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 contribute to health care disparities through implicit bias, explicit bias, and by creating and perpetuating structural forms of inequity. Both the Van Ryn and Fernandez articles make important points related to communication as one area from which health disparities can stem, and most often this can be seen in preventative services and chronic disease management. An area of health care of interest to me, advance care planning (ACP), has intersections at both preventative care and chronic disease management, and relies heavily on effective communication.
Indeed, disparities in advance care planning exist, with patients of color being less likely to complete forms such as advance directives, and less likely to be engaged in ACP conversations by their physicians. Currently, our lab has three RCTs ongoing that also captures data on physicians’ race/language concordance with patients. We will correlate this data with several ACP outcomes. It is our hope that the website we created, with input from diverse patients and family, will be an easy-to-use, literacy- and culturally-appropriate tool to help engage diverse older adults in ACP and reduce disparities.
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. Ambulance diversion. There was a recent UCSF study (Renee Hsia) that showed how black patients that experienced ambulance diversion (often an indicator of crowded emergency departments in the area) and who were having an acute MI, had worse 90-day and 1-year mortality rates compared to white patients. The article also mentioned that “black-serving hospitals” were more likely to experience emergency department crowding and to put their ED’s on diversion (meaning, not excepting new patients via ambulance) than hospitals with fewer proportion of black patients. Not directly relevant to my research, but the article was interesting.
2. Lack of monitoring for disparities. You may not know disparities exist if you’re not looking for them. This issue is of particular interest to advance care planning, as it is an under-studied topic. Furthermore, until recently, there did not exist a uniform definition of what ACP is, and what outcomes are deemed essential for successful ACP. Meaning, if we don’t have an agreed-upon definition or specific outcomes to look for, how can we look for disparities?
3. Language/Literacy. Many times on my rotations I was in a situation where a physician opted to “get by” with their language skills instead of going through the process of dialing an interpreter. In addition to this in-person language inequity, language barriers persist in the written communications we provide patients that do not address literacy. In our advance care planning research, we looked at the average reading level of a standard advance directive and found it to be beyond the 20th grade. Creating easy-to-understand materials for patients is difficult work but necessary for adequate communication. We designed our ACP website to meet the literacy needs of most older adults by having it at a 5th grade reading level and in multiple languages.
4. Lack of diversity among organizational leadership. Without a diverse group of minds and people with diverse experiences, it may be difficult to address issues that the leadership may not have an understanding of or an experience with. Getting a wide range of perspectives and aiming for inclusivity and representation would be helpful in creating advocates who can impact change to dismantle structural components that contribute to institutional racism. I believe this extends beyond race/ethnicity and should include diversity in stakeholders: such as having a diverse patient/community advisory boards. For our trials we created a diverse group of patients/community members to serve on our advisory board. We ran study protocols, consent documents, and piloted study materials with this group and received important feedback.