Posted by: notdeaddinosaur | October 6, 2012

Why the Social Situation is Part of the Doctoring

It was a busy summer. Marrying off daughters, enlarging driveways, saying goodbye to half my population of ancient cats, and a couple of day trips to serve as “vacation” has produced a significant lag in my response time. The post that inspired this musing originally appeared back in June, and I jotted it down on my list of things to blog about. Only now am I finally getting around to responding. Sorry for the delay.

My good friend and blog colleague Dr. Bob Centor has written about the difficulties of treating patients in the hospital, only to have them get well (or at least better than they were), and leave the controlled inpatient environment to go back to wherever it was they came from, which often contained the seeds (or was the outright cause) of what made them so sick in the first place:

You can fill in more information about the patient, unstable social situation, often homeless, often estranged, and much sicker than they should be.

So we perform great rescues in the hospital, stabilize the patient, restart the appropriate medications, institute physical therapy.

Then we start discharge planning and everyone – physicians, nurses, case managers – deals with the frustration of the social situation.  Actually the problem is the lack of a social situation.  The patient usually has no, or minimal social support.

Welcome to my world, Dr. Bob. The world of outpatient medicine, aka “real life”, is where our patients live; only when they’re not interacting with us, they’re known as “people”, not “patients”. Out here (“there” to you) they do things like smoke, drink, have sex, and use drugs. Some of them also go to work, bring home paychecks, care for families, tend gardens, clean their homes, go to movies, exercise, pay taxes…you know, live their lives. As you would probably agree, our job is to get them to a state of health where they can do all those things, and whatever else they may choose to do, with as little involvement from us doctors as possible. That’s the goal.

It is sadly true that there are many people out there who lack social support. They may have no family nearby, or have alienated them for one reason or another. Limited financial resources are profoundly, well, limiting. We can no more ask a person with no money to pay for expensive medications than we can expect a dialysis patient to suddenly start making urine.

The inpatient setting is inherently artificial. Controlling a patient’s activity, dietary intake, and medication consumption while carefully monitoring assorted biochemical parameters is vital acutely, but not something that can be realistically maintained after discharge. Yes, patients have to take responsibility for their health and its maintenance, but sometimes we tend to overestimate their ability to do so, blaming them for failures of medication and dietary adherence when things like monetary barriers are insurmountable.

Of course it’s easier when our patients have the social supports necessary to get and stay well as outpatients. Think of the social situation as a co-morbidity. It’s something we have to take into account when treating a given patient, even if it means not being able to follow guidelines or “best practices”. Just as chronic kidney disease complicates the treatment of arthritis, and diabetes complicates the treatment of just about everything, mental illnesses like depression and schizophrenia make it more difficult for patients to adhere to complicated outpatient regimens for both their physical and mental conditions.

Dr. Bob says:

We get frustrated with these patients, but this frustration really reflects our frustration with the social confounders of disease.

I submit that the social situation is an integral part of the patient’s condition. (Note to learners: this is why a Social History — beyond mention of smoking, drinking, and employment — needs to be far more than an afterthought at the end of the H&P.) Dr. Centor likes to champion practitioners of Internal Medicine as specialists in complexity. Caring for a patient with diabetes, heart disease, asthma, and a festering foot ulcer is certainly more complex if he is a homeless alcoholic veteran. But why should the patient’s social situation be singled out as more frustrating than the diabetes or the asthma?

Dealing with social situations that complicate the patient’s medical management are part of the doctoring, not something that interferes with it.


Responses

  1. Yes, yes, yes! One of my first patients as a nursing student was an old woman with leg ulcers, who had to be repeatedly admitted as they began to deteriorate as soon as she left the hospital. She would take her bandages off, and the ulcers would fester. Everyone on ward 10B — Female Medical — knew her as a jolly soul. [In those days it was an open ward, with curtains between the beds, so the patients all chatted with each other]

    The resident wanted a psych consult to determine why she was “self-harming”. My instructor informed him, after a brief talk with the old lady, that she was alone in a 4th floor walkup, and feared dying without anyone knowing. She also found it impossible to lug groceries up the stairs. No one had ever asked her how she would cope “on the outside”. In the hospital she was secure, and happy, and had friends.

  2. I definitely agree with you. Clearly we all try to address the social confounders. Outpatient medicine success, if you are measuring performance measures, often depends on the patient’s motivation, and my point is that too often the social situation negatively impacts that motivation.

    Many patients that informed my post never make that outpatient visit. Our frustration in the hospital comes from knowing that excellent outpatient internists and family physicians can prevent many hospitalizations. But they can do nothing if the patient will not go to the office.

    In our patient population, too many patients cannot get an outpatient appointment other than the “free clinic”.

    I hope this adds to the idea I was trying to explain in my post.


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