Closing the Health Equity Gap in Neurosurgical Care

Race and ethnicity are associated with whether patients with neurological injuries choose hospice care, life-supporting treatments and other interventions, according to research at Massachusetts General Hospital.

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Theresa Williamson, MD, a neurosurgeon in the Department of Neurosurgery at Mass General and teaching faculty at the Harvard Center for Bioethics, conducts studies on decision-making and health care disparities in the field of neurosurgery. By identifying those disparities and the factors that lead to them, she aims to improve patient-surgeon interactions so that patients from all backgrounds receive optimal care for neurosurgical disease and trauma.

"I'm interested in understanding how care is affected by a broad network of cultural differences, including race and socioeconomic status, as well as factors like the region of the country you live in," she says. "As neurosurgeons, we have a major impact on people's lives—not only through what we do surgically, but also in the way we communicate with patients and lead them on a challenging medical journey."

Dissecting Racial/Ethnic Disparities in Traumatic Brain Injury

Racial and ethnic disparities in health care access have been documented across fields of medicine. But in some ways, those disparities may be magnified in the experience of neurosurgical care.

"So much of neurosurgery is acute. Decisions are made very quickly, and those decisions are often some of the biggest decisions of a person's life," Dr. Williamson says. "There's a real need to think about how people from different backgrounds might respond differently in these very high-stress scenarios."

To begin to understand those differences, Dr. Williamson, who completed a fellowship in surgical ethics through the American College of Surgeons/University of Chicago Maclean Center of Ethics, delved into the data. In one study, she and her colleagues evaluated data from the National Inpatient Sample to assess racial and ethnic differences in the utilization of tracheostomy placement, gastrostomy tube placement and hospice utilization among patients with severe acute brain injury. Their analysis, published in the Journal of Intensive Care Medicine, found that patients found that patients of color were more likely than white patients to receive a tracheostomy or gastrostomy tube, and were also less likely to be discharged to hospice. In other words, these patients were more likely to choose options that would extend life after severe brain injury, and less likely to receive hospice care after making that choice.

In another study, published in JAMA Surgery, she and her colleagues examined the decision to continue or withdraw life-sustaining treatment in patients with severe traumatic brain injury (TBI). Analyzing data from the American College of Surgeons-Trauma Quality Improvement Project, Dr. Williamson and colleagues found that Black patients were less likely than white patients to withdraw life-supporting treatments. But race was not the only factor that influenced this decision. They also found that overall, self-pay patients and those with Medicare were more likely to withdraw treatment than patients with private insurance.

Data also shows that Black patients are less likely than white patients to undergo craniotomy following a TBI, she says. "So you can imagine a scenario in which an African American patient ends up in a poor long-term state because they are reluctant to undergo surgery but also don't want to choose comfort care."

Among her current research, Dr. Williamson is exploring whether improved communication can prevent those poor outcomes. In a forthcoming article for Neurocritical Care, she explored the role of palliative care consultation in decision-making around life-supporting treatment.

"We found Black patients were significantly less likely to get a palliative care consultation after a brain injury. But when they do receive a consultation, they are less likely to choose treatments such as tracheostomy," she says. "This suggests there is some effect of having a communications expert come in to talk to patients of color around end-of-life decision-making after a trauma."

Exploring Barriers to Neurosurgical Care

Race is only one way that patients may experience health care disparities. Dr. Williamson has also explored regional disparities in surgical interventions for patients with traumatic spinal cord injuries (SCI), in a paper published in The Journal of Trauma and Acute Care Surgery. She found that patients with traumatic SCI admitted to level 1 trauma centers were more likely to have early surgery, particularly if they were admitted directly, rather than transferred from a smaller center. The findings suggest that patients from more rural regions may be susceptible to disparities in the surgical treatment of traumatic SCI.

In ongoing work, Dr. Williamson is beginning to extend her research to investigate health care gaps beyond acute settings. "My newer projects are looking at elective surgeries for degenerative spine diseases and the types of barriers that prevent patients from getting the care they need, whether that's surgery or other treatments, like physical therapy," she says.

Improving Patient-Physician Trust and Communication

In her work addressing health care disparities in neurosurgery, Dr. Williamson is often asked to draw on her own experience as a biracial neurosurgeon, which she describes in a recent article for the New England Journal of Medicine. In the piece, she pinpoints several factors that may contribute to a lack of trust between Black patients and clinicians:

• Underrepresentation—Just 5% of physicians are Black, and most Black patients do not have the experience of being treated by a physician who looks like them. Underrepresentation may be particularly notable in Dr. Williamson's field. "Neurosurgery is not a very diverse specialty, though it is evolving," she notes
• Lack of trust—Black patients face an all-too-real legacy of poorer-quality care and, frequently, outright racism, Dr. Williamson says. "There's often a valid underlying reason why people don't trust medical professionals"
• Poor communication—"Physicians are not well trained in cultural competency and communication," she says

Despite those challenges, providers can improve communication and trust with patients. One way to do so, Dr. Williamson says, is to rethink the way they communicate with patients in the face of an uncertain prognosis.

"Research has shown that when doctors don't know the prognosis or are uncomfortable, we often start throwing out big words and hide behind the jargon," she says. "Patients absolutely pick up on our uncertainty."

For a patient already mistrustful of medical professionals, that appearance of uncertainty may lead patients to trust them even less, she adds. "One way to improve that is to improve our prognostic data. But it's also important to communicate uncertainty with both humility and competence."

She also recommends taking time to practice cultural humility.

"This is something I try to do to make myself a better provider. Instead of assuming how a patient will behave based on their race or the language they speak, I make a point to ask questions and engage in genuine conversation," she says. "As physicians, we're experts in a lot of things, but we're definitely not experts in other people's experiences."

Anti-Racist Initiative at Mass General

Though efforts to improve communication and cultural competence are valuable, individual physicians can only do so much. "Using a new communication tool can help, but it doesn't erase years of racism and historical precedent," Dr. Williamson says. "There needs to be a systemwide effort to address racial disparities in health care."

To support that goal, Dr. Williamson is leading the research efforts of Mass General's United Against Racism initiative. The initiative is a Mass General Brigham systemwide anti-racist road map for delivering solutions to patients, communities and staff, with broad social justice and equity goals, and strategies, specific timelines and metrics for success.

As Mass General and other institutions continue to address such longstanding inequities, work like Dr. Williamson's helps identify areas for improvement and points towards solutions. In the process, however, it's important not to paint communities of color as victims, nor emphasize disparities in such a way that patients of color expect to receive subpar care, she says. "As we do this work, we have to be thoughtful about our messaging. Health disparities aren't just a story of vulnerability. There's so much strength in these communities."

Learn more about Mass General's United Against Racism initiative

Refer a patient to the Neurosurgical Spine Service