By Megan Sandel, MD, MPH
Early in my residency, a young girl was hospitalized in the intensive care unit for a severe asthma attack. We were puzzled; her asthma was previously well controlled. But a single piece of vital information explained everything: The family had just gotten a cat and the girl was severely allergic. Her parents found a mouse in her bed and they had tried to get their landlord to fix problems with the building, but he was unresponsive. Desperate, her parents faced an awful choice: live with the mice that were making their daughter sick, or get a cat that was just as harmful to her health. As her physician, I knew none of the medicines I could give her would help her breathe well in her home. The prescription I wanted to write was for healthy housing.
I wish this story were unusual, but the truth is, I’ve seen this type of case more often than I can count over the past decade. It’s made me as passionate about “prescriptions” for inspections to enforce housing codes as prescriptions for asthma medications. Research shows that only about 15 percent of preventable diseases can be improved with access to better medical care; the rest depend on such factors as where people live and what they do (and don’t) eat. So much bad health is caused by under-enforced laws and policies, underfunded public programs, and ill-conceived public policies; these fall far outside the scope of issues health care professionals are trained to address. But what should the role of health care providers be in diagnosing and treating social determinants of health? And how can we train doctors to respond to them?
I think as physicians we should be taking housing and hunger vital signs at every visit, just as we check heartbeat and blood pressure. If a patient is failing to thrive because of poor nutrition, no amount of diet advice will help them plan for food they cannot afford to buy. We need to know if they have enough food or enough money to buy food; these issues are common and critical to the treatment plans we develop. These vital signs should be evidence-based and part of the formulary. Children’s HealthWatch recently developed a hunger vital sign, a two-question validated screen that detects food insecurity.
Teaching medical residents to take housing and hunger vital signs helps meet the competencies that equip every doctor to perform Entrustable Professional Activities (EPAs). In an Academic Pediatrics article, Drs. Melissa Klein, Dan Schumacher, and I laid out vignettes illustrating the differences in competencies from a totally rote, uninformed pediatric resident (level one) to a fully engaged, community-networked physician (level five). If we include the assessment and management of social determinants of health as an Entrustable Professional Activity, with the same emphasis as any other preventative or chronic disease evaluation and management, then we will create physicians ready to use hunger and housing vital signs to their full effect.
But what happens once we’ve detected a problem with housing, food, safety, or insurance? Physicians need resources and partners to help treat the health problems that fall outside of medicine’s reach. I’m lucky because I work at one of the 230 hospitals and health centers that currently have a medical–legal partnership (MLP). At MLPs, civil legal aid lawyers—trained to appeal housing evictions, handle public benefit applications, and help protect against domestic violence—join the health care team. When I detect a housing problem, I can call an attorney to my patient by enforcing a housing code or securing a housing subsidy. It’s similar to when I detect a heart problem: As a primary care pediatrician, I need to know what a heart murmur sounds like, and I need to know when to call a cardiologist. I don’t necessarily have to know what type of murmur it is or the specific course of treatment.
Perhaps most critically, regularly referring patients to the lawyers at the hospital helps detect the broader policy problems at the root of poor health and helps us intervene upstream. When doctors and attorneys work together regularly, they start to see patterns in which multiple patients are affected by the same bad social policy, and together they have the tools to fix it. Sometimes it’s an ill-conceived law that is causing illness or injury, such as the booster seat law in Atlanta that was rewritten by an MLP to reduce child head trauma. Sometimes those kids with asthma are all living in buildings with the same landlord, and MLP can fix the problem at its source. That was the case in Cincinnati, where the MLP got 19 buildings rehabbed and under new management. The more of these policies we can change, the fewer patients will come into our clinics sick from their effects.
Many people argue that physicians already have too much to do in a 15-minute visit without asking about housing or food, but it is exactly by screening for these problems and partnering with new members of the health care team to address them that I’ve been able to get back to the business of medicine. Most important, it’s what our patients need. Sixteen years ago, asking the girl’s parents, “Did anything change in your house?” was the most important thing I did while she was in the ICU.
Megan Sandel, MD, MPH is an Associate Professor of Pediatrics at the Boston University Schools of Medicine and Public Health. She is the medical director of the National Center for Medical–Legal Partnership and a co-principal Investigator of Children’s HealthWatch. Follow her on Twitter: @megansandel