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?
The JAMA opinion piece by Katherine Brooks and the article by van Ryn & Fu give endless examples of individual physicians contributing to health care disparities. Some biases are implicit, such as unconsciously activated beliefs about a patient’s accuracy in describing symptoms, ability to adhere to treatment plans, or ability to understand nuances of a diagnosis. Other biases are explicit, such as consciously activated beliefs about patients of certain race/ethnicity or class being more likely to have STIs or substance use disorders. An interesting point in the van Ryn & Fu article is that physicians may impose biases by over-applying group probabilities to decision-making about individuals, relying on statistical probabilities that were biased in the first place. This compounds biases and reinforces marginalization. Further, physicians perpetuate these compounded biases in their teachings to future generations of physicians.
It was interesting to read “A Silent Curriculum,” because I have seen almost every situation that the author describes. Coincidentally, the author went to medical school where I did residency, but I would guess that her stories are consistent with the national landscape in medical education. As a topic in medical education, it would be interesting to research a medical school’s lecture slides or the national board exam questions and evaluate the effect to which they perpetuate biases in patient evaluation, diagnosis and medical decision-making.
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. Language barriers. The Fernandez et al. article makes clear something that many of us have experienced as clinicians: providing care when physician and patient are language discordant is difficult, and it leads to clear disparities in health outcome.
2. Affordability of medical care. Fiscella & Sanders argue that our health insurance system, even “revamped” as the ACA, perpetuates health care disparities by institutionalizing tiers of bronze, silver, gold, and platinum. Poorer families and individuals can more easily afford the bronze plans, but the deductibles on these plans are so high that even one-third of the deductible ($400) is an amount that nearly half of Americans could not afford without borrowing or selling something in exchange.
3. Choices constrained by geography. Patients and referring physicians may opt for less-specialized care for very specialized medical needs because of difficulty traveling to major institutions.
4. Lack of choice in care provider. Fiscella & Sanders report that black, Hispanic, and Asian patients are more likely to be operated on by senior residents than by attending surgeons operating alone. They also report that senior residents have higher rates of major and minor complications compared to attending surgeons operating alone.
Staying on the topic of medical education, trainees can be taught ways to intervene at each of the problems listed above. Taking the first example of language barriers as an example, we are not learning universally as medical trainees that we should uphold ourselves to the highest of language standards and pass medical interpreter exams before we consider ourselves fluent enough to use our second language with our patients without an interpreter. Not having a standard language assessment for physicians leaves a lot for subjectivity and is an area where research could help create stricter guidelines.