Series: What Are We Missing?

12. Pandemic Healthcare Disparities

SOUND BITE (Dr. Christopher Colbert):
In a perfect healthcare world, we would start off with better sandwiches and juice.

Dr. Jane Caldwell:
What do better sandwiches and juice have to do with healthcare disparities? Do disparities widen…become more obvious in a pandemic? Welcome to On Medical Grounds, your authentic blend of timely, scientific, and medical knowledge.

I’m your host, Dr. Jane Caldwell.

On its website the CDC says and I quote, “The COVID-19 pandemic has brought social and racial injustice and inequity to the forefront of public health. It has highlighted that health equity is still not a reality as COVID-19 has unequally affected many racial and ethnic minority groups, putting them more at risk of getting sick and dying from COVID-19.”

Why do some people have better access in treatment in healthcare than others? How has the pandemic influenced disparities? Today we are speaking with Dr. Christopher Colbert, Assistant Program Director of the Emergency Medicine Residency Program at the University of Illinois. He will talk about the effects of disparities in healthcare, what can be done to close the gaps, and how we can improve in the future.

Hello, Dr. Colbert. Welcome to On Medical Grounds.

Dr. Christopher Colbert:
Jane, I appreciate the invitation and the opportunity to expand this discussion. Thank you very much.

Dr. Jane Caldwell:
Excellent. Let’s start with a story. Can you give me a recent example of a patient who had difficulty receiving care, and how that influenced the services or the lack of services received?

Dr. Christopher Colbert:
As an emergency room physician, this is something that we can do quite frequently. A perfect example would be at the beginning of COVID. At the beginning of COVID, we made available, well, the hospital made available vaccines. And one of the biggest challenges to the most hardest hit of patient population was access to these resources to receive the vaccine. We noticed immediately there was a specific patient population that was abundantly... Their numbers were very high, to receive the vaccine, where the hardest hit were not available.
And when we looked 24 hours into why this was significant, it was because we had a location that was not very public transportation friendly. And so just that alone, public transportation access, and to the extent of the access as well. As an example, in Chicago in December it’s ridiculously cold and sometimes the snow is two to three feet.

In addition to the destination of the event, it’s how far, how many blocks do you have to walk with your family member? Initially, the vaccinations were available for those individuals of a specific age. So not only did we not think of the resource of transportation and transportation availability, but how far is the bus stop to the place where we’re giving the vaccine as well? How far will you have to push your mother in a wheelchair, two or three blocks in the Chicago cold, plus-minus snow, to stand in line for the vaccination?

And when we have these conversations we sit down and think, “What’s the best way to impact and have that positive impact on patient population?” And that was one of the small things that were not part of our thinking and not part of the conversation. We made accommodations moving forward, but that is a huge example of social determinants of health. And by definition, your social determinants of health are non-medical factors of healthcare that affect healthcare outcomes. And believe it or not, social determinants of health account for 80% of healthcare outcomes.

Dr. Jane Caldwell: Social determinates such as transportation influence access to healthcare. In the article, “Traveling Towards Disease”, researchers at the University of Illinois summarized the literature on transportation barriers. They estimated that 3.6 million people do not obtain medical care due to transportation issues. These individuals were more likely to be older, poorer, less educated, female and from an ethnic minority group. Regrettably, people carrying the highest burden of disease also faced the greatest barriers. Major barriers were: distance to a treatment center, access to a vehicle and finding someone to drive them to a facility.

Dr. Jane Caldwell:
Can you go back and describe what accommodations were made for transportation?

Dr. Christopher Colbert:
Well, we moved our site of vaccination. We would just ... Took a step back.

Dr. Jane Caldwell:
Made it more convenient.

Dr. Christopher Colbert:
We made it more convenient. But also to amplify that, we had conversations with other resources that offer vaccine and, well, and said, “Hey, don’t make the same mistake we did. Don’t overlook this. Ensure that this is a part of your thinking when you plan.” Because providing this vaccination is extremely important and having the conversation of how to best provide this resource is important for everybody. Not just University of Illinois, but for anyone. Just think about this.

