CHICAGO—To drive home the importance of how social determinants can make or break a person’s health, Jillian Rose, LCSW, MPH, the director of community, engagement, diversity and research at the Hospital for Special Surgery in New York City, told a story about a gardener planting flowers at the 2018 ACR/ARHP Annual Meeting.
Explore this issueJanuary 2019
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In the story, “The Gardener’s Tale,” by Camara Phyllis Jones, MD, MPH, PhD, the gardener has just moved into a new home and uses the flower pots that still have soil in them, rocky and ill-nourished, for pink flowers. At the same time, she plants red flowers in pots with new soil. The red flowers flourish, and the gardener tells herself: “I was right to prefer red over pink.”
In the healthcare world, Ms. Rose said, the old soil equates to crucial, but often overlooked, factors that can steer a person to health or illness: food, lack of transportation, poverty. Too often, she said, healthcare providers breeze past these factors in their interactions with patients, usually without even realizing their own biases.
“We’re often the gardeners in our patients’ lives,” Ms. Rose said, “unconscious of how the care we’re providing is laden with unconscious biases, shaped by our experiences, and how they can influence outcomes by triggering our patients’ thoughts, feelings and perceptions, which causes them to [either] build trusting relationships with us and grow and get well, or to just wither away.”
What to Look For
Social and economic factors account for 40% of health determinants, according to a 2017 publication by the Center for Health Care Strategies, a figure also cited by the Los Angeles County Public Health Department.1 Biases can be rooted in race, age or gender, Ms. Rose said, and they have real consequences.
“Not assessing social history or challenges can lead to inappropriate care, such as a patient not being able to afford the medication we prescribe,” she said. “That treatment has fallen apart as soon as that patient has left the room.”
Providers must look for “clinical red flags,” she said, such as child or elderly abuse or human trafficking, using a selective inquiry based on clinical considerations. Don’t think of it as an extra layer of the clinical visit, but just a normal part of the clinical evaluation, intended simply to treat appropriately.
Tools for helping understand the patient’s context for health include PRAPARE, the Protocol for Responding to and Assessing Patient Assets, Risks and Experiences, and the Center for Medicare and Medicaid Innovation’s Health-Related Social Needs Screening Tool.
Talk to Your Patients
Ms. Rose said one clinician recently did not want to prescribe infusions to a patient who routinely missed appointments, worrying the patient wouldn’t be able to maintain the rigorous infusion schedule. But Ms. Rose suggested the doctor take the time to talk to the patient.
The clinician told the patient she thought an infusion might work best, but added, “I know you have had trouble getting to your appointments in the past. What do you think about this?” The patient said she didn’t want steroids any longer. “I am concerned about you getting here on time each week for the next six weeks,” the clinician continued.
The patient said, “Well, this is important to me. Since it’s only six weeks, I can arrange with my daughter and her husband to pick up my grandchild, so I won’t have to pick her up and be late.”
“That sounds like a plan,” the clinician said.
“It took a little bit of time,” Ms. Rose said, “to assess and to share and to come to a decision together where the clinician assessed what was valuable to the patient.”
Adena Batterman, MSW, LCSW, senior manager of inflammatory arthritis support and education programs at the Hospital for Special Surgery, said rheumatic disease has a profound impact on patients physically and emotionally. Patient-centered, empathic care, therefore, must to pay attention to both.
“Each patient who walks into our office has their own unique story and background, so we must broaden the focus of our inquiry and discussion like the lens of a camera,” Ms. Batterman said. “It requires adjusting and widening the field of vision.”
Healthcare providers must be attuned to subtle clues embedded in speech, the stories patients tell, non-verbal communication and health behaviors, she said. These clues can reveal vital information about unresolved feelings about the illness and treatment, unspoken fears about their condition, or depression and anxiety, she said. Understanding and acknowledging the patient’s full experience is essential to developing trust in patient-provider relationships, and positively impacts treatment discussions.
Picking up on patient clues requires “active, empathic listening and observation,” and being in-the-moment during the patient encounter, she said. Sometimes, this can be as simple as pausing after describing an aspect of treatment, rather than rushing on to the next point. Research has found this tactic effective.2
“When physicians acknowledged the emotions of the families and allowed a pause, rather than quickly continuing the discussion about treatment, families were significantly more likely to share concerns, hopes and values,” she said.
Mental health issues, such as depression, are more prevalent in inflammatory arthritis patients and can affect not only relationships and quality of life, but also limit treatment efficacy and adherence and contribute to long-term disability, pain and mortality, Ms. Batterman said. She underscored the need to engage a multi-disciplinary team, and to assess and treat, and provide support and education around these issues.
Providers must take care of themselves, too, by maintaining activities outside of work, talking to friends, colleagues and family, getting enough sleep and exercise, and creating space for colleagues to share support in processing sometimes difficult and challenging feelings related to caring for chronically ill patients.
All of this helps clinicians connect with, and be present with, their patients, she said.
“Examining our own experiences and backgrounds, and how these influence our perspective, is an integral part of empathic care,” Ms. Batterman said, “and benefits both patient and provider.”
Thomas R. Collins is a freelance writer living in South Florida.
- Los Angeles County Public Health Dept. (2013 Jan) Social determinants of health: How social and economic factors affect health.
- October TW, Dizon ZB, Arnold RM, et al. Characteristics of physician empathic statements during pediatric intensive care conferences with family members: A qualitative study. JAMA Netw Open. 2018;1(3):e180351.