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?
As mentioned in the article on implicit bias mentions, physicians are trained to make decisions efficiently, often with incomplete information, and based off of pattern recognition of illness scripts. When making these decisions, physicians bring with them their entire learned life experience along with implicit biases and sometimes explicit biases or prejudices. In an effort to be efficient, it is easy for physicians to make quick decisions without considering how their actions might further health disparities. Since most physicians in practice have had little or no training on recognizing or addressing, physicians, who are mostly, generally well intended can contribute to a system of inequity.
In childhood leukemia, treatment is divided into many different phases. The phases with the most intensive chemotherapy are predominately inpatient, however, the majority of leukemia treatment is given as an outpatient, and patients receive 1-2 years of mostly oral chemotherapy at home. This therapy is critical for achieving and maintaining a durable remission, but compliance is a challenge for certain groups, especially adolescents and young adults (and even more among minority AYAs). In my personal experience, these patients are labeled as difficult, frustrating, or even mentally ill. It would be interesting to research what are the factors contributing to the challenges with treatment adherence among these groups, and what interventions can improve adherence and thus help prevent disease relapse.
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?
Scheduling: The majority of clinics are open on weekdays during business hours, and few have extended hours. Specialist clinics are less likely to have extended hours and often have limited availability. Because of this, poorer patients are at a disadvantage because they are more likely to have inflexible jobs with fewer benefits. On top of that, many clinics have policies where if a patient is late, the appointment is cancelled. These obstacles can prevent patients from receiving the care they need in a timely fashion.
System designed to treat acute illness: In large part, our medical system is poorly designed to treat chronic illnesses. Chronic illnesses such as hypertension, diabetes, and obesity are major contributors to disparate outcomes in different racial groups. Because the healthcare system is better equipped to treat acute illnesses, and it can be challenging to establish outpatient care (see scheduling), many patients with these chronic illnesses bounce from hospitalization to hospitalization and acute complication to acute complication while their health steadily declines. This structure is particularly relevant to my practice as children with cancer are living longer and longer and the practice model is changing to a chronic illness. These patients experience multiple physical and psychological side effects and toxicities related to their therapies and it can be challenging for them to navigate a system that is disjointed and not designed to fit their needs.
Written materials/language barriers-As discussed in the Parker article, patients who speak a different language than their provider experience challenges interacting with the healthcare system regardless of the presence of interpreters. Even when patients and their providers speak the same language, communication can be difficult in a healthcare setting due to the technicalities and jargon inherent to the field. Written materials are generally written at a 6th grade reading level, but for patients with limited education, who are likely experiencing other barriers to health, even these materials could be difficult to understand.
Lack of diversity among providers-All three of the readings from this week touched on this idea. Stereotypes are allowed to continue and even grow in a homogenous culture. When stereotypes are held about groups without significant power, they can be passed on as fact to successive generations of trainees unchecked. Without a divers provider workforce, where providers of diverse backgrounds are empowered to speak and are listened to, our system will not be equipped to identify biased ideas or practices which contribute to health disparities.