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?
Referencing the Van Ryn article, physicians potentially contribute to disparities through self-perception, communication and as their role as a ‘gate-keeper’. I will use the lens of early metabolic syndrome in adults (non-alcoholic fatty liver disease, prediabetes), to describe these contributions. There are potential huge gains on limiting disease progression with lifestyle modification and nutrition modification in early metabolic disorder in adults. These intervention are heavily reliant on behavior modification, self-perception/actualization, household/community support and one’s sense of value. The provider may mentally assign the individual to class/group and influence the providers’ beliefs and expectations- thereby impacting the counseling, goals and referrals placed. This thereby impacts the patient’s self-perception of their own disease and expectations. As the Fernandez article reports, language discordant care (as well as class/culture/etc) impacts communication, ability to gather/integrate/deliver/monitor chronic disease care and impact outcomes. Lastly, the provider’s perception of what the patient can accomplish impacts referrals; a provider may be less likely to refer a perceived poorly supported/adherent non-white patient to intensive lifestyle (diabetes prevention program), nutrition counseling or behavior health if they think they were less likely to adhere/navigate resources.
Similar to Fernandez et al, one could assess provider and patient characteristics (language, race/ethnicity/class) with referral rates to diabetes prevention programs, nutritionists, mental health counseling/psych meds (SSRI) and metformin. The National Diabetes Prevention Program should continue efforts of addressing race/ethnicity, class and culture disparities through additional criteria in their accreditation process – such as requiring subgroup analysis, language accessible programs and equity in reach/participation/outcomes.
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?
1. Inaccess due to cost/insurance: Through deep structural economic and power inequalities, racial and ethnic disparities in insurance coverage persist despite improvements through ACA. This has profound implications in early metabolic disorder in adults with in-access to routine care to reinforce/modify lifestyle and early preventative pharmacologic efforts, access to nutrition/structured lifestyle/mental health services, testing supplies and later presentation with end-organ damage.
2. Intervention generalizability: Most large-scale evidence-based behavior modifying interventions were designed and validated among homogenous population in an academic-setting. Since these programs are heavily reliant on individual’s language, culture, support, etc. – implementation and uptake varies widely among different groups (ie DPP). Further, individuals capacity to adhere to recommendations (ie >150 min activity/wk) impacted by competing interests (income, dependents) and environment (green space, public safety, walkability, etc).
3. Language/cultural barriers: As described above and in Fernandez et al, language-discordant providers have poorer glycemic outcomes, likely leading to disparities in NAFLD disease progression and advancement of metabolic disease. System issues in a clinic include use of interpreter (in-person v telephone), utilization of telephone/SMS/online portals, cultural mediators and inclusion of family/community resources.
4. Provider bias – Referencing Brooks et al, through early medical training through residency, team and education built structures encourage and reinforce societal perceptions of subgroups. For example, resident presenting a “59 yo Spanish-speaking male with obesity” impacts both the resident’s plan and preceptor’s oversight in the patient’s plan by perceived biases in the patient’s self-reliance, support, literacy and potential to benefit from metabolic preventative services.