1) 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?
Examining structural issues in health care relates directly to my dissertation topic on VBAC decision tools. To date, decision support tools have not been sufficient to increase the number of women attempting VBAC, pointing (I believe) to larger, structural issue that constrain the individual decision maker. However, a response to this homework question depends on how we define “structure,” a term that has been much debated in the social sciences, with various applications in anthropology, linguistics, and economics (to name a few). In these realms, structure is understood to be a stable arrangement of social processes that create difference, order, and hierarchy in society. I find Marxist Louis Althusser’s definition to go a step further. He defines structure (in his case: class hierarchy) not only as economic inequality (workers not owning the means of production), but also those processes required to “reproduce the conditions of reproduction.” That is to say, the ruling ideas (ideology) and institutions of the state must also naturalize difference, order, and hierarchy in order to maintain the structure (Ideology and Ideological State Apparatuses, 1970).
In the health sciences structure has often referred to social categories (race, gender, etc), but also architectural elements--like neighborhood, transportation—and societal regulations, laws, etc. Jonathan Metzl (a psychiatrist) has recently advanced the concept of “structural competency” for the health professions and incorporates elements of all of the above but also defines structure as: “the oft-invisible diagnostic and bureaucratic frameworks that surround biomedical interactions, and that potentially shape the contents within.” The structures below contribute to a disparity of gender and I am still considering how they map onto race and class.
- Malpractice: Is a system of insurance against risk and uncertain medical outcomes, but also is a structure that reproduces what a society values at a specific time and place. For instance, uterine rupture with fetal neurologic injury (or death) has been singled out as the most important malpractice risk in VBAC compared to other risks (for instance, maternal injuries). I believe this relates to dominant ideas around the relative value of the unborn vs. pregnant women.
- Providers: Fear of liability in cases of uterine rupture (even though uterine rupture happens in less than 1% of VBACs) has become a principle factor whether obstetricians and hospitals offer VBAC. This leads to disparities in access, which depending on geography and racial mix of the hospital’s surrounding population could produce race/class disparities in access to VBAC.
- Motherhood: Motherhood is a role structured by societal forces that may be outside a mother’s control, for instance: policies (maternity leave or not), division of labor in the home (single vs not, balanced division vs not), wage inequality, domestic violence. There are also strong social norms around what is a “good” vs a “bad” mother, which implications for what one eats during pregnancy, purchases for a newborn, or the duration of breastfeeding. All these dynamics that “structure” the role of motherhood can impact the decision to have a repeat cesarean or VBAC, as well as a mother’s recovery after her delivery.
- Informed consent: Derives from bioethical principles and is supposed to be a neutral, rational discussion of risks, benefits, and alternatives between a provider and a health care decision maker. However, the structure of an ethical conversation frequently precludes certain options. VBAC and repeat cesarean section are the two options presented in this bioethical, “shared” framework. When I was in practice, I cared for a pregnant woman who wanted to go into labor and then have her scheduled cesarean. This type of cesarean does not fit well into hospital routines. How many women would prefer to start labor (for which there can be some benefits, and some different risks), instead of scheduling their cesareans? We don’t know. Also, the above structures frame the informed consent conversation, in that risks/benefits are not always presented in an unbiased fashion. A nationally representative survey of American women with a prior cesarean showed that their conversations with their providers were biased toward repeat cesarean.
2) 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?
While structures (by their very nature) are often invisible and larger than the individual physician, a physician (or any provider) can contribute to health disparities as individuals (through unconscious bias, conscious acts of discrimination) and also as a professional group (through lobbying against health care reforms). For my own area, I have noticed that despite the structural challenges, many obstetricians and midwives are able to provide care that meets professional and ethical standards. I think studying how and why these providers are able to work in difficult structural environments would be informative to many. Studying these providers could inform behavioral interventions that would support the training of “structurally competent” providers. Metzl defines these five areas of structural competence: (1) recognizing the structures that shape clinical interactions (2) developing an extra-clinical language for structure (3) rearticulating “cultural” presentations in structural terms (4) observing and imagining structural intervention (5) developing structural humility.
Soc Sci Med. 2014 Feb;103:126-33. doi: 10.1016/j.socscimed.2013.06.032.
Structural competency: theorizing a new medical engagement with stigma and inequality.