Carlos Pellegrini: From Success to Significance

NIH/ACS Symposium on Surgical
Disparities Research
A Joint Effort of the American College of Surgeons’
Committee on Optimal Access and the NIH’s
National Institute on Minority Health and Health
Disparities (NIMHD)
May 7-8, 2015
Bethesda, MD

From Disparities to Parities…
Carlos A. Pellegrini MD, FACS
Immediate Past-President, American College of Surgeons
The Henry N. Harkins Professor and Chair
Department of Surgery
University of Washington

From Success to Significance:
A Call for Leadership

“Strive not to be a success,
but to be of value”
Albert Einstein

From Success to Significance:
A Call for Leadership
From Disparities to Parities…

HEALTH DISPARITIES
THE ISSUE IS
COMPLEX
RACISM PLAYS
A MAJOR ROLE
PERFECT TIME TO
ADDRESS IT
MULTIPLE STEPS
TO SOLVE IT

Health Disparities Arise Because
• There is a difference in quality of care received
within the system
• There is a difference in the access to care
• There is a difference in life opportunities, in
education, in nutrition, in exposure, and in a
myriad of social issues not directly related to
the health system

Adapted from C P Jones: Tales of a Gardener
COMMITTEE ON
OPTIMAL PATIENT
ACCESS

Eliminating Health Disparities
• Health Equity is assurance that the conditions
exist for the provision of optimal health for all
people
• Achieving Health Equity requires:
– Valuing all individuals and populations equally
– Recognizing and rectifying historical injustices
– Providing resources according to need
– FIXING EVERY INTERMIDIATE ASPECT THAT
AFFECTS OUTCOMES FOR A GIVEN DISEASE

THREE EXAMPLES:
Transplantation in Minorities
Emergency General Surgery
Lung Cancer Death

End Stage Renal Disease
> Diabetes and Hypertension are the most common
cause of end stage renal disease
> Incidence of ESRD in minority population 1.5 – 3.6X
higher compared to whites
> Prevalence in minority population 2.3 – 4.2X higher
compared to whites

vol 2 Figure 1.5 Trends in (a) ESRD incident cases, in
thousands, and (b) adjusted* ESRD incidence rate, per
million/year, by race, in the U.S. population, 1980-2012
Data Source: Reference tables A.1, A.2(2). *Adjusted for age and sex; the standard population was the
U.S. population in 2011. Panel b: ~Estimate shown is imprecise due to small sample size and may be
unstable over time. The line for Native Americans has a discontinuity because of unreliable data for
that year. Abbreviations: Af Am, African American; ESRD, end-stage renal disease; N Am, Native
American.
(a) Incident Cases (b) Incidence Rates
UNITED NETWORK FOR ORGAN SHARING

vol 2 Figure 1.6 Trends in (a) ESRD incident cases, in thousands, and
(b) adjusted* ESRD incidence rate, per million/year, by Hispanic
ethnicity, in the U.S. population, 1996-2012
Data Source: Reference tables A.1, A.2(3). *Adjusted for age, sex, and race. The standard population
was the U.S. population in 2011. Abbreviation: ESRD, end-stage renal disease. United States Renal Data
System 2014 Annual Report
(a) Incident Cases (b) Incidence Rates
UNITED NETWORK FOR ORGAN SHARING

KI 1.5 Characteristics of adult patients on the kidney transplant
waiting list on December 31, 2002 & December 31, 2012. SRTR &
OPTN Annual Data Report, 2012

KI 4.6 Characteristics of adult
kidney transplant recipients, 2002 & 2012

Fan et. Al, Access and Outcomes Among Minority Transplant Patients, 1999-2008, with a focus on determinants of kidney graft
survival. Am J Transplant 2010; 10(part 2):1090-1107

Fan et. Al, Access and Outcomes Among Minority Transplant Patients, 1999-2008, with a focus on determinants of kidney graft survival.
Am J Transplant 2010; 10(part 2):1090-1107
Graft Survival

Results
• Over 116,000 admissions undergoing EGS
• African American patients had a 10% higher
chance of dying compared to Whites
• All patients treated at hospitals who had
higher than 6% AA patients had a higher
chance of dying (adjusted odds ratio 1.16 to
1.42 p<.002)
Eric C. Hall et al, Am J Surg 2015

