Dec 7 2011

Dr. Douglas Jutte: My Patient's Most Pressing Health Issue was a Broken Carburetor

Idea Gallery is a recurring editorial series on NewPublicHealth in which guest authors provide their perspective on issues affecting public health. Today, Douglas Jutte, MD, MPH, offers a physician's perspective on how unmet social needslike access to nutritious food, transportation assistance and housing assistanceare affecting the health of Americans.

During medical school and pediatric residency I spent over a year living in the Dominican Republic and Guatemala, so when I finished my training I wanted to continue my work with Spanish-speaking families. My first job was in the neighborhood clinic of East Palo Alto, California, a low-income community inhabited primarily by first- and second-generation Mexican immigrants.

One of my earliest patients in East Palo Alto was a little boy with Down syndrome and a serious congenital heart defect, a common feature of that condition. When I met him, he had recently undergone open-heart surgery and had a gastric tube placed so that he could be fed without requiring him to eat. His mother was enormously attentive but had very limited resources and spoke only Spanish. Together we monitored his health as he stabilized, grew and began to eat on his own. With a full medical recovery, his continued healthy development now relied primarily on obtaining the proper setting for his schooling.

With no caseworker or nurse in my clinic to help me out, I made calls and wrote letters to enroll him in a fantastic school near the Stanford campus. Months later, before a pending well-child visit, I called the school to get an update on his development. I was shocked to learn that it had been weeks since he had last attended. When he and his mother came in for their appointment, I learned her car had broken down. She was saving money for a fix, but had no one to rely on for her son’s transportation and hadn’t known where to turn for help. Desperate, I called the school and discovered that not only did they have a shuttle service but also it was free for needy children.

This was a crystallizing moment for me. The long-term health and well being of a developmentally delayed child whom I had helped coax through recovery from prolonged hospitalizations and multiple complicated surgeries hinged not on the quality of my medical care but on a taxi voucher and a broken carburetor.

This month the Robert Wood Johnson Foundation, in partnership with Harris Interactive, released a poll indicating that the majority of physicians are not only conscious of the relationship between the social risk factors of their patients and poor health outcomes, but they perceive these factors to be as important as their patients’ medical conditions. In regard to that latter point—the recognition that social needs are as important as medical conditions—I was, admittedly, a bit surprised. And when I told a colleague of mine, her response was, “Are you kidding me?”

Our experience has been that, in many ways, the medical field rejects or downplays the notion that social factors are as important to consider as biological factors. It’s not the way we, as doctors, are trained. Two years ago, I completed an article comparing the importance of social and biological risk factors in predicting poor health and educational outcomes for children, but was forced to publish in an epidemiology journal. Several medical journals rejected it, their reason: not “clinically relevant.”

Perhaps the tide is turning. But what can be done to compel more health care providers to recognize this relationship? And what must be done to ensure they have the support to address these important social needs effectively?

  • We need stronger evidence. We need more science that makes the link between social factors and health, at the patient-doctor level, and what can best be done about it. Common sense may say there is a tie between the social needs of our patients and their health, but the medical field will not address the issue unless it is more than just a hunch, and until we have evidence for how to “treat” it. We also need cost-benefit data. Advocates for preschool have succeeded in increasing access across this country because they had data demonstrating that the benefits to society outweigh the costs. We need to ensure we can do the same.
  • We need to reevaluate the fee-for-service model. Doctors should be reimbursed for all interventions they make to better the health of their patients—not just the procedural ones. If the critical health issue requires a call to the school, or a letter to the landlord, or efforts to find a social service agency and arrange a referral, the doctor should be reimbursed for those efforts just as they are for a skin biopsy or blood pressure re-check. Currently the only way to get this work done is to spend our own—uncompensated—time, working longer days. As primary care physicians, we are already among the lowest paid doctors in this country. Is there any question as to why most medical students are not choosing to pursue primary care?
  • Doctors need to spend more time in the community. I have a vision that primary care doctors would have a compensated half-day per week—or perhaps every other week—to spend in the community, testifying at city council meetings, visiting neighborhood associations and consulting with schools and other community organizations. To free up more time for physicians, we should consider restructuring primary care clinics to increase the role of other health care providers like nurse practitioners and physician assistants. Doing so would allow doctors to focus both on the most complicated patients and on building an enhanced role in the community.
  • We need to evolve the medical training of young doctors. Unfortunately, most doctors, if given a half a day to spend in the community, would not know where to begin. Medical student training is focused on pathophysiology and in-patient care. During residency, we are educated primarily in a hospital setting—not in clinics—and we don’t receive explicit training on a physician’s role in dealing with the social needs of our patients. Some progress has been made in this area, for example pediatric residency programs now require an advocacy rotation of all their trainees involving work with community groups or expert testimony before state legislatures, but more efforts like this are needed.
  • We, as health care providers, need to make a commitment. Ultimately, nothing is going to change until doctors demand changes to the system of which they are a part. I am confident that most doctors became doctors for the right reason: to keep our patients healthy and to help those who are not healthy to get well. As shown by the RWJF/Harris interactive poll, we physicians increasingly recognize that having a warm place to live, food to eat and an income to support their families are integral to achieving those goals. However, that is only a first step. Next we must advocate for the services, policies, education and reimbursement structures that will better allow us to treat these critical, social determinants of health.

>>Weigh In: What do you believe needs to change to better enable us to address the social factors that put our patients' health at risk?

>>Readers Respond: We rounded up some of the best comments on this piece from Dr. Jutte. Hear what other readers had to say.

Tags: Social determinants of health, Health care delivery system, Healthy communities, Access to Health Care, Community Health, Health disparities, Idea Gallery, Prevention, Transportation