The Arrival of Social Emergency Medicine

Social emergency medicine is an emerging branch of emergency medicine. By definition, it’s the interplay of social forces and the emergency care system, and how they interact to affect the health of patients and the community. It is aimed at acknowledging and addressing what are known as social determinants of health. SBH has been a leader in this field, recently creating a one-year fellowship in social emergency medicine.

Dr. Jeffrey Lazar, vice chair and medical director of the department of emergency medicine at SBH Health System, recently discussed this burgeoning specialty on the podcast, SBH Bronx Health Talk. Here is an excerpt.

Ok, so we gave a definition, but from a practical hands-on sense what does social emergency medicine mean and what does it look like?

Well, in its broadest, most generous sense, it includes all of the forces that have contributed to a patient’s chief medical complaint and why that patient ended up in an emergency department. A patient typically arrives with a presenting complaint; however, that complaint might be thought of as the tip of an iceberg. Social Emergency Medicine challenges to take into consideration what lies below the surface.

To give an example: if a patient comes in with a chief complaint of back pain, utilizing a sort of social emergency medicine paradigm, in addition to
investigating from a clinical perspective the pathophysiologic etiology of the patient’s back pain and what needs to be done about it, we look at it within the scope of the patient’s life and how that complaint brought them to the emergency department. Was the back pain as a result of the patient falling down outside because they were out walking the streets? Or because they don’t have a bed to sleep in and are sleeping on a sidewalk or park bench? Or are they more sensitive to their back pain because they haven’t had anything to eat in the past 48 hours and they know that if they get treated for their back pain there’s a chance they may also receive food in the emergency department? Was the back pain sustained in a fight and so violence played a role in the patient’s presentation? Or did they fall down after drinking alcohol or using drugs? To accurately treat and care for a patient, it is essential that we consider and potentially act upon and study and acknowledge the contributing forces that landed that patient in our emergency department.

So that means really drilling down and asking a lot of questions?

Yes, it does. It is a clinical skill not unlike learning to recognize heart or lung sounds, and it is not something that’s traditionally been taught in medical school nor been seen as core competency in American medicine. So part of our job as an academic emergency department is to train our young physicians, our resident physicians, to begin to incorporate that consciousness and awareness in their histories and physical exams of
our patients. A physical exam begins by observing a patient: you walk into the room and one of your first observations may be that the patient is there with a roller suitcase. Well, okay, you know then your medical history-taking is going to want to include the fact that you acknowledge that this patient appears to be carrying all of their belongings with them, and what are the circumstances that are responsible for that.

And obviously in a setting like here in the south-central Bronx you’re seeing
that right? You’re seeing people who are coming in where the social determinants of health are making a difference in their lives and are affecting their health?

Absolutely. One tends to see a bigger role for social emergency medicine in communities that are affected by healthcare inequity and socioeconomic
disadvantages. Here in the Bronx, our community faces a number of challenges and those challenges often play no small part in contributing to why our patients are seeking emergency medical care.

How new a phenomena is social emergency medicine?

Interestingly, the actual designation or the term social emergency medicine was agreed upon a little over a decade ago. So emergency medicine as itself is a very young specialty, and then this nascent field of social emergency medicine is yet an even newer phenomenon so it’s really just in in the infantile stages of being a recognized sort of subspecialty of emergency medicine.

Now is this something that also occurs in a primary care setting? I mean how is what you do different than what a family medicine doctor does?

It impacts every field of medicine. If a patient presents to the ED and is rapidly
taken to the cath lab for a life-saving intervention, the contributors to that
patient’s disease state will still need to be addressed in their post-cath and
follow-up care. Is the patient addicted to tobacco? Are they eating healthfully?
Are they able to obtain their medications? So it tends to play a role in every area of medicine. However, the emergency department is really ground zero and a hot spot because it is the place in society where people tend to go when they have a need, be it an emergency medical need or anything else. It tends to be sort of a clearinghouse for people with problems and what we’re saying is we want to start dedicating ourselves and taking an evidence-based approach to recognizing, addressing, researching, advocating for, and ultimately acting upon those problems so they don’t show up back in the emergency department the next week with the same issue.

Are patients forthcoming with their stories typically?

I believe that when patients appreciate and understand where their physician is coming from, and what the physician’s motives are, that they are more than willing to cooperate. So you know there may be an initial reluctance for the patient to think, “Oh, if I tell the doctor that I’m here because I want a sandwich or because I want a place to sleep that they’ll kick me out and nobody will care.” What we’re trying to do with our patients, and our physicians, is let them know that if we begin to acknowledge those underlying causes we can begin to do something about them. We may not be able to solve as many problems as we’d like in the ED, but I believe we can, and need to, do more than the scope of our jobs once dictated. In many ways, the U.S. suffers from a grossly failing safety net; this is painfully obvious in most emergency departments. Housing insecurity, food insecurity, the opiate crisis, lack of universal health insurance, insufficient mental health resources, the impact of firearms: these are just some of the issues driving patients into emergency departments. Some misguided politicians like to argue that anyone in the U.S. can get healthcare, they just need to go to an ED. Well, no, that is not how one provides intelligent, optimal, affordable, effective healthcare to society. But so it goes. We live in the country we live in, and so we are learning how to optimally confront determinants of health in our ED’s.

