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?
Individual physicians contribute to health care disparities through implicit and explicit bias. In kidney disease, physicians may have implicit bias about a patient's level of understanding and education, which may lead them to under-educate and counsel patients of lower SES or racial minorities. Physicians may have implicit bias about patient's adherence levels, which may lead them to assume patients of certain groups will not adhere to medications or treatment plans. Furthermore, physicians may have implicit bias about a patient's ability and level of social support required to perform home dialysis or receive a transplant, which may lead nephrologists to under-recommend these therapies to those with low SES or racial minorities.
Examples of explicit bias include not calling appropriate interpreter services for language discordant patients, and not providing care to uninsured patients or those with Medicaid insurance, who are more likely to have low SES or be 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?
Insurance status - Insurance in the US is tied to and subsidized by employment, so lower SES groups and racial minorities are more likely to be uninsured or underinsured. This may lead to less primary and preventative care, delayed diagnosis of kidney disease, and eventual "crash" dialysis starts.
Immigration policies - Persons that are undocumented often do not quality for state Medicaid programs. In kidney disease, uninsured undocumented persons with end-stage renal disease in many states (notably Texas) have to obtain "emergency-only" dialysis in the emergency department ~1x per week, as opposed to standard 3x per week dialysis in a dialysis facility. This practice is more costly and leads to worse mortality in this population.
Segregation - Historical factors have led to a high degree of racial segregation in neighborhood of residence (https://demographics.virginia.edu/DotMap/) Racial minorities are more likely to live in low income neighborhoods with higher crime rates, less access to healthy foods and parks, and potentially lower access to high quality medical care which leads to worse health outcomes. This leads to higher rates of obesity, diabetes, and hypertension in minority populations which are all risk factors for kidney disease.
Housing policies - Zoning in San Francisco of many neighborhoods for single-family homes has led to a housing shortage and housing unaffordability. This results in housing insecurity and homelessness, which results in worse health outcomes. Our homeless dialysis patients at San Francisco General Hospital have a much higher rate of hospitalization, readmission, and mortality than those with access to housing, and are denied access to home dialysis and transplantation.