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?
The Chapman et al article provided an extremely clear foundation for how this is possible. First, the author recognizes that historically, groups that represent negative cultural stereotypes tend to also experience the greatest health disparities. This implies a systematic perpetuation of bias. Furthermore, the author asserts through examples that even those who hold non-prejudiced explicit thoughts, they can still hold implicit biases. Often these biases are rooted in childhood and so deeply embedded that one may not consciously recognize the changes in their behavioral interactions that occur as a result of this bias.
In terms of physicians, I appreciate the acknowledgment of what within healthcare can contribute to perpetuation of these biases. Increased need for efficiency and scientific approaches to patient care are two ways that could contribute to implicit biases held by physicians which contribute to perpetuating health disparities. This article points out that physicians, vulnerable to implicit bias, may interact differently with certain patients, may differentially evaluate patient, and may recommend differential therapy/treatment plans to certain patients. These sometimes subtle, sometimes overt, deviations in care are not only associated with worse patient outcomes from a management standpoint, but often the patient can notice the difference increasing the likelihood they will be less likely to engage in care in the future which perpetuates disparities further.
As a future specialist in reproductive endocrinology and infertility, I can constantly identify disparities. The example that comes to mind resonates from my work as a resident where I met a young lady diagnosed with cervical cancer. No referral was placed to a fertility specialist to discuss oocyte cryopreservation or options for future fertility. The assumption was that the patient likely couldn’t afford it so why place the referral. ASRM specifically addresses this and notes there are prevalent racial, socioeconomic, and demographic disparities in access to fertility preservation in young women diagnosed with cancer.
Within this field, it is reasonable to examine areas in which disparities exist and determine an algorithm for treatment. When I think about fertility preservation, providers should be required to discuss this with all patients who are premenopausal and newly diagnosed with cancer. They then should document this discussion and place a referral to a fertility specialist as indicated. Once could then examine the number of patients who attended a consultation for fertility preservation prior to and after this program implantation to see if there is a change. Furthermore, one could perform focus groups for those undergoing gonadotoxic therapy and subject to this intervention vs those who did not receive the intervention to determine whether this addition was important/beneficial/harmful for patients.
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?
Access to language services – as others have pointed out, this is a huge contributor to health care disparities. I sat in on a recent patient encounter in which the patient spoke Mandarin and our video translator services were not functional. Instead of switching machines or calling for a phone interpreter, we relied on the patients’ daughter to translate. I’ve seen this occur far too many times and despite understanding that one is provided substandard care, we as providers may feel pressured to finish a consultation in a timely manner and remain “efficient”. This behavior likely leaves us without a clear understanding of the patients’ perspective and therefore, often promotes less ideal treatment options for the patient.
Access to information/referral-based systems – This resonates with my work as so many patients who come to see a reproductive endocrinologist do so after being referred. If one’s primary care provider does not broach the conversation or recommend treatment, we often do not see patients on their own accord. This is problematic as providers differentially refer patients to receive specialist services (e.g. affluent, well-educated women more likely to receive counseling about elective fertility preservation options compared to others).
Access to insurance coverage – There is an acknowledgement that millions of individuals lack insurance coverage however it can be easy to forget about the differences between insurance companies and plans that perpetuate disparities. I bring up the ex of elective fertility preservation because it represents an area within my field that is so unique in California compared to other states. Different companies (many of which are based in Northern California) provide options for elective oocyte cryopreservation. The debate of whether this is useful or not depending on the patient’s age is not what I find fascinating. The option for coverage for this elective procedure provides hope – hope that one can delay childbearing until they’re ready. This option is not afforded to everyone – and not everyone will want to utilize this option, however, the limitations in insurance coverage for fertility preservation and treatment perpetuates disparities in access to care.
Geographic access to care – Most reproductive endocrinology and infertility practices are located in large cities with a greater number of practices in states with mandated IVF insurance coverage and a high median income. This means there are limitations to access to many communities. For example, in the ASRM disparities bulletin as of 2015, 16 states had five or fewer reproductive endocrinologists in practices that were accredited. This geographic limitation may impede many from seeking or proceeding with treatment.