Q&A: Why strained EDs can’t overlook social factors driving health

Timothy M. Smith , Contributing News Writer

AMA News Wire

Q&A: Why strained EDs can’t overlook social factors driving health

Apr 10, 2023

Soon after Dhara Amin, MD, finished her residency in emergency medicine and went to work at the public safety-net hospital in Chicago, her hometown, in 2015, she began to realize how ill-prepared she was for the job. Or at least the job as she saw it.

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“I was the attending, and I recognized I knew the medicine really well, but I did not know the needs of the population,” said Dr. Amin in an interview conducted at the 2023 AMA National Advocacy Conference, in Washington. “It became very clear to me that the care patients needed often went outside of medical care—things like transportation, health literacy and being able to eat the right diet. It made me sad, and I wished there was something we could do about it.”

Dhara Amin, MD
Dhara Amin, MD, leads ED quality efforts at Cook County Health in Chicago.

Then she realized there was something she and her colleagues could do about it—they just weren’t yet trained to do that work.

She started learning more about social determinants of health and how “life expectancy varies by ZIP code.” And at the same time, she searched for other opportunities for furthering her knowledge.

That included joining the master’s program in health care quality and patient safety at Northwestern University Feinberg School of Medicine, in 2020. Then about halfway through her second year, she came across a post on LinkedIn calling for applications for the second cohort of the Medical Justice in Advocacy Fellowship, an education initiative from the AMA and the Satcher Health Leadership Institute at the Morehouse School of Medicine.

“This looks perfect,” Dr. Amin thought upon learning about the fellowship. She had by then been promoted to director of quality improvement and patient safety in the emergency medicine department at Cook County Health in Chicago. Dr. Amin knew she “believed in the principles that were written in the description.”

The fellowship aims to prepare the next generation of physician advocacy leaders to generate and exchange solutions and drive meaningful policy and structural changes. Its 14-month program begins with a three-day intensive and features monthly virtual trainings, as well as regular mentor engagement.

Dr. Amin, an AMA member, took time during the conference to discuss how the Medical Justice in Advocacy Fellowship has already affected her work and how she hopes to use the tools she has picked up to further her advocacy in coming years.

At the top of that list: giving patients more of a voice in Cook County Health’s work to improve patient safety and quality.

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AMA: As a young physician in a safety-net setting, how would you describe the challenges you face day to day?

Dr. Amin: The workforce is dwindling—we’re losing a lot of physicians to burnout—and I think social determinants of health and health equity play huge roles in that.

If my job was just to talk to a patient, try to figure out what's wrong with them, give them a medication or a treatment or a follow-up plan, then shake hands and say goodbye, that would be manageable. But that’s not my job. Each visit is complex, and often you don’t have support services. So then you feel responsible. When you hear, for example, that a patient can't take their insulin because they're transitioning from one home to another and they don't have a refrigerator. All of a sudden, the treatment plan you had been taught doesn't work.

It feels overwhelming, so I think many of us try to protect our psychological safety. I often felt I should be taking on the role of social worker, pharmacist, any number of things. The rest of the workforce is feeling that too, and many of them are leaving because they're thinking: “I don't mind asking those questions, but when a patient needs something, there should be the resource I can point them to.” That’s the problem: Often there isn’t one.

AMA: You did your emergency medicine residency in Los Angeles, so you must have encountered many of the same issues you’ve since seen in Chicago. Did you have that same feeling of coming up short? Did you think it would be different once you were attending?

Dr. Amin: I definitely saw it, encountered it, felt it. But at that point, I was so focused on learning the medicine that I didn’t grasp what was going on in the larger system. My mind was on getting the test right, getting the diagnosis right. I was hearing patients’ stories and they were affecting me, but I was focused on becoming a doctor and gaining some sort of credibility in society and finishing what I came here to do.

But the thoughts about social determinants of health were always there. It’s considered a soft science, and I wondered how I could tackle all that while learning how to take care of patients. So at first I just put it in the back of my mind.

AMA: What drove you to apply to the Medical Justice in Advocacy Fellowship?

