1) 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 may contribute to health care disparities in many ways. This is often done unintentionally and likely as a result of underlying assumptions or biases that one carries about a particular group. For example, a native English speaking physician may give a more detailed explanation about a diagnosis or treatment to a native English speaking patient, as opposed to a patient who only speaks Spanish, unconsciously believing that the native English speaking language is “more educated” or has “higher health literacy” and, therefore, better equipped to understand such an explanation. Also, a physician may be less likely to prescribe a more expensive non-formulary medication to a Hispanic/Latino patient due to an unconscious belief that they would be less likely to afford the out-of-pocket expenses that may be associated with such medications.
One of my areas of interest is in obesity management and prevention. In this field, weight loss medications are oftentimes prescribed to patients, many of which are expensive and/or may not be covered by insurance. In order to better understand the effect of individual physicians on health disparities, perhaps one could study the prescribing patterns of physicians in a weight management clinic, using race/ethnicity as a predictor and type/frequency of medication prescribe as an outcome, controlling for additional sociodemographic characteristics including insurance type, income, and education. Such a study may help elucidate if physicians have different prescribing patterns based upon race/ethnicity when controlling for additional sociodemographic factors.
2) 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?
Another of my areas of research interest is in diabetes prevention and management. Below are 4 structural issues within health care delivery that might contribute to health care disparities.
a. Language Barriers: Even with the use of phone or in-person interpreters, from my clinical experience I believe that language barriers still exist. I find communication through a phone or in-person interpreter to be much more challenging than when such a service does not need to be utilized. Further, I often find myself more concerned after an encounter if a patient who is not a native English speaker “fully understood” everything that I attempted to explain during the encounter. As was seen in the Schillinger DISTANCE study, limited English proficiency appears to be an independent predictor for poor glycemic control among insured US Latinos with diabetes, an association that was not observed when care was provided by language-concordant physicians.
b. Distance to Health Care: Studies have shown that individuals who live farther from medical facilities (often rural areas) may have less access to health care. For example, Zgibor et al. (J Diabetes Sci Techol, 2011) found that residing more than 10 miles from a diabetes management center was a significant contributor to having an A1c greater than 7%, even after adjusting for individual and community-level factors.
c. Health Insurance: Diabetes is associated with high health care costs and it is important for individuals to have a way to afford their medications. Without insurance, the out-of-pocket expense for a vial of lantus is 275 dollars (goodrx.com)! As such, it can be extremely challenging for patients without insurance to cover the cost of their medications and testing supplies. It would be expected that patients without health insurance would likely have worsened glycemic controls due to having more difficulties with affording the cost of medications and supplies related to diabetes care.
d. Built Environment: The “built environment” refers to the manufactured surroundings that provide the settings for activity, including buildings and parks, and “area deprivation” denotes an area’s potential for health risk and includes the ecological concentrations of poverty and economic disinvestment (Anderson et al., Epidemiology, 1997). Individuals of low SES are more likely to live in neighborhoods with less greenery (Martin, Landscape and Urban Planning, 2004) and fewer physical fitness resources (Estabrooks et al., Ann Beh Med, 2003). This may contribute to obesity, thereby leading to an increased risk for developing diabetes.