Doctors are already busy, but do they need to do more in a day? If you think a physician’s job is to take the best possible care of patients, then the answer is a resounding yes. But additional responsibilities do not necessarily mean more work—they just require different training.
It doesn’t take unique insight to understand that doctors, in many ways, act as social workers. They help patients schedule follow-up appointments, aid in translating jargon for the medically illiterate, substitute generic medications to curb the cost of prescription drugs, maintain close relationships with patients and their families or caretakers, and at least try to make sure that the patients can procure the necessary care or medications they need until the next visit.
Even so, the extent of social care that physicians provide sometimes seems to fall short. Some patients, after all of that hard work, still do not take their medications or follow up with their health appointments. According to a 2010 analysis of nearly two hundred thousand electronic prescriptions, up to 20 or 30% of prescriptions in the United States go unfilled. In some cases, the reasons for this are straightforward—maybe the patient just cannot afford the drug. Communication isn’t always frank or direct. A doctor may ask if the cost of a drug is prohibitive to a patient, but the patient may be too ashamed to admit that they cannot afford it. I have heard countless stories of patients splitting pills into twos or threes, or taking a one-a-day medication every three days, in order to make the bottle last longer. In other cases, medical illiteracy plays a part—where should a patient go to find the right medications at the right price, and is it possible to substitute a generic for the real thing?
In most inpatient settings, social workers are available to physicians to spearhead the effort to provide adequate social care to patients. Most physicians and hospital staff highly value what social workers bring to the table because they save everyone time and effort and help to provide better, more focused care to patients.
But social workers are not the final answer to all social care questions. Physician contact with social workers is not always as extensive as it should be. What’s more, when a patient leaves the medical center, the social worker’s obligation to or access to the patient is gone (they are, after all, paid to provide social care to patients while they are at the hospital). Further complicating matters is that margins are so razor thin at many private practices that it is very difficult to hire social workers (never mind that at practices with thirty-plus physicians, a one thousand dollar payment cut per year per doctor would be enough to hire a social worker to take care of the group’s sickest patients—that is a separate issue). Indeed, according to a 2008 membership workforce study by the National Association of Social Workers, private for-profit groups accounted for less than 25% of all health social worker employment (another 55% is employed by private non-profit groups and the remainder by the government). In contrast, the percentage of physicians in private practice as opposed to hospital employment varies depending on the source, but seems be hovering around 50%. Finally, medical social work does not seem to be structured to cater to the sickest patients, on a matter of principle, even though this “hot-spotting” strategy might prove to be effective in the future.
Doctors must therefore be trained to be better social workers. As is, most of the training is on the job. Training from experience is necessary, and it is how most physicians learn how to provide social care to their patients. But physicians should get more social care training and resources than those provided “on the fly”—as several physicians put it. Comprehensive medication and pharmacy cost databases need to be provided for physicians. Students and young doctors need to be taught how to use these databases while they are being trained—in medical school and residency. Currently, these databases are scarce, and we learn how to use them, again, “on the fly”.
If we are telling patients to get a drug or procedure, we are doing them a grave disservice if we do not help them by letting them know how to get it and where to get it cheaper. A physician is the patient’s advocate. Focused social care training efforts will go a long way toward making sure that patients get the best advocacy possible, and they might not take a significant set of resources to implement.
Just as the basics of medicine are taught in the classroom before actual medicine is learned on the wards, the basics of medical social care should be provided in a concentrated way for physicians to build off of as they begin to see patients. Training physicians on social care should be a more focused and organized effort.
Arvin Akhavan is a medical student who blogs at Leslie’s List.
