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?
Physicians contribute to health care disparities in many ways:
1. Stereotyping. This starts during training by the “hidden curriculum” due to offhanded stereotypical comments by faculty.
2. Constrained choices and decisions made by the type of insurance a patient has. The uninsured may not be referred for specialty consultation.
3. Implicit racial bias. This leads to less patient centered communication and informed decision making with minority patients. It can also lead to greater unnecessary health care for whites compared to minority patients.
4. Language barriers, leading to less effective health care to minorities.
My interest is lung cancer. Smoking causes 85% of all lung cancers. This can lead to suboptimal care of lung cancer patients due to inherent blame attributed to the patient for the high-risk behavior. Cigarette smoking is strongly linked to employment status, education, occupation and income. The prevalence of smoking is higher in minorities. Consequently, the incidence of lung cancer is 20% higher in black men.
To decrease the effect of physicians on health disparities, one can design prospective studies with exposure targeted towards the physicians and their practices. For example:
1. To decrease the physician bias to blame a lung cancer patient with history of smoking. One can a design a RCT using a cluster randomization design. Cases will have physicians who have undergone training highlighting this physician bias and controls will have physician without such training. One can then measure stage-specific outcomes.
2. To decrease the physician bias due to language barriers. Interpreters are underutilized. One can design a RCT with sample population consisting of patients who have limited English proficiency. Intervention will be mandatory presence of an interpreter during the patient encounters. One can then measure outcomes including quality of care measures in patients cared for in the presence of interpreters compared with those without.
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?
A. Language Barriers. This issue has been reported in many studies including Fernandez et al, 2010. Limited English proficiency can lead to limited patient-physician communication leading to poor outcomes, lack of patient satisfaction and suboptimal health promoting behaviors.
As with any aspect of medicine, language barriers are an impediment to providing quality health interventions in lung cancer prevention and treatment. Language barriers impact smoking cessation interventions. It impacts quality of life for patients undergoing chemotherapy as discussions about the side effects of treatment may be limited and poorly understood. Follow-up care and well checks over the phone are also compromised.
B. Barriers due to Differential care. Health care is largely dictated by the type of insurance. Patients without health insurance are most affected. For example, veterans who do not have dental coverage from the VA seldom get any preventative dental care and end up with multiple and frequent tooth extractions.
In lung cancer, patients without medical insurance are usually cared for at the county hospital and are unable to obtain the newest drugs. Even patients with do not have comprehensive coverage have difficulty obtaining newest treatments as they may be denied by their insurance.
C. Geographical Barriers. Physicians and hospitals are concentrated in major cities. Patients living in rural areas and certain geographical areas such as southwestern area do not have available the same quality of care.
Treatments for lung cancer are often compromised as patients living at far distances are unable to arrange frequent transportations for chemotherapy or daily radiation treatments.
D. Barriers imposed by Healthcare organizations. In some healthcare organizations, patients are segregated as private and clinic patients. Clinic patients are usually cared for by residents and due to their time constraints, the continuity of care may suffer. Also, by segregating patients, there is a potential of differential care provided to them by the clinic staff.
In oncology, this is usually not an issue as patients are closely monitored by the staff physicians. However, patients generally do not appreciate the changes in their health care providers as they have to reestablish a relationship with the new provider.