Question # 1:
I am an Emergency Physician in current clinical practice. I therefore have an interesting perspective on the influence of structural stratifiers (income, education, occupation, social class, gender and race/ethnicity) on the presentation of specific diseases on the front lines of medicine. Intermediary factors (such as housing, work conditions, psychosocial factors, material circumstances and behavioral/biological factors) also have a very important effect on the presentation of disease to the emergency department (ED). I have been in clinical practice for several years, and while I currently work in the ED at Stanford, I formerly worked at LA County + USC Medical Center and Columbia-Presbyterian Medical Center. It has been fascinating to see the differences in presentation of disease among the patients presenting to the ED at a private, suburban hospital like Stanford vs. county/city hospitals like USC and Columbia. Choosing income and race/ethnicity as the structural stratifying factors, there is a huge difference in the presentation of disease at Stanford vs USC and Columbia. At USC, the hospital served as the safety net system for all those in LA County without insurance. In addition, the hospital had a dedicated Jail ED to care for the inmates of the LA County Jail system. Columbia also provides care for an under-served population, being in upper Manhattan with over 70% patient base of persons from the Dominican Republic. It was amazing to see the difference in the presentation of disease at these 2 hospitals, in-reference to Stanford. Because of the effect of income and race/ethnicity on access to health insurance and basic preventative care, many of the patients in LA and NYC presented to the ED when their diseases had progressed to a very advanced state. Their lack of access to basic primary care made many patients wait longer to seek medical care, to a point where diseases were much more difficult to treat. Stanford patients tend to have access to primary care, and therefore the overall severity of disease is lower in the patients presenting to this ED. Housing, or lack thereof, also plays an important role as an intermediary factor in patient presentation to the ED. As the ED is frequently the only place where persons living on the street can access care, I tend to care for many homeless persons on a routine basis. Again, these patients have chronic diseases that could easily be managed with a comprehensive team oriented medical care system. Unfortunately, they more often do not get routine care and present with advanced disease.
My research is focused on the use of imaging in the ED. I hypothesize (after years of observation) that there may be an unconscious bias among well-meaning Emergency Physicians to use imaging liberally in the well-insured patient of high socioeconomic status. At the same time, I hypothesize that patients of lower socio-economic status, persons of color and homeless patients may receive less imaging. I will be looking specifically at imaging of abdominal pain in patients presenting to the ED, and I will be very interested in looking to see if there are differences in the rate of imaging among persons of different income, gender, race, ethnicity and in the homeless. Especially when the healthcare staff may be of a different ethnicity/race than the patient, we in medicine must be very careful to not treat patients differently. My research is not primarily focused on racial and ethnic disparities, but as I learn more from this course, I see how important it will be to set up the study to also look at any disparities, in addition to my other outcomes.
Question# 2:
Socioeconomic factors play an integral part in a person’s life health status, from birth to death. Interestingly, working in upper Manhattan, I saw a much higher rate of childhood and adult asthma than at Stanford. My mother is a Professor in Public Health at Columbia University (Frederica Perera) and her research has focused on exposure to chemicals in-utero, and later development of disease, specifically asthma. Interestingly, poorer neighborhoods in upper Manhattan have very high rates of cockroach bug infestation. Her research has demonstrated a clear association between exposure to cockroach antigens in-utero (through drawing cord blood at birth) and later development of asthma. This finding was reflected in the increased rates of asthma seen in the Columbia-Presbyterian Hospital ED’s, as compared to Stanford.
As far as imaging in the ED and socioeconomic history, I will also attempt to ask questions that I had not previously thought of in my research study. Asking if a person had health insurance and access to medical care may not be enough. I will add a question on whether the parents of the patient had health insurance and access to medical care to further investigate the link between one’s life course and the use of the medical system, rate of imaging and the development of disease.