How can social determinants of health be integrated effectively into medical education and clinical practice?
This episode focuses on the topic of social determinants of health, or the social and environmental factors that influence our health and access to resources. Center for Ethics Assistant Director Libby Bogdan-Lovis and Associate Professor Dr. Karen Kelly-Blake speak with College of Human Medicine student Brittany Ajegba, who emphasizes the need for standardization when training physicians on social determinants of health. From medical education to clinical encounters, they provide a variety of perspectives on this increasingly important work.
This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.
About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.
“We overworked, underpaid, and we underprivileged They love us, they love us (Why?) Because we feed the village”
– Killer Mike of Run the Jewels
“Lie, Cheat, Steal,” Run the Jewels 2 (2014)
In the United States, persons of color suffer disproportionately from a host of health care disparities related to racism, discrimination, lack of access, and undertreatment. When considering this disproportionate suffering, it is relevant to note the impact of the current physician shortage. That shortage is especially acute for underrepresented in medicine (URiM) physicians. Moreover, it is equally salient to recognize that URiM physicians provide care for underserved populations at levels disproportionate to their professional representation. There is a powerful narrative that a diverse and representative medical workforce, one reflecting general population characteristics, can effectively address access issues, increase satisfaction, and ultimately improve health outcomes. It seems reasonable to surmise that shared concordant characteristics (e.g. race/ethnicity, language, gender, geographic location, etc.) between patients and physicians might lead to improved communication and satisfaction in the clinical setting. Alsan et al. found that black patients paired with black physicians were more likely to agree to preventive screening, leading the authors to conclude that the racial/ethnic concordance between patient and physician was a significant factor for the observed increase in screening adherence. Kelly-Blake et al. found that the most mentioned rationales for increasing patient-physician concordance were patient-physician relationship and service commitment to care for the underserved.
A 2001 IOM (now the National Academy of Medicine) report warned that “we must be vigilant against the potentially pernicious effects of creating the expectation that minority physicians are being trained solely to provide health care services to minority patients or to research minority health issues.” It is now 2019 – nearly 20 years on – and so it seems a good time to revisit that prudent caution. Have we heeded the IOM’s prescient warning? I invite you to join me for a brief thought experiment. Suppose we made the profession of medicine responsible for caring for our most vulnerable—the sickest sick and poorest poor? Imagine that all patient panels included a significant number of homeless, poor, mentally ill, and uninsured. Imagine an equal, fair, and just distribution of medical care service to the underserved. The described distribution would lighten the service expectation on URiM physicians. We know that URiM physicians bear a disproportionate burden of providing care for the most vulnerable patients in the most challenging resource poor environments. It’s not unreasonable to imagine how such a burden might substantially constrain their ability to meet quality care metrics for reimbursement. Moreover, as we move from volume to value for reimbursement, for those URiM physicians who carry comparably higher educational loan debt and work to a greater degree than their white counterparts in resource poor communities with the sickest sick, the challenge of achieving measurable improvements in quality care would seem untenable.
The individual altruistic motivations of URiMs to “give back,” “make a difference,” and “help the community” are powerful. And indeed, those motivations are likely influenced by “community” expectations that people will return “home” to practice. Certainly, URiMs have valuable insider experiential knowledge about navigating the challenging, socially-layered U.S. landscape. Those perspectives would undoubtedly bring an enhanced sociocultural perspective to the clinical encounter. Community expectations align with similar sentiments. Individuals coming from underserved communities who desire to become a physician are often supported, encouraged and, yes, expected to come back to serve in the community. The community understandably holds out hope that someone from the neighborhood will come back and do good work for the community. While understandable, is such a community expectation fair?
Image description: an individual with angel wings wearing blue surgical scrubs, a face mask covering their mouth, a cap, and glasses is standing with their arms crossed in front of a neutral background. They have a stethoscope around their neck. Image source: Sathish Kumar Periyasamy from Pixabay.
