Category: Social Determinants of Health

We Deserve a Better Healthcare System, We Deserve Medicare For All

Recently, I was taking care of a gentleman in his sixties with high blood pressure and diabetes. My goal, I explained to him, was to prevent a heart attack or stroke which are too frequently the  consequence of these diseases. I will closely monitor his kidney function and blood sugar levels so that I can recommend the safest and most effective medications for him so that he can live as long and symptom-free as possible. This medical care is based on the latest medical evidence and guidelines, and I am proud to provide it. 

If I am to truly be a steward of his health, however, it is not enough to focus on his medical care. I must also carefully consider the greater social context of his life. Reducing consumption of refined carbohydrates and sugar is crucial to blood sugar management in patients with diabetes. Are fresh fruits and vegetables still affordable to him or is he mostly eating cheap processed foods to stretch his grocery budget? For this patient, insulin was necessary to prevent painful neuropathy in his hands and feet. How much are the copayments on his insulin? Is he taking the full recommended dose, or is he cutting back because of expense? 

Understanding these social determinants of health is a core competency of high-quality medical care in the twenty-first century. Given that the majority of premature death is attributable to factors other than medical care, I would be remiss as a primary care provider if I didn’t engage with the social and environmental factors that bring illness into my patients’ lives.

One harmful social condition that I must engage with every day is the commercial health insurance system which mediates access to medical services. In this system, insurance companies collect enormous amounts of money through premiums in exchange for limited access to doctors and medications only after you additionally pay co-pays and meet your deductible. 

The expense of co-pays and deductibles all too often push those with chronic illnesses into poverty. Nearly half of the people diagnosed with cancer end up with negative net worth in the subsequent two years. Every year in America 530,000 people file for bankruptcy in part due to medical debt. Many find themselves being sued by hospitals when they struggle to keep up with their bills. 

I see this damage done by our current commercial insurance system every single day. I see how poverty leads to disease which requires medical treatment which then exacerbates poverty and the cycle begins anew. It’s enough to drive you to despondency. 

But let me tell you, I’m not despondent at all. In fact, I’m quite hopeful.

I’m hopeful because there is a presidential candidate who is working to break this cycle of illness and poverty. There is a candidate who believes that health care is a human right. There is a candidate who believes that no one should be impoverished by illness or made ill by the deprivations of poverty. There is a candidate who is fighting for my patients, for me, and for you.

That candidate is Bernie Sanders and his plan for Medicare For All will put an end to the financial destructiveness of our current health care system. By providing a universal, comprehensive health care benefit that is free at point of service for all Americans, we can finally have the health care system we deserve in this country.

As a primary care doctor, I can think of no better advocate for health and well being of my patients than Bernie Sanders and I am proud to join Doctors For Bernie in endorsing him for the democratic nomination.

Care Of Vulnerable Adults: Balancing Independence and Safety

Last night, I watched ProPublica and Frontline’s excellent documentary, Right to Fail, about New York’s struggle to find the balance between independence and safety in the care of people with disabling mental illness.

Finding this balance between independence and safety is something that I struggle with in primary care frequently. Most of the time, you can find a balance by bringing family members into the conversation and focusing on harm reduction and quality of life. But sometimes it’s not enough.

I took care of a gentleman in the emergency department the other day whose blood oxygen was dangerously low because of a condition called aspiration pneumonitis that he got because he was choking on the food that he was eating. He had neck surgery a couple months prior and the muscles that coordinated his swallowing reflex had not fully recovered. I advised him to come into the hospital until his lungs recovered enough that he wouldn’t need supplementary oxygen or we could arrange to have an oxygen tank delivered to his home. I told him I was worried that with prolonged low oxygen levels, his brain, heart, and kidneys may start to be damaged or fail. He declined admission, but couldn’t really repeat back to me an understanding of the risk he was taking by leaving against medical advice. I offered to call a family member on his behalf, but he didn’t want to worry them. I was stuck…

As someone with a strong professional and emotional drive to protect people from physical harm, it hurts me to see people suffering because of a limited capacity to take care of themselves. I often feel the impulse to say, “well let’s just have someone else take care of you.” I’m not alone in that. I think most people, when they seem someone on the street who is clearly unwell and in distress, feel suffering on that person’t behalf.

