I’ve often wondered how we have come to call what we have in our country the American “healthcare” system. Within that system, we have large “healthcare” institutions, “healthcare” providers and patients or employers buying “healthcare” insurance. Yet, most of the work done by these entities doesn’t have much to do with keeping people in good health. Oh, we certainly do a great job at restoring health to those who are ill.
As a neonatologist, I’ve seen tremendous advances in my 35 years of practice in our ability to save the life of a premature baby. Babies who had no chance of survival 10 or 15 years ago routinely survive. But the parents of these babies often have unaddressed needs related to the stress of having a critically ill infant. The resulting parental anxiety and/or depression has a tremendous impact on that child’s subsequent development. Have we really done our job of “caring” for the “health” of that family?
Obviously, this example is from the world of my specialty, but other examples are abundant throughout our current system of care. The problem is that we address the consequences of poor health but rarely the root causes of that poor health. In my example, the best solution for the baby and the family would be for the premature birth to have been prevented in the first place. Yet, in all my years of practice, we have accomplished very little in discovering why a baby is born preterm and how we can prevent it.
That’s not to say we don’t give lip service maintaining good health. We do “wellness” visits, give nutritional advice and perform preventative screening tests. Still, the vast portion of our time is taken up treating illnesses. The vast portion of one’s healthcare premium dollar goes to paying for hospitalizations and medications, and the vast portion of hospital and healthcare system costs (and profits) are from treating disease, not promoting health. Further, I would argue that all our wellness visits and all our well-intentioned advice and screening is not addressing the underlying root causes of the poor health that we see in our patients.
The driving forces behind most of our health problems are known. The American Hospital Association (AHA) estimates that 80 percent of health outcomes are determined by socioeconomic factors, health behaviors and the physical environment. But, to date, the healthcare system’s response to this reality is to try to manage the consequences of these social determinants, not to address their causes. Of course, it’s easy to understand why this is the case. Trying to address the causes of poverty, hunger, homelessness and violence is something that we are neither trained for nor have “medical” solutions for. Because of this, it’s easy to say, “These are not our problems.” But trying to “treat” the consequences of adverse social conditions and the stress they cause results in excessive medical expenditures and contributes to physician burnout.
We get frustrated when patients don’t follow our advice to quit smoking, lose weight or stop drinking. But do we recognize that these adverse health behaviors may be that patient’s only coping mechanisms to deal with the stress experienced by their financial condition, or by the fact that they’ve been abused or discriminated against, or by their exposure to community violence? Do we understand that this chronic stress is behind many of the mental health issues we see all too frequently?
We shouldn’t be surprised, or judgmental, when our advice or education is not heeded. Rather, we need to find ways to identify social stressors in a trauma-informed manner, support patients impacted by these stressors, involve them in appropriate community human services and continue to work with these agencies on a continual basis.
What I’m suggesting cannot be accomplished by doctors alone. The entire healthcare system, payers and providers alike, needs to change its approach to one that promotes good health, not just treats poor health. The entire system needs to develop and pay for models of care which value a multidisciplinary team approach to modifying social stress. These models must enhance communication and collaboration between traditional healthcare providers, public health and human service programs, and the multitude of community service nonprofits in our area. It is only through this collaboration that we can help our patients develop the resiliency needed to combat social and financial stress. This type of care requires time. Time for physicians and other providers to develop meaningful and trusting relationships with their patients. This time is not currently there in our present model of care.
Of course, our ultimate goal, as an entire society, must be to minimize the toxic and chronic stress brought about by poverty, violence and disparities. Increasing meaningful employment opportunities, decreasing poverty (especially in children) and addressing systemic racism (and all the other -isms) are all needed to achieve this goal. Until then, we must do a better job at helping patients deal with their stressors by providing social and emotional buffers to minimize them turning to maladaptive health behaviors. The task ahead of us is not easy. It will demand that everyone involved in this system rethink what we really mean by “healthcare.” But, when I think of accomplishing large, difficult tasks, I harken back to the words of JFK, when he said:
“We choose to go to the moon … not because (it) is easy, but because (it) is hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win …”
Our challenge isn’t going to the moon, but it is converting our healthcare system into one that truly promotes health in a caring way. This challenge is every bit as important as going to the moon, and likewise cannot be postponed.