Editor's Spotlight/Take 5: Do Patient Race and Sex Change Surgeon Recommendations for TKA?

Abstract

The great strength and the great shortcoming of medicine is that it is practiced by human beings. While we can imagine a world in which computers make us better diagnosticians [4], and we remain agnostic about whether robots make us better surgeons [3], the qualities we look for in a healer are distinctly, uniquely human: Empathy, compassion, and the ability to share encouraging words and gestures. Somewhat vexingly, human empathy and compassion often come packaged in units that contain other distinctly human traits, including prejudice. Large studies have found racial disparities in usage of surgical procedures [5], including TKA [6], despite attempts to minimize them. And focused, scenario-based experiments have shown that surgeons are less likely to recommend TKA to women than men in similar clinical situations [1], and less likely to engage women than men in shared decision-making [2]. However, that scenario-based experimental study on gender and surgeon recommendations [2] drew from a geographically narrow physician population, and may have been influenced by differences in the presentation styles of its two sample patients, one man and one woman (each of whom presented to several dozen family physicians and orthopaedic surgeons), which was the very subject the study sought to evaluate. And those older studies on racial discrepancies [5, 6] could not evaluate whether the observed differences in utilization reflected actual differences in need. Against this backdrop, Christopher J. Dy and colleagues at the Hospital for Special Surgery crafted a video-based simulation employing four actors - a white man, who served as the control, a white woman, a black man, and a black woman - each of whom delivered an identically-scripted presentation of advanced, activity-limiting knee arthritis. Participating surgeons, who generally were high-volume arthroplasty providers and who knew only that the topic of the experiment was clinical decision-making (and not that it involved questions of race or gender), viewed the control patient's story and were randomized to see one of the other three videos. Afterwards, they were asked to decide whether to offer TKA to each patient. The surgeons did well. They recommended surgery in similar proportions regardless of each patient's gender or race. When there were discrepant recommendations, they did not consistently tilt either towards or away from surgery based on race or gender. Importantly, the experiment was powered to detect even reasonably small differences, should they have been present. Even so, we probably are less effective than we might be at identifying the biases and prejudices that accompany us into our exam rooms. While this study's findings are reassuring in that surgeons did not withhold surgery from patients based on race or gender when surgery plainly was indicated, so many other questions remain on this critical topic. Would this finding hold if the scenario were a closer call? Are there less-labor-intensive ways to study this important topic? What kind of study is most likely to give us the answer - simulated patients, real patients used in experimental studies [2], assessments of usage from large databases, or some other approach yet-to-be devised? Join me as we go behind the discovery with Dr. Dy in the Take 5 interview that follows.Figure: Christopher J. Dy MD, MPHTake Five Interview with Christopher J. Dy MD, first author of “Do Patient Race and Sex Change Surgeon Recommendations for TKA?” Seth S. Leopold MD:Congratulations on a well-done study. So, should we breathe a sigh of relief - there is no bias in surgical practice? Christopher J. Dy MD, MPH: Thank you for your thoughtful commentary on our paper. While I wish we could say that there is no bias in surgical practice, I think bias is an inherent and inescapable component in how we practice. Understanding our own biases and how they may consciously and subconsciously affect our decision-making processes is critical to pr