Week #5 HW

Week #5 HW

by Rachel -

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?

Access to public transportation: This is a major problem in the delivery of health care. Taking San Francisco as an example, despite being a small city (7x7 miles), access to public transportation differs dramatically depending on what part of the city you reside. While there are multiple routes that run through downtown, fewer routes run in the outskirts of town (eg. Bayview/Hunters Point, Outer Richmond, Protrero Hill behind SFGH). Thus, if a patient does not own a vehicle, it makes it challenging to access care when needed. In my own research, all patients must go to SFGH to complete a colonoscopy once they have a positive stool-base screening test. Limited access to transportation is likely a contributor to the low rates of follow-up we observe.

Homelessness/lack of stable home addresses: One strategy that has been proposed to help reduce disparities in care by limiting barriers to access of care, has been mailed tests and health care related information. In my practice, this comes in the form of mailed stool-based tests for colon cancer screening. This method of outreach assumes that all patients have stable housing or a reliable home address at which they will receive testing and educational materials. When this is not the case, the barriers to receiving otherwise necessary care, still exist. Furthermore, not having a stable home without constant access to a functional restroom, makes it almost impossible to complete the bowel prep necessary prior to colonoscopy completion.

Suboptimal access to translators/unmodified scheduling and evaluation structures: At the SF county hospital, despite access to translators, there are many challenges that providers face in delivering care to patients of discordant languages that are not accounted for in scheduling, reimbursements, or evaluation structures. As an example, several phones in the clinics don’t work well, leading to longer wait times for translators and longer than necessary phone interactions when treating patients who require translators. These barriers to care are not accounted for in scheduling, so pressure mounts on providers and staff as clinics become delayed, other patients become unhappy about long wait times, and as a result, departments and divisions receive poor ratings in patient satisfaction. This pressure from above, is passed down to providers and staff who are then at a higher risk of contributing to health care disparities as they are placed in an unideal situation to provide the best patient care.

Limited Access to Support Staff: A shortage of support staff could also lead to disparities in care. Research has shown that patient navigation are a feasible and cost-effective intervention in patient care, particularly in cancer screening and follow-up. Unfortunately, not all medical facilities have the financial resources to hire such staff to assist providers and patients.  

 

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?

a) Using the suboptimal access to translators/unmodified rescheduling and evaluation structures as an example, this is an area where individual physicians contribute to health care disparities. While implicit bias (historical or contextual) may contribute, I would also be interested to study the effect of better resources and less reimbursement/evaluation pressure could have on these interactions. A study might be to assess health outcomes or patient satisfaction between 2 groups of patients requiring translator services. In the 1st group, patients and providers would have access to working equipment and adjusted scheduled to account for language discordance. In the 2nd group, patients and providers would be in the current/normal state of practice. I would imagine that health outcomes and patient satisfaction would be higher in the former group, but if there were no differences that would be an interesting outcome as well.

 

Re: Week #5 HW

by Christine Dehlendorf -

The structural barriers you mention are very important, and obviously relate to the social determinants of health. When thinking about them in the context of health care disparities specifically, it may also be helpful to consider that the issue is not only lack of transportation, for example, but the health care systems lack of response to this lack of transportation through measures such as ensuring services are in central locations or providing shuttles. There is a similar issue with lack of housing - e.g. the health care system could develop "work arounds" to ensure that even those without an address were able to get the colon cancer screening the needed. This is not to say we should ignore fixing the SDH, but that the health care system can also do some bridging work to compensate for these SDHs even if they cannot be entirely resolved, using such mechanisms as the care coordination, like you mention. In terms of the interpersonal issues, I would encourage you to think more specifically about what the provider themself is doing and how they are responsible, rather than only how the provider is being affected by the system. They are both relevant, but I think providers have an ethical responsibility to consider their own culpability.

Re: Week #5 HW

by Rachel -

Thanks for your comments Christine and I would absolutely agree that individual physicians should take responsibility in these circumstances and my comments were not intended to absolve physicians of all responsibility. Speaking from my own experience and others within my specialty, many of us skip educational conferences (usually scheduled during the noon hour or after clinics) to spend additional time with patients for a myriad of reasons and spend many hours coordinating respite care services for our homeless patients so they can have a safe space to complete their bowel preparation. Ultimately, I think we all want to do what is right for our patients and do so at the expense of other factors. I recognize that many physicians bring implicit bias into patient encounters that leads to disparities in patient outcomes, but in trying to approach this from a different perspective, I wonder if the health care system further exacerbates these biases through its functionality? Similar to how medical education may exacerbate biases through the educational style. Part of my research interest is trying to figure out ways to optimize delivery of care from the level of providers and health care systems to address health care barriers, recognizing that this is a contributor to disparities, but certainly not the entire cause. 

Re: Week #5 HW

by Christine Dehlendorf -

Thanks Rachel for your response - I absolutely agree both ethically and practically about the importance of attending to system issues that are a large contributor to disparities (and how hard it can be for those of us working in our "system" to provide the kind of care we would like).