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?
At the level of individual physicians, implicit bias is an important way that physician decisions can contribute to health care disparities. These biases are generated and reinforced throughout training and experience, and can also be self-propagating, and they influence decisions physicians make (i.e. prescribing pain medications, assessing subjective symptoms) that can cause differential outcomes and care experiences for patients. In nephrology this is particularly relevant in times surrounding patients approaching end-stage kidney disease -- where a lot of discussion is focused around eligibility for transplant and eligibility for home dialysis modalities (where patients are responsible for performing their own dialysis and which requires a certain degree of health literacy, manual skill), which are especially susceptible to implicit bias as they require taking into account an assessment of social support, (perceived) adherence, and home environment. Research to understand this effect would explore the impact of patient/physician factors that can affect perceptions of, for example, patients' ability to perform peritoneal dialysis. I think to decrease this effect, we need more standardized tools to deliver education about dialysis modality and to assess candidacy for modalities, but research is also needed to ensure that such tools do not exacerbate disparities (for example, a challenge may be that rural patients do not have wi-fi to access online educational videos).
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?
Structural contributors related to health care delivery may include:
-Transportation/distance to necessary health services. For example, availability of hemodialysis centers and rural patients. Transplant centers and proximity for short-term followup, complications after kidney transplant. Patients with a lot of means may travel to be evaluated for transplant at multiple centers to access a shorter waitlist.
-Payments do not do a good job to incentivize high quality care. Patients with advanced kidney disease nearing dialysis need a lot of time to discuss treatment, need frequent blood tests and followup to monitor for decompensation/need to start dialysis (if within GOC) -- but that does not necessarily pay more compared to seeing less severe CKD patients, and also, dialysis pays more and is a lot less burdensome for the physician.
-Patient-provider language discordance. As above, shared decision making and an accurate understanding of patients' social situation is highly relevant to advanced kidney disease discussions, and language concordance (and relatedly, cultural concordance) may help physicians make more informed/patient-centered, potentially less biased, recommendations.
-Hemodialysis in-center vs home modalities (hemodialysis or peritoneal). The dialysis infrastructure in the US strongly supports in-center hemodialysis as the "default" treatment option. As a result, the majority of US nephrologists are far more experienced and comfortable with in-center HD than with other modalities. This leads to physicians potentially being highly selective and risk-averse when it comes to which patients are recommended home modalities, and when the assessment of modality candidacy is largely subjective, opens the door for further manifesting implicit biases.