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?
There are an incredible number of ways that physicians contribute to health care disparities. Every interaction is an opportunity for implicit bias to present itself – with patients, with colleagues, with the public. The conversations had can perpetuate stereotypes or bias, representing these as acceptable. The things that are said, the tests that are ordered, the patients that are cared for, the speed at which patients are seen, the duration of visits, the follow up – there are so many opportunities for differential care.
In addition, the things we focus on as physicians during history-taking and interviewing play a role in how we view a patient’s health and can contribute to health disparities. If we don’t consider the role that education, income, language, home environment, and other social determinants of health play, then we are bound to worsen disparities that already exist.
I think it would be fascinating to look at how intensivists approach health disparities: How much do they look into the factors contributing to health disparities? How much do they even seek to know about their patients at these levels? Thinking about it from a research perspective, it would be hard to capture some of these elements. One way to provide an early measure is to see how often social determinants appear in a provider’s notes. This would not be entirely inclusive, as notes do not encompass in full the care provided for a patient, but it could be an early start. Surveys and interviews also could be revealing.
On a more micro level, I would be interested in seeing the frequency of use of interpreters for critically ill patients and their families who are not English proficient. While there is a lot more to be gleaned from literacy as a whole, I would be interested in seeing what effect this may have on understanding of health care, attitudes toward health care and providers, and adherence to treatment plans following discharge. Awareness of these effects could do a lot to move toward making important changes that better equalize health care for all.
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?
Availability of interpreters is a major structural issue associated with my area of research. Within the hospital system, there are a limited number of in-person interpreters during limited hours, which does impact the interactions that can be had with patients. In the off-hours – assuming an interpreter is used – a video or telephone interpreter can be used. While there are some standalone machines, many areas are moving toward using a computer-based interpreter, which physically can be challenging, as these are mounted on large carts that often cannot be optimally placed so the patient and providers can both see and be seen. In the perioperative setting, it is even worse as there are no individual rooms or spaces, and any given morning there can be a number of interfering conversations being had with video interpreters with only curtains to separate these private discussions. The care patients are provided when adequate interpretation is not involved can be subpar and can impact health disparities.
Appointment registration systems also can be huge barriers for patients. In order to get an appointment, there is the basic expectation that a patient has a phone (or in some cases, Internet access), and even using an automated system can require exorbitant amounts of time that may not fit within someone’s break schedule. All of this is to assume that there are even appointments that may be available for patients who work non-standard (non-daytime) work schedules that do not require time off of work (which for many, puts their employment in peril).
In addition, there is a bias toward written teaching. While it is helpful that things like After Visit Summaries exist to help remind patients of what was discussed, this method of learning does not take into account varying levels of education and literacy. There are patients who do not have any level of literacy, and there are some who may be able to read the information but who may not be able to interpret it. There is often not time set aside for additional teach-back to ensure understanding. In addition, for many patients who are not English-language proficient, there are no options besides having their visit summarized in a language they do not speak.
For many patients, the physical distance and ability to get transit to a particular medical system alone can be challenging if not impossible. They may not actually physically be able to get to a particular appointment because of lack of personal transport, and public transit systems may not easily get them to their desired locations, requiring significant amounts of time investment to make it to an appointment. This can be challenged by making these patients late (which can be penalized in some way or can result in a visit cancellation), or can be stressed by having the appointment time run late (further encroaching on the patient’s limited resources in travel time, including bus schedules or the generosity of friends who may have driven them). Insurance barriers are known to contribute to the kind of care patients can receive and who they see, as well as the medications they may be prescribed or even fill.