Eric C. Hall et al, Am J Surg 2015

Racism
• A system of structuring and assigning value
based on the social interpretation of how one
looks (which is what we call race)
– Unfairly disadvantages some individuals/groups
– Unfairly advantages other individuals/groups
– Saps the strength of the whole society through
the waste of human resources
Jones CP Am J Public Health, 2000

Institutionalized Racism (Bias)
• Differential access to goods, services and
opportunities of society by “race”
• Examples
– Housing, education, employment, income
– Medical facilities
– Clean environment, healthy neighborhoods
– Information, resources, voice
• Explains the association between social class
and “race”
Source: Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health. 2000 Aug;90(8):1212-5.

Personally-Mediated Bias
• Consciously held beliefs towards a group based on gender,
“race” or other characteristic
• Unconsciously held attitudes (stereotypes) held towards a
group based on gender, “race” or other characteristic
• Differential actions based on either consciously held beliefs or
unconscious stereotypes
• Examples
– Physician disrespect
– Workplace discrimination
– Teacher devaluation
– Police brutality

Internalized Bias
• Acceptance of stigmatized “races” of negative
messages about our own abilities and intrinsic
worth
• Examples
– Self-devaluation
– Imposter syndrome
– Resignation, helplessness, hopelessness
• Accepting limitations to our full humanity

Describe your state of health
• Excellent
• Good
• Fair
• Poor

I AM IN EXCELLENT/GOOD HEALTH
0
10
20
30
40
50
60
70
WHITE BLACK HISPANIC AIAN
RACE
RACE
Jones, CP, 2008

Race as identified by others/self
WHITE BLACK HISPANIC AIAN OTHER
WHITE 98.4 0.1 0.3 0.1 1.1
BLACK 0.4 96.3 0.8 0.3 2.2
HISPANIC 27 3.5 63 1.2 5.5
AIAN 47.6 3.4 7.3 36 5.8
OTHER 59.6 22.5 3.8 5.3 8.9
S
E
L
F
How usually identified by others
Jones, CP, 2008

How you are perceived matters!
0
10
20
30
40
50
60
70
Hisp/Hispa Hisp/White White/White
Self/Others
Self/Others

How you are perceived matters!
0
10
20
30
40
50
60
70
AIAN/AIAN AIAN/White White/White
Self/Others
Self/Others

Barriers to Progress
• A-historical culture
– The present as disconnected from the past
– Current distribution of advantages/disadvantages as happenstance
– Systems and structures as unchangeable
• Narrow focus on the individual
– Self-interest narrowly defined
– Limited sense of interdependence
– Systems and structures as invisible or not relevant
• “Myth of meritocracy
– Its all hard work
– Denial of bias/racism

This is the perfect time
• Society has evolved in its understanding of
diversity
• The new generation is focused on social
justice
• The profile of the US population is changing
• Disparities have been well defined…but they
persist

Social Justice
• The concept of equal rights as a
moral imperative
• A fair amount of legislation to
protect civil rights
• Affirmative action programs to
promote advancement of minorities

From Success to Significance
Diversity as a moral imperative –
Social justice
Diversity beyond morality

A new strategy to advance diversity
1. Stresses the value of diversity
2. Focuses on Inclusion
3. Broadens the concept
4. Makes leaders accountable

1. Stressing the value
• Diversity as a “value-driven proposition”
• Diversity as a “dividend”
• Diversity as a “tool”
Diversity is a PATH to
excellence

Evolution of Diversity Programs
DOS 1.0
1960s-70s
• Isolated Diversity Programs
• Diversity and Excellence Competing Ends
DOS 2.0
1980s-2000s
• Peripheral Diversity Programs
• Diversity and Excellence Parallel Ends
DOS 3.0
2000-2020
• Integrated Diversity Programs
• Diversity is Integral to Excellence
DOS 4.0*
2020 forward
• Diversity integral to global competitiveness
• Diversity is a public imperative and national priority
Sources: Nivet, Academic Medicine, 2011
*Laurencin, IOM Discussion Paper, 2014

