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 have an active role in influencing the lives of their patients in terms of the quality, consistency and involvement in their patients lives. Like all humans, physicians are not immune from carrying the baggage of implicit bias and statistical discrimination. Even the most liberal minded practitioners have been taught things such as "blacks have much higher susceptibility to HIV than other races". I used to think this was only due to receptor physiology and chemistry and other innate characteristics. Now I am starting to see that a big part of this statistical notion is caused by circular and self-fulfilling prophesy that manages to skew providers into framing their patients as automatically high risk and promiscuous. This can have many downstream repercussions on their self-esteem to the point that many will take fewer steps to protect themselves. I have overheard many friends and patients in the LGBT community say things like "oh its inevitable I will get HIV so who cares anyway." Hospital and provider reinforcement of self-defeating concepts is a large part of the structural harm that is a prime cause of poorer health outcomes for marginalized groups.
Add low English proficiency (LEP) as another structural issue and you also find that patients have misconceptions about key concepts in methods of transmission, prevalence and risk. This causes some ethnic groups to confuse treatment as prevention as being the same as having HIV and avoid or are late to adopt a new treatment such as PrEP.
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?
Newer forms of treatment for at risk groups for HIV= can be slow to gain acceptance as often the newest types of treatment often involve increased negative stigma. With pre-Exposure-prophylaxis (PREP), a new preventive chapter in the fight against HIV/AIDS began and changed the course of an epidemic and greatly reduced the numbers of new HIV infections. Providers from many walks of life argued that PREP would encourage promiscuity and lack of condom use and sex and disease was subject to "morality" arguments once again. Since due to the cost of drug (over $3000.00 a month), it was initially difficult to obtain and primary care physicians and insurance companies tended to disproportionately control who had access to Truvada as PrEP early in its history. Many of these doctors were part of a the structural system that made it challenging for anyone other than whites to get PrEP prescribed as most PCP's will not mention treatment as prevention strategies or be overly concerned about adherence with their non-white patients. Later on it became easier to have initial care and testing occur at local STD clinics who are much better informed about medical and finance issues and are more equipped to handle drop in testing and monthly maintenance HIV tests for diverse populations. Infection rates are slowly getting more concordant across race as acceptance and awareness of PrEP increases. A future risk is and key structural problem is that research for a cure has slowed down as PrEP has given many a sense that the epidemic is over. There is a risk that there may be a new wave of infections if too many in the younger generation become complacent and simply do not remember how high the infection and death rate was in the early to mid 80's.
In my area of research for work in Interventional radiology, I run cancer studies involving new drug and device treatments. Most clinical trials still automatically exclude patients from participation if they have a chronic illness such as diabetes or HIV even though an HIV patient on ART (anti-retroviral therapy) with undetectable viral load and high CD4 count is essentially as healthy as any other participant and definitely a population worth testing new treatments for unrelated diseases.
The most harmful and discriminatory structural issue facing the LGBT community by far is the FDA policy that all gays regardless of HIV status and promiscuity are not allowed to donate blood until they can declare that they have not sex with a man for over 1 year. Most countries eliminated this archaic rule long ago as it basically declares "all gays have HIV" instead of making sure that the blood supply is adequately tested.