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?
This is an important question. I think there are two layers: first, the individual actions of physicians that contribute to health disparities; and second, the level of trust and rapport physicians build with their patients. These are related, as actions of physicians have consequences for trust-building, but it is important to understand that physicians have multiple ways they contribute to health disparities. As Brooks mentions in the opinion piece, stereotypes are ingrained in physicians at the outset of medical training, and deferential or even preferential treatment may be given to white patients, leaving less advantaged patients with fewer options or substandard care. I found it interesting in the van Ryn article that specific avenues for this to occur are identified: narrative perpetuation and communication differences. When I think about populations most affected by the HIV epidemic, I am certain that these issues are prevalent. To begin, there is a great deal of provider mistrust in the LGBT population, due to fears of disclosing one’s sexual orientation or HIV status. Further, racial minority LGBT patients have reported significant mistrust in the provider. This is clearly the result of provider-patient interactions. Further, medical providers do not treat their patients the same. Whereas one patient might be offered pre-exposure prophylaxis, others are not. In order to reduce these disparities, it would be important for providers to ask all of their patients in a non-judgmental manner what their sexual risk is, and to prescribe PrEP according to clinical guidelines.
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. Education: there are a lot of myths about how HIV is and is not transmitted. Some individuals believe applying alcohol wipes after sex can prevent HIV, or are unaware of risky behaviors. Improving sex education in schools is one way to address this structural inequity.
2. Transportation/Geography: Disparities according to rural status vs. urban status have been documented. Further, certain urban areas without sufficient public transportation options struggle with access to care, particularly Atlanta where medical institutions cannot be easily reached (or not at all) by bus and so owning a vehicle is a significant barrier. Homeless populations in particular struggle with this, as paying for public transportation is not always an option.
3. Job discrimination: LGBT minorities are treated differently in the hiring market, particularly trans patients. Without employment, insurance benefits can be different or non-existent and this can contribute to less access to healthcare, or engagement with healthcare if HIV-positive.
4. Language: many underserved populations are non-english speaking, and this can lead to a variety of difficulties. First, navigating the healthcare system is harder if you don’t speak English, making it difficult non-english speakers to obtain adequate insurance and access to providers. Second, patient-provider interactions can be hindered by language barriers, either when the physician does not understand a patient’s concern or a patient does not understand a physicians recommendation. Interpreters are very helpful in these situations, but may not be sufficient to counteract the cumulative health disparity.