Diversity as a path to excellence
• “When learners
assumptions are
challenged by
socialization across racial
and ethnic groups,
perspectives are
broadened and
intellectual and cognitive
benefits accrue to all
members of the class”
• Research Agenda

Innovation
And Creativity
New Ways of
Thinking
Vitality
Diversity

Diversity Fuels Discovery
• Increased creativity: diverse teams are more creative than homogenous ones,
particularly when addressing complex problems. (Page and Hong, 2004; Sessa and
Taylor, 2000)
• Broadens the scope of inquiry: expands the range of research questions, some of
which may have been neglected. (Leung, 2008; Whitla et al., 2003; Gurin, 2002;
Noah, 2003)
• Increases health equity: a diverse team of researchers will be more likely to ask
and pursue the most appropriate questions in the most appropriate manner.
(Satcher, 2009)
• Promotes and ensures fairness: in a society where past wrongs have conditioned
the workforce demographics, it is important that nether historical wrongs nor
emerging circumstances hamper the pursuit of research careers by
underrepresented minorities

MISSION STATEMENT CHANGES (UW)
“… we embrace diversity as a core value that
embodies inclusiveness, mutual respect, and
multiple perspectives and serves as a catalyst
for change resulting in healthcare equity and a
reduction/elimination in healthcare disparities.”

2. Focusing on Inclusion
• “The act of recognizing, embracing and
maximizing diversity” - Gilbert Casellas
• Shattering the glass cieling
• Promotion of a climate that fosters
advancement to higher levels for all, with
particular attention to diversity
• It must be placed at the center of the
institution’s mission

Faculty Code, Chapter 24 Appointment
and Promotion of Faculty Members.
… In accord with the University’s expressed
commitment to excellence and equity,
contributions in scholarship and research,
teaching and service that address diversity and
equal opportunity may be included among the
professional and scholarly qualifications for
appointment and promotion.
Approved by Faculty Senate: May 17, 2012

3. Redefining Diversity
Going beyond just
race and ethnicity

3. Redefining Diversity
In this context, we are mindful of all aspects of
human differences such as socioeconomic
status, race, ethnicity, language, nationality,
sex, gender identity, sexual orientation and
expression, spiritual practice, geography,
mental and physical disability and age.

4. Making leaders accountable
• Grass root efforts were important at the start,
are important today, but are not sufficient
• Cultural change requires involvement and
commitment at the top level of the organization

Faculty Code Amendment
Passed January 29, 2015
BE IT RESOLVED, that all University of Washington faculty search committees
be given a mandate and adequate resources to participate in some form of
“Equity, Access and Inclusion in Hiring” training developed in collaboration
with the Office for Faculty Advancement that informs participants on best
practices regarding faculty candidate outreach, assessment, recruitment and
retention; and
BE IT FURTHER RESOLVED, that all UW unit heads are accountable to
University leadership for making improvements in the area of
faculty diversity by reporting unit participation in “Equity, Access and
Inclusion Hiring” training efforts as well as reporting diversity hiring activities
and outcomes.

US Diversity by Generation
Definitions:
Gen Z: 2000+
Gen Y/Millennials:1980-2000
Gen X: 1960-1980
Boomers: 1945-1960
Silent Gen: 1925-1945

US Population Projections
2012 to 2060
63% 59% 55% 51% 46% 42%
17% 19%
22%
25%
28%
30%
12% 12% 13% 13% 13% 13%
5% 5% 6% 7% 7% 8%
2012 2020 2030 2040 2050 2060
White Hispanic Black Asian AI/AN NH/PI Other
Source: US Census, National Population Projections, Middle Series, 2012

United States Diversity by Age
Nearly half of children under 5
years of age were non-white
in 2010
There are areas with high
concentrations of non-white
children in our region

Trends in Diversity by Community Size
30.0
48.3
22.8
36.6
18.7
29.0
0
10
20
30
40
50
60
1980 1990 2000 2010
EntropyIndex(E)
Metro (50,000+) Micro (10-50,000) Rural (<10,000)
60.8%
60.2%
55.2%
% Change 1980-2010
Entropy Index: 0-100; 100=most diverse

