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?
This week’s readings put a fine point on issues that we increasingly realize to be an unpleasant truth of healthcare and society: physicians contribute to disparities through explicit and implicit bias. Implicit bias in particular is worrisome because it is so insidious and so common. Implicit bias allows even well-meaning people to perpetuate the social processes supporting structures of racism and reinforcing disparities. Furthermore, physicians may contribute to healthcare disparities when they fail to address underlying structural issues that discriminate against some patients. In my field of nephrology, there are multiple points along the continuum of care at which implicit biases seep in and alter outcomes for minority patients. As already highlighted by my colleagues in previous posts, the use of kidney replacement therapy in advanced kidney disease represents major racial and ethnic disparities. For many patients, home peritoneal dialysis (PD) confers a survival benefit and is less intrusive to activities of daily living compared to in-center hemodialysis (HD). However, non-white patients may be less likely to be recommended PD by their doctors. I would contend that implicit bias on the part of physicians in large part drives this disparity. Assumptions about patients’ living situations, education level, and ability to perform the home dialysis safely all color how likely a physician is to recommend that modality. Non-white patients also experience more barriers to kidney transplantation, and are less likely to be referred for pre-emptive transplant, for example. Finally, non-white patients with advanced kidney disease may be offered conservative care and palliative nephrology care at lower rates. Research to identify these disparities has already been underway, a necessary first step to ameliorating them. Besides training physicians to recognize and root out their own implicit biases, explicit systems to encourage more equitable kidney care are necessary. Restructuring payment systems and incentivizing home dialysis is one concrete step the U.S. government is taking in hopes of improving access to these modalities. In addition, improved access to kidney transplant may be achieved by standardizing the process for transplant referrals and streamlining all patients’ paths to transplant evaluation could begin to overcome the inequalities in kidney transplant. As a whole, these top down solutions serve to insulate patients from variability across individual physicians by standardizing the decision points where implicit bias can sneak in.
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?
Language Barriers: Though we are increasingly cognizant of the ways that the healthcare system fails many LEP patients, there is still a long way to go. Even when clinics have available professional medical interpreter services (in-person or video/telephone), communication may still fall short at visits. A reality of interpreted conversations is that they take longer; however, visits with LEP patients requiring interpreter services are not scheduled for longer, leading to unavoidable compression of available time with patients. This leaves even the most conscientious physicians struggling to communicate adequately with patients. Language barriers thus make complicated and nuanced conversations, such as those planning dialysis initiation, extremely difficult. I worry that as a result, LEP patients often aren’t given enough information to make big medical decisions effectively and unable to ask as many questions as patients that do not have speak through an interpreter.
Distance/transportation: Travel difficulties are another way through which the neighborhoods in which patients live can manifest as health outcome disparities. End-stage kidney disease patients who live farther from dialysis units or who lack stable transportation face significant challenges. Travel distance becomes a very large hurdle to cross to in order to undergo dialysis, a procedure that usually has to be repeated 3 times a week. When getting to and from dialysis can add several hours to a process that is already 3-4 hours, patients find it difficult to maintain their prescribed dialysis while at the same time attending to activities of daily living. Patients who struggle to get to and from dialysis are more likely to miss sessions, which increases their risk of morbidity and mortality as well as leads to unplanned hospitalizations.
Access to healthy food: The ability to obtain and prepare healthy food is a key component of any person’s health. Kidney failure entails a very restricted diet—inability to follow this diet can have dramatic consequences in the short and long terms. Patients who are dependent on dialysis need to limit intake of salt, potassium, and phosphorus. Unfortunately, many foods that are cheap and require little cooking/processing are high in salt/phosphorus/potassium causing patients with the most limited resources to have the most difficulty keeping their lab values in safe ranges.
Education/access to knowledge resources: Thriving on chronic kidney replacement therapy requires a lot of learning and sophistication on the part of patients. Many of the patients with the best outcomes, particularly those on home dialysis, are those that learn the in’s and out’s of what it means to have kidney failure. This means having a good understanding of recommended diet, exercise and activity guidelines, and warning signs of trouble (e.g. recognizing infections related to dialysis access). Patients that can find and process this information thus have a huge advantage. Reliable access to the internet and the ability to discern high-quality vs. low-quality information online appears to be an increasingly important factor. Moreover, literacy is necessary to being able to use written resources. It is exceedingly common for patients to be handed informational materials without assessing whether they are able to read and comprehend that information.