Thought provoking op-ed and why community service to the vulnerable matters

[LizzyM]

This piece in the NYTimes is my gift to you. It gives a glimpse of the non-clinical issues that face physicians in 2024 and why, reflecting back on the advice I've given here over the years, non-clinical volunteering with the poor in America is very relevant to the practice of medicine.

Opinion | Many Patients Don’t Survive End-Stage Poverty

If health care is interpreted in the truest sense of caring for people’s health, it must extend well beyond the boundaries of hospitals and clinics.

www.nytimes.com

I'd love to hear others thoughts on this piece.

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[Mr.Smile12]

This piece in the NYTimes is my gift to you. It gives a glimpse of the non-clinical issues that face physicians in 2024 and why, reflecting back on the advice I've given here over the years, non-clinical volunteering with the poor in America is very relevant to the practice of medicine.

Opinion | Many Patients Don’t Survive End-Stage Poverty

If health care is interpreted in the truest sense of caring for people’s health, it must extend well beyond the boundaries of hospitals and clinics.

www.nytimes.com

I'd love to hear others thoughts on this piece.

Read the comments (which are moderated by NYT staff) too.

From our archive (from the AAMC staff):

How To Demonstrate Service Orientation - SDN

The Student Doctor Network provides free tools, resources, and advising services to help students become health professionals.

www.studentdoctor.net

 

[Hollow Knight]

Thanks for the article LizzyM!

You can't provide good medical care if you don't think about social determinants. Also, the way that our healthcare system currently runs, all of us (and any of you premeds reading this) will have pressures on you from corporations to cut corners in patient care for the sake of dollars. Sometimes, you're going to have to be late for dinner or something to make sure a patient gets the care they need.

I don't know how else to evaluate this quality in premeds other than seeing if they've been serving their community already. But, in my opinion, it's not good enough for physicians to just say "Here's your pills, I don't care if you can afford it, bye." We have to take more responsibility than that.

 

[Moko]

But, in my opinion, it's not good enough for physicians to just say "Here's your pills, I don't care if you can afford it, bye." We have to take more responsibility than that.

I agree with this in theory if we had unlimited resources. But in practice, there are many times we discharge patients on non-optimal medication regimens because of cost considerations.

For things like heart failure and non-valvular AFib, there are usually lower cost work-arounds (e.g. we can use an ACEi or ARB medication instead of Jardiance or Entresto, and warfarin instead of an anticoagulant like Eliquis or Xarelto), but even then, these cheaper alternatives are no longer first line for those with means.

However, for asthma and COPD, maintenance inhalers are uniformly prohibitively expensive for the uninsured and under-insured. And even when they come into the hospital for a COPD exacerbation, there are very limited financial resources that social work has to pay out of pocket for patients (especially if/when they need multiple expensive medications, which is often the case). In these cases, there simply is no good affordable alternative, and we often do need to discharge patients without optimal care.

So what should physicians/hospitals do in these cases with our current broken healthcare system? Sure, we can advocate for change, but that's not going to help people in the near-future (or potentially ever given the way our political system is run). We can get patients plugged in with any insurances that they do qualify for and see if there are coupons available, but even then, many medications remains prohibitively expensive. Patients can take the inpatient inhaler home with them since that will otherwise be thrown away, but of course, that's only a two week supply. I've paid out of pocket for some of my patients if they genuinely cannot afford it and the copay is not high (i.e., not inhalers), but this obviously is not a sustainable solution. And neither is expecting hospitals to shoulder the burden. Some food for thought.

 

[LizzyM]

What struck me was the smartest med student on service was searching online to find a man's estranged daughter who might take in her formerly homeless father who was well enough to be discharged but too sick to live on the streets.

There aren't enough social workers and the social safety net is over-stretched and not holding.

 

[Mr.Smile12]

What struck me was the smartest med student on service was searching online to find a man's estranged daughter who might take in her formerly homeless father who was well enough to be discharged but too sick to live on the streets.

There aren't enough social workers and the social safety net is over-stretched and not holding.

What's just as striking is that there are tons of people who want to be doctors but very few who want to do social work.

 

[LizzyM]

What's just as striking is that there are tons of people who want to be doctors but very few who want to do social work.

No prestige and no money. No brainer.

 

[Goro]

What's just as striking is that there are tons of people who want to be doctors but very few who want to do social work.

And yet they all want to "help people".