Many people with disabilities are glad to have assistance when that assistance is provided with compassion not condescension and supports of positive sense of self. I strongly believes that we need much better programs to support people with disabilities to maximize their capacity to live independently. But for those who who expose themselves to significant harm by rejecting assistance while having a questionable capacity to understand the risks and benefits of that decision, it gets difficult.

Institutionalizing someone against their will can be traumatic and harmful and must be a last resort. That being said, I do think it is sometimes the right thing to do, and it needs to be an option on the table.

In summary, 1) watch Right To Fail, 2) support programs that help people with disabilities live independently with dignity, and 3) consider that there are (rare) situations where loss of agency can be a net benefit to an individual with severe mental illness.

Anti-Racism Reading Group #4: White Fragility

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health care practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here, part two here, and part three here.

For the third reading of the anti-racism reading group we focused on White Fragility. Our reading was the article White Fragility from the International Journal of Critical Pedagogy which you can download here. Supplementary materials were Dr. DiAngelo’s White Fragility and Rules of Engagement and this comedic White Fragility Workplace Training Video.

What is White Fragility? In Dr. DiAngelo’s words:

White Fragility is a state in which even a minimum amount of racial stress be- comes intolerable, triggering a range of defensive moves. These moves include the outward display of emotions such as anger, fear, and guilt, and behaviors such as argumentation, silence, and leaving the stress-inducing situation. These behaviors, in turn, function to reinstate white racial equilibrium.

Continue reading “Anti-Racism Reading Group #4: White Fragility”

Securing Housing For All

As a family doctor in Seattle, I take care of numerous patients experiencing homelessness. The toll this takes on their bodies is impossible to ignore. Sleep deprivation, chronic stress, physical and sexual assault, temperature extremes, and malnutrition all weather the body rapidly. As a physician sworn to preserve and prolong life, it is profoundly disturbing to come up against such profane and preventable degradation on a daily basis.

For this reason, I joined the Housing For All Coalition last night as they put forth a call to action to a packed hall at the Seattle Labor Temple. Speakers from the Transit Rider’s Union, Socialist Alternative Seattle, Nickelsville, SHARE/WHEEL, and DESC each spoke to the urgency of ending Seattle’s housing crisis. While each speaker brought a unique perspective, including the perspective of the formerly and currently homeless, they all emphasized the importance of increasing access to both affordable permanent housing and safe temporary shelter.  Continue reading “Securing Housing For All”

Anti-Racism Reading Group #3: Perinatal Mortality

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health care practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here and part two here.

For the third meeting of the anti-racism reading group, we focused on increased rates of perinatal death (i.e. death around the time of birth) for black women with this excellent piece of reporting by NPR and Propublica. NPR’s Code Switch team produced an excellent podcast on this same story which you can listen to here or read the write-up here.

This is an especially timely reading given Erica Garner’s recent death at age 27 from a heart attack just three months after giving birth. Erica was the daughter of Eric Garner who was murdered by the New York City Police. Since his death, she had risen up to be a prominent and effective activist against police violence.   Continue reading “Anti-Racism Reading Group #3: Perinatal Mortality”

Innovations in Primary Care: Moving Beyond Fee-For-Service

The American medical system has long operated under a fee-for-service model in which only specific, narrowly-defined medical services qualify for reimbursement from insurance companies. This system is reasonably well-suited for procedure-oriented specialties in which services with clear indications, processes, and outcomes such as colonoscopy or knee replacement can be appropriately paid for.

In America’s fee-for-service system, reimbursement for primary care services is limited to short office visits and certain outpatient procedures (such as a joint injection). Many primary care doctors have felt that they could offer better care for their patients if the payment structure allowed for more flexibility in services offered, but opportunities to test this hypothesis have been limited.

Today, three groups in the Seattle area – Landmark, Concerto, and Iora – are independently demonstrating the value of flexibility in primary care to improve patient outcomes at overall lower cost. They’ve accomplished this by arranging for alternative payment models with local Medicare Advantage plans (private insurance plans who contract with Medicare to provide health insurance to seniors). Rather than operating under fee-for-service, these companies get a per-member, per-month payment. This payment structure provides a flexible budget with which they can offer services that don’t necessarily fit into the established fee-for-service structure.   Continue reading “Innovations in Primary Care: Moving Beyond Fee-For-Service”

Anti-Racism Reading Group #2: Theft of Black Wealth

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here. 

