What if I had access to real solutions? What if I had resources to provide to a person to help them overcome their problem? As a primary care provider with over 20 years of experience, I know viscerally that I will never “fix” anyone. I can teach, I can guide, I can comfort; but I’m never going to fix a single person. Still, I wish I had more to offer.
In my current iteration, I take care of people experiencing homelessness. Having spent much of my career taking care of people with homes, I’m currently grant-funded to care for people experiencing homelessness. The problems, I find, are not fundamentally different, but the phenotype, the manifestation of common, universal problems, such as social isolation, poor nutrition, insecurity, addiction, comes with sharper edges.
Take, for example, a gentleman I saw yesterday. He came in for “blocked ears.” He sometimes said “rocks and things” came out of them. On exam, they were dry and scaly but otherwise looked normal.
During my exam, he developed a sudden and urgent itchiness of his eyes and couldn’t seem to shake it. He had trouble staying awake even in our very brief visit. In my role on a mobile medical van, the resources at my disposal allowed me to prescribe a drop to help with itching, get him an appointment with a social worker, and another to establish primary care at a local clinic. I think the likelihood he will keep his appointments is just a bit lower than the likelihood he will pick up the drops.
What if I had more to offer? A quick review of his chart revealed that his last interaction with the health system (we can access a fairly comprehensive picture of our region) was about 10 months ago when the emergency room chart note told me he’d complained of suicidal thoughts and was “displaying behavior consistent with using the ER to meet his comfort needs.” Wow.
A slightly deeper dive showed ER visits once or twice yearly, a handful of short, involuntary stays at a couple of the local mental health hospitals, and one short jail stay in the last decade or so. What if, after any of the ER visits, or even after one of the mental health stays . . . What if he’d been offered peer counseling, a safe and therapeutic housing option, a case manager, or even a comprehensive assessment of his mental, physical and social health needs (that could possibly be accessible to future service providers?) Quite objectively, would we have spent less money as a society caring for him? More humanely, would he have had a better decade? Would he even have perhaps learned the skills, gained the resources, tangible and intangible, to allow him to be a participating member of mainstream society? I wish I could try out such a system.
A few years back, in their wisdom, Medicare decided that to incentivize safe over quick discharges, they would penalize hospitals if people were re-admitted within 30 days of discharge. This spurred many hospitals to start figuring out how to help people safely transition from hospital to home. Things got a little better. Even further back, as a resident, we developed a system we called “tag you’re it” to solve the problem of people who called us for help being given the runaround; burdening those in need with the chore of figuring out whose job it was to solve the problem.
Wouldn’t it be great if, when a person in need, such as my gentleman with ear pain, came to me, or interfaced with any service provider, we became “it”; tasked with the job of embracing the complexity of the situation and helping to change the trajectory with a robust solution; guiding and helping him toward genuine improvement in his situation? I don’t blame the emergency room doctor. They didn’t believe he would benefit from a short in-patient mental health stay because they knew what that entailed; another temporary fix to a much bigger problem. But if the ERs and mental health facilities had skin in the game; if it mattered to them what happened to him after his visit, we would quickly learn what resources are available (and which are in short supply) to help assure him a safe transition.
As long as the system continues to reward us for reducing complex presentations to simple ones, turning homelessness and mental illness into ear pain or homelessness and suicidal thoughts into “using the ED to meet comfort needs,” we will never even start investing in actual solutions to the complex problems of social isolation, poor nutrition, mental illness, homelessness, addiction, and so many others.
Nancy Connolly is an internal medicine physician.
Image credit: Shutterstock.com
