Portal de Periódicos da CAPES

Emergency Physicians as Community Health Advocates

2019; Elsevier BV; Volume: 74; Issue: 5 Linguagem: Inglês

10.1016/j.annemergmed.2019.08.453

1097-6760

Michael Clery, Joneigh S. Khaldun,

Cardiac Arrest and Resuscitation

The evening shift is as busy as yesterday, with new patients constantly appearing on the tracking board, assigned to hall beds that do not officially exist and require a bit of detective work to find. The next one up is a 20-year-old man with chest pain. He's thin and black, and the chart lists no medical history. He smokes occasionally—sometimes cigarettes, sometimes marijuana—and rarely drinks alcohol. He looks comfortable leaning back in the stretcher, but in between his providers' listening to normal heart and clear lung sounds, the rest of the story almost eagerly slips out: he has not been sleeping. His small apartment is full, with 2 toddlers, his wife, and his mother. It is located nearby in a low-income neighborhood in a city with a high incidence of violent crime. He paces the halls at night while his family sleeps to ward off possible home invasion, assault, or car theft. During the day, he hustles with odd jobs to bring in some money and watches his children but expresses fear of taking them to the park to play because of gun violence in the neighborhood. After review of a normal ECG result and chest radiograph, clinical guidelines are clear: he can be discharged home to follow up with a primary care physician.1Mahler S.A. Riley R.F. Hiestand B.C. et al.The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge.Circ Cardiovasc Qual Outcomes. 2015; 8: 195-203Crossref PubMed Scopus (249) Google Scholar Emergency physicians who understand the social context of medicine cannot accept this as the standard of care. What if, because we are the only contact with the health care system for many patients with complex and challenging life experiences, we address the real issues of people who present to our emergency departments (EDs)? What is the responsibility and role of emergency physicians in broader community health, given that we are frequently the ones who observe firsthand the effect of these social determinants of health? What are the tools emergency physicians need to be able to have an influence on improving the health of a broader community, beyond the walls of an ED? These questions confront us daily as we find that our prescription pads and astute diagnostic capabilities have little effect on the recurring disease and injury that bring patients to our doors. Understanding the need to address health outside of the constraints of a health care system, emergency physicians are developing skill sets and tools that reach from bedside interventions to policy implementation. As we embrace the role of advocates for our patients on every level, there are 3 principles that guide us. First, our work interfaces with the complex social circumstances of our patients, about which they are the experts. Interventions must be driven by objective data but built on the insight and expertise of patients and communities. Second, emergency physicians should understand all conditions from a primary, secondary, and tertiary prevention standpoint. Although there are certainly unpreventable circumstances that contribute to disease, numerous ailments can be prevented or their courses slowed. If we treat only the outcome and not the cause, we are failing our patients. Third, emergency physicians are uniquely suited to lead larger community, policy, and public health efforts to address community health challenges. We ought to embrace this role and equip the next generation of emergency physician leaders with the skills needed to effectively advocate for and lead these broader efforts. We can practice the leadership necessary to reshape the field of emergency medicine and the health care system overall. EDs are a primary gateway through which patients are admitted to a health care system, which, because of EMTALA, includes all patients regardless of ability to pay.1Mahler S.A. Riley R.F. Hiestand B.C. et al.The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge.Circ Cardiovasc Qual Outcomes. 2015; 8: 195-203Crossref PubMed Scopus (249) Google Scholar Given the national trend toward value-based payment, systems are searching for mechanisms to provide better care at lower cost and avoid hospitalization for all these populations.2Khullar D.M.M. How community health workers could create less-costly, higher-quality care.https://blogs.wsj.com/experts/2019/02/07/how-community-health-workers-could-create-less-costly-higher-quality-care/Google Scholar Many programs focus on community-level supports—community health workers—who are well-respected neighborhood peers who can help people access and navigate the complexities of the health care system, and others focus on directing people to behavioral health services.3Anugu M. Braksmajer A. Huang J. et al.Enriched medical home intervention using community health worker home visitation and ED use.Pediatrics. 2017; 139: e20161849Google Scholar As an example, physicians in Camden, NJ, focused their efforts on directing some of their most vulnerable patients to medical care and services, resulting in a significant decrease in ED utilization and hospitalizations.4Gawande AM. The hot spotters: can we lower medical costs by giving the neediest patients better care? 16, January 24, 2011. Available at: https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters. Accessed October 2, 2019.Google Scholar Beyond using these interventions for quality and cost-control aims, in Alachua County, FL, they have recently been used to advocate for resources to address health disparities and social determinants of health.5Hardt N. Neighborhood-level hot spot maps to inform delivery of primary care and allocation of social resources.Perm J. 2013; 17: 4-9Crossref PubMed Scopus (27) Google Scholar Demographic, socioeconomic, and health indicator data were overlaid with geographic information systems mapping to create "hot-spot" density maps. These were used to urge academic health centers, city and county government, community organizations, and funders to reprioritize philanthropic efforts and mobilize resources such as health system outreach and a mobile health clinic.5Hardt N. Neighborhood-level hot spot maps to inform delivery of primary care and allocation of social resources.Perm J. 2013; 17: 4-9Crossref PubMed Scopus (27) Google Scholar Physicians can begin to become involved in addressing social determinants by listening to their patients. As physicians, we can inquire about a patient's circumstances and ability to follow intended treatment plans, such as by asking patients whether they will be able to keep their physician appointments or be able to afford prescribed medication. Even asking these questions is a form of patient advocacy. In public health, primary prevention refers to preventing the disease from occurring in the first place, secondary prevention refers to preventing the effect of the disease once it has occurred, and tertiary prevention is, for often long-term conditions, improving the quality of life or disease management