For the second meeting of the anti-racism reading group, we read part one of Ta-Nehisi Coates’ The Case For Reparations. In our first meeting, we discussed big-picture theory of race, so we followed that up by focusing in on particular racial project called redlining which had been a major contributor to both racial housing segregation and wealth inequality in America today. Continue reading “Anti-Racism Reading Group #2: Theft of Black Wealth”

Anti-Racism Reading Group #1: Racial Projects

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. 

For the first meeting of the anti-racism reading group, we read a selection from Racial Formation In The United States by Michael Omi and Howard Winant. You can download a PDF of this selection here.

In this section, the authors describe race as existing in the interaction between 1) social structures which organize society by race and 2) the cultural representations and experiences of race. Racial projects is the term given to the mediators of this interaction. Continue reading “Anti-Racism Reading Group #1: Racial Projects”

Innovations In Primary Care #1: Introduction

As part of my family medicine residency training, I’m taking a month-long elective called Innovations in Primary Care. This month is an opportunity for primary care doctors from family medicine and internal medicine residency programs in Seattle to explore some of the different primary care models being trialed in the Seattle area and to use those experiences to fuel discussion about how primary care (and really, all medical care) can be improved in the United States.

Today was our first meeting, during which we gathered to collectively write an H&P for our current medical system. For those reading this who are not in medicine, the History and Physical or H&P is a semi-standardized note-writing structure that doctors use to describe the subjective and objective information about a patient’s health, assess why  the patient is experiencing illness, and describe the next steps we need to take (diagnostic tests and/or treatments) going forward. It’s a structured way of thinking about a patient that helps us be rigorous and methodical.

It was a gratifying process because each of the doctors at the table shared a passion for making our health care system better, but brought a different set of experiences and priorities to the conversation.

Some of the take-aways I had from this conversation are as follows (in no particular order):

  1. The insurance framework for paying for health care, while originally conceived to improve access to surgical services which would otherwise be prohibitively expensive to most people, was quickly recognized by doctors as a way to extract larger fees for patient care. After all, when a third party (the insurance company) pays the bills, people tolerate much higher fees even if the end result is steady rise in out-of-pocket costs for everyone. Doctors, hospitals, and pharmaceutical companies have abused this system so greedily under the previous usual-and-customary payment system that increasingly rigid cost-containment measures have had to be implemented to control costs. We now live in a society where the average doctor makes $294,000 per year–more than 98.9% of Americans–while medical bills bankrupt patients and health insurance cost suppresses wage growth. Recognizing and holding ourselves accountable to how capitalism in medicine has brought out the worst in us is necessary before we can even begin to conceptualize a new system.
  2. The costs of most important and effective interventions to improve health, including primary care, are recurring and predictable costs that are best paid for through public health funding, NOT through health insurance. Access to clean water, nutritious food, safe housing, and preventive medical care is necessary for All People at All Times.
  3. America fails to invest in public welfare programs because of racism. The idea of the racialized-and-thus-undeserving Other benefiting from public welfare programs (e.g. the racist specter of the Welfare Queen that Reagan so infamously promoted) is fundamentally intolerable to White America. We are comfortable with 1 in 7 people in the United States facing food insecurity if it means we can prevent one person from buying steak with food stamps. There is no justice without racial justice.
  4. Many participants are needed to transform our medical care system into a true health care system. While there are only physicians in this particular group, the real work requires public health professionals, community health workers, housing experts, policy wonks, political activists, artists, chefs, personal trainers, behavioralists, and many others to both design an implement a better system.

I’m looking forward to the experiences and conversations this month will bring, and I hope to walk away with greater insight into how I can be a better advocate for effective and equitable health care in this country.

Critical Race Theory in Medicine: A Reading List

Inspired by this letter by Jennifer Tsai and Ann Crawford-Roberts, I’m working on putting together a reading list to jump start conversation about Critical Race Theory in medicine at my family medicine residency. The goal of such a conversation is to develop a more effective anti-racism praxis in our medical system and our lives more generally. I’ll update this list as I get more recommendations. Please let me know if you have recommendations to add.

Professor Adrienne Keene’s open-access course in Critical Race Theory at Brown: Introduction to Critical Race Theory 2017

Recommended by Michelle Munyikwa
Recommended by Jeremy Levenson

If you are having trouble accessing any of these articles, let me know!