San Francisco Chronicle
I had known and adored Jeremy's family for several years. So when the sandy-haired, good-natured 8-year-old came to see me in my clinic with abdominal pain, I bent over backward to find out why his tummy hurt. I poked and prodded; did tests of his urine, stool and blood; and took X-rays, over the course of several months. When those tests came back normal, I did more. I had trained at a top medical school and gone on to one of the best residencies in my specialty; in Jeremy, I thought I had identified a real clinical mystery. But in the end, the mystery was not a best-seller It turned out that Jeremy's family couldn't afford to buy food.
It had never even occurred to me to ask his mother about how much food there was in the house.
In Jeremy's case, I had diagnosed "abdominal pain" when the real problem was hunger; I confused social issues with medical problems in other patients, too. I mislabeled the hopelessness of long-term unemployment as depression and the poverty that causes patients to miss pills or appointments as noncompliance. In one older patient, I mistook the inability to read for dementia. My medical training had not prepared me for this ambush of social circumstance.
Real-life obstacles had an enormous impact on my patient's lives, but because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether. And so, despite being a physician, I was surprised when, in June, Secretary of Health and Human Services Kathleen Sebelius announced that $250 million originally designated for dealing with the social issues that cause problems like Jeremy's would instead be used to train more primary-care doctors.
Given dramatic and worsening shortages in the primary-care medical workforce, these efforts to increase access are laudable. But if we think that increasing access to doctors will solve America's health care problems, we will have not only missed the rescue boat but also put holes in the raft we jumped on.
Because the Obama administration is not likely to find more money in the midst of the recession, we need to train these new doctors to deal with the problems we seen in the clinic. There are several important reasons that this new workforce - and the old one - should increase its skills to tackle the social factors that affect health.
First, we will not be able to pay for medical care unless we address the avoidable causes of disease. Unavoidable disease is costly enough. I spent a lot of our health care dollars looking for reasons for Jeremy's pain. If I had known more about the resources available to Jeremy's family, I might have recognized sooner that his real problem was hunger; it would have been a lot cheaper to connect his family with a food bank than to do a battery of medical tests.
Second, the social causes of disease directly affect clinical care and clinical decision-making in ways unrelated to money. Over the past 10 years, multiple studies have shown that health care providers bring the same social biases into clinics that create disease outside of them. In one study, patients' race, income and education changed the way physicians diagnosed and treated their illnesses. Health care providers unaware of and not ready to challenge the social factors that affect disease are not health providers that you want to see.
Third, problems of medical care quality and access account for only about 10 percent of avoidable deaths in the United States. In other words, health is much bigger than medical care. But most people only think about their health when they go to the doctor, and the doctor rarely talks about the other 90 percent of things patients can do to stay healthy - like how to finish school, or where to find a job. By not training our health care providers and their staff about the other 90 percent, the opportunity is lost to talk with the majority of people about how to avoid dying earlier than they should.
There's a strong argument that these millions directed toward the health care workforce would be better spent on community programs that directly address the avoidable social factors that either make people sick or sicker than they could be. But the fund redesignation might be difficult to reverse. To turn those dollars going to health care access into lemonade, at the very least our new workforce should be able to recognize, treat and help change - whether through collaboration or direct advocacy - the social factors that make Jeremy hungry, and any of us sick.
It is time to ask all health care professionals to put aside the debate about whether social problems fall within their domain and just ask them to think about what's good for the nation's health.
