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?
Implicit biases that the individual physicians have can contribute significantly to health care disparities. In the field of nephrology, these biases play a major role in health care disparities in care of end stage kidney disease patients. There are studies that show patients from lower socioeconomic background and racial minorities have lower rate of referral to kidney transplantation compared with more affluent and white patients. Implicit biases the nephrologists may have about the higher likelihood of non-adherence to the transplant medications after transplant or about the eligibility of these patients for transplant due to concern for financial barriers and lack of social support are possible contributors to this disparity. To better understand these implicit biases, we can try to identify these biases through surveying nephrologists about what issues can serve as barriers when they are considering referring end-stage kidney disease patients to the transplant clinics. After identifying these biases, we can try to address them at different levels including policy and individual physician levels. For example, currently there is a bill in the congress that aims to extend immunosuppressive medication coverage by Medicare from 5 years post-transplant to life-time coverage. This policy can hopefully improve the implicit bias some nephrologists may have regarding financial barriers in patients with from lower socioeconomic background and racial minorities.
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: When physicians and patients do not speak the same language, this can contribute to disparity in care. When there is a language barrier, physicians must use an interpreter. Depending on how good the interpretation is, some information may get lost in the process. The other issue is that using an interpreter is time-consuming and considering physicians are usually allotted the same amount of time for all patients irrespective of whether they need an interpreter or not, using an interpreter can decrease the time physicians have to discuss different issues with patients and this would also contribute to health care disparities. This is a major issue in the field of nephrology as I have personally seen that non-English speaking patients with advanced kidney disease often do not have a good understanding of their disease and alternative options they have for renal replacement therapy including kidney transplant and at home hemodialysis or peritoneal dialysis.
Lack of access to healthy food: Lack of access to a healthy diet plays a major role in health care disparities. People who live in poor neighborhoods may not have access to healthy food options like fruits and vegetables and unfortunately their options are often limited to the processed foods. Even if more healthy options are available, many of the people from lower socioeconomic background cannot afford the healthier options. This is a major problem in the field of nephrology because patients with advanced kidney disease need to adhere to a low-sodium, low-potassium and low-phosphorus diet but processed food is usually high in sodium, potassium and phosphorus and this can result in worse outcomes in these patients.
Lack of access to transport: Lack of access to transport in patients with lower socioeconomic background can play a major role in health care disparities. In the field of nephrology this is a major issue because lack of transport results in higher chance of non-adherence to dialysis in patients with end-stage kidney disease. Lack of transport may also limit advanced kidney disease patients’ access to kidney transplant because usually transplant centers are in major metropolitan areas and it may be hard for these patients to visit these centers and undergo transplant work-up.
Structural problems with health insurance and financial reimbursement systems: The structural problems with health insurance and financial reimbursement systems are major contributors to health care disparities. US health care system is known for incentivizing treatment and expensive procedures instead of cheaper preventive visits and interventions. This is a major issue in the field of nephrology because many patients with earlier stages of kidney disease do not have access to health care and nothing gets done to help them prevent the progression of their kidney disease. However, when they develop end-stage kidney disease and need dialysis, then they usually get Medicare or Medi-Cal (in California) coverage to cover the cost of their dialysis.