Desire to serve and to give back are laudable and admirable virtues, but is the “narrative of service” subtext disproportionately and perhaps unfairly limiting URiM potential professional opportunities? In our desire to have URiMs serve the underserved as physicians, are we paradoxically denying them opportunities to serve the profession of medicine as Chairs of Departments, Deans of Medical Schools, Chief Executive Officers of Hospitals, or Heads of NIH? Are we saying, “welcome to the house of medicine, but we need you to work in the basement kitchen”? If URiM have become the workhorses of medicine, who then is provided the opportunity to become the stallions and thoroughbreds? White medical student and physician counterparts do not receive the same targeted messaging about service commitment.
Research has shown that higher numbers of primary care physicians lead to better health and decreased mortality. Despite the call and the need for more primary care physicians, medical students are not choosing primary care specialties. Mona Signer, CEO of The Match, suggests that income is a factor because choosing a non-primary care specialty means a higher paycheck. The highest paying specialties remain overwhelmingly white and male. Who then is allowed the unfettered freedom to make the non-primary care specialty choice? Who gets to have access to opportunities untied to community and societal expectations? The burden of serving exhausts URiM talent and expertise. So, who reaps the benefits? If the argument is that: 1) society benefits from more primary care physicians in underserved areas, especially critical in rural areas, 2) medical schools benefit by meeting more stringent LCME accreditation requirements for student diversity, and 3) patients benefit by having physicians in their community that look like and sound like them, then undertaking strategies to ensure a broadly representative medical workforce is indeed a national priority. But, if the argument is that URiM value is to “serve the underserved” then the IOM warning has indeed been ignored. Racial congruity alone is insufficient to address the disparities gap in U.S. health care, and like-to-like patient-physician matching may dangerously and perversely heighten discrimination against URiM physicians.
URiM should not be selectively steered, based solely on assumptions of their background, to pursue a particular medical career pathway. The healthcare workforce should reflect the nation’s population and equally, it is still fair and just to question why we are channeling URiMs to do work not expected of the entire medical workforce. How might we ensure equity of healthcare work practice? Ensuring such equity is a moral obligation and the rightthing to do. Professional fairness and responsibility within medicine mandate that the medical workforce equitably and fairly assume shared responsibility for meeting the healthcare needs of the underserved. Continuing an expectation of burdening the already overburdened is not just health care.
Karen Kelly-Blake, PhD, is an Associate Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine in the Michigan State University College of Human Medicine.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 1, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.
You must provide your name and email address to leave a comment. Your email address will not be made public.
Center Associate Professor Dr. Karen Kelly-Blake is co-author of a research article in the July 2019 issue of the American Journal of Preventive Medicine. The multi-institution research team includes lead author Dr. Masahito Jimbo of the University of Michigan.
“Interactivity in a Decision Aid: Findings From a Decision Aid to Technologically Enhance Shared Decision Making RCT” reports on a study that used a randomized control trial to compare the effect of a web-based decision aid that addressed colorectal cancer screening. They concluded that the interactive decision aid did not improve the outcome compared to the non-interactive decision aid.
The full text is available online via Science Direct (MSU Library or other institutional access may be required to view this article).
The Center for Ethics and Humanities in the Life Sciences is thrilled to announce the promotion of Dr. Karen Kelly-Blake to associate professor. Dr. Kelly-Blake holds an appointment in both the Center for Ethics and the Department of Medicine in the College of Human Medicine (CHM).
Dr. Kelly-Blake holds a PhD in medical anthropology from Michigan State University and specializes in health services research, shared decision-making, and medical workforce policy and development. She joined the Center in 2009 as a project manager on a grant of Dr. Margaret Holmes-Rovner’s, became a research associate in 2011, and assistant professor in 2014. She has played an integral part in the development and implementation of social context of clinical decisions (SCCD) content in the CHM Shared Discovery Curriculum.
Dr. Kelly-Blake is currently working with colleagues in the Department of Medicine, the Department of Writing, Rhetoric, and American Cultures, and the Department of Epidemiology and Biostatistics to resubmit an NIH R01 to assess implementation of the Office Guidelines Applied to Practice Program for medication adherence for heart disease management in people with diabetes in Federally Qualified Healthcare Centers across the state of Michigan. She is also working with colleagues at the University of Michigan to submit a new NIH R01 to assess a multi-level clinical intervention for patient navigator enhanced colorectal cancer screening in community primary care practice settings. Additionally, she is working with the Assistant Director of the Center for Ethics on a project to assess the value of patient-physician concordance on patient health outcomes.
