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 by making medical decisions and interacting with patients based on both implicit and explicit biases. Explicit bias derives from conscious stereotypes that physicians ascribe to specific populations. These could include not offering complicated surgeries to African Americans because the physician assumes that they are more likely to be non-adherent to treatment plans post-operatively because of poorer education. Implicit biases are unconscious associations made based on prior experiences that still result in stereotyping specific groups. This also results in healthcare disparities because the physician is making treatment decisions and treating patients that do not address the individual patient’s circumstances and needs and can disproportionately affect specific populations. In sarcoidosis, it has been well documented that African Americans have poorer health outcomes that Whites. A potentially important contributor to this could include individual physician’s perception of patient’s willingness to adhere to complicated treatment regimens that care specific risks. Research has shown that African Americans receive non-steroid sparing agents less frequently than whites. While physicians’ decisions may be influenced by insurance coverage and access to laboratory care, implicit bias based on physicians’ perception of how adherent African Americans are in general is a likely source of this decision process. Therefore, research that determines these extent of this implicit bias, for example determining the treatment practices among practicing clinicians using example cases where race is stated vs. race not stated. By making practicing clinicians more aware of these disparities, it can hopefully decrease the effect of implicit biases and ensure individual-focused assessments are made.
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?
Structural issues that contribute to health care disparities include racism, income and financial resources, education, and gender. As stated above, explicit or implicit bias related to race can lead physicians to withhold treatments (e.g. pain medications or complicated surgeries) based on stereotypes that are perpetuated by society, including perceptions that minorities are “less adherent” or “exaggerate their pain” relative to whites. Income and financial resources have a large effect on access to insurance and therefore access to healthcare, including the non-insurance resources necessary to adhere to treatment plans and visit physicians. Differences in education levels can affect patients’ awareness of symptoms and hinder their ability to navigate the healthcare system to receive care and rely on specific treatment plans that require more complicated instructions (e.g. dosing of insulin based on calculations of carbohydrates). Perceptions of gender can cause disparities based on physician’s assumptions on how women tolerate pain, report symptoms, and understand/adhere to treatment plans. All four of these structural issues play a role in health care disparities in sarcoidosis. Patients with limited income and financial resources have more limited insurance and healthcare access and therefore can have a delay in diagnosis due to access to specialists. Delays in diagnosis can lead to more severe disease and permanent lung impairment. Patients with lower education levels may be less familiar with complicated dosing regimens (e.g. calculating the dose needed for a prednisone taper while starting a steroid-sparing agent) and therefore be less likely to respond to therapy. The disease has a higher prevalence in women, yet women’s symptoms may be ignored by their physicians due to perceptions on how women experience fatigue or muscle aches, which are characteristic of sarcoidosis, but are non-specific. Finally, there are large disparities based on race. As stated above, African Americans have worse outcomes related to sarcoidosis than whites. While some of the disparity in African Americans is likely mediated by these other structural issues (e.g. lack of financial resources (insurance limitations lead to delay of diagnosis and therefore more advanced disease at diagnosis), assumptions about how well African Americans adhere to treatment, follow-up with providers, and report symptoms that are based on implicit or explicit bias have direct impact on their care.