I became a Chicagoan 9 years ago. My first job in the city was in a small community hospital on the north side, serving a mostly immigrant, low income neighborhood. Many of my patients were uninsured and emergency department visits were a mixture of urgent care complaints and long term consequences of unrecognized or undertreated chronic medical conditions. The hospital’s staff physicians of all specialties generally strived to be egalitarian in our provision of compassionate care in critical situations. I remember fondly some of “my” success stories: the grandma who was brought in by ambulance as soon as the facial droop started and thrombolytics reverted her stroke; the middle aged man with chest pain whose wife insisted that he shouldn’t wait to see his doctor and was rushed to the catheterization lab shortly after arrival to the ED and discharged 3 days later; the grandpa in cardiac arrest who received chest compressions by his daughter, was defibrillated at the scene, was cooled upon arrival, and lived to share his story.
These cases illustrate how early action and teamwork can save lives and are the reason why many of us choose this specialty. Emergency medicine training prepares us with the expertise to care for critically ill patients with complicated diseases. We love sharing stories of lives saved thanks to our timely delivery of critical interventions after potentially catastrophic events. These cases are a boost of confidence on otherwise challenging shifts and we enjoy exchanging stories with our colleagues after a successful day. Yet, as patient volumes continue to increase, we are confronted with adopting an increasingly disproportionate role in serving patients with unmet social needs.
In that same emergency department, I saw patients die due to unrecognized or undertreated chronic disease and remember those cases just as vividly. The 55 year old woman who couldn’t afford antihypertensive medications and died from a type I aortic dissection; the 44 year old male with end stage renal disease who had a cardiac arrest after skipping dialysis because his wife just got a new job and they had no one else to take care of their disabled child; the 63 year old homeless man with hypothermia who confessed that he would never stay in a shelter because he feels safer in a tent on the street. These are the cases that weigh us down. We feel disempowered as we witness the burden of social determinants of health.
The emergency department is the port of entry into the health care system for our most disenfranchised populations. Emergency physicians arguably understand better than most of our colleagues in other specialties how race, gender, identity, social class, illness and policy converge. We take great pride in the role of emergency medicine in society, always ready to provide care 24/7 to anyone who walks through our door. Yet, the success of most of our interventions is entirely dependent on the reality of our patients outside of the walls of our emergency department. The health of our patients and our communities will only improve when we expand our role beyond individual diagnosis and treatment of their medical problems. We must also play a role in the diagnosis and treatment of social determinants of health.
More emergency departments are taking ownership of the social determinants underlying health and illness and are leading the way in the development of systematic interventions to improve population health. This practice, known as social emergency medicine, stems largely from necessity, as we face the formidable obligation of caring for an ever increasing volume of patients with unmet social needs. Recent examples of successful social emergency medicine interventions in Chicago have focused on the development of coordinated care models providing ED patients in need with comprehensive medical and social services. For example, the “Better Health Through Housing” program aims to reduce healthcare costs and provide stability for the chronically homeless by moving individuals directly from hospital emergency rooms into stable, supportive housing, with intensive case management, resulting in improved health and cost savings for the city. Another example of an ED-centered program is Project HEAL (HIV & HCV Screening, Education, Awareness, Linkage to Care) a routine screening initiative to identify patients with positive HIV or HCV tests and ensure that the patients receive their results, are provided education and counseling, and receive care coordination services to facilitate linkage to care and treatment. These are just two examples of multidisciplinary models intervening at various stages of ED care: at triage, in the department, and on discharge.
We must also expand our role beyond advocacy for individual patients and become engaged with our communities. One example of a successful community-wide intervention is the Illinois Heart Rescue Project (ILHR). Established in 2011, this multidisciplinary, multi-institutional collaborative was established to achieve one goal: to ensure that every victim of cardiac arrest gets state of the art care at the scene, in route to, and at the hospital. Systematic surveillance of cardiac arrest locations allowed the ILHR team to recognize how disparities in bystander CPR and subsequent cardiac arrest survival closely mirror social inequities. Through community engagement and advocacy, we have increased bystander CPR rates and this has led to improved survival outcomes in priority communities.
All across the nation emergency medicine is taking the lead in interdisciplinary interventions to improve population health. I propose that you consider practicing social emergency medicine, community engagement, and activism as a solution to burnout. We know that physician burnout is correlated to a personal sense of disempowerment to effect change in the work environment. I urge you not only to consider the social determinants underlying health and illness in the patients you see in your shifts, but to also develop local and systematic interventions to make our communities healthier. Measure their effects through surveillance, collaborate with multiple disciplines, and advocate for policies that will improve the health of our patients. We should feel empowered in knowing that our service can extend beyond the confines of our clinical encounters.
Watch the full FIX17 talk below!