Lecture 5B: Health Disparities I

Introduction to Health Sciences

Lecture 5B: Health Disparities I

Instructor: Jen-Hao Chen, Ph.D

Why Health Disparities Exist?

Important features of health disparities

It’s about GROUP, not about two individuals

It’s not due to biology

It’s preventable

It disproportionally affects disadvantaged populations

Why Health Disparities Exist?

Why they exist?

Since they are preventable and not due to biology, if we know why they exist, then we can eliminate health disparities

Why Health Disparities Exist?

Three factors may explain the existence of health disparities

Healthcare system

Social structure

Culture

The Healthcare System

Coverage

Insurers

Providers

Patients

Unequal Coverage in United States

The Healthcare System

Access (to medical services)

Insurers

Providers

Patients

The issue of access

We can consider two levels of access

Whether you get access to a specific treatment/healthcare. For example, whether you get access to a specific surgical treatment

Whether you get access to “quality” healthcare

Both two levels of access can be determined by

Insurance coverage

Medical professions (today’s focus)

Myth of Healthcare Access

If you ask your friends the following question:

What is the most important factor can help people improve their health and reduce health disparities?

Myth of Healthcare Access

Conventional wisdom assumes that people will have improvements in their health if they are able to access to healthcare

Even medical scientists hold the belief, until 1972……a study by Dr. Julius Roth (1972), a professor at the University of California, Davis

Dr. Roth went to hospital emergency rooms to study and observe how people got treated differentially

Myth of Healthcare Access

Here is an excerpt from Dr. Roth’s observation:

Patients who are labelled as drunks as more consistently treated as undeserving than any other category of patient. They are frequently handled as if they were baggage when they are brought in by police……they are usually treated only for drunkenness and obvious surgical repair without being examined for other pathology; no one believes their stories; there statements are ridiculed; they are treated in an abusive manner……they are ignored for a long periods of time……emergency-ward personnel frequently comment on how they hate to take care of drunks (Roth 1972, p.843)

After Dr. Roth’s research, scientists begin to realize that patients are openly treated differentially based on observable characteristics

Myth of Healthcare Access

Differential practices are found in

Diagnosis

Medical treatment

Information given…….etc.

In a report published by the U.S. Institute of Medicine, prejudice that prevails in treating women, the elderly, the LGBT community, the obese, minorities…… a large percentage of the health care consuming public.

Social disadvantaged populations are more likely to receive unfavorable treatment

Examples of Unequal Treatment

Women with symptoms of heart disease often are not transported by emergency medical services to health facilities as rapidly as men.

Women and blacks with heart attack symptoms are not given cardiac catheterizations and other appropriate clinical tests at the same rate as white men.

Latinos and African-Americans do not receive the same pain medication for long bone fractures as do their fellow citizens.

Why Differential Treatments Exist?

Why Differential Treatments Exist?

Of course, ability to pay for the medical service is one crucial factor. Doctors need to make money to raise their families too. But, even after accounting for ability to pay, differential treatments remain. So WHY?

Patient-provider(doctor) relationship is considered as a social relationship.

Medical sociology offers good tools to understand why physicians openly treat patients differently ?

Explanation 1: Assessment of social worth of patients

Explanation 2: Cognitive bias

Assessment of Social Worth of Patients

Medical organizations are not value-neutral spaces where people provide professional services

Rather medical organizations are spaces in which professionals apply cultural and professional knowledge to make decision

Assessment of Social Worth of Patients

Thus, sociologists find out doctors do not apply “medical knowledge” universally

Rather, doctors assess the ”worthiness” of a patient to determine if he or she “deserves” specific procedure

Doctors may or may not be aware of their mental “assessment” of worthiness of patients

Assessment of Social Worth of Patients

A patient’s characteristics (gender, race, SES, type of employment, cloth…etc) are evaluated by doctors

Based on this mental assessment process, patients may be classified as “good patients” or problem patients” by doctors

For example, patients assessed as dirty, smelly are likely to be delayed in accessing care and hurried through the process

They are also likely to be viewed as not able to follow instruction for medications

Assessment of Social Worth of Patients

Example 1: A doctor decides if he/she provides procedural recommendation (by assessing a patient’s socioeconomic status)

Example 2: A doctor decides if he/she provides a specific medication (by assessing if a patient can follow his/her instruction to take the medication)

Note: Because the doctor never knows if the patient can follow the instruction or not. But he/she just makes the decision by his/her own assessment of the patient based on the patient’s characteristics without discussing with the patient. This is unequal treatment!

Assessment of Social Worth of Patients

Overall, medical sociologists find that the lower the social standing of a patient, the lower the likelihood that the staff would exhaust all options to save him or her

Cognitive Bias

Cognitive bias includes

Stereotyping

Prejudice

Studies from medical sociology shows that many medical professionals (like the ordinary people) hold cognitive bias!

Cognitive Bias

Don’t confuse cognitive bias with assessment of social worth

Cognitive bias: preexisting belief (implicit or explicit)

Assessment of social worth: first impression/first encounter

For example

White physicians find it difficult to make sense of minority patients’ symptom presentation and rely on their previous experience with people from that group

A doctor think Latino patients can only speak little English so he/she avoids providing detailed explanation

A doctor hurries through the examination process because the patient wears dirty cloethes

Cognitive Bias

Cognitive bias can be detrimental

Misdiagnosis

For example, cognitive bias may cause a doctor to focus on identifying symptoms of sexually transmitted disease (STD) among LGBT patients but ignore other symptoms

Unequal Treatment and Medical Education

After many years, the medical community starts paying attention to medical education, consider how medical education curricula show reform to make doctors’ treat their patients better

In a recent article published in the New England Journal of Medicine (Ansell & McDonald, 2016)

“We feel it is essential to begin a conversation about our role in addressing the explicit and implicit discrimination and racism in our communities and reflect on the systemic biases embedded in our medical education curricula, clinical learning environments, and administrative decision-making. We believe these discussions are needed at academic medical centers nationwide……. we should talk about bias, with our students, our faculties, our staff, our administrations, and our patients. Maybe then we’ll have a chance to finally eliminate the racial health care disparities that persist in the United States” 

Unequal Treatment and Medical Education

However, it makes no recommendation on how medical education curricula should be changed……