1) Physicians, like all people, have inherent biases-- opinions that shape the way they view the world and their patients based on past experiences. There is nothing fundamentally wrong with biases, since we all have them, and not every bias is negative. But it is important to be aware of one’s own biases because they affect the decisions that one, as a physician, makes. A doctor may have had many negative experiences trying to get his Black patients to lose weight or take pills more regularly, so he stops addressing these issues in his primary care practice, even with patients he has not previously approached about these topics but who fit the phenotype of what he deems to be a “more resistant” patient. Another doctor may hear from one of her Latino patients that he deals with life stressors by praying and unconsciously apply that assumption to other Latino patients, suggesting spiritual guidance as a lifestyle change for an anxious Latino man who happens to be agnostic. Yet another doctor may treat an older, white, female population, all of whom remind him of his grandmother. And since he would be uncomfortable asking his grandmother about her sexual history, he doesn’t ask his patient cohort, thereby not providing them with complete medical care. Biases affect patient care every day, and it takes a conscious effort for medical providers to recognize and check these biases to give every patient quality medical care.
In neurology, research could be done to look at how doctors approach patients of different races about their diets. I will always remember a “health coaching” teaching session in my first year of medical school where, during which they offered 2 patient scripts—a 65-year-old Latina woman who ate 9 tortillas a day and a 47-year-old woman who ate fried chicken and soul food almost every day. This is how the designers of the class saw these phenotypes: obese women of color who ate poorly but also culturally. While I don’t doubt that those exact scenarios exist in the world, approaching every overweight Black woman and bringing a bias that she “probably eats fried chicken and soul food every day” damages a providers sense of how the provider and the patient can make strides toward eating healthier.
2) Structural barriers to health care delivery:
a. Accessibility of a health care provider: This barrier includes everything from lengthier wait times in ERs in low-income and predominantly Black communities to delay in scheduling appointments with a PCP because of shortages in low-income communities and communities of color. This is relevant in my area of research because strokes have both preventative and interventional components of care that are important for lessening morbidity and mortality. A patient who is unable to see his/her PCP more than once a year because of the PCP’s busy schedule is unable to monitor hypertension as tightly or change medications as appropriately. He/She may be less likely to remain adherent to a treatment plan because of a significant side effect, major change in health status, or just inability to pay for all the medications. On the interventional side, a 2017 retrospective study in NY (Springer et al) found racial and SES differences in transport time to the hospital after the onset of stroke symptoms. Other studies have supported these results, showing that hospitals that serve a “predominantly Black” population are more likely to be crowded and stop accepting non-emergent patients.
b. Transportation: Transportation to clinics can be difficult if the closest clinic that accepts your insurance is multiple miles away and not accessible by public transportation. This could result in fewer visits to a PCP or specialist, which, in the case of strokes, could mean worse health outcomes because patients are not being well monitored (HTN, DM), are not taking the medically optimized, or are not receiving adequate adjunct care (ie. rehab after a stroke).
c. Neighborhood safety: One of the most common suggestions to patients who need to lose weight is to start by taking walks around his/her neighborhood for 30 mins a day. This could be more dangerous for some patients than others, depending on the safety of that neighborhood. If walking is unsafe, the patients may be less likely to exercise and more likely to keep the weight on and all the negative health sequelae that comes with obesity (HTN, DM, cardiovascular disease, stroke).
d. Language discordance: While this could be/is usually classified as a cognitive barrier, the root cause of language discordance is a structural issue in the way we educate and expose students of color to career options. Latinos account for more than 17% of the population, but only represent 7.5% of medical students and 5.5% of licensed physicians (AAMC). After a stroke, when communication and understanding can be complicated by injury to the brain, it is important to have care providers who can converse with patients in the language they find most comfortable. Additionally, prescriptions written in English for only Spanish-speaking patients can result in medication use error and potentially significant ADEs.