Beginning to Find the Missing Piece: Social Determinants of Health as a Contributor to Disparities in Plastic Surgery.

Abstract

At few times during recent history have social determinants of health been more glaring. Effects of the coronavirus disease of 2019 pandemic have accentuated existing sociodemographic disparities. Considering the tenets of medical ethics and the current social climate, including the Black Lives Matter movement, each medical discipline is called to examine barriers to equitable health care across racial, ethnic, and socioeconomic spectrums. Within the field of plastic surgery, our understanding of how poor social determinants contribute to disparities in surgical access and outcomes is incomplete, limiting our ability to develop targeted interventions. Social determinants of health are the conditions in which people are born, grow, live, work, and age, which are shaped by the distribution of economic resources and power. Factors such as socioeconomic status and stability, education, living environment, social support, and health care provider availability and cultural competency influence patient behaviors and health equity. These factors may account for a greater percentage of patients’ health outcomes than the specific medical care provided.1 Examples in Philadelphia are representative of many American metropolitan areas. Just 5 miles from Center City, the average life expectancy drops by 20 years as less affluent neighborhoods with greater minority representation are reached.2 Current and historical structural drivers of inequity may account for a greater proportion of Black and Hispanic patients facing unfavorable social determinants than do white patients.1 Slowed efforts in reducing school segregation have limited the well-known contributions of desegregation to improved health and well-being of minority students.3 People of color may be shown fewer properties when purchasing or renting homes.3 Despite declining unemployment rates for all races, income for indigenous, Black, and Hispanic people has only modestly improved, presenting difficulty for households to keep pace with rising living costs.1 These structural drivers shape patients’ health behaviors and approach to the health care system. Low health literacy, challenges with navigating the insurance and health care systems, medical distrust, and lack of transportation or childcare, in addition to geographic constraints, are barriers to using medical services, remaining in the system, and maintaining the actual quality of care.4 Implicit bias toward minority patients may compound existing issues by compromising communication and trust. Consider that minority patients are less likely to receive a referral for reconstruction after mastectomy, and more likely to be unaware of options for breast reconstruction.5 Or that Black and Hispanic patients are more likely to be referred later than white patients for the treatment of craniofacial conditions. Understanding that these observations likely influence outcomes is a first step in providing equitable care. As the majority of plastic surgical research on disparities has involved descriptive studies of breast reconstruction, a gap exists in developing subspecialty best practices. Culturally congruent programs are likely to have the greatest impact.5 We are called to deepen our knowledge of the barriers patients face, the discrepancies in care provided, and most importantly, the interventions that best promote equitable care. As plastic surgeons practice in diverse settings, understanding the social barriers that impact patient care is not only essential, it is our moral duty. DISCLOSURE The authors have no financial interest to disclose. No funding was received for this article.