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Training Physicians to Think Broadly About Health and Wellness

Every Saturday morning, I see patients at the Bronx Transitions Clinic, which serves formerly incarcerated individuals. For most of my patients who are coming home from prison, acquiring stable housing and employment is a higher priority than managing their chronic illnesses. As a primary care physician, I may not be able to offer them jobs; however, without recognizing the impact of joblessness on their health and wellness, there is no way I can make a correct diagnosis.

Homeless person sitting at base of stepsAt a time when more medical students are specializing, with narrower focuses and more emphasis on procedures and technological interventions, we need to train physicians to think broadly about health and wellness and give them opportunities to effect change. We’ve narrow-mindedly focused on problems that can (or cannot) be fixed—tumors to remove, joints to replace, hearts that need a “tune-up”—at the expense of prevention and health promotion. Data demonstrating the pernicious effects of some social determinants of health, such as poverty or racism, are irrefutable. But these social conditions are not easily fixed.

Physicians as Patient Advocates
Nonetheless, physicians need to attempt to address these problems. Advocating for a healthier and more equitable society is one way to do it. Dr. Mary Bassett, the health commissioner of New York City, wrote a passionate call to action for physicians to speak out on racism. I agree completely. In primary care, I also see the effects of poverty daily. If my patient is stuck in housing with mold that is worsening her asthma, I can’t be satisfied with “stepping up” treatment with extra medication. I can also refer her for legal assistance and advocate for more-affordable housing. Physicians need to remember that their patients spend 15 minutes (or less) in their offices, and the rest of their lives in a world where homelessness and gun violence are risk factors for poor health—risk factors that are not modifiable within the doctor’s office.

Soon after I moved to New York City to attend medical school, this relationship between social conditions and medical care was clearly demonstrated to me. I was speaking with a young homeless man who was sitting on the steps of a church near Washington Square Park. He told me he was HIV positive. I had thought that people living with HIV/AIDS were guaranteed housing in NYC, but he explained that he was forced to move every 30 days, so he had simply given up on the emergency housing. I was outraged. How could someone establish stability in managing a complex chronic illness when his entire life was uprooted monthly? But what could I do about this?

Three years later, as a fourth-year student at Albert Einstein College of Medicine, I was still troubled by how housing instability would affect my future patients’ health, but I hadn’t learned much about it in my classes. I participated in an elective in research-based health activism (RBHA) at Montefiore Medical Center, which challenged me to develop a research project to better understand the problem. I chose to study housing instability and access to medical care for HIV.

Now, more than a decade after all that, I’m the course director for the RBHA elective. Students visit Montefiore from all over the country for the month-long elective and develop research proposals investigating health disparities that they’ve observed in their communities. Students learn to approach their research with rigorous methodology, but they also develop an advocacy plan to maximize the impact of their findings. Publishing high-quality research in academic journals isn’t enough. Our studies should directly affect policy; therefore, it is our responsibility to bring our findings to the decision makers—whether they are hospital administrators or elected representatives—who can effect change. I recently discussed this in a piece published in the AAMC Reporter.

Moving Advocacy Focus from One to All
Physicians are comfortable advocating for individual patients, especially in the era of restrictive managed care, to make sure that they receive the care they need; however, public advocacy, which promotes social, economic or political change to address threats to human health and well-being, has not been stressed in medical education. Researchers from Harvard’s School of Public Health and Medical School surveyed more than 1,600 physicians, and more than 90 percent rated community participation, political involvement and collective advocacy as important professional roles. But few practicing physicians actually perform these roles. Overburdened schedules likely limit physicians’ time for public advocacy, but without the skills to advocate for social change, few will even attempt to get involved. Courses such as the RBHA elective are necessary to prepare physicians to fulfill their professional duty.

My study on housing instability and HIV did get completed, and luckily the policy requiring changes in emergency housing every 30 days was lifted, due to the efforts of community activists. More recently, I have been working with a broad coalition to advocate to the state government for better reentry services for older prisoners who are coming home following release, especially for those with chronic health conditions.

The most rewarding part of my job as a physician is still seeing patients whom I have known for more than a decade. But now, when I am feeling outraged at the things affecting my patients’ health that are out of my control, I have a plan for action.

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Aaron Fox, M.D., M.S.

Aaron Fox, M.D., M.S.

Dr. Fox is assistant professor of medicine at Albert Einstein College of Medicine and a clinician-investigator in the division of general internal medicine at Montefiore Health System. His research currently focuses on opioid addiction and the criminal justice system. Dr. Fox is the co-director of the Bronx Transitions Clinic, which provides care for patients who have recently been released from correctional facilities.

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