Wake up. Prepare for the patients of the day: past medical history, medications, recent notes, labs, vaccines due, establish a plan. Next patient. Rinse and repeat.
As a medical student training by telemedicine in the era of COVID-19, I have come to find that providing comprehensive patient care can be difficult over a camera. When there are 20 patients to squeeze into the day, quantity demands efficiency. For me, this has meant: address the chief complaint, review the chronic medical conditions, ensure the patient is on the appropriate medication, encourage adherence, order the appropriate labs, refer to the necessary specialist and follow up regularly. While treating patient care like an assembly line does make for quick work, it often overlooks essential components of the underlying social determinants driving health outcomes. Social determinants are the conditions in the environment in which people are born, live, work, play, worship and age that affect their risk for certain diseases and health outcomes.
I have had the privilege of spending this past month working closely with patients during my third-year family medicine clerkship on our Mobile Health Clinic. This service is essentially a bus with two examination rooms and access to basic testing (e.g. blood work, urinalysis, ECG, pap smear). The population of patients we work with is mostly uninsured, undocumented and high risk.
If there is one thing I have learned, it is that what we, the medical providers, think is important may not necessarily be the priority of the patient. We want to know: why are your sugars uncontrolled? How is your diet? Have you been able to take your metformin? However, for the patient, these things are often trivial. The patient wants to know: how will I be able to afford these medications with my part-time job? How am I expected to see a specialist without insurance? Should I be going outside to exercise, or will I contract coronavirus? I am stressed that my son doesn’t have access to the internet to complete his homework. I need to secure groceries, but I lack transportation right now. The list goes on.
As physicians-in-training, we seek to treat disease. We are taught to recognize “zebras,” conduct a thorough workup, look to evidence-based guidelines and suggest appropriate treatment options. While it might be considered standard to pacify a patient complaint or an abnormal lab value with medication, we now also realize the unparalleled importance that social determinants have on health outcomes.
Take a case of poorly controlled diabetes for example. Management can be as theoretically straightforward as prescribing insulin, checking hemoglobin A1Cs every three months and continuing to encourage diet and exercise. However, standard treatment can overlook key aspects of care, such as identifying community support groups, reviewing proper dosing and administration of insulin, assessing for food insecurity, inquiring about safe spaces for exercise, ensuring patient understanding of the disease process and evaluating their motivation for change. What about identifying barriers to care, targeting affordable medication options, addressing psychosocial stressors and complications? The list goes on. Understanding these details requires time, purposeful inquiry and attention to detail. But these are the details that make all the difference.
We live in a world driven by metrics. We are rewarded for “controlled” lab values, vaccination rates and medication adherence. However, metrics rarely consider patient priorities, concerns or wellness. We know that 80 to 90% of health outcomes are driven by social determinants. Not disease; not treatment. Therefore, it is our responsibility to recognize and embrace this. We can do everything by the textbook, from making the correct diagnosis to starting appropriate treatment, but at the end of the day, it means nothing if undermined by social barriers.
We have the opportunity in medical school to work with a diversity of patient cohorts. We also have the privilege of spending more time to obtain a thorough patient history. Throughout the course of our clinical training, with each patient interaction, we are establishing the foundation that we will take with us into our careers. I urge that as we move forwards we consider how the frequently overlooked social history contributes to the pathology we witness. I urge that we transform the social determinants of health from a topic learned in the classroom to an anchoring section of our patient interviews.
Over this past month, my most important role has not been to instruct but rather to listen. It is said that if you listen to the patient, they will often lay out the diagnosis for you. But if you listen closely, and with intention, they may even share why they developed the diagnosis in the first place.