And also, something common as well is think about: having ramps. We would be at a place and offer vaccinations, and we would have to go out very often and help individuals in wheelchairs or with walkers to accommodate eight or six steps. And eight or six steps may not be much to squawk at for me, but it is for my family members that are in their eighties or sixties or utilize a walker. And something like that is huge. And that played a huge role in our decision-making and a part of our conversation with other institutions that offer those resources as well. In the grand scheme of things, we were able to make a larger impact by expanding the conversation, the best way to offer these resources.

Dr. Jane Caldwell:
Are there other ways that the pandemic has affected disparities in healthcare?

Dr. Christopher Colbert:
I think the pandemic brought to light some of the health disparities. It just amplified them and it put them in the forefront for conversation.

As an example, there was something to be said in reference to specific patient populations, specifically Black and Brown populations, having a higher morbidity and mortality, secondary to COVID. But if you look at those populations and those hospitals, maybe their ICU only has four beds. Maybe they don’t have a pulmonary critical care physician. Where at different institutions, at academic institutions, not only do you have three or four pulmonary critical care physicians, you’ve got fellows.

So at one hospital that will have the same patient population concern, you have one doctor. And travel six blocks to another hospital, literally six blocks, and that hospital has eight. That has a significant effect on patient outcome. Resources, academic resources, and just beds as well.

Just the actual structure, the having beds availability. The pulmonary techs as well, that’s huge in maintaining standards of care.

Dr. Jane Caldwell: According to a study funded by GoodRx Health, more than 80% of counties across the U.S. lack adequate healthcare infrastructure in some shape or form. That means that over a third of the U.S. population lives in a county where there is less than adequate access to pharmacies, primary care providers, hospitals, trauma centers, or low-cost health centers.

The GoodRx Health study mentions income as a notorious, and well-researched, determinant of healthcare access. Nearly 1 in 3 families report skipping some form of medical care due to cost. When people can’t afford their healthcare, they may be forced to make decisions between paying for food and rent or paying for their primary care visits or prescriptions. Medicine follows the money. Lower socioeconomic communities have fewer facilities overall and provide fewer doctors and specialists at the facilities they do have.

Dr. Jane Caldwell:
I see. If you were to boil this all down, what would you see as the number one problem facing healthcare disparities?

Dr. Christopher Colbert:
Ooh, that’s a great question. Number one, problem, healthcare comes in a package. Before you go to surgery, you have to be prepped. Before you’re prepped, you have to speak to your anesthesiologist. And before the anesthesiologist, then the anesthesiologist takes a look at your healthcare, and then you’re going off to get this new hip. And then you see the orthopedic surgeon.

If I looked at the healthcare system in reference to health disparity, what would be my biggest ... a point is, to me, what’s the benefit of access if there’s no resources once you get there? And it sounds very cliché-ish and corny, but if you provide resources to get to a hospital, but the hospital doesn’t have OB there, or it doesn’t have rheumatology, it doesn’t help those individuals in that specific community, is to bridge.

I think the biggest thing is, what I find is, you have to tailor your resources to where you live. And it sounds, again, corny and cliché-ish, and it’s not a cut and dry answer, but you’ve got a canvas. You’ve got to know your audience; you have to know your audience. In some patient populations, there’s going to be more lupus, there’s going to be more sickle cell. Provide those resources for that environment.

Dr. Jane Caldwell: The GoodRx white paper describes areas devoid of healthcare services as healthcare deserts. Here is a quote from that white paper, “Caring for one’s health is multidimensional and includes an array of healthcare services. [To help its members stay healthy], a community will need providers, hospitals, trauma centers, pharmacies, and community health centers. On top of that, people need to be able to access these facilities. Without insurance, or access to the internet, it will be difficult to gain access to these facilities, no matter how close they are to one’s home.

