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?
In “A Silent Curriculum”, a medical student describes her experience and observations as a trainee in the medical field, and what she noticed and at times what she was taught with regards to the differences in pain tolerance, risks for diseases, and stereotypes of patients of different races. For me, her experience was definitely a familiar one. These biases, as well as the mentality of blaming patients for miscommunications and poor adherence, are being passed down to trainees of all levels. It is a systems problem, but also a way that individual physicians are contributing to health care disparities when they are expressing these opinions to students.
In Chapman et al, implicit bias of individual physicians is also contributing to health care disparities, as well as language discordance described in Parker et al. In the latter study, they were able to show the positive effect of language concordant providers for Spanish speaking patients with regards to diabetes management.
For me, I am interested in how hepatologists can better care for patients with alcohol-associated liver disease and non-alcoholic fatty liver disease that is associated with obesity, diabetes, hypertension, and hyperlipidemia. In both settings, standardized counseling is often used, which does not take into account individual patient’s limitations with regards to access to healthy food, time to exercise, time and effort to travel to and from appointments, ability to cook for themselves, treated/untreated mental health conditions, education level and health literacy. When counseling patients without fully understanding their barriers to implement lifestyle modification, the patient is set up for failure, and the physician may then perceive the patient to be nonadherent, unmotivated, or lazy. This further contributes to health care disparities. Research to better understand the barriers that exist for patients, as well as providers’ attitudes toward these patients and knowledge of their barriers will be important going forward.
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?
Number of patients seen in a day and the amount of time designated per patient – often limits the physician to addressing only a few items and makes it more challenging to understand the patient’s individual needs. This is particularly true with language discordance.
Inability to get in-person interpreters – at UCSF, often have interpreters scheduled, but at SFGH have to request an interpreter over the phone which takes significant amount of time, sometimes unable to hear the interpreter or they are unable to hear the patient.
Transportation to and from clinic visits – timing of visits and limitations to pre-arranged transportation, cost of parking, clinics are often only one afternoon per week and this inflexibility makes it more difficult for patients of lower SES to attend appointments
Absence of available records at visits – particularly for patients who may be seen at other EDs or in clinics that do not have EMRs or whose EMRs are not available in Care Everywhere. Without this information, physicians cannot follow up on studies or visits, have difficulty knowing updated medication lists, are uninformed of outside providers’ (specialists’) diagnoses or recommended work up. If the patient has difficulty providing this information, this can lead to frustration for the patient and the physician and creates a poorer relationship.