 

[Mr.Smile12]

Opinion piece

Health Systems and Social Services—A Bridge Too Far?

This JAMA Forum argues that hospitals and health systems should not take the lead in programs to address social determinants of health and provides examples and reasons why.

jamanetwork.com

 

[Nontrad_FL_LGBT]

And yet they all want to "help people".

Honestly, it's okay to not want to be in financial hardship. My aunt is a social worker and makes $35-40k after like 15 years with her group. I'm not a money driven person, but I'd never be happy to get a MS for money like that. God bless anyone that is okay with literally living in poverty alongside their patients, they're basically saints.

 

[saxyotter]

Opinion piece

Health Systems and Social Services—A Bridge Too Far?

This JAMA Forum argues that hospitals and health systems should not take the lead in programs to address social determinants of health and provides examples and reasons why.

jamanetwork.com

One of the assumptions the author made is that independent-local social service providers exist in the areas they are needed. I don’t think that that is a strong argument. If you look at quality of life measures across places like rural Appalachia for instance, this is clearly not the case. I am also thinking of my own city of 150,000 which has maybe one homeless shelter, a few group homes/small rehab facilities, and a handful of rent controlled living facilities mostly aimed at helping elderly folks on Medicare/medicaid.

 

[awood]

This piece in the NYTimes is my gift to you. It gives a glimpse of the non-clinical issues that face physicians in 2024 and why, reflecting back on the advice I've given here over the years, non-clinical volunteering with the poor in America is very relevant to the practice of medicine.

Opinion | Many Patients Don’t Survive End-Stage Poverty

If health care is interpreted in the truest sense of caring for people’s health, it must extend well beyond the boundaries of hospitals and clinics.

www.nytimes.com

I'd love to hear others thoughts on this piece.

There was also another interesting NYT article discussing a study about the impacts that forgiving medical debt has on people that was super interesting:
Paying Off People’s Medical Debt Has Little Impact on Their Lives, Study Finds

 

[CitrusPeel]

The phrase "moral dissonance" in this article caught my attention. It's something I've felt a ton while working in hospitals -- just one example, being assigned to 1:1 a patient who was an "elopement risk," physically well enough to be discharged, but mentally not well enough to live alone. There was no reason for him to be trapped in that horrible beige room, except that no one could find him a suitable discharge placement. Telling a grown man he couldn't leave his room for months on end... I would have gone mad, too. It was an insult to his dignity and it felt sickening to enforce.

But then, the culture of medicine seems to to discourage political activism. I had multiple doctors tell me to take the years I've put into leftist organizing (SNHP, DSA, etc) off my application; one interviewer told me it was unsuitable and inappropriate for doctors to be involved with "radical" causes (aka a peaceful campaign for statewide universal healthcare).

Everyone agrees the system is unsustainable, but when you go beyond "advocating for patients" to what seems like the logical next step to me -- organizing for meaningful systemic change -- it gets very lonely. Maybe those with power in admissions, teaching, and training should be rewarding political work rather than shutting it down as somehow extraneous to medicine.

 

[LizzyM]

The phrase "moral dissonance" in this article caught my attention. It's something I've felt a ton while working in hospitals -- just one example, being assigned to 1:1 a patient who was an "elopement risk," physically well enough to be discharged, but mentally not well enough to live alone. There was no reason for him to be trapped in that horrible beige room, except that no one could find him a suitable discharge placement. Telling a grown man he couldn't leave his room for months on end... I would have gone mad, too. It was an insult to his dignity and it felt sickening to enforce.

But then, the culture of medicine seems to to discourage political activism. I had multiple doctors tell me to take the years I've put into leftist organizing (SNHP, DSA, etc) off my application; one interviewer told me it was unsuitable and inappropriate for doctors to be involved with "radical" causes (aka a peaceful campaign for statewide universal healthcare).

Everyone agrees the system is unsustainable, but when you go beyond "advocating for patients" to what seems like the logical next step to me -- organizing for meaningful systemic change -- it gets very lonely. Maybe those with power in admissions, teaching, and training should be rewarding political work rather than shutting it down as somehow extraneous to medicine.

Not everyone can be Quentin Young, but maybe you can walk in his footsteps.

Dr. Quentin D. Young, Public Health and Civil Rights Advocate, Dies at 92 (Published 2016)

The doctor was a personal physician to the Rev. Dr. Martin Luther King Jr. and Barack Obama, and fought for universal health care.

www.nytimes.com

 

[Mr.Smile12]

Maybe those with power in admissions, teaching, and training should be rewarding political work rather than shutting it down as somehow extraneous to medicine.

