July 31, 2020 BY THOMAS BUNNING
For all our talk about health care, health care providers too often get caught up in treating diseases instead of patients. We emphasize numbers and x-rays and blood tests. We lose sight of the big picture: our patients’ lives. We fail to account for the social determinants of health: the conditions in which we are born, grow, live, work, and age. Keeping patients healthy requires more than treating disease. It requires a cohesive approach to a healthy life. Social workers can play a vital role in filling this gap.
I met Ellie my first year of medical school. Ellie is a patient at the Duke Outpatient Clinic, just four miles from Duke University Hospital. She was 63 years old, she had chronic back pain and limited mobility, and she had spent years trying to get her blood pressure under control. Each time she saw her doctor, she diligently recounted her attempts to eat right, walk around the block, and take her medicines when she could. Both her and her doctor were stumped. But what these 15-minute check-in visits missed was everything else in Ellie’s life that affected these goals. She didn’t have a car, and she depended on inconsistent visits from her daughter to bring her food, which was mostly packaged and shelf-stable. She knew that walking was healthy, but she lived on the second floor of an apartment complex with no elevator and steep stairways, so every trip out the door was painful and dangerous. She had no way to get to the pharmacy for her blood pressure medicines, and often couldn’t afford them anyway.
It might seem easy to blame Ellie’s doctor for not recognizing or solving these problems, but that isn’t how our medical system works. Most people still expect their doctor to manage all aspects of their health, but in today’s world that simply isn’t the case. The growing number of patients and increased emphasis on delivering efficient, cost-effective care has changed the game. Physicians play a central role, but a complex team of countless other professionals (PA’s, NP’s, nurses, psychologists, nutritionists, etc.) share certain niches of responsibility. Outside the clinic, it is social workers that reach patients in the community to promote adherence with treatments and facilitate access to health resources.
The community-based role of the social worker is paramount. As Ellie shows us, maintaining health is far more complicated than getting to the doctor’s office. An estimated 80 percent of a person’s health problems are determined by “social determinants of health”: income, education, housing and food security, and personal relationships. Optimizing these factors is beyond the reach of a physician, but this is a social worker’s wheelhouse. If a doctor prescribes a medicine but the patient can’t pay for it, the intervention is wasted. If a nutritionist details a health plan but the patient can’t access a grocery store, the benefit is lost. Social workers bridge this gap by connecting patients to food, medications, insurance, transportation, rehabilitation, and virtually anything else we may need to better our health. And they do it as inexpensively as possible.
Two years later, Ellie now works actively with a social worker through her clinic. She used public housing vouchers to move to a ground-floor apartment, she receives fresh groceries with simple cooking recipes from Meals on Wheels, and her medicines are delivered in subsidized blister packs from a local pharmacy. Her blood pressure is back to normal, she feels more energetic, and she is happier than ever.
Doctor’s offices serving Duke, UNC, and WakeMed all incorporate outpatient social workers to extend the reach of the clinic into patients’ everyday lives. Not only should we encourage medical providers to continue implementing and supporting social work programs, we need to continue to grow demand by utilizing these services as patients. Only with a coordinated, integrated team of multidisciplinary professionals can we optimize health care for all in our growing society.
Thomas Bunning, 2019-20 NC Schweitzer Fellow, Duke University School of Medicine