Regionalized Challenges
Low health literacy and limited access to specialty care are common challenges in rural and economically depressed areas, according to Hassan Ramadan, MD, MSc, professor and chair of the department of otolaryngology–head and neck surgery at West Virginia University in Morgantown. In West Virginia, a mountainous state with a low population density and providers concentrated in bigger cities, environmental barriers impact all areas of patient care. One particular area of concern, he said, is the high incidence of smoking in his state.
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November 2020
There probably is a lack of community-based participatory research, at least in pediatric otolaryngology. We have to really get out and say, “What do you need, and how can we connect with your community?” —Emily F. Boss, MD, MPH
“Secondhand smoke for kids, especially kids with allergies or asthma, may lead them to have issues with their asthma,” said Dr. Ramadan. “There aren’t enough providers to serve the needs of the populations in these [small] communities. Many have to travel long distances to get access to care, so these kids don’t go to get allergy treatment. All these factors will have an impact on the health of the population.”
Transportation, technology, and access to specialists aren’t solely rural issues. In fact, Dr. Ishman noted that Medicaid provides low-income patients a few advantages: no copays and coverage for most medications, including Tylenol, with no out-of-pocket cost. “It’s more of a concern that the patient can find reliable transportation to pick up the medicine or have enough minutes on their cell phone to set up appointments,” she said. “Those issues are in contrast to patients in the next tier up, meaning those who are working but don’t necessarily have health insurance or have really high deductibles.”
Dr. Ramadan said he would trade additional research for additional resources to help patients navigate a complex healthcare system. “We all talk about what the problems are, but nobody has provided a solution,” he said. “I believe it can be multi-factorial and can be related to certain geographic areas. It all boils down to resources for support. The other issue is the education and awareness. We need to work on the health literacy of the population. That takes resources.”
Implicit Bias or Social Conditioning?
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Every provider has some unrecognized bias that needs to be identified, understood, and eliminated, Dr. Preciado said. Training in this area is sparse, added Dr. Boss, especially with regard to the way otolaryngologists deliver complex information to their patients.
“We have to recognize the biases for all populations, not just the underrepresented minority populations,” said Dr. Boss. “You can have kids with the same problem and all the same test results, and the families will have very different wishes of how they’d go about care.”
Dr. Johnson said social conditioning is real and plays out in the background of every medical practice, noting a recent study showing infant mortality drops for Black children if they are just assigned a Black physician (Proc Nat Acad Sciences. 2020;117:21194-21200). He said otolaryngologists, no matter the background, training, or location, have to ask tough questions and be willing to change.
“Are we more likely to recommend tympanostomy tubes to the child of a white mother who has a higher education and more money than we are to the child whose Black mom works in the cafeteria? Maybe, maybe not. Will you have special hours for Medicaid kids, or do you not even see Medicaid kids, period? I understand the financial issues for some not seeing these children. But if you do it, do you separate them out from others? If you do, that conditions you to think about those patients in a certain way.”