I agree, and George Floyd's death and COVID gave an opening to ask for advocacy activities on applications. Many student organizations have appeared to bolster advocacy and leadership beyond just legislature advocacy days. But the same professional hierarchy also rules in academe and residency. It's going to take a long time.

 

[jhmmd]

Back on topic. Why are we blaming social workers for "end-stage poverty," if there is such a thing?

 

[jhmmd]

There's a lot of things at work when someone becomes poor enough become hospitalized or go to jail rather than become homeless.
1) The family who is afraid to help due to extraneous circumstances
2) The negligent caregiver(s)
3) Society
And yet we rush to blame #3, because it's the easiest. Social workers are a red herring. If someone is at the point where they need a social worker to plan out their life for them, then what's the problem?

 

[Nontrad_FL_LGBT]

Honestly, a lot of the people who fall into these situations don't have families that are equipped to help them either. They live hand to mouth and another mouth that can't help provide would make it impossible. Even if they do make enough money to help, a lot of people are incredibly uneducated about mental illness or scared/resistant to help people with it. Shadowing a doctor in BFE WV a while ago, no sh1t, a parent was talking about their "******ed" child (who had autism and was just a little delayed from what I could tell) with a straight face like they were discussing the weather.

Living in rural SW PA/WV area really changes your perspective.

 

[karaya]

Back on topic. Why are we blaming social workers for "end-stage poverty," if there is such a thing?

I don't see evidence of anyone blaming social workers. The consensus seems to be that social work is underpaid, under-resourced, and ill-equipped to combat systemic social determinants of health.

 

[LizzyM]

No one is blaming social workers for "end stage poverty". They are a necessary part of the care team and in short supply.

Anyone can get to the point of needing a clinical social worker. They are experts in 1) local facilities providing rehabilitation and custodial care for the disabled and elderly, 2) locally available home care services, and 3) the rules around reimbursement for that care. Families with children with disabilities, newly disabled persons with issues around mobility or sensory losses, and frail older adults who are in cognitive decline can all benefit from clinical social work regardless of their income. There is a lot of red tape and if you haven't anyone (like a spouse, adult offspring, or sibling) to help sort it out, and if you haven't many financial resources yourself, you are in serious need of a clinical social worker.

 

[jhmmd]

I don't see evidence of anyone blaming social workers. The consensus seems to be that social work is underpaid, under-resourced, and ill-equipped to combat systemic social determinants of health.

This is a bit negative. Are you speaking as a social worker? I was just trying to re-direct the thread.

 

[Alejandro]

Again, there are many ways to help others. Being a physician is one way, but certainly not the only way.

I feel like I am a social worker every day I am at work. I feel like I am a therapist even when I have never had any training to do it.

Funny, I had a patient who likely needed a gallbladder out who wanted to leave. Why? Because he said he is currently moving, has a few commitments he absolutely cannot miss out on, and him skipping work was going to jeopardize his job. People who don't have to worry about the basic stuff so much would absolutely prioritize admission and care over the rest, but for many others including this guy...healthcare will simply have to wait.

I love asking this type of question in interviews because I love seeing how students miss the nuance of the question. They often just think about 'does he have decision-making capacity'...lolololololol. If it only were that simple....

 

[Nontrad_FL_LGBT]

Again, there are many ways to help others. Being a physician is one way, but certainly not the only way.

I feel like I am a social worker every day I am at work. I feel like I am a therapist even when I have never had any training to do it.

Funny, I had a patient who likely needed a gallbladder out who wanted to leave. Why? Because he said he is currently moving, has a few commitments he absolutely cannot miss out on, and him skipping work was going to jeopardize his job. People who don't have to worry about the basic stuff so much would absolutely prioritize admission and care over the rest, but for many others including this guy...healthcare will simply have to wait.

I love asking this type of question in interviews because I love seeing how students miss the nuance of the question. They often just think about 'does he have decision-making capacity'...lolololololol. If it only were that simple....

Unfortunately, society is at a point where most professionals are now taking unpaid additional work being counselors because our students/patients/clients just live in hell. I've been teaching underprivileged young adults and older career changers in a vocational class for years and it's insane how much emotional labor is involved.

 

[saxyotter]

If the need for good physicians is eminent, then the need for excellent social workers and therapists is a mandatory corequisite.