Dr Ray Bignall II on Understanding the Environment Patients Live In


Access to care remains a key issue when trying to deliver equitable kidney health care to patients, explained O.N. Ray Bignall II, MD, assistant chief diversity and health equity officer at Nationwide Children’s Hospital.

Addressing access to care is key for pursuing equitable kidney health and kidney health professionals must understand the environment in which their patients live, said O.N. Ray Bignall II, MD, assistant chief diversity and health equity officer at Nationwide Children’s Hospital.

Bignall II spoke during a session at the American Society of Nephrology (ASN) Kidney Week 2022 meeting, titled, “Stony the Road We Trod: Fighting for Kidney Health Justice.”


Can you speak on the most pressing issues facing equitable kidney health care delivery that will be addressed during your talk at Kidney Week 2022?

So, there's a number of issues that are incredibly important for addressing kidney health equity and pursuing kidney health justice for our patients. I think probably paramount to those are issues related to access to care. So, there are a lot of things that interfere with or interrupt access to care.

I think traditionally, people think about having the presence of kidney health professionals in their communities. This is certainly very important for our patients, both in rural and urban areas and everywhere in between. But there are some other issues that challenge access to care as well. One, for instance, is education, our patients need to know what the challenges are surrounding their kidney health. Many of our patients don't know that information.

They've not been communicated with clearly by their health care professionals, whether they be kidney health professionals or otherwise. Many of them have challenges or limitations around health literacy or health numeracy, which prevent them from understanding the information that we as their health care providers have shared with them. So, there really are some unique challenges that surround access to care issues for our patients.

I also think that we can't underestimate the impact of social determinants of health on our patients’ lives. It's important to remember that everyone experiences social determinants of health, not just those who are marginalized or minoritized in our society. So, access to education, as mentioned before, access to housing, food—nutritious foods, particularly for patients with kidney disease, are often inaccessible to many of our patients in the lower socioeconomic status range.

I think that there are a great many important considerations in society that impact our patients as well. I think it's important that as physicians and health care professionals, we don't sequester our work to simply what takes place in the clinic or what takes place on a hospital ward. It's important for us if we really do want to pursue equitable and high quality care for all of our patients, that we become active in ensuring that our patients have the social drivers of health that they need as well.

What are some factors that nephrologists should consider in designing a care management plan that addresses the needs for each specific patient with kidney disease?

Nephrologists and kidney health professionals must be absolutely laser focused on understanding the circumstances and the milieu—the environment—that their patients are in and must work with their patients in a collaborative way to develop a care model that is going to be most effective for them.

We can sometimes get stuck in ruts, let's say, when we're providing for patients from one particular experience or one particular community. And then when we're faced with a diverse palette of patients, we might find ourselves trying to use the same models of care delivery that worked for, let's say, a suburban, well-educated, well-resourced population that might not work for a rural patient or family that seeking care or an urban, low income patient or family that seeking care.

So, I think it's really important that we speak with our patients, understand what some of their barriers are to reaching the care goals that we've set for them. I also think it's important for us to understand body language, understand when our patients are hesitant to follow through with what we're saying.

Very often it can be very difficult for our patients and their families to effectively communicate with us, what their challenges or hesitations are around the care plan that we've suggested. They may nod their heads and smile to be polite in the clinic setting with us, but decide later, “I just can't do what Dr Ray asked me to do. I don't have the bandwidth. I can't take the time off work. I don't have the finances to be able to make that work for us.”

So, instead of communicating that to us, they will politely nod their heads and then remain nonadherent to our therapeutic plan. That doesn't serve anyone, it certainly doesn't serve the patient who's not receiving the care, and it doesn’t serve me as a health care professional who's trying to treat disease in my patients. It's really, really important for us to spend some time to learn what each of our individual patients' challenges are, and then provide them with the resources to eliminate as many of those barriers or mitigate as many of those barriers as possible in order to effectively deliver care.

That often will mean that we need to be partnering with our multidisciplinary colleagues, our allied health colleagues. I think about, at Nationwide Children's Hospital, where we have a fantastic psychologist who works with our patients and helps to address some of the psychosocial barriers that exist there.

We have a terrific social work team that is part of our team that helps to address challenges with regards to resources, fantastic medical dietetics team that addresses the nutritional challenges for our patients, and so forth and so on. We have to be building these broad coalitions of teams together that enable us to achieve the goals for our patients.

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