Structural Racism as a Fundamental Cause of U.S. Health Disparities: A Critical Examination of Race in Orthopaedic Total Joint Replacement Surgery

The history of discrimination and injustice experienced by Black Americans within U.S. health care is horrific, but this knowledge is critical to understanding the roots of racial health disparities today. Harriet Washington’s “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present” details the course of mistreatment of Black Americans since the earliest slaves in the U.S. to the present—from the unconsented use of Black bodies for dissections in medical education, to the unethical treatment of Black men in the infamous Tuskegee syphilis study, to the surgical experimentation of gynecologic procedures on enslaved Black women by the once revered Dr. J. Marion Sims.³⁵

This deep history of devaluing Black bodies in healthcare has—consciously and/or subconsciously—instilled a sense of contemporary racial superiority in many white providers, as one form of internalized racism.^41,42 Rapidly mounting studies around implicit bias in health care have demonstrated the impact of implicit bias on health care quality and outcomes, and the exacerbation of racial disparities.⁴³ Implicit bias within the context of total joint replacements may include suboptimal postoperative pain management secondary to the unconscious misbelief that Black patients have lower pain thresholds—though, it must also be called out here that a concerning number of health care providers, including medical students, still consciously believe this dangerous myth.⁴⁴ Similarly, implicit bias may involve a surgeon subconsciously taking more care in the operating room when performing surgery on a patient that resembles that surgeon—whether in regards race, ethnicity, sexual orientation, age, or other identity.

Studies have demonstrated the association between race-concordant clinical relationships and increased healthcare utilization,⁴⁶ improved quality of care (e.g., more comprehensive histories and physical examinations⁴⁷), improved medication adherence,⁴⁸ and positive patient-reported health care experiences.⁴⁹ Without race concordance in patient-provider relationships, interpersonal racism (conscious or unconscious) can occur. Thus, increasing minority race-concordance in patient-provider relationships helps to ensure that health care providers resemble their patient population.^50-56

Optimizing minority race-concordance is a substantial challenge in the field of orthopedic surgery where white, cisgender, heterosexual men form the vast majority of orthopaedic surgeons, with little change in recent decades. From 2006 to 2016, the percentage of African-American or Black orthopaedic surgeons only inched up by 0.3%, from 1.6% to 1.9%.⁹ In fact, orthopaedic surgery is the least diverse specialty—on many measures, including race—across medical specialties.⁵⁴