Doctors treating patients who live in lower-income urban areas must be prepared to ask more questions and may need to take other steps, including venturing outside the office, to better understand their patients' life circumstances, according to specialists in urban health and social medicine.
Otherwise, a doctor who recommends optimal care can be sabotaged by unforeseen forces, said Jada Bussey-Jones, MD, co-director of the Urban Health Initiative at Atlanta's Emory University in Georgia. For example, a heart failure patient perceived as noncompliant might instead lack the health literacy skills to understand his or her medications or have little to no access to decent produce at grocery stores in his or her neighborhood, she said.
“We typically don't think beyond the office visit,” she said. “We think about what happens in the 4 walls and that clinical encounter.”
To help get their doctors out of the exam room, Emory's Urban Health Initiative has launched a number of projects, including planting a community garden with the help of doctors and those who live in the neighborhood. In Cleveland, doctors at University Hospitals have adopted a similar community approach, teaming up with the Hunger Network of Greater Cleveland to discuss healthy living and provide screenings at food pickup locations. Urban health and social medicine also are featured by some residency programs, with related tracks.
But any doctor practicing in an urban area should be prepared to delve beneath the surface if a patient appears to be struggling with a health condition or treatment recommendation, said Lenny Feldman, MD, FACP, who heads up the urban health residency track at Johns Hopkins School of Medicine in Baltimore. Are patients struggling to keep the electricity or water on? How much alcohol do they consume each day? Are they forced to choose between medicine and food?
“To not have a sense of what the patient's home life is like is in many ways I think putting your head in the sand,” Dr. Feldman said, “because those issues certainly impact many of the concerns that patients have or health prescriptions we give folks.”
Not surprisingly, gaps in adequate food and other daily stressors can erode health. In the United States, 11% of all households and nearly 18% of those with children report some degree of food insecurity, with gaps in the quality or amount of food available, according to data published in the November 2015 Health Affairs. Food-insecure senior adults were 2.33 times more likely to report being in fair or poor health compared to those with stable food access, the researchers found. There were fewer data on nonseniors, they wrote, but there appeared to be a correlation, with food insecurity associated with higher rates of mental health problems, reported poor health, and diabetes.
At Johns Hopkins' urban health program, residents treat patients coping with these sorts of daily stressors through their clinical work at East Baltimore Medical Center, Dr. Feldman says. Nearly two-thirds of the households in the surrounding community don't earn more than $25,000 annually, he said.
Projected life expectancy in this area also is among the shortest in Baltimore, ranging from 66 years to 69.5 years, according to an analysis by the city's health department. Meanwhile, an adjacent neighborhood falls into the second highest quintile, with a life expectancy of 73.7 years to 76 years. In Atlanta, Dr. Bussey-Jones points to similarly stark differences, with projected lifespans ranging from as low as 71 years to as high as 84 years in neighborhoods separated by just short distances.
The physical and social conditions where patients live can undercut their health in many ways, according to findings from the Affordable HOME study, which is being conducted by the Albert Einstein College of Medicine in Bronx, N.Y. The study, which focused on the link between types of low-income housing and health among Hispanic residents living in the Bronx, looked at various health outcomes, including sleep patterns.
According to the analysis of Hispanic residents of low-income housing published in 2014 in Behavioral Sleep Medicine, researchers found that sleep was more likely to be disrupted if people considered their building's condition inadequate and if the surrounding neighborhood had signs of deterioration such as vacant lots with trash and litter on sidewalks, said Earle Chambers, PhD, MPH, a co-principal investigator on the Affordable HOME study and primary author on the sleep analysis.
Such conditions tend to correlate with unsafe streets, a lack of green space for exercise, fewer places to buy healthy food, and other factors that make it difficult to be healthy, Dr. Chambers said. “It's an indication of a lack of investment in these particular communities,” he added.
Dr. Chambers suggested that doctors try to get a better sense of patients' living environments in addition to where they live. Identifying “upstream” conditions that expose patients to factors affecting their health, such as how stable their housing situation is or how they feel about the community they live in, can be an important step in disease prevention and treatment.
Delving into determinants
When training residents in the urban health program, Dr. Feldman teaches them to move beyond lecture mode with patients. Rather than scold patients about their cigarette habit or their increasing obesity, Dr. Feldman says that patients should be encouraged to talk more and reflect back on their own health. One statement he frequently floats is “Tell me what you think are the biggest issues that are threats to your health?”
