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?
Implicit racism: My team at SFDPH recently published findings from a study assessing the feasibility of prescribing naloxone to patients on long-term opioid therapy in 6 safety-net clinics in San Francisco. Results showed a trend towards African Americans being less likely to be offered a naloxone prescription than whites. The clinicians in these 6 clinics are likely to be very socially-conscious given how present race/ethnicity/SES factors are in the clinics in which they work and that they have chosen to devote their careers to working with un/underinsured and underserved populations. Why then, were blacks less likely to receive this potentially life-saving medication? Could it be because physicians made assumptions that their black patients could access naloxone from syringe exchanges more easily than their white counterparts? Maybe it was because their black patients tended to have higher medical needs and they didn’t have the time to prescribe a preventative medication? Regardless, the finding was surprising to our research team and equally surprising to the clinic staff when we presented it.
Clinical uncertainty: Since the 1990s, pain has been considered a “5th vital sign” in the US, however pain is difficult to measure. The utility of pain scales has been questioned, given that quantifying pain is a subjective process. Thus, pain often falls into the category of “clinical uncertainty”. This means that a provider must rely more on their own assessment and contextualization of the problem than if the symptom could be measured by a standard procedure or universal measure. Evaluating and managing pain becomes a space where it is easy for providers to show implicit racial/ethnic/sexist bias (e.g. Hoffman article).
Similarly, determining if a patient is at risk for developing opioid use disorder is also complicated. Risk factor assessments try to predict risk, but there is little evidence that they accurately do so. Therefore, this is another instance where providers must rely on a personal assessment to determine what they think will be a patients risk for developing opioid use disorder and whether they are a viable candidate for opioids. As the Hoffman article indicated, blacks are often under-prescribed pain relieving opioids. (*Note: I wished that article focused on a broader range of opioid stewardship efforts to reduce pain, including physical therapy, buprenorphine etc. But of course I understand that it’s easier to look at records of opioid prescribing than a range of pain management modalities). This is again a problem of clinical uncertainty and implicit racism.
Patient/provider relationship: Two excellent safety-net clinics in San Francisco, General Medicine Clinic and Family Health, both care for a large number of minority and uninsured San Franciscans. These clinics are resident-run clinics. While they may (and do) provide excellent patient care, they unfortunately do not allow for long-term rapport-building between patient and provider because providers rotate through the clinic. This high turn-over could have negative implications that largely effect minority populations.
Language: In the naloxone prescribing study I mentioned above, we noticed that the language providers used to speak with chronic pain patients about their potential risk for overdose was poorly received. Pain patients often did not associated with the term “overdose”, since they were not using “illicit opioids like heroin” they were only using the opioids prescribed by their provider. In a small sample of 60 patients, 45% denied ever having an overdose but admitted to having a “bad reaction” that, when defined, was the same physiologically experience as an overdose. I bring up this example because “patient-centered communication” is more than being able to communicate in the same language. Patient-centered communication means that providers can convey medical concepts to patients in a way that they actually understand and resonate with. As we saw from our naloxone study (only English-speakers were eligible for our interview) this was difficult enough to achieve when speaking the same native language. When dealing with an additional language barrier, this becomes even more difficult to achieve.
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?
Many of the examples I outlined above directly illustrated physicians (conscious or unconscious) contribution to health care disparities. Individual physicians contribute to healthcare disparities via implicit racism, subjective decision making around clinically uncertain evaluations, communication with patients and sustained relationship building with patients. Something we’ve talked about in this course already is having physicians take the implicit racism test (sorry, I forget the name). I would love to see more providers and health care professionals take this same test. Some research that could be conducted around this area: (1) implementation research around how best to rollout a naloxone prescribing program (evaluating language, time spent with patients etc); (2) qualitative research with patients and providers about their care experience; (3) research that focuses on the expansion of pain care provision from opioids to include alterative options such as physical therapy, buprenorphine, counseling etc; and lastly (4) I would like to conduct a series of qualitative interviews with patients who were offered a naloxone prescription and denied the offer. This would be a critical perspective to understand how to improve the patient/provider relationship and why patients may oppose certain care choices.