1) How do individual physicians contribute to health care disparities? Thinking about an area of health care of particular interest to you, what research do you think could be done to either understand the effect of individual physicians on health disparities, or to decrease this effect?
I think individual physicians contribute to health care disparities all the time and in multiple ways. We all live in a world where structures of oppression impact many aspects of our patients lives outside of healthcare, and in the ways in which they access healthcare. By failing to work to fight these structures of oppression, or at the very least become knowledgeable about how structural racism and other forms of structural oppression impact our patients, physicians are in some ways complicit within the system. At a more direct level, physicians may also contribute to disparities through differences in communication, expectations of patients, trust in patients—and all of these factors can lead to differential treatment of patients and thus health care disparities. I am interested in general in health care disparities around pregnancy including pregnancy counseling, contraceptive counseling, options counseling, prenatal care, pre-conception counseling. An important aspect of this is understanding how physicians perpetuate these disparities at an individual-level. One way to study this, as discussed in the AJPH article, is to use clinical vignettes. Another way is to ask patients about their experiences. One potentially dangerous aspect of focusing on the effect of individual physicians on health disparities, is that it allows people to distance themselves from the results—that the findings of the study are due to other physicians, who are very different from the people who are reading the study. I think in this way people can hide from confronting systems of oppression and hide in the belief that health disparities are perpetuated by other physicians, and not you. We as physicians should all be responsible for fighting systems of oppression and health disparities.
2) Structural issues within health care delivery are implicated in health care disparities. Please brainstorm 4 structural issues that might contribute to these disparities. Which of these are relevant to your particular area of research, and how?
Location of healthcare system/access: Healthcare systems may be located in areas that are less accessible to some. If a healthcare system is located in a majority white neighborhood with higher SES, it may be more challenging for patients who are non-white, lower SES to access care. This is relevant to how women access abortion care.
Health insurance: some healthcare delivery system may only take some forms of private insurance, or may offer differential care to patients depending on what types of insurance people have. In our prenatal care clinics at UCSF, some clinics only take private insurance, those with public insurance are more likely to have multiple providers throughout their pregnancy.
Health provider workforce. The same structural factors that create health disparities also create disparities in educational opportunities and access to medical education. The health provider workforce often times does not resemble local community demographics. Diversity in provider workforce may work to decrease disparities by increasing concordance in language and culture.
Language. Healthcare systems may be unequipped to take care of the needs of patients who do not speak English. This may perpetuate disparities. I think this is relevant to all aspects of health care, including in areas around contraception, abortion, and pregnancy.