Dr. Jane Caldwell:
So in a perfect healthcare world, what would you wish for?

Dr. Christopher Colbert:
In a perfect healthcare world, we would start off with better sandwiches and juice, because I think we just have ... we give sandwiches and juice to our patients in the emergency room and like, “These are really the best sandwiches.”

That’s a great question. In a perfect world, I would want the administration to take a step outside of the hospital. And again, I get it, it sounds corny and clichéish, but you can’t be a doc in the box. You’ve got to be a doctor that knows the patients before they come in. What environment do you live in? Is this a Polish-speaking community? Is this a Spanish-speaking community? What is very common in this specific community?

As an assistant program director, and specifically in Chicago, we have a very diverse patient population, from Chinatown to Polish communities, to Black and Brown communities, to very affluent communities. And every community deserves a little bit and needs a little bit .... Their needs are just a little bit different. And if you don’t accommodate those needs, they don’t go away. If you don’t address those needs, they don’t go away. They just present to the emergency room and everyone goes, “Whoa, how did we get here and what do we do?”

Well, take the time and the dignity to walk into the community and say, “Hey, what do you like on your sandwiches? Do you like mayonnaise on your sandwiches? If you don’t like them, we’ll make sure we don’t get them.” And something that small has such a huge effect. Again, I’m the assistant program director at the University of Illinois, but I moonlight on the South Side of Chicago. It keeps my hands fresh. I get tons of procedures on the South Side of Chicago. It’s more of a knife and gun club, and we get a lot of bread and butter, what we call bread and butter emergency medicine. Poorly controlled hypertension, poorly controlled diabetes, poorly controlled high cholesterol.

And the wants and the needs of those patients are a little bit different in reference to follow-up resources. You can go to the emergency room and I can say, “Hey, follow up with a primary care doctor,” but there’s very limited primary care clinics in those communities. So if your most recent appointment will be in three months, I’m going to the emergency room.

Dr. Jane Caldwell:
If I could summarize here, you’re saying don’t be a doc in the box.

Dr. Christopher Colbert:

Dr. Jane Caldwell:
Get out in your community and walk the walk.

Dr. Christopher Colbert:
Because our community is coming to you anyway. The immediate is going to come to your emergency room. A little forward-thinking and take the time to go into the community and find out what their needs are.

Dr. Jane Caldwell:
Dr. Colbert, we appreciate your efforts to educate others and improve healthcare disparities. Thank you so much for taking time from your busy schedule to speak with us.

Dr. Christopher Colbert:
I appreciate the invitation. Thank you very much for the opportunity to amplify this conversation, and hopefully, have a positive impact on patient outcome.

Dr. Jane Caldwell: One positive aspect of the COVID pandemic is that it has amplified and made us more aware of healthcare disparities. What are some creative solutions?

The authors of “Traveling Towards Disease” suggested interventions and new public policies to reduce transportation barriers to healthcare. Interventions such as public transit discounts or medical transportation services were cited. Because access to a vehicle was consistently associated with increased access to healthcare, especially in rural areas, they recommended programs which provide temporary access to cars. Finally, reimbursement for travel, whether by public transportation or vehicle-for-hire, could help reduce healthcare disparities.

Healthcare deserts are a larger, long-term issue as they require new or better infrastructure, more insured individuals and more trained personnel. Investors need incentives to build new hospitals and clinics close to populations in need. Universities need to admit more medical students and residency positions and reduce training times while maintaining quality. Affordable care should facilitate insurance for all. Legislation and public policies should support these goals.

Dr. Jane Caldwell:
And thank you for listening to the On Medical Grounds podcast. We know your time is valuable. Further resources on healthcare disparity and suggestions for how providers can “walk the walk” can be found with this podcast at OnMedicalGrounds.com. Please be sure to check the “Subscribe” button to be alerted when we post new content. If you enjoyed this podcast, please rate and review it and share it with your friends and colleagues.
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