Nov. 8, 2023
By Christen Johnson, M.D., Ed.D., M.P.H., FAAFP
“What questions do you have for me?” I asked the patient as I was closing the encounter.
“None, Doc. Thank you. I’ll see you in three months,” they replied as we stood.
Then there was a knock at the door.
“Hey, Doc. Sorry to interrupt but we have a patient out here with chest pain and they have a heart history,” my MA said with fear in her eyes.
I excused myself from the patient in front of me and walked into the hall. This was how we met.
Fast forward: I’ve taken care of them through three cardiac events, four jobs and a slew of hoops the system has gifted us to navigate. During the past three years, as they’ve traversed the challenges of being healthy in a broken health care system, they’ve also had to navigate the crippling impact of inequities and vulnerabilities built within our world at large.
Some may ask why this patient has been so sick. Don’t they take their medications? Aren’t outcomes like this a product of this patient not doing their job to take care of themselves?
I disagree wholeheartedly. Clinical care accounts for roughly 20% of the variation in a population’s health outcomes, while the other 80% is dictated by factors like ZIP code that can dictate job opportunities, stress levels and even what people eat.
I’ve watched this particular patient learn to control their diabetes, even while having to alter their usual culturally relevant diet. I’ve also seen specialist visits delayed because interpreters weren’t available when they called. This patient has made sacrifices to buy new medications that have been extremely expensive even on the 340B Drug Pricing Program. I’ve also witnessed how difficult it can be to get basic assistance.
I’ve grown to understand some of the cultural barriers that patients who are not from the United States experience, not only when trying to navigate the health care system, but to keep their jobs when they are ill.
By knowing the community in which I work, I’m able to help my patients get more of what they need and to understand some of their struggles. For example, many of my patients work jobs that don’t offer PTO or sick leave, and often there is little job protection when they experience extended illnesses, especially for those who are new Americans or have been incarcerated. Thus, even coming to a doctor’s appointment can be a large sacrifice of lost wages, gas money, and copays or medication costs.
Worse, being too sick in this system without enough resources begets illness and can even lead to being fired — even for people should be eligible for things like FMLA or disability. Loyal employees who disclose health needs can swiftly come to be considered a liability to the organization that they depend on to feed their families and pay for their health needs. Situations like this disadvantage patients of lower economic status; as a result, our offices may not be the easiest place for them to be. These issues are often overlooked.
Yet, there is something so beautiful about the opportunity to meet patients where they are, to learn about their world and partner in their health with them. I signed up for a job that would forever be rooted in service to others in a space that would let me serve both my community and the individuals in it. In my practice, I’ve met a host of other patients just like this one. We learn about the social determinants of health and health disparities, but health equity isn’t always a one-size-fits-all experience. The barriers seem to get larger by the year.
I remember writing my personal statement for residency, intertwining my love for art and impressionist paintings with this beautiful work that I get an opportunity to be a part of. As the Zulu word sawubona encapsulates, I get an opportunity to truly see my patients. I remind them that I see them and stand to appreciate their inherent value and humanity even when the system has assigned an alternate idea of worth to their needs.
AAFP Tools for New Physicians
The AAFP has created a resource hub specifically for new physicians that includes tools to help physicians screen patients for social needs and identify local assistance; health equity issue briefs; implicit bias training and more.
The webpage also offers
Although this often requires longer visits, additional resources, and some creativity to help my patients create pathways to health, it fills my cup. For my colleagues who haven’t had the same training and experiences, I know that this is a daunting task, but it isn’t a task that we have to do alone.
The tools are there to help us to manage this large feat. Knowing how one’s own biases and experiences can affect how we treat patients is a first step. This is a huge undertaking, but the AAFP has invested in ensuring America’s family docs are ready to provide equitable care no matter the population. Understanding the stigma that creates challenges for our patients can help us to better align with health equity. Having the experience to better define disparities in our communities and our practices is key to moving the needle forward. Using validated tools to improve our workflows and collaboration with other health care workers can allow us to build teams that support our patients so we’re not trying to shoulder the system alone.
The AAFP has everything from toolkits and guides to CME opportunities to guarantee we are prepared. And of course, caring for ourselves and our teams is imperative to giving our patients the care they need. The AAFP has our back there, too.
My passion is helping my patients overcome the obstacles that are out of their control, and preparing my colleagues and the next generation to do the same. It’s a lot, but we have help. And in the end, it’s worth it.
Christen Johnson, M.D., Ed.D., M.P.H., FAAFP is the director of medical education and research at a federally qualified health center in Columbus, Ohio, and faculty lead for culturally responsible curricula in medicine at Wright State University Boonshoft School of Medicine. She is an inaugural member of the AAFP Commission on Diversity, Equity and Inclusiveness in Family Medicine, and served as a 2021 AAFP Health Equity Fellow.