The Crossroads of Social Determinants

According to the US Department of Health & Human Services, “Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”  Thus, there is a spectrum of attributes that characterize SDOH, and people vary greatly along these attributes.

How might one meet people embodying this range of variations?  My experience has been that people in waiting rooms in urban urgent care and emergency departments within the US healthcare ecosystem provide a panorama of insights into SDOH.  Personal and professional experiences in these types of organizations have provided a wealth of insights.

I have experienced these organizations in Atlanta, Baltimore, Hoboken, Newark, and Washington.  Some instances were due to personal falls and injuries.  Others were related to research studies of the operations of these organizations.  In all cases, unlike most of the rest of the healthcare system, the patients arrived with a variety of maladies that were completely unscheduled.  Consequently, some form of triage began up front.

While waiting, I had the opportunity to observe the population also waiting.  Many people were obviously rather poor, with ill-fitting clothing.  A surprising number wore bedroom slippers, even though the weather was cold.  Quite a few talked to themselves, a bit too loudly.  Some of these people walked around as they talked.

Many were quite friendly, although I often could not understand what they were saying.  I remember an older woman going to the snack vending machine and buying cookies for an unhappy child, even though she was not at all related to the child.  Everyone tended to make sure that all people had seats, shifting around to create space.

The staff, in one place where I interviewed care workers, referred to some patients as “frequent fliers.”  They would repeatedly appear in the emergency department, often seeking pain medicine.  One patient in Baltimore had shown up 200 times in two years.  When I asked why, the care worker said, “He doesn’t know what else to do.”

Interviewing nurses and social workers, they told me substance abuse was usually just one of several challenges.  Patients often had other health issues, were unemployed, and homeless.  Consequently, they needed a range of health and social services that were difficult to schedule.

In one instance I observed, a physician was very frustrated with the backlog of patients and berated a patient, telling her that she was wasting his time, despite the fact that she had arrived by ambulance.  When she asked a nurse what she had done wrong, the nurse replied, “Don’t worry.  That is just his style.”

Waiting is the currency in emergency departments.  Unless the triage gives you priority, the wait time is usually hours.  One of our studies in Atlanta determined that incompatibilities between IT systems in the emergency and radiology departments were causing an extra hour of wait time for everyone.  As is often the case in healthcare, the ultimate cause was allowing each department to choose their own “best in class” IT support, without considering compatibility across departments.

One of my colleagues related an astonishing story.  Her grandmother was waiting for attention in an emergency department.  The wait was so long that she died in her seat.  I am sure that this is not a unique event as the department addresses “emergencies.”  Yet, it is quite sobering to imagine this woman’s experience.  To an extent, it is a shared experience across everyone spanning the social determinants of health.

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