More than twenty years ago in family practice residency, we were introduced to caring “for the whole patient.” We were supposed to know everything about their entire lives, their jobs, economic status, their families, and so forth. The logical discipline was, of course, that really knowing someone would translate to better treatment, better care. That makes sense. Yet even in the then slightly less cynical recesses of my brain, I wondered just exactly how far this was to extend. Occasionally a social worker, even an attending might pimp us on what we could do to make sure a patient actually used the free sacksful of meds they were given or got to their appointments on time. I started vaguely wondering if a patient couldn’t pay their water bill, or needed a tire changed if the good ‘ol family doc was supposed to swing by their house and fix those problems too.
Fast forward to 2014, and the weak-kneed “American Academy of Pediatrics is recommending physicians ask parents about family finances to help reduce the long-term health problems caused by poverty.” One of their clowns described it as “the ultimate in preventive medicine.” Of course, nowhere in that particular does it recommend that pediatricians advise parents to stop having children they (or someone) clearly can’t afford. What, too judgmental?
In 2015 the disconnects over at the AAFP published this prize, “Poverty and Health – The Family Medicine Perspective.” (An aside, but how many in medical associations, as in great swaths of academia, fall all over themselves to publish things that were already common knowledge, propose utterly unworkable “solutions”, or spout ideologically approved gibberish, just to see their names in print? Of course, some of you may have accused me of that, in which case, where’s my damn tenure??)
The AAFP wants us to understand “The Complex Ways that Poverty Affects Health,” solutions contained therein by – wait for it …
– providing a patient-centered medical home (PCMH)
– practicing cultural proficiency
– screening for socioeconomic challenges
– set priorities and make a realistic plan of action
– help newly insured patients navigate the health care system
– Provide material support to low-income families
– Advocate on behalf of low-income families and neighborhoods
This article has a nifty chart attached, which topics include residential segregation, migrant labor, fear of crime, and cigarette taxes. So after the approved, mainstream, team player primary care doc runs through the rest of a largely pointless, bloated office note, he can throw out some foreign language phrases, ask about the patient’s credit rating, tell the patient to pay their water bill and consider a vasectomy/tubal ligation as a sound investment, give the patient directions to the local health department and a pamphlet explaining how to get free health care (likely ignored), and head out to the get-cigarettes-out-of-high-crime-migrant neighborhoods rally. That’s a recipe for professional happiness if ever I hear one.
But now the former mayor of San Francisco and current governor of California is going to do us all one better. Gavin Newsome arguably the most able governor of any province since Mitt Romney fixed health care in Massachusetts, has publicly recognized the link between “physical health and brain health.” This, he says, is the principle fault line in the homeless crisis, which he proposes to fight with new spending, opening up state properties to homeless sheltering, suspending anti-construction environmental regulations, and … prescriptions. “’Doctors should be able to write prescriptions for housing the same way they do for insulin or antibiotics,’ Newsom said. ‘We need to start targeting social determinants of health.’”
And there you have it. When not busy as financial advisors, community organizers, and substitute parents, physicians should now be empowered as housing commissars as well.
What will be the parameters of these exciting new abodes, and how exactly are they to be funded? Does showing up at an upscale apartment building with a script get the door open, and will new legislation need to be passed to prevent doctors from getting the 3% commission? These are exciting days for primary care.