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?
One of the ways individual physicians contribute to health care disparities is by relying on their slow learning systems during clinic visits and patient workup. The stress and time pressure of the environment in which physicians have to synthesize a complex set of data to make judgements about diagnosis and treatment can make it easy to fall back on the default slow learning system. But that can result in the unconscious (and unintended) support of implicit biases and beliefs. An area of health care that is of interest to me is cancer clinical trials, and one way to study the impact of individual physicians on health disparities would be to study clinical trial recruitment. It would be interesting to look at the recruitment of racial/ethnic minority patients by white physicians, versus minority physicians. Another study could be to look at the the recruitment and enrollment of racial/ethnic minority patients by physicians who have recently received implicit bias training, versus those who have not received such training. Not only would these studies give us a more comprehensive understanding of the impact of implicit bias on clinical trials recruitment, they could also help guide future efforts to reduce the impact of implicit bias, through training and the recruitment of more minority care providers.
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?
Social Disadvantage: Because healthcare costs in the United States are so high, a lack of access to comprehensive healthcare is linked to socioeconomic status. Many neighborhoods with lower SES have fewer health care resources available, from emergent care to primary care practices. In addition to a lack of care resources, individuals with fewer financial resources can experience more difficulty obtaining adequate health insurance. The effect of the social disadvantage of being in low resource neighborhoods, combined with low individual SES contributes to poorer health outcomes in low SES individuals (vs high SES individuals), especially when considering the long-term management of chronic illnesses.
Language Barrriers: Hospitals that do not have adequate medical interpreter services face two major problems: (1) patients not possessing a full understanding of the care they are receivings, and (2) physicians not possessing a full understanding of what the patient would like out of their care. Lack of understanding on the part of the patient or the physician can result in inadequate care being delivered, lack of compliance, lack of trust on both sides of the patient-provider relationship, and a lack of follow-up in the long-term. This can all contribute to disparities in health care delivery and outcomes in predominantly non-English speaking communities.
Geographic Barriers: Racial and socioeconomic segregation that occurs on a city, state, and/or regional level can lead to a type of ‘pooled disadvantage’ and communities with compounded problems: low SES, a population more likely to be stereotyped within the healthcare system, and, in some places, diminished political power to promorote the high-level policies and changes neeeded to reverse these effects. The result is geographic areas (communities, neighborhoods, etc) that experience differences in the level of care that they can access and receive.
Structural Bias: Research has shown that even within the same hospitals there can be two levels of care, for example: the track for those with private insurance, or VIPs, and the track for those with Medicare, Medicaid, or the uninsured. Or the patients who see residents and trainees and the patients who see staff physicians or faculty. Implicit bias plays a role in assigning patients to these tracks, which often results in a reinforcement of disparities within a single hospital or healthcare system.
Of the four structural barriers I have identified, I think that social disadvantage, geographic barriers and structural bias, are particularly relevant to my area of research: hypertension in the African-American community. In the United States, African-Americans have a lower median income and double the unemployment rate than their white counterparts, all of which contributes to greater socioeconomic disadvantage. They have a history of being targeted by policies like red-lining which has geographically created low-resource neighborhoods for communities of color; and they are more likely to be negatively stereotyped within the health care system by providers. Lack of financial resources, on the individual and community level, combined with a difference in the quality of health care received, makes it makes it difficult to manage hypertension, which can require lifestyle change on top of a pharmaceutical intervention.