A week after returning from Dallas, I had lunch with my fellow fourth year residents. They are all compassionate, fierce advocates for patients, and without hesitation they support the principles of social emergency medicine. It would be difficult to not do so after training at our under-resourced county hospital. Yet they expressed valid skepticism for the implications of social EM in their practice. As grizzled senior residents, they have met frustration in trying to help patients with bleak housing situations or severe substance abuse disorder. They also have seen how fast and loose the practice of emergency medicine can be in the community. They did not doubt that social determinants of health were the key driver of patient outcomes, but they felt a lack of empowerment to recognize and intervene on those social determinants during a Tuesday night shift.
Empowerment is the key word that I reflect on even months after the Inventing Social Emergency Medicine conference. I believe that all emergency physicians want to practice social emergency medicine. But they need the tools to do so. And the tools have to meet the demands of our daily practice.
I was surprised with the outward-facing nature of the discussion in Dallas. The participants were a select group of researchers and community leaders with whom I was honored to even share the same room. Yet they recognized the need to make social EM relevant and vital to all emergency departments and providers.
How can we empower physicians and nurses to screen for social determinants of health? How can we help them help patients? I now believe this to be the central research and policy question in social EM, for whatever domain you might consider: housing, substance abuse, intimate partner violence, healthcare access.
Part of the conference discussion centered on the idea that to practice good emergency medicine was to practice social emergency medicine. None of us can adequately treat back pain if we do not ask whether patients use injection drugs. None of us can discharge a patient with pneumonia if there is no way for them to fill a prescription for antibiotics. These are the questions that we should be asking, and for the most part, many of us are.
Yet we can and should extend our work beyond screening and addressing acute illness. We should be able to initiate substance abuse treatment for the patient with back pain when their MRI is negative. We should be ale to find a medical respite or medication assistance to the patient with pneumonia and avoid a costly and preventable hospital admission. For this next level, we cannot expect emergency physicians to invent these solutions on the fly – there are twenty patients in the waiting room and a line of ambulances waiting for triage. These solutions must be developed outside of the shift. We should empower champions to engage in this work, making this part of the central administrative and quality efforts of every emergency department.
Another thread of the conference discussion focused on the need for both local and structural responses for social EM. Local solutions are needed for local problems, finding housing options, obtaining access to mental health resources, or developing programs for complex care management. One of the key strategies should be to find community partners and resources that already exist, and to integrate the work of the ED more fully into the community.
At the same time, there are larger policy and regulatory interventions that can drive and sustain these efforts. Policymakers, regulators, insurers, public health advocates – they can set expectations for every emergency department, whether urban, rural, county, private, or academic. We can enlist JCAHO and CMS to make sure every ED provides social work and case management, makes policies to screen for social determinants of health, and provides solutions to common patient problems. EMTALA, in some ways, was the first and most consequential policy to address social emergency medicine – we now have to deliver on its initial promise and truly provide people with the stabilizing care that they need. The role of research should be to find evidence-based, effective interventions that allow the development of policies and system changes.
My fellow fourth year residents are ready to embark on careers in emergency medicine, and we are all headed in different directions. One thing that unites us is the motivation to do our best for our patients. The promise of social emergency medicine is to make our best even better. Ultimately, empowerment does not just benefit our patients – we will have more rewarding careers, face less frustration and burn-out, and stay true to our original vision for becoming physicians.