So now are you working closely with residents and attendings in scripting them and having them ask the right questions to elicit the answers you’re looking for?

Absolutely, so we do that on multiple levels from sort of role-playing and
simulation in small groups, to having outside experts and guest speakers come to our department to educate our physicians, to working with outside
organizations. One that we partner closely with and have done a number of projects with and continue to work with is BronxWorks. So yes, we are continuing to actively train ourselves and our trainees in becoming more expert in this field.

Is this similar or different than Public Health?

I would say that this is Public Health; it’s sort of a newly identified area of Public Health, and I think there’s growing recognition of the enormous potential to engage patients at risk in an emergency department. They’re
challenging places and there’s resource limitations, but I think there’s increasing recognition that this is where we need to put more resources. So whether it comes to the field of substance abuse, whether it’s housing insecurity, whether it’s communicable diseases, emergency departments are high-yield opportunities to engage patients at risk and we need to start putting the attention and the resources in that area.

I would think an additional challenge is that you’re also running against the clock. You’ve got a room full of patients, you’ve got people who are waiting hours to see a doctor, and yet it takes more time obviously to ask these kind of questions, right?

It absolutely does take more time. What we need to learn is that a short investment now can save us a longer investment or longer cost in the long term. And so, for example, taking 10 minutes or 15 minutes to get to the reason for the patient’s visit, if let’s say it’s minimally related to their stated
complaint, there’s an underlying social need that in the long term it’s in everyone’s best interest to spend those 15 minutes on that initial visit than to
ignore the issue and have the patient come back the next day for a 2-hour
visit and the next day after that. So there is a small price that comes with these interventions, but the thought is that the benefits will ultimately very significantly outweigh the costs. So we need to learn to take a little more time with our patients today to prevent their needing us tomorrow. We won’t always be successful, and unfortunately, there are many problems we won’t be able to solve during an ED visit. But we definitely can do better than we have been doing.

Give me an example if you could of a patient whose health has really been impacted by a problem you were able to identify.

Sure, I mean I can think of sort of broad categories of patients. We saw one
patient who presented with very elevated blood sugars because she was not able to afford her diabetes medications. So we worked with a number of parties in our health care system to make sure that this patient would have access to affordable medication and diabetes care follow-up. So not only did we treat her elevated blood sugar in the emergency department, but we then took the added time to make sure that when the patient left the emergency department we had a system in place for the patient to get her medication in the short term and also the appointments scheduled that would be necessary to make sure that this patient would then have her medications in the long term. We’ve also had a number of successful housing interventions with patients who have come to the emergency department. It’s been recognized that one of the motives for their coming to the emergency department was simply that they didn’t have any place else to go and we were able to engage the patient with BronxWorks Housing Coordinators and ultimately work in getting them into housing that diminished their need to come to the emergency department to simply find a place to sleep.

I would also think that a project like Bronx Rises Against Gun Violence or B.R.A.G. sort of falls into the category of social emergency medicine as well, right?

Absolutely. Unfortunately, our community is a hot spot for interpersonal violence and we see this unfortunately on a daily basis in our trauma bay; victims of assault and other violence injuries, and so we have partnered with the Bronx Rises against Gun Violence program and we actually just had a meeting reviewing how they engage our patients in the hospital and we’re looking to actually advance that project to expand the number of patients they engage in our emergency department because these are all preventable injuries.

Is the hospital planning to expand the B.R.A.G. program?

We are. They’ve traditionally been more involved with patients on our hospital’s trauma service, but that’s only a subset of patients who have been admitted into the hospital and we see a far greater number in the emergency department. So we will be working with B.R.A.G. to see how we can more effectively capture patients who come to our emergency department as victims of violence, but don’t necessarily get admitted to the hospital.

I guess the other area which I think does overlap a little bit is the fact that the hospital has opened a geriatric ED dedicated towards older patients.

Absolutely, and again a case that comes to mind that I saw in our emergency department was a geriatric patient who due to his dementia hadn’t been to work for decades because he’d been retired and due to his dementia one day got into his car and drove to work even though he hadn’t been there for 20 to 30 years. He eventually ended up in our emergency department and it took a bit of work to figure out where he came from and what services he would need to prevent a similar situation occurring in the future. Our emergency department’s social worker, Robert Reda, is an invaluable member of our team who very often plays a key role in assisting in the care of our most vulnerable patients. But, yes, the geriatric population is another subset of patients where social factors are very much at play in their lives whether it’s around mobility, whether they are getting the food and medications that they need to stay healthy, fall prevention, whether they’re getting checked on at home, and what resources are in play if they suffer from dementia.