Dr. Amin: What I recognized after residency is the harm we're doing by, say, giving a patient a referral that doesn't work. It gives them false hope to suggest they just need to do something that we know our organization doesn’t have the capacity to do or that federal funding won’t cover. That's where a lot of physicians today are drawing the line. We all took an oath: Do no harm.

Also, we’re not looking just at the health of individual patients; we should be looking at the health of the community too. The COVID-19 pandemic was a great example. If I told someone they had to isolate, and I knew they couldn't, I was harming not only them and their family members but also the community they lived in—because I gave them instructions they couldn’t follow. I think that's when it became glaring to me that population health and clinical recommendations are often disconnected.

AMA: What is another example of how inequities play out in a public safety-net hospital?

Dr. Amin: An obvious example has to do with language. For example, we had documents and discharge folders in Spanish. So one day I asked, “If someone calls this number, will a person answer in Spanish?” And they said, “Oh, we didn't think about that.” So just adopting a health equity lens can give us some valuable insights.

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AMA: How has the fellowship helped you so far? What’s the content you’re working from?

Dr. Amin: One of the resources is the “Prioritizing Equity” video series, which has dozens of tutorials on health equity. There’s one on root causes of health inequity, one on quality improvement, one on voting. And I’ve pushed that tool forward to residents. I’m a core faculty for our emergency medicine residency of 68 residents. So there can be a multiplier effect. If I learn something, I feel like it's my responsibility to pass it on.

Also, J. Mori Johnson [ambassador engagement director and health equity liaison at the AMA] has been crucial because she has helped me understand the art of communication. We physicians tend to communicate really well with patients and colleagues but not so well with the public. Mori gave a virtual lecture and used great examples of how our stories and our patients’ stories can change people's opinions on a lot of issues.

I've stayed in touch with her, and every time she has office hours—she provides those to us monthly—I take advantage of them because she's really good at reading the room, and I don't think I have that kind of perspective yet.

This National Advocacy Conference has taught us how important a polished pitch is. A lot of us who do advocacy—we're not polished. We tend to think it’s just about appealing to people's feelings and explaining why an issue matters. We're learning that to push things forward, you need to couple that emotional appeal with some organized strategy.

That includes making connections with other organizations. I myself have never dabbled in that, but I realize now we're not alone. So I need to explore the community around me and find those organizations that may not be as big as AMA but are still fighting for the same things. Partnership-building has strategy behind it, and strategy will push the things I care about into policy.

AMA: What do you hope to accomplish in terms of patient safety and quality improvement in your department or elsewhere? Where do you hope to be in, say, five years?

Dr. Amin: I want patients and the community to have more of a voice in the decisions that are made within Cook County Health. For example, some patients will say, “Hey, I can't meet your blood pressure goal” for some reason, and that feedback is invaluable. So instead of being passive recipients of our care, they can become active stakeholders in it. They can help improve it.

Of course, we need a framework for that, so I helped create the volunteer patient and family advisory council [PFAC]. I co-chair it with our chief experience officer. At our first meeting, we had about 20 suits there, but we didn't even have a lot of patients. So I knew it was going to take work. The community trusts us to some extent already—they get their care from us—but we have to continue to build trust if they’re going to share their honest opinions about what we're doing. And when they voice their opinions, we have to follow up with real change.

In five years, I hope the PFAC’s input becomes the basis for almost everything happening in the hospital. I want the administration to evaluate every decision by asking: What did the PFAC say?

AMA: So even the PFAC needs a process of continuous quality improvement?

Dr. Amin: That’s right. For example, I think patients should be compensated for their time. They're giving us vital information on how to make our organization better.

I remember a physician working in the patient-experience arena once told me that his medical center gave out gas cards. But in Chicago at least, a lot of our patients use public transportation or the Medicaid ride service—they don't need gas cards because they don't have cars.

So why don't we ask them what they would find most meaningful? It might be a meal. It might be something else, like a discount on their utilities or help getting connected to the Internet. If we just start asking the community, they'll give us those answers.