“Social issues.” Doctors must continue to address determinants of health beyond the realm of medical care.
At the end of every rotation for which I serve as a supervising attending for an in-patient general internal medicine team at my VA hospital, my residents and I exchange feedback on how the rotation went. In a recent feedback session, I insisted on receiving constructive criticism from my senior resident. Initially hesitant, she surprised me with something I hadn’t heard before: she told me that I had unrealistic expectations for assisting our veterans with their social issues.
Ah, the “s” word. It’s a reason medical students decide not to choose internal medicine for residency and why fellow residents decided not to enter general medicine or primary care. “Too many social issues.” So my first reaction was to scoff at this clichéd criticism of my chosen field. But as she explained, I realized that her point was not that she didn’t care about the socioeconomic contexts of our patients (in working with her, I already known that this wasn’t the case). Instead, her emphasis was that what we could achieve for our vets was beyond our control. And she was right. At the VA, social issues abound.
Currently my team is caring for an eighty-year old alcoholic who cannot leave his cancer-stricken wife at home, a sixty-five year old man with severe heart failure who cannot afford to get physical rehabilitation, and a homeless veteran with opiate dependence and chronic pain who simply wants a place to eat and sleep. For this abundance, we hold “social work rounds,” innovative interdisciplinary meetings during which we do discharge planning to identify needs and opportunities to ensure that the medical care we provide lasts well beyond the hospital stay: follow-up clinic visits, care coordination, case management, home-based primary care, nursing visits, telephone care, high-risk tracking, and a slew of other tools. These are tools that in the private sector may not be reimbursed well but that at the VA, we know provide huge benefits for the limited budget we have.
But even with these tools, the problems are unwieldy. Fixing homelessness, poverty, unemployment, poor education, health illiteracy, loneliness, and the repercussions of psychiatric disorders and drug dependence (much of which result from service to our country) seem not to be the task of a hospital or a physician. And as things stand in the U.S., perhaps not even of a health care system. Medical care in our country is dominated by a biological and curative model, one that fights disease based on anatomy and physiology inside the body, largely ignoring the need to fight environmental and socioeconomic ills that lie outside of it. Medical science discovers pharmacologic and procedural treatments for ailments after they have stricken instead of researching preventive strategies before they have arisen.
Indeed the achievements of modern medicine to treat and cure disease are remarkable, and the thrill and reward of doing so for the physician are unmatched among professions. The skill of the interventional cardiologist in emergently opening a clotted coronary artery to save a woman’s life from a severe heart attack is incredible. The ability of dialysis machines to keep someone alive for a decade and the transplantation of a kidney to take someone off of dialysis are life-changing. To cure a child of leukemia must rank among the most rewarding accomplishments for a physician that there is. The list is endless.
So why shouldn’t physicians and hospitals care more about medical care instead of social work? I find myself also struggling with this point: Physicians should work at the top of their license. After years and years of training in an ever-changing field impossible to master, doctors can’t be expected to cure their patients’ unlucky social contexts, established well before they hit the health care system and lasting beyond their doctor-patient encounters.
Yet as the CDC details, these social determinants of health seem to have far more influence on the outcomes of individual patients than many doctors understand and more influence on the health of the population than we could ever effect as doctors. The WHO defines social determinants as “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.” Poverty and poor health are inextricable. Along with poor neighborhoods. In the south and west sides of Chicago, huge swaths of “food deserts” exist where fresh produce is less accessible than in other neighborhoods, while liquor stores and fast food dominate and poor health follows accordingly. The Institute of Medicine’s 2002 report Unequal Treatment overviewed health disparities among racial and ethnic groups. Even for those diseases for which we know there are clear “unlucky” genetic determinants, the socioeconomic status of individuals play an independent part in their survival. A study published in 2008 in the journal Cancer (published by the American Cancer Society) found that cancer patients with low socioeconomic status have more advanced cancers at diagnosis, receive less aggressive treatment, and have a higher risk of dying in the five years following cancer diagnosis. Other specific studies published address prostate cancer and income, breast cancer among African-American women, and colorectal cancer survival and socioeconomic status.
But teaching about social determinants of health is allotted little time in medical education. Researching them at academic medical centers is held in lower regard than clinical drug trials and basic science. Discussing them on rounds seems tangential and distracting. And actually addressing them for an individual patient, the real human being in his or her social, behavioral, and economic contexts seems impossible.
It’s no wonder then that solutions for “social issues” have been so ignored at the health system level until this past year, with the passage of the Affordable Care Act. And worse, it’s no wonder that real efforts threaten hard-fought achievements. Republicans have threatened to de-fund the Affordable Care Act, and one of the elements they chose was the Prevention and Public Health fund. The fund began this year with $500 million and will grow to $2 billion per year by 2015. At $15 billion over the next 10 years, the fund was targeted as a prime source of deficit-cutting in order to pay for yearlong “Doc fix” for the flawed Sustainable Growth Rate (SGR) formula for Medicare physician reimbursement. The strategy is to pit doctors against the public: to create the false choice that we can either afford to pay doctors for the curative medical care we provide or finally set aside large money to create healthier food choices for children, environments for physical fitness, funding for prevention research, and much more.
Unfortunately, the false choice strategy has some grounding to work. The top 2 items on the legislative agenda of many physicians’ professional societies have long been tort reform and the permanent fix for the SGR. Not public health and prevention.
“But,” as Dr. Lucas Restrepo wrote in yesterday’s blog, “we must be physicians in spite of ourselves, for medicine has a social mission.” I have faith in the medical profession in this regard. The idealism and oath we devote to the health of our individual patients can be generalized to that of the society. My resident was correct. My creative social work dreams for the patients on our service were unrealistic. If we truly wish for the treatments and cures and prevention that we provide on a daily basis to individual patients to actually work, doctors must continue to advocate for public health policy that addresses social determinants of health—factors that are beyond the realm of medical care.