Source:DiversityinMedicalEducation,AAMC,2012
2002 2011 2002-2011
Difference
2002-2011
% ChangeN % N %
White 10,044 58.0% 10,783 56.1% 739 7%
Asian 3,042 17.6% 3,767 19.6% 725 24%
Black 1,087 6.3% 1,129 5.9% 42 4%
Hispanic 959 5.5% 1,336 7.0% 377 39%
AIAN 123 0.7% 135 0.7% 12 10%
NHOPI 55 0.3% 49 0.3% -6 -11%
2010 Census
White 63%
Asian 5%
Black 12%
Hispanic 17%
AIAN 1%
NHOPI <1%

US Medical School Faculty, 2011
White
62.2%
Asian
12.7%
Black
2.9%
Hispanic
4.1%
AIAN
0.1%
NHOPI
0.1%
Other/Unknown
17.8%
Source:DiversityinMedicalEducation,AAMC,2012
N=135,305

Major Deficit in the Number of
Underrepresented Minority Academic
Surgeons Persists
Paris D. Butler MD; Michael T. Longaker MD, MBA, FACS; L.D. Britt
MD, MPH, FACS

Results
U.S.
Population(%)
U.S. Surgical
Residents
(%)*
U.S. Surgical
Faculty(%)*
U.S. Surgical
Tenured
Professors(%)*
Caucasian 199,744,494/
299,398,484
(66.4)
10,096/
15,668
(64.4)
Asian-
American
12,881,639/
299,398,484
(4.3)
2,689/
15,668
(17.2)
African-
American
36,689,680/
299,398,484
(12.3)
736/
15,668
(4.7)
Latino-
American
44,321,038/299
,398,484
(14.8)
793/
15,668
(5.1)
Other 5,987,969/299,
398,484
(2.2)
1354/
15,668
(8.6)
Courtesy of L.D. Britt

Black, 2
Black, 9
Black, 3
Black, 5 Black, 4
Hispanic, 22
Hispanic, 22
Hispanic, 14
Hispanic, 24
Hispanic, 16
AIAN, 7
AIAN, 3
AIAN, 6
AIAN, 6
AIAN, 4
NHPI, 2
NHPI, 2
NHPI, 3
2010 2011 2012 2013 2014
Numbers of URM Students Accepted to UW, 2010-2014
11%*
12%*
9%*
13%*
9%*
*Percentage of Entering Class
% URM of Population
WWAMI: 16%
WA: 17%

Medical School URM Benchmarks
United States: mean=18% median=12%
Harvard: 20%
Stanford: 16%
UCSF: 25%
UCLA: 17%
UCSD: 12%

Results
All U.S.General Surgeons vs. U.S. Academic General Surgeons
(2004)
71.1
11.2
5.4 4.8 7.5
75.5
10.6
3.0 3.3
7.8
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Caucasian Asian Black Latino Other
(Ethnicity)
PercentageofCohort(%)
All U.S. General Surgeons U.S. General Academic Surgeons

Results
0
10
20
30
40
50
60
70
80
90
White Asian Black Latino
(Ethnicity/Race)
(%oftotal)
% of Medical Students
% of Surgical Residents*
% of Surgical Faculty
% of Surgical Professors
•Each step along the path to a career in academic surgery
minority representation declines !

Results
•*Includes General, Orthopedic, Otorhinolaryngology, Urology, Plastic and Reconstructive, Cardiothoracic, Vascular, Transplant, and Neurosurgery
3.6
4.3
5.6
4.9
4.2 4.2
4.7
2.7 2.8
3.3 3.4
1.4
2.8
4.3
0
1
2
3
4
5
6
7
8
Surgery* Int. Med. Fam. Pract. Pediatrics Anesthes. Psychiatry OB/Gyn
(Medical Discipline)
Comparison Among Disciplines (Latino Americans)
Lation American Faculty
Latino American Tenured Professors

Results
•*Includes General, Orthopedic, Otorhinolaryngology, Urology, Plastic and Reconstructive, Cardiothoracic, Vascular, Transplant, and Neurosurgery
Comparison Among Disciplines (African Americans)
2.9 3.1
6.1
3.4 3.6
3.1
7.6
1.8
1.2
2.5
1.2
1.9
1.2
3.0
0
1
2
3
4
5
6
7
8
Surgery* Int. Med. Fam. Pract. Pediatrics Anesthes. Psychiatry OB/Gyn
(Medical Discipline)
African American Faculty
African American Tenured Professors

