Innovations in “Upstream” Care

My last blog was on how today’s medical system fails by not addressing the real needs of our patients and their communities. Here, I highlight three projects that take such an “upstream” approach to healthcare:

Doctors can give prescriptions for medications, but why not a prescription for healthy foods and safer housing? Health Leads employs young people (usually college graduates interested in careers in health) to be advocates who assist doctors in clinics and ERs in connecting patients with community resources. They help with everything from food assistance to job training to legal counseling. They help to “fill” the other prescriptions that people need to achieve better health.

Recognizing that black males have significant health disparities and that outreach and education must start in the community, Project Brotherhood was conceived from a simple idea: give patients free haircuts, and use barber shops as a place to screen and counsel on illnesses such as high blood pressure and STI prevention. Its model of multidisciplinary, culturally competent care incorporates other aspects of social support, including on fatherhood and job support.

 The New York Times just published a story about an “EMS Corps” in East Oakland that specifically recruits at-risk youth and train them to be emergency medical technicians. They provide mentorship for young men who come from backgrounds of poverty and violence, and train them to become professionals who will serve their communities. As the story cites, these men are taught that they aren’t the problem—they are the solution.

These are only some of the some of the many innovations occurring around the country. We need far more interventions that go beyond “band aid” care. In the words of public health doctor Rishi Manchanda (whose recent TED talk I highly recommend), we must change our entire approach to healthcare, away from simply treating the effects of illnesses to targeting interventions to where people live, work, and play—where health really begins.

An Emergency Physician, on the Need for Primary Care Doctors

Bill M. is a 22-year old college student who has had asthma and diabetes since he was a child. He comes in with trouble breathing because he has no primary care doctor and is out of his inhalers. While he’s in the E.R., he also says that his diabetes hasn’t been followed for years, and now his blood sugars are out of control and he has new problems with his kidneys and his eyes.

Rani K. is a 46-year old who moved from India to take a research position. She has had dark stools for a month, and now feels intermittently lightheaded. Her blood counts are borderline low. She needs an endoscopy and further testing—tests that can be done as an outpatient, but she gets admitted because she has no primary care doctor and the wait for to see a new one is 103 days.

Annie K. is a 35-year mother of three who has an infection in her leg that will probably get better with antibiotics, but will need to get checked by a practitioner in two days. Her doctor does not have an appointment for a month, so she is told to come back to the E.R. for a wound check. Even with insurance, each ER visit will cost her $250.

I am an emergency physician. These are real stories of patients I see in the E.R. Patients like Bill come in with severe complications of problems that can be prevented or managed—if they had a primary care doctor to follow-up with. Patients like Rani who get admitted to the hospital or like Annie who get told to return because they need urgent follow-up—but have no primary care doctor available to them.

The dearth of primary care physicians is a serious problem facing the U.S. healthcare system. The deficit for doctors is astounding, with a predicted shortage of 100,000 physicians by 2020. This shortage is particularly acute in primary care fields and in underserved areas. The reasons are multifactorial, and have to do with historical policies limiting physician workforce as well as ongoing problems with reimbursement, lifestyle, and service inclination.

We emergency physicians will always treat all-comers to our E.R.s to the best of our abilities. Emergency physicians are a creative bunch, and already, we have created value in areas of greatest need, for example, with pioneering observation medicine units and starting urgent-care follow-up clinics. Still, we as a society need to recognize that to deliver really excellent medical care, we must ensure a robust primary care system, and take steps to strengthen our existing primary care infrastructure through coordinating and task-shifting medical care, reconsidering payment and incentives, and realigning medical education with societal need. Primary care is the backbone of our society, and here in the E.R., we see why it is so urgently needed, every single day.