioscience training, require not only practice to automaticity, but also cognizance of how our behaviors, both subtle and overt impact outcome.