The Physician’s Calling and Science Promote Health Equity and Outcomes—Reply

Abstract

COMMENT & RESPONSEIn Reply Our study of adolescents and young adults with sickle cell disease (SCD), caregivers, and clinicians provides initial validation of the Social-Ecological Model of Adolescents and Young Adults Readiness for Transition to Promote Health Equity (SMART-E). 1 This work builds on the extant widely used and validated SMART framework, 2 and it joins the rigorous scientific literature illustrating how systems of power can influence the behaviors and beliefs of health care clinicians, which can have downstream effects on patient health and well-being. 3 We agree with the letter writer regarding the incredible advances led by scientists and physicians to develop disease-modifying therapies (DMTs) in SCD. Prior to July 2017, there was only 1 medication approved by the US Food and Drug Administration; to date, there are 4. However, health equity cannot be achieved solely through biomedical discoveries. Indeed, even a study referenced in the letter demonstrates that despite the increased availability of DMTs for SCD, only 1 in 4 individuals with SCD are using any DMT. 4 Further, the National Academies of Sciences, Engineering, and Medicine report, "Addressing Sickle Cell Disease: A Strategic Plan and Blueprint for Action," 5 written by leading scientists and physicians in SCD, recognizes the role racism within the health care system has played in delaying the development of DMTs for SCD. This report, alongside national practice guidelines, has elucidated the clinician's responsibility in the recognition and management of socioecological factors, either through direct screening or by facilitating referrals to psychosocial and community resources. This is precisely what SMART-E describes within the context of the transition to adult-oriented health care. 1 In alignment with this, the National Institutes of Health, the American Society of Hematology, and JAMA Pediatrics have expressed a commitment to inclusion and health equity, urging scientists and physicians to take active steps to reduce bias in their science and patient care. The JAMA Network has directly stated that "the JAMA Network journals can and must do better and advance toward inclusion and antiracism in all journal-related activities," and "JAMA Health Forum issued calls for manuscripts on prevention and effects of systemic racism on health." 6 While clinicians represent just 1 aspect of the multifaceted structural and interpersonal factors influencing patient outcomes, understanding how clinicians can mitigate disparities merits exploration and intervention to improve patient outcomes. "The physician's calling" is to deliver the best possible care to their patient, and this entails a humble assessment of institutional and personal biases that may influence behaviors, such as DMTprescribing practices and communication with patients and families, to ensure they are not contributing to health disparities and impeding progress toward achieving health equity.