How can shared decision-making tools and evidence-based guidelines be used to ensure that every patient receives the best care possible? How can patients be activated and equipped to interact with their provider and manage their health condition? In this episode, three Michigan State University researchers—Dr. Bill Hart-Davidson, Professor in the Department of Writing, Rhetoric, and American Cultures, Dr. Karen Kelly-Blake, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine, and Dr. Ade Olomu, Professor of Medicine in the Department of Medicine—discuss a shared decision-making tool they developed called Office-GAP, Office-Guidelines Applied to Practice. Together they discuss the origins of the project, and the results so far in improving outcomes for patients managing chronic illness by using a simple checklist to get patients and providers on the same page.
This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.
About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.
Center Assistant Professor Dr. Karen Kelly-Blake is co-author of an article published in Health Services Research and Managerial Epidemiology, “Sex Differences in Statin Prescribing in Diabetic and Heart Disease Patients in FQHCs: A Comparison of the ATPIII and 2013 ACC/AHA Cholesterol Guidelines.”
The team of Michigan State University College of Human Medicine researchers, Nazia Naz S. Khan, Karen Kelly-Blake, Zhehui Luo, and Adesuwa Olomu, found statin underprescribing for both men and women with atherosclerotic cardiovascular disease and diabetes mellitus in Federally Qualified Health Centers.
The full text is available online with open access via Sage Journals.
An article from a multi-institution research team led by Center Assistant Professor Dr. Karen Kelly-Blake and Assistant Director Libby Bogdan-Lovis has been published in the September 2018 issue of Medical Education.
In “Rationales for expanding minority physician representation in the workforce: a scoping review,” the authors discuss “rationales for and approaches to expanding under‐represented minority (URM) physician representation in the medical workforce” found in their scoping review of fifteen years of literature.
The full text is available online via Wiley Online Library (MSU Library or other institutional access may be required to view this article).
Dr. Kelly-Blake and Libby Bogdan-Lovis further discussed their article in an interview for the Medical Education podcast series.
The authors suggest that the expanding emphasis on URM service commitment and patient–physician concordance benefits warrants ongoing scrutiny providing a cautionary tale of unintended consequences for medical educators globally https://t.co/ryvUWIzINf@msubioethics#MedEd
A public uproar ensued when a video revealed hospital staff literally dumping a woman wearing only a gown and socks in frigid weather on the streets of Baltimore. Imamu Baraka, a psychotherapist, witnessed the incident and recorded it on his cellphone. In the video, we see Mr. Baraka questioning the security personnel about their activity, and then we see them silently walking away.
Image description: a crumpled hospital gown is pictured on the edge of a concrete ledge. The background is a concrete sidewalk. Image source: Lynn Park/Flickr Creative Commons.
The fact that the public appeared to be surprised by this event was bewildering. Patient dumping is hardly a new phenomenon, and in fact, it should not come as a surprise that those being dumped in this fashion are predominately non-white, poor, homeless, mentally ill, uninsured, and drug users. So, what is patient dumping? It is when hospitals that are capable of providing necessary medical care fail to screen, treat, or appropriately transfer a patient, or alternatively, when they turn the patient away because of the patient’s inability to pay for services.
Hospitals have long relied on this tactic as a way to offset care for those patients who cannot cover their costs, and so the hospital then is not reimbursed—it is an economic profit-loss decision. But, this blog is not about blaming hospitals. It is about recognizing that patient dumping is a symptom of larger healthcare system and societal ills. Consider the following:
Thirty million people in the U.S. remain uninsured after Affordable Care Act (ACA) implementation. Forty million adults experience mental illness in a given year. 554,000 people in the U.S. are homeless. Forty-three million live in poverty. Every day, the opioid epidemic claims 175 lives. These many data points speak to the U.S.’ combined lack of healthcare and social safety nets. Filling those gaps alone could potentially avert patient dumping.
By default, public, not-for-profit hospitals are charged with caring for such vulnerable patients. In the era of value-based, pay-for-performance, and accountable care organization (ACO) reimbursement models, those hospitals consequently will struggle to meet Centers for Medicare & Medicaid Services quality care metrics.
