Adil Haider, MD, MPH, describes his role as director of BWH’s Center for Surgery and Public Health as his dream job. A prominent health services researcher and trauma surgeon, Haider has training in the fields of surgery and public health, and his passion for both have threaded through his career and path to the Brigham. Haider earned his MD at Aga Khan University Medical College in Karachi, Pakistan, and received his MPH from the Johns Hopkins Bloomberg School of Public Health in Baltimore. Before joining the Brigham, he served as the director of the Center for Surgical Trials and Outcomes Research at the Johns Hopkins University School of Medicine.
The Center for Surgery and Public Health (CSPH) at BWH is a joint program with Harvard Medical School and Harvard School of Public Health, founded in 2005 by Michael Zinner, MD, BWH Surgery chair. Its mission is to advance the science of surgical care delivery by studying effectiveness, quality, equity, and value at the population level, and to develop surgeon-scientists committed to excellence in these areas.
Haider discussed his research findings on disparities in patient outcomes at surgical grand rounds in January. He recently shared more insights into his research with Clinical & Research News and answered questions about his interest in public health and trauma surgery and his path to the Brigham:
Your research on disparities in patient outcomes is fascinating, and it forces us to confront something we don’t like to think about: our biases. It doesn’t seem like something that would be an issue for trauma care, but what did you find when you looked at the data?
AH: Implicit bias or unconscious preference – the attitudes or stereotypes that may affect our interactions – is not something you would typically associate with my area of medical practice. My job is to take care of injured people. But there are plenty of disparities in terms of patient outcomes. A number of researchers have observed and published on disparities in fields such as cancer care where early access to care may differ. But what could possibly explain differences in outcomes after trauma surgery?
In our first paper on the subject, published while I was a Trauma Fellow at Johns Hopkins, we found differences in outcomes for children after surgery: minority children had worse outcomes in their ability to eat, talk and walk after having an injury than white children. When we looked at a larger database of adults, we found that for black patients, risk of death after surgery increased by about 20 percent, and for patients who were Hispanic, risk went up by 50 percent.
We were not the only group to show this; in fact, there was a group here at CSPH that subsequently published similar results. We all knew something was going on – we wanted to understand why.
What accounts for these disparities?
AH: I truly believe that people don’t go into trauma surgery or any other field of medicine to treat people differently, but individuals may have an unconscious preference without even realizing it: you don’t know that you’re treating people differently or relating to certain patients better than others.
That’s why we started looking at unconscious bias as one of several potential mechanisms. We raised this as a question, and we’re now trying to answer it. And in raising it, we’re raising awareness about disparities, that this is a problem we need to address.
Do trauma surgeons and other medical professionals show unconscious preference?
AH: Unconscious preference is a reality. Over a million Americans have taken an implicit association test [link] and data shows that seventy percent unconsciously prefer Whites – or Americans of European descent. In our studies, we have given the same test to hundreds of medical students, resident, nurses and fully trained surgeons – and they all had implicit preferences – similar to the general population, in that nearly two thirds prefer White Americans. This is not surprising given the make up of our population – it’s easier for people to relate to those who look similar to what they see in the mirror everyday.
In some studies, unconscious bias on the part of the provider has been linked to differential treatment. However, in our work, when we presented all of these groups with clinical vignettes and asked them how they would treat a patient, unconscious preference was not associated with treatment decisions. This is different from what others have found and before we conclude that bias doesn’t impact the way we treat patients – I must acknowledge that there may be an issue with the way several of the previous studies including ours were carried out. We relied on simulations and clinical vignettes, so the next step would be to observe real patient-provider encounters to truly understand what is going on. We know that implicit bias is there; we just don’t know its impact just yet.
Are there other mechanisms that might explain differences in patient outcomes?
AH: Yes, and we’re looking at many difference mechanisms and grappling to understand them. We’re looking at issues on the patient level – patients who may be more susceptible to bias – and at the systemic level. When we look carefully, we find that not all trauma centers offer the same quality of care. And several of the ones that are not so great are the ones that are predominantly taking care of patients who are minorities. This is a complex, systemic issue. The hospitals that do take care of minority patients also end up taking care of many uninsured patients. So before we say “minority serving” hospitals are doing a bad job, we need to acknowledge their real financial challenges and should be trying to create policies and solutions that can help them do better.
Coming back to additional provider related mechanisms; an additional mechanism we’re studying are differences in what’s called empathy. How we relate to a person based on how they look may influence the degree and extent of our involvement in their care. We are trying to quantify that. We are also looking at mindfulness – the difference between telling someone to “eat more fruits and vegetables” before sending them on their way, and inquiring on their home environment and community in order to understand ability to access fresh produce.
I must say that more than any degree or class I have learned the most from patients that I have had the privilege to treat and get to know. Sometimes patients who have a well-founded distrust of the medical establishment may not want to open up and talk about issues of poverty, violence or health care inequities. But as their trauma surgeon, I have a great opening line. I’ll say, “Hey, now that you’re alive, and I had something to do with you being alive, can we talk about something important.” And they let me in and have taught me enormously. In fact, by getting to know my patients, I’ve learned so much about myself.
How did you become a trauma surgeon with an interest in public health?
AH: I wanted to be a trauma surgeon because of a TV show called “Trapper John” – a spinoff from MASH about this guy who could operate and fix anything. I was six years old and wanted to be that guy. Later on, I also understood the impact of public health, which is why I pursued a master’s of public health degree right after medical school – something very uncommon for an aspiring surgeon 16 years ago.
When I was a young medical student, my plan was to become a trauma surgeon and just go around the world and fix trauma systems everywhere. Turns out that it’s not that easy, but my goal remains to work with teams that have a real impact for patients both here at home and abroad. During my trauma fellowship, I went to Africa and spent many nights operating nonstop. I loved it and thought I was making a big difference and began to make plans to work overseas. But when I got home to Baltimore, my mentor made a very poignant comment – he said, “You don’t need to go to Africa to take care of people who could use your help. They are right here.”
There was no shortage of people in East Baltimore who needed help, and Johns Hopkins provided a perfect vantage point to begin this work. I started getting to know my patients better. And that’s when I started thinking about disparities and solutions to eradicate them.
Why did you accept the position of Kessler Director of the Center for Surgery and Public Health at Brigham and Women’s?
AH: This is the dream job for me. Meeting the team here was extremely inspiring – everyone cares about making a difference and we have just the right combination of resources, and will, to truly have an influence on the art and practice of surgery to impact the health of millions from Boston to Botswana. Our institution’s history is also extremely compelling. The founding documents of the Brigham proposed building a hospital for patients who are in indigent circumstances: that’s our founding principle, and it’s reflected in so many of the hospital’s priorities. BWH’s commitment to global equity and surgery extends from President Betsy Nabel, MD, throughout the institution. The opportunity to come and work here and lead a center charged with doing this work felt like a true calling, and I’m thrilled to have been chosen to do it.