Health Disparities Forum

Please read required readings and write your responses and upload to the CLE by 12 pm February 7.

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?

My research focuses on providing transitional care to young adults who have congenital urologic conditions as they transition out of the care of pediatric urologists. There are many structural issues that impact the health care and health outcomes of these patients.

1. Language barriers without access to in-person interpreters – many of these families speak a language other than English, and this can make things very difficult when having to have conversations about life-changing surgeries designed to impact someone’s quality of life. It is not the same to use a telephone interpreter to have a conversation about incontinence of urine or stool, and it is difficult to achieve the same level of familiarity when talking with patients and their families through an interpreter. This obviously impacts patients differentially, affecting only those who do not speak English.
2. Limited office hours – by restricting office hours to typical business hours, this severely impacts those families that may require both caregivers to work such that it makes it very difficult for them to take their child to an appointment. This often requires that they have to take time off of work to do so, which can sometimes be difficult. Those families that have the luxury of having one family member at home or with a more flexible job because they are not as reliant on income therefore may have better access to care, whereas those who cannot afford to take time off of work may have more difficulty coming to appointments. Often patients who have a child with a congenital condition require that both parents are working to support this child who might never be able to earn a livelihood for themselves.
3. Limited appointment times – in general appointment times are not long enough to truly give patients the time they need when taking into account chart review, in-person discussion, and documentation. The transitional patient population is a very complex patient group, and there are issues ranging from bladder management to infertility to sexual function to discuss. Even a 30 or 40 minute time slot does not provide enough time to comprehensively deal with these issues! As such, care becomes fragmented and only one or two areas are focused on, which are the most pressing (usually as determined by the physician). I worry that this means that other important issues that are more related to quality of life can then get pushed off to deal with another time, and sometimes this means that they are never actually dealt with given the perpetual time constraints.
4. Geographic location and transportation – specialty tertiary centers are located typically in large cities, and these centers can often be difficult for people to access if they live far away, differentially impacting those who do not live in a metropolitan area and/or who do not have good transportation options. Because these are complex patients, they receive better care at a specialty hospital with a multi-disciplinary approach to their care. But because of these geographic constraints, some people don’t actually reach these centers.
   
   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?
   
   Individual physicians contribute to health care disparities through their underlying biases or assumptions about particular groups (ethnic, language, race, age, gender, etc). These are probably not overt decisions, but subtle biases that affect the way they provide patient care. In the urology population, one area where I think we could see this bias is a disparity in treatment of sexual function by gender. As urologists, we are often well-trained (and it is socially acceptable) to talk about male sexual dysfunction. Yet we do not know how to ask about female sexual dysfunction and it is not something that has become socially acceptable. Medicare pays for treatment for male erectile dysfunction, premature ejaculation, and testosterone for low libido. However, there is (only recently) even one medication developed designed to address any female sexual dysfunction. If we surveyed patients seeing a urologist (or even a PCP!) and asked if they were asked by their physician about sexual dysfunction, or if they had sexual dysfunction and if it had ever been addressed by their physician, I am sure we would see a start difference by gender. As an aside, we may also see this difference by language, given that it’s much more difficult to have these conversations through an interpreter!