Today the nursing staff held a birthday party for a patient. The party was not to celebrate with her, but to cheer on her departure from the service. She had moved into a new age bracket, and as a result, would receive care on the far side of campus. Her details are important insofar as she was a difficult case, a hassle overnight, and poor. The more details emerged, the clearer it became – these people had loved her for the past two decades. So perhaps it was not as much a celebration, but a remembrance. Over rich cake and cold pizza, I asked about her family, what made her tick, and why she kept coming back to the hospital. True, she had some congestive heart failure and often needed transfusions. But not one of the staff reported ever seeing her mother in 22 years on the floor. I immediately caught a glimpse of the elephant looming in the room – the poverty that surrounded her illness. We talk about our patients’ poverty all the time. In academic journal clubs, we call it socio-economic determinants of health; on the wards late at night we call it a shame, and during daytime hours we call social workers to organize outpatient services.
In medical school I had a singular assignment that asked me to think beyond what we can provide for patients as acute inhabitants of the hospital. The essay prompt began “If you had unlimited resources for your patient, what would you do?” I wrote about a 35 year-old patient with schizoaffective disorder, a bright kid, stuck, and now estranged from his family. After researching literature on the proper balance of psychotropic medications, I concluded we should help him buy a dog. A number of pilot studies showed benefits of pets to patients with schizophrenia, and he seemed to fit the bill. I wrote passionately about this. Then I realized: the healthcare system will adapt to spend hundreds of thousands of dollars on dozens of inpatient hospital admission. The system will never buy him a dog.
We in medicine would do well to be more open to the following: that the medical model may not capture how to make our patients healthier over time. An obligation stemming from this is to use our industriousness and meticulous attention to detail to uncover how in fact to do this. Our meticulousness has reached beyond the point of diminishing returns, and our cognitive capital could be better cashed in elsewhere. To be specific, instead of trolling the charts and reading endlessly about a mom with Munchausen by proxy, we may do well to spend a few hours with her, and set up a team of people to devote time to getting her help.
Here is one place to start. Along with a social history, plot out a social future. In a disease-based model, every illness has a characteristic onset, time-course and resolution. Our medical system is highly adept at diagnosing and documenting this with great attention to detail. When it comes to taking a social history, we often view this as an appendage. But what if we plotted out the potential social futures of our patients? How might this change how we view them, what is at stake in their care? On an epidemiological level, we know that an Asian female has a life expectancy of 21 years more than an urban black male. If we believed that a new stomach virus was causing men to lose 21 years of their lives, one can imagine an outpouring of scientific research, spurred on by the medical community. We know that the boy with ADHD and autism, growing up in Boston has a poor chance of attending and graduating a four-year college. The solutions to these inequalities do not exist in our electronic medical system. We cannot write orders to alleviate poverty and inequality.
As we practice hospital medicine, we bear witness to the downstream effects of such inequality, while doing the best we can to treat it now, with the best technology. But rare are the forums to discuss our role as medical practitioners in combating the poverty that causes and exacerbates our patients’ health. We eat cake and jokingly rejoice in one fewer difficult patient. But underneath this, there is a pride in caring for a girl through the most challenging part of her life, and underneath this, the lingering questions, “where was her mom?” and “why did she keep coming back?” We need rituals to bring people together to discuss the elephant of poverty; how it affects us, our work, and our patients. On an individual level, imaging social futures may yield a fruitful place to start, and follow with the question “If you had unlimited resources for your patient, what would you do?”