Federal legislation such as the Hill-Burton Act and later the Emergency Medical Treatment and Labor Act (EMTALA) were instituted to address legal and ethical concerns about patient dumping. Signed in 1946 by President Truman, Hill-Burton directed hospitals to make services available to anyone living in the geographic region of the hospital and to provide care free of charge to those individuals unable to pay. Signed in 1986 by President Reagan, EMTALA was enacted to protect all individuals seeking treatment at Medicare-participating hospital emergency departments. In addition to federal statutes, states also have passed legislation requiring hospitals to provide care irrespective of ability to pay and require that patients be medically stable before transfer. Regrettably, federal and state laws have not performed as was intended. Statutes designed to prevent patient dumping are criticized for 1) having narrow and unclear definitions of what constitutes a medical emergency; 2) failing to clarify what it means to stabilize patients before a transfer; and 3) failing to adequately provide the means for monitoring and enforcement (Ansell & Schiff, 1987).
Image description: An aerial photo of a medical waiting area shows rows of blue chairs, and three seated individuals dispersed throughout. Image source: Erwin Morales/Flickr Creative Commons.
It would seem that patient dumping is symptomatic of larger macroeconomic and macrosocial issues. What possible solutions exist?
Suppose we actually provided health care to everyone? The ACA has greatly expanded insurance coverage by extending Medicaid, but many people remain uninsured due to prohibitive costs. Imagine having access to health insurance that was not employment dependent. Imagine that people with mild, moderate, and severe mental illness received comprehensive health services. Imagine a system of care that recognized that social determinants of health profoundly influence health outcomes. Imagine having food assistance folded in as part of a medical treatment.
Suppose we eradicated poverty and homelessness? Imagine a time when people could actually support themselves and their families because they made a living wage. Imagine that support was available for people to simultaneously work and pay for childcare.
Suppose we actually utilized comprehensive discharge planning for patients? Imagine planning documents that were easy to read and comprehend because health literacy was important. Imagine patients understanding the medications they needed to take when they got home. Imagine that prior to discharge patients had appointments scheduled for follow-up visits and had the transportation in place to get them there. Imagine providing support visits for elderly patients to make sure they were living in decreased fall risk environments.
Suppose we made the profession of medicine responsible for caring for our most vulnerable—the sickest sick and poorest poor? Imagine that all provider-patient panels included a significant number of homeless, poor, mentally ill, and uninsured individuals. Imagine an equal, fair, and just distribution of medical care service to the underserved that lightened that specific expectation on under-represented minority physicians (URMs). We know that URM physicians bear a disproportionate burden of providing care for the most vulnerable patients. Such a burden might substantially constrain their ability to meet quality care metrics for reimbursement.
Incidents of patient dumping such as the one recorded in Baltimore should not be cause for public consternation. The public protestation should instead be about macro-level systems and social ills that make such responses unsurprising. The above suppositions are probably wild-eyed idealist notions. But for a moment, just suppose they weren’t?
Karen Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine at Michigan State University.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 9, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.
You must provide your name and email address to leave a comment. Your email address will not be made public.
The U.S. project of mass incarceration reveals that more than 2 million people are jail-involved at any given time. That rate far exceeds that of any other nation in the world. Incarcerated patients are sicker, bearing an increased burden of chronic disease, namely addiction, viral infections, and mental illness. Conditions often exacerbated by solitary confinement. Moreover, those incarcerated are disproportionately from communities of color suffering from historical racial discrimination. Consider the following: Whites (non-Hispanic) comprise 64% of the U.S. population, 39% of the U.S. incarcerated population, and the national incarceration rate (per 100,000) is 450; Hispanics make up 16% of the U.S. population, 19% of incarcerated population, and the national rate is 831; Blacks are 13% of the U.S. population, 40% of the incarcerated population, and the national incarceration rate is 2,306 per 100,000.
