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?
Individual physicians contribute to health care disparities in multiple ways. The most pervasive contribution is likely a passive approach to recognizing and addressing structures of oppression that impact patients. At a health system level physicians contribute to disparities in the types of health insurance they accept and available office hours. At the patient level, implicit biases of physicians contribute to disparities by leading to differences in how physicians communicate with patients and expectations they have the care relationship, both of which have downstream impact on management decisions and services offered. In the general pulmonary clinics, particularly subspecialty clinics such as interstitial lung disease, advanced asthma, and lung transplantation, many of the patients travel from throughout northern California for care – and for many patients this poses a significant financial barrier for patients. Telehealth visits have been identified as a means of expanding access to patients for whom in-person follow up in difficult. However it is unclear whether this intervention addresses the issue of accessibility for the population in question. Telehealth visits should be piloted in a standardized clinical pathway to test the impact on follow up visits, potentially stratifying patients by geographic location.
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?
1. Location/geographic barriers: As discussed in the above example, many patients seen in our subspecialty pulmonary clinics travel a significant distance to access care. While close follow up is recommended for the majority of patients seen, for a subset of patients follow up at UCSF poses a significant financial barrier, perpetuating disparities.
2. Language Barriers: This is a significant issue in Interstitial lung disease clinic. While we are generally able to provide an in-person interpreter for non-English speakers, the majority of educational information is not available in most languages, which limits our ability to support patients’ understanding of complex diagnoses and management decisions, and further perpetuates disparities in communication and expectations.
3. Access to flexible resources: Care for patients with interstitial lung disease is primarily composed of components outside of pharmacologic therapies. For patients with lung disease due to environmental exposures, we often recommend removal of items (down pillows or comforters), professional cleaning of mold/mildew, or in cases in which the exposure is unknown but we have high suspicion that it is something within the home, many providers recommend relocating for an extended period of time. All of these recommendations require access to flexible resources that patients can use to cover the associated expenses.
4. Insurance: Under-insured and uninsured patients face a major barrier to accessing health care. For patients with health insurance there are often co-pays that make medications difficult to afford (particularly certain immunosuppressive medications used to treat interstitial lung disease, and newer anti-fibrotic drugs that are the only medications approved for treatment of idiopathic pulmonary fibrosis, but often not covered by insurance). We are also often limited in the diagnostic workup that is covered by insurance providers, leading to practice variation in whether specialty blood work or pulmonary function testing is done, both of which are critical to diagnosis and management.