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?
I think the evidence is clear that individual physicians do contribute to health disparities, although acceptance of this evidence may be difficult in the general care provider population. Individual physicians are susceptible, just like all humans, to implicit bias. Several studies have examined the impact of this on health outcomes, including receipt of opioid medications, transplant offers, receipt of guideline-recommended therapy for chest pain etc. There is some evidence that decision support tools can be of benefit for decreasing disparities, for instance in VTE prophylaxis. Other areas in which there are disparities that could benefit from decision support are recommended screenings such as colon cancer where there are documented disparities. However, there are aspects of the patient-provider experience the decision supports cannot touch, and other solutions may be necessary. Attempting to achieve language concordance when possible will likely benefit patients with LEP. Additional training may assist communication disparities by racial/ethnic disparities, but I doubt this will be sufficient alone.
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?
Multiple structural issues impact care delivery, including transportation, scheduling, insurance availability, and lack of monetary resources. Transportation is a significant barrier for patients accessing PrEP. Pharmacy assistance is usually available in centralized places such as San Francisco General, but transportation access to ZSFG is poor. Many of my patients work downtown and are busy and making their way to ZSFG is challenging. Insurance availability is a huge issue with PrEP: Gilead's assistance program may soon stop (which requires significant navigation support for most patients to access) and uninsured, health SF, and some patients with private insurance (including Kaiser) have difficulty accessing PrEP. Scheduling is affected by LEP and barriers to obtaining appointments. Many of my patients, who tend to be young, of racial/ethnic minorities, and often with distrust of medical system find calling and waiting on hold for an appointment intimidating and challenging. Many of my patients participate in the gig economy and may have to work suddenly, which interferes with the scheduled appointment model. Finally, monetary resources affect the ability to prioritize PrEP, particularly if there are co-pays, which may be more acute for patients deciding to take a preventative medication as compared to chronic diseases.