Image description: a black and white photograph showing a person’s hands reaching through from behind metal fencing. Their hands are grasping the fence in the foreground, and the rest of the person’s body is not visible. Image source: Tiago Pinheiro/Flickr Creative Commons
In the 1976 Estelle vs. Gamble ruling the U.S. Supreme Court established that “deliberate indifference to healthcare for inmates constituted cruel and unusual punishment, and was thus prohibited by the U.S. Constitution.” In April of this year, a class action lawsuit was filed in the State of Illinois arguing, “health care inside the Illinois Department of Corrections systematically puts inmates at risk of pain, injury, and death.” In effect, Illinois has been put on notice that the correctional health care it provides (or the lack of provision), violates the 1976 Supreme Court ruling. Of course, Illinois is not the only state faced with this problem. A recent ruling found the Alabama Department of Correction’s mental health care system to be “horrendously inadequate.”
The challenges to delivering health care in correctional institutions are similar to those experienced in delivering care in any under-resourced setting that serves vulnerable patients. Overcrowding and understaffing are oft-cited explanations for the inadequacy of correctional health care delivery. An additional, deeply concerning factor is the privatization of prisons with related underbids, cost overruns, and vast gaps in the actual services provided. With increasing numbers of women cycling in and out of prison, women prisoners have specific health needs related to the increased likelihood of being victims of domestic and sexual violence. There is a pressing need for correctional health care services to address these health issues.
Image description: a close-up photo of the bars of a prison cell, with the bars in focus in the foreground and an empty green/yellow cell visible in the background. Image source: Dave Nakayama/Flickr Creative Commons
As a matter of justice, incarcerated patients should receive the same level of care that they would receive in a community setting. Unfortunately, this notion is not politically popular. Nevertheless, work is being done to merge correctional health and public health to ensure continuity of care once prisoners are released. Significantly, the Affordable Care Act (ACA) specifically addresses the importance of ensuring that the jail-involved have access to the same benefits as the non-incarcerated. The ACA expansion of Medicaid eligibility supplies a critical opportunity to treat prisoners once released. Untreated substance abuse and mental illness among the jail-involved increases their likelihood of future imprisonment.
Health care providers often find themselves serving two masters in correction settings. Providers have a duty to provide care that is in the best interest of the patient, but equally, they are also employed by the institution that has other, often conflicting interests, namely to confine, punish, and possibly, rehabilitate. This conflict is referred to as dual loyalty. The virtual societal silence on larger issues about the nature of the institution of incarceration is problematic and makes many correctional health providers “complicit as the United States has embarked on a vast and unprecedented social program of mass incarceration.” Given this state of affairs, providers should use their professional power and work to advocate for and insist upon substantial reforms in clinical care within prisons. A key critical reform is to eliminate solitary confinement. Medical providers also must advocate for change in the criminal justice system. The current project of mass incarceration in the U.S. harms the individual health of prisoners and the public health of the community.
Because of lawsuits or the threat of lawsuits on behalf of prisoners, as well as the dedication of committed health care professionals, activists, and advocates, the quality of health care in prisons has steadily improved. Yet there remains vast room for improvement in clinical care. Physicians hold leadership and management positions in correctional institutions. Combined with the social privilege afforded them in the U.S., physicians have the power, and I would argue the obligation, to spearhead reforms in correctional health care and ensure that the incarcerated sick are at no greater risk than the non-incarcerated of pain, injury, or death.
Karen Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine at Michigan State University.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 10, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.
You must provide your name and email address to leave a comment. Your email address will not be made public.
Center Assistant Professor Dr. Karen Kelly-Blake is a co-author of an article in the April 2017 issue of the American Journal of Preventive Medicine. The article, “Correlates of Patient Intent and Preference on Colorectal Cancer Screening,” is co-authored by Masahito Jimbo, MD, PhD, MPH, Ananda Sen, PhD, Melissa A. Plegue, MA, Sarah T. Hawley, PhD, MPH, Karen Kelly-Blake, PhD, Mary Rapai, MA, Minling Zhang, BS, Yuhong Zhang, BS, and Mack T. Ruffin IV, MD, MPH.
From 2012 to 2014, a total of 570 adults aged 50–75 years were recruited from 15 primary care practices in Metro Detroit for a trial on decision aids for colorectal cancer screening. The article discusses the results of that trial. The full article text is available on the ScienceDirect website (MSU Library or other institutional access may be required to view this article).
No Easy Answers in Bioethics Episode 18
This post is a part of our 
Karen Kelly-Blake, PhD
Center Associate Professor 
An article from a multi-institution research team led by Center Assistant Professor 
MSU Bioethics 