Why is it important to increase
diversity?
• Four hypotheses for how health professions
diversity will lead to improved population
health outcomes:
1. Service Pattern Hypothesis
2. Concordance Hypothesis
3. Trust in Health Care Hypothesis
4. Professional Advocacy Hypothesis
• Analyzed 55 studies for evidence of the
above
DHHS/HRSA Report 2006

Concordance
• Report concluded:
– URM health professionals disproportionately serve
URM/medically underserved populations
– URM patients receive better interpersonal care from
concordance with their providers (esp mental health)
– Non-English speaking patients receive better
interpersonal care, medical comprehension and
likelihood of follow up appts when language
concordance is present
– Insufficient evidence regarding the linkage btwn
provider diversity and greater trust or advocacy for
disadvantaged populations

National Health Care Disparities Report, AHRQ 2013

National Health Care Disparities
Report, AHRQ 2013

How are we doing in reducing
disparities?
• How do we move the needle and get from
simply cataloguing disparities to reversing
them?
Healthcare
Disparity
Healthcare
Parity

Why do disparities exist?
Healthcare
Disparity
Healthcare
Parity
- Access to care
- Quality of
care
- Economics
- Genetics (??)
- Environment
- Culture
?

How to impact disparities by targeting
cultural differences
Healthcare
Disparity
Healthcare
Parity
Culture
1. Increase diversity of
provider workforce
2. Increase cultural
competency of
existing workforce

How cultural competency lead to
improved healthcare outcomes?
Healthcare
Disparity
Healthcare
Parity
Culture
1. Increase diversity of
provider workforce
2. Increase cultural
competency of
existing workforce
1. Improve service
delivery patterns
2. Improve patient-
provider
concordance
3. Improve patient-
provider trust
4. Improve advocacy
for underserved
populations

Change outcomes being measured?
It seems intuitive that these
outcomes being measured
are good candidates to
measure effectiveness of an
intervention as they are
clinically linked to the
condition in question, but are
there intermediary steps???
Cancer
Screening
Pap smear,
Colonoscopy,
MMG
Prenatal Care
Low birth
weight
Diabetes Hgb A1c, BMI
CVD
Lipids, Blood
Pressure
Health Disparity Health Outcome

Intermediary outcomes
Belief System
Behavioral
Change
Health
Condition
Environment
Environmental
Change
Health
Outcome
Biology
Biological
Change
• Most interventions aimed at reducing disparities target patient or provider belief
system
• Some target environment by addressing some barriers to care
(language/access)
• Very few target patient biology for intervention (pharmaceuticals)
• Most measure the clinically relevant health outcome, but inconsistently
measure intermediary outcomes

Intermediary Outcomes for Belief system Intervention
Cancer
Screening
Cancer
knowledge
Physician
breast
exam
Self-breast
exam
MMG
Prenatal
Care
Prenatal
visits
Prenatal
vitamins
Prenatal
testing
Low birth
weight
Diabetes
Home
glucose
monitoring
Food log
Use of
weight loss
program
Hgb A1c,
BMI
CVD
Home BP
monitoring
Food log
Use of
weight loss
program
Lipids,
Blood
Pressure
Health Disparity Health OutcomeIntermediary Outcomes

Multiple Small Steps to Solve a Complex Problem
• Moving away from the traditional framework
– Patient, Provider, Health Systems Factors
• Concentrating on improving outcomes of a
disease by addressing in MULTIPLE STEPS all
the factors that affect that disease
• Spending time and effort in answering
questions that lead to ACTION

How can the NIMHD help?
• Set the agenda by directing scientific
investigations that hit priority health areas,
with well-defined measurements that are
well-aligned with the proposed interventions
• From Success to Significance will require
moving from knowing to DOING!

• LIFE’S MOST PERSISTENT
AND URGENT QUESTION IS,
WHAT ARE YOU DOING FOR
OTHERS?
– Martin Luther King Jr.

Carlos Pellegrini: From Success to Significance

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