to prevent worsening health consequences (Table).6Kisling LA, M Das J. Prevention Strategies. Available at: https://www.ncbi.nlm.nih.gov/books/NBK537222. Accessed: Sept 23, 2019.Google Scholar The health care system, and particularly emergency medicine, has most naturally focused on tertiary prevention. However, there is a unique opportunity for emergency physicians to lead these more upstream preventive efforts.TablePublic health approach to prevention.LevelDefinitionIntervention ExamplePrimaryPrevent initial disease/injurySafER TeensSecondaryPrevent reinjury, recurrence, transmissionDLIVETertiaryPrevent sequelae, worse outcomesTrauma-informed care practicesDLIVE, Detroit Life Is Valuable Everyday. Open table in a new tab DLIVE, Detroit Life Is Valuable Everyday. One example of how this role can be embraced is in treating violence. There are many emergency physicians who are leading these evidence-based efforts to prevent violence by using a public health and prevention lens, building on their clinical experience and unique understanding of the social circumstances of their patients. A primary prevention effort that has been successful in decreasing violence is the SafER Teens study. These researchers demonstrated that a motivational interview intervention performed with drug-using youth in Flint, MI (both general population and those presenting after a violent injury), resulted in a persistent, significant decrease in peer aggression and peer victimization at 12-month follow-up.7Carter P.M. Walton M.A. Zimmerman M.A. et al.Efficacy of a universal brief intervention for violence among urban emergency department youth.Acad Emerg Med. 2016; 23: 1061-1070Crossref PubMed Scopus (38) Google Scholar Secondary violence prevention through hospital-based violence intervention programs attempts to reach individuals who have been injured, with the goal of preventing further injury or death.8Dicker B.R.A. Gaines B.A. Bonne S. Violence intervention programs : a primer for developing a comprehensive program for trauma centers.Bull Am Coll Surg. 2017; 102: 30-36PubMed Google Scholar Detroit Life Is Valuable Everyday (DLIVE) is a hospital-based program in Detroit, MI. It identifies violently injured youths in the ED and directs them to trusted interventionists from a similar neighborhood and personal background to provide support navigating the healing process and directing them to education, employment, and transportation assistance (personal communication, Tolu Sonuyi, Wayne State University, 2017). Trauma-informed care practice has also been demonstrated as a best practice for preventing retraumatization of ED patients, which improves tertiary prevention.9Fischer K.R. Bakes K.M. Corbin T.J. et al.Trauma-informed care for violently injured patients in the emergency department.Ann Emerg Med. 2018; 73: 193-202Google Scholar Prevention approaches can be applied to many of the injuries and illnesses encountered in the ED, and there may already be health department or community-based services available. By contacting the local public health department and directing patients to available services, an ED can potentially shift patients' trajectories. Our expertise and dedication cannot remain only at the direct service level, whether at bedside or in an intervention program. Emergency physicians are ideal leaders across multiple settings, including hospital leadership, government, and other organizations. At this publication, there are emergency physicians who are the directors of large urban health departments, an emergency physician serving as the state chief medical executive, an emergency physician in a top role at the Robert Wood Johnson Foundation, and another as the leader of the country's largest public health organization. Countless more serve as leaders in their hospital and EMS systems and in key local and national government roles. The flexibility in scheduling that the profession provides is also uniquely suited to pursue these outside interests, and many ED chairpersons have become accustomed to and supportive of these endeavors. Our skill set is one of identifying and prioritizing needs and threats and then acting judiciously in treatment. Our training programs must build on these natural skills and provide additional opportunities for the next generation of emergency physicians to develop a deeper understanding of their community, effective ways to advocate, and how the health care system works. There are detailed policy and public health fellowships that provide invaluable experiences that can steer emergency physicians toward blended careers in policy and public health.10Emergency Medicine Resident AssociationEMRA fellowship guide.https://www.emra.org/books/fellowship-guide-book/11-health-policy/%0Ahttps://www.emra.org/books/fellowship-guide-book/20-population-health-and-social-emergency-medicine/%0ADate accessed: February 10, 2018Google Scholar Leaders of residency training programs should support integration of these topics into the basic curriculum as well. Emergency physicians must practice adaptive leadership, which recognizes that many of society's most difficult problems do not have known solutions. Rather, they require reorientation, challenging of values, and growth to the point at which a problem can be solved.7Carter P.M. Walton M.A. Zimmerman M.A. et al.Efficacy of a universal brief intervention for violence among urban emergency department youth.Acad Emerg Med. 2016; 23: 1061-1070Crossref PubMed Scopus (38) Google Scholar For our health systems to truly treat the risk of recurrent illness and reinjury, the services for which we are reimbursed must change. We will need to challenge the ingrained belief that there is no cure to violence or drug abuse, or that those who experience them are less deserving of care. We must demonstrate that by investing in patient-centered treatment, even individuals most at risk or hardest to engage with can have improved health. Emergency physicians who understand the social context of medicine will define a new standard of care. We cannot let our society look past the patients of our halls. This means holding up a mirror to our laws, practices, and medical societies to ask whether this is how human life should be valued and treated. This means shining the light on the forgotten streets of our cities to ask whether we can truly do nothing more to prevent the loss of irreplaceable human life and potential of individuals who live there. This means reminding those who write our laws and budgets that their responsibility is to all of our patients and not only those with income or influence. Emergency physicians must understand the applicability of their skill set across various settings, the need for their voice in important policy conversations, and the influence they can have by becoming leaders across multiple settings outside of clinical medicine. We who understand the chasm between health, equality, and wellness and the current care for the most ill and forgotten of our patients know that we have a long road ahead. The immensity of this task will require all of us to practice this leadership from wherever we are, be it by a patient's bedside or on Capitol Hill.