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Tuesday Dec 18, 2018

What a Barefoot Patient Taught Me About Health Equity

It was a Friday afternoon, and a long and busy week on inpatient family medicine service was drawing to a close. My co-resident and I were working together to discharge several patients after the rest of our team members had left for clinic. We completed med recs, closed the loop with consultants and prepped instructions for patients. Shortly after clicking that golden "discharge" button, a nurse called from the floor to tell us that one of the patients could not leave because her shoes and clothes had never made it over from the facility where she was staying before being admitted. Although the nurses could offer her scrubs to wear for the moment, we knew we could not send her barefoot into the Chicago winter. She needed her shoes.

[feet of a young patient in hospital bed]

Our patient had arrived with vague GI symptoms and was admitted for mild-but-not-dismissible lab abnormalities that had essentially resolved within a day of admission. However, she remained on our service for several days while we worked with the case managers and social workers to determine "placement" -- where the patient would go after discharge. Although the clinical workup had never been too concerning, we saw in this patient a set of alarming symptoms we had seen many times before: those indicative of a social safety net quickly fraying at the edges.

Between mental health struggles, a history of trauma, chronic diseases and housing insecurity, our patient faced many challenges and couldn't seem to catch a break. She didn't want to return to the facility she had come from (where her shoes were) and preferred to go to a shelter where she had previously had a positive experience. We made plans for followup primary care and even transportation, but this did not solve the shoe problem. As I held the nurse on the line, I looked at my colleague and asked, "So … do you want to go down the street and get her shoes, or hold the pager while I do?" She looked at me, clearly thinking the same thing, laughed, and grabbed her coat.

Although my interests were wide, and I considered many specialties, I chose family medicine because it was where I found "my people." Family medicine has kept me captivated because of my deep desire to be trained by and among physicians who are motivated by a desire for social justice and health equity. My role models in family medicine are physicians who continually consider the social and environmental contexts that surround a patient's health and look for ways to connect individual patient care to advocacy within the larger health system.

The evidence is clear: The medical care we provide as physicians is only a small slice -- as low as 10 percent -- of what actually determines the health status of patients and communities. Studies estimate that although another small piece is health behavior, roughly two-thirds of health outcomes are mainly determined by systemic societal factors outside of patients' control.(www.cdc.gov) These social determinants of health are the conditions under which people are born, grow, live, work and age. Family medicine physicians are uniquely poised to address these social determinants because of the multitude of settings in which they practice and the lifelong relationships they share with patients.

There are, of course, stellar physicians in every specialty who are committed to health equity and consider the social determinants in their patient encounters, whether in the clinic, the hospital or even the operating room.

Nevertheless, family medicine captivated me because of its exceptional dedication to these issues. When rounds slip into an academic pontification about which diabetes drug is more effective in a particular physiological situation, it's the family physician who asks which medication the patient can afford, knowing that's the only one they'll use.

Family physicians are more likely than primary care physicians from other specialties to work in underserved areas,(www.annfammed.org) including in rural communities with vulnerable populations, or in health professional shortage areas. Studies have shown that residents trained in a teaching health center residency program are even more likely to serve in these communities.  

On an individual level, family physicians have the opportunity to both screen and intervene with patients on issues such as food and housing insecurity, violence, and mental health. On a larger scale, we are advocating on issues such as socioeconomic inequity, public health infrastructure, education and mental health. The AAFP is addressing the social determinants through its efforts on payment reform related to risk-adjustment protocols in alternative payment models.

The Academy also has resources to help members address health equity and the social determinants of health through The EveryONE Project.

As a second-year family medicine resident at a teaching health center on Chicago's West Side, I'm grateful to be trained by and with physicians who know that my patient's neighborhood and employment status have a far larger impact on her health than my choice of blood pressure medication. The #FMRevolution and primary care transformation our communities so desperately need hinge on our understanding of the social determinants of health and our advocacy for addressing them. I'm proud to be part of a team that realizes that before you can discharge a patient, you need to make sure she has shoes.

Michelle Byrne, M.D., M.P.H., is the resident member of the AAFP Board of Directors.

Posted at 03:22PM Dec 18, 2018 by Michelle Byrne, M.D., M.P.H.

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