When patients acknowledge a harmful habit, then the doctor can ask why they are still pursuing it, Dr. Feldman said. What do they like about, say, smoking that convinces them to continue? What are the short- and long-term consequences? “Hopefully that starts to create ambivalence,” he said, leading to eventual change.
Just recently, Dr. Feldman and residents on hospital rounds spoke with a man who had had a heart attack. “We said, ‘So why do you think you had this heart attack?’ And during the conversation he said, ‘I know it's the smoking and I know it's the cocaine. And I know I need to stop doing those so I don't die.’”
To elicit some of the underlying social determinants that could be affecting patients' health, Dr. Bussey-Jones recommends a screening tool described in a 2002 Academic Medicine article. Dubbed with the mnemonic S-E-L-F, it highlights various influences that can be discussed. Among them are Social stressors and sources of support; personal Environment and experiences of medical care; Life control and literacy; and Faith in the facts and family beliefs. That final element explores what patients and their families understand about their medical conditions and treatments.
Time constraints might make it difficult to routinely review these questions with all patients. But they can be pulled out if a patient is not making any headway with a chronic condition, such as high blood pressure or diabetes, Dr. Bussey-Jones said. “So I'll say, ‘I'd like to spend some time exploring what are the things that are going on,’” she said. “‘And some of the issues that I see in some of my other patients, I'd like to explore if those could be issues for you.’”
Flagging patients who might be having food access struggles is particularly crucial in certain circumstances, such as when a patient is an insulin-dependent diabetic and vulnerable to hypoglycemia when food becomes scarcer toward month's end, said Sharad Jain, MD, residency director of the University of California San Francisco/San Francisco General Hospital primary care medicine residency program. Two screening questions that have been validated in the literature are “Within the past 12 months, did you worry that your food would run out before you got money to buy more?” and “Within the past 12 months, did the food you bought not last before you had money to get more?”
Normalize the conversation, making it clear that such questions about food, alcohol use, and personal safety are asked of all patients, Dr. Jain said. Also, don't fall into the trap of assumptions, he said. Someone who is overweight may still be running out of food periodically and thus resorting to high-calorie cheap food to assuage hunger pangs.
Patients can at times be surprisingly forthcoming about their challenges, if asked, Dr. Jain said. “This is our job as doctors,” he said. “What we've learned is that it's with the people where you least expect it where you might get a positive response that changes the approach you take with your patient.”
Tying into the community
As awareness has risen about the health impact of social determinants, so has the interest in trying to assist and better support the communities where patients live, said Leslie Mikkelsen, MPH, RD, a managing director at the Prevention Institute in Oakland, Calif.
She cited a housing-related effort that emerged from St. John's Well Child and Family Center in Los Angeles after clinicians there identified high lead levels in a toddler who was showing severe developmental delays. Continued testing showed a worrisome rate of elevated readings, and other patterns such as insect and rodent bites resulted in a push for improvements in substandard housing locally.
In the Cleveland area, the Stay Well Project helps to connect doctors with those living in the community by providing health education and screenings in nearly a dozen locations, such as churches, where food is already being distributed by the Hunger Network of Greater Cleveland and thus residents feel comfortable gathering, said Prakash Ganesh, MD, one of the Stay Well researchers and a fellow in family medicine and preventive medicine at University Hospitals Case Medical Center's department of family medicine and community health. Since 2012, the project has reached more than 16,000 people, according to Stay Well data.
The family medicine residents from University Hospitals don't give medical advice but provide screenings for blood pressure and other risk factors and discuss nutrition and healthier behaviors, Dr. Ganesh said. Participants are introduced to vital health services including assistance with community navigation and Medicaid enrollment with the help from essential community partners, he said. He noted that the discussions aren't as time pressed as during a typical clinic day.
“I found that we were able to build a stronger relationship compared to the usual office visit because we were able to see participants in their own home communities with the support from dedicated partners who are there every month. This sort of collaborative relationship could lead to improved health care,” he said.
Along with Emory's community garden, the Urban Health Initiative runs a monthly walking program, dubbed Walk with a Doc, part of a national initiative to encourage exercise. Community residents can walk a nature trail in Atlanta with a doctor who answers health-related questions along the way, and the conversations benefit both sides, according to Dr. Bussey-Jones.
“Importantly, it demystifies for the community members the physician's role,” she said. “They are not in their white coat. They are asking and answering questions and really building trust, and saying that it's OK to talk and ask questions of your provider.”