Mind The Gap: Health Happens Everywhere

BY GRACE MOEN

Smoking, drinking, sugar, salt, sleeping next to your iPhone, caffeine, gluten, meat, eating before bed, sitting all day, parabens, microwaving plastic, drug use, sun exposure… the list of no-nos goes on. We’ve all more or less agreed that we shouldn’t engage in these unhealthy habits. And there is certainly enough science and data to underscore their potential harm. I’d like to point out though, that these examples also share an element of agency and free choice. What isn’t free choice however are the myriad of social determinants that dictate the level and quality of care you receive from the formal healthcare system. Social determinants of health include, but are not limited to, access to education, transportation, safety, and healthy food. All you have to do is take MUNI through San Francisco’s Bayview neighborhood to see this in action: children consuming donuts and soda for breakfast while your heart sinks and hopes that this diabetes-inducing diet won’t completely hijack their chances of success in the world.

The US spends more on healthcare and less on social services than any other developed nation globally. I want to let that sink in for a moment: more on healthcare, less on social services…! That’s a pretty privileged model, and one that frankly isn’t working. The US also has some of the lowest quality of care globally. I believe this approach is backwards and is a reflection of the value systems that dictate treatment protocols and how we deliver care. One might be led to wonder how effective the model really is. Especially considering our friends in the UK or the Netherlands spend less and have healthier markers in every social determinants category (The Commonwealth Fund). There are some specific gaps we can identify, so let’s look at a few…

Gap One: Medical School Is it the patient’s responsibility to provide details around their housing conditions, how many buses they took to the hospital, their diet yesterday, air quality at work? Or perhaps might a doctor make these contextual details a priority by asking directly? By skipping the conversation, doctors are missing a critical narrative that often points to underlying causes of sickness or discomfort. It would behoove all of us for this dialogue to be strengthened and during medical school is a huge opportunity to do so. Even amongst top medical institutions, UCLA specifically, curriculum around the social determinants of health wasn’t introduced until 2016. Physicians are slowly but surely being trained on the signs to look for and the resources to offer, which is a better-late-than-never start. On a systemic level though, it is taking an inordinately long time to apply comprehensive solutions. And in the meantime, we’re missing people. Organizations like the World Health Organization as well as the US Census Bureau are filling in the gaps by providing services and education where traditional medical school hasn’t.

Gap Two: DemandA staggering number of people wish their doctor would initiate the conversation on this subject. A whopping 86% in fact believe that their providers should “look beyond their pure medical needs in order to find underlying causes of their health issues” (according to The Physicians Foundation survey courtesy of our friend Jane Sarasohn-Kahn). Not only do patients want to have these conversations but physicians do too.  83% agree that social determinants have significant impact on patient outcomes, and 80% of physicians believe that unfortunately they don’t have the resources or staff to address this. Furthermore, 64% believe that they simply don’t have the time to have these conversations during a routine consultation, especially when the average visit is a paltry 15 minutes long.

What would happen if we flipped the model, to address social determinants first as a means of triage? Would it reduce costs and lighten the load on care delivery, on cost, on rates of emergency room visits, on the prevalence of chronic illness, across the whole system? Staten Island Performing Provider System thinks so. They have built a wide network of providers and social services that work together to triage and guide patients towards the best resources. Their model is proactive rather than reactive and the results they’re seeing underscore it’s success: a 25% reduction in avoidable emergency room visits in just three years. Let’s all take a page out of their book as we look to the future.

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