SEM

Lynton Scholar Austin Kilaru, MD, Reflects on the SEM Consensus Conference, September 2017

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.

Lynton Scholar Theresa Cheng, MD, Reflects on the SEM Consensus Conference, September 2017

The local Emergency Department (ED) is a microcosm of its surrounding communities and the social determinants of health impacting residents’ abilities to pursue individual wellbeing. As our societal safety net, EDs – and the providers within – are in a unique position to address medical and social emergencies. Emergency physicians are given the opportunity to intervene on behalf of patients as advocates of essential medical and social needs. Social Emergency Medicine (SEM) is a timely and increasingly necessary field as the future of our healthcare system is becoming more uncertain and more patients find themselves seeking the ED as a last resort. Institutionalizing SEM through the consensus conference “Inventing Social Emergency Medicine” formally establishes the field, providing context and space from which EM providers may work. As a Lynton Scholar, I was privy to this roundtable discussion that assembled leaders of the field, from experienced forebears of Emergency Medicine to current trailblazers in SEM research. While participants presented distinct research on topics such as homelessness and community violence, the common goal of health equity was palpable throughout – the conference was a chance to define, mediate, and enhance the interplay between medicine and social justice that naturally exists in the ED. Central to our discussions was the recognition of the need to expand the ED’s role in incorporating population-based health research and interventions while leveraging already-established resources in local communities. Stronger ties with fellow providers, such as social workers and nurse practitioners, would bolster our abilities to address social needs in the ED; meanwhile, connecting with unexpected allies, such as lawyers and anthropologists, would innovate the way we deliver this care. By integrating social structural analyses to medical and public health curricula, we would be providing future generations of health professionals with the lenses to identify, treat, and ultimately prevent social determinants leading to disease. The need for SEM, as reflected in the realities of many of the patients we encounter in the ED, extends beyond the moral imperative as this pragmatic approach can help to reduce ED recidivism and overall healthcare costs. By identifying and addressing our patients’ unmet social needs, we seek to disrupt the multi-faceted causes of their illness and improve the overall health trajectory. Through “Inventing Social Emergency Medicine” and future such collaborations and conferences, SEM has become not just a doctrine within medicine, but a way of practice and a way forward in advancing health justice.

Post Script: I am extremely grateful for the Lynton Scholarship that allowed me to take part in the inaugural conference of social emergency medicine. Many thanks to the family of Jamie and Michael Lynton as well as the Andrew Levitt Center for Social Emergency Medicine for this momentous opportunity.

Lynton Scholar Rebecca Karb, MD, PhD, Reflects on the SEM Consensus Conference, September 2017

by Rebecca Karb, MD, PhD

It was an honor to attend the Social Emergency Medicine (SEM) Consensus Conference at the American College of Emergency Physician (ACEP) headquarters in Dallas, Texas. What an inspiring experience to get together with such a thoughtful, motivated, and justice-oriented group of EM physicians. The dialogue raised many important questions regarding the priorities for SEM as well as the strategies for pursing our mission. What is the most appropriate and effective strategy for addressing social determinants of health? And where is the most effective space to do so? Addressing SDOH in the ED is, by constraint of necessity, an individual-level intervention. As such, it should certainly be one of the tools that we research and develop as ED physicians; however, it cannot be the only space in which we intervene if we truly wish to address health inequalities.

We must be active and engaged at the community and policy level to change the underlying structures of inequality. For example, we may be able to develop an effective screen for homelessness or housing insecurity in the ED, and as a result provide an individual patient with the resources necessary to obtain secure housing. However, we have not altered the more upstream fundamental causes of disease but rather modified their effect on our individual patient. This is not unimportant and it is what we do as physicians—we treat individual patients. But our SEM mission must extend outside the walls of the ED and into our local communities and government. As ED physicians, we are on the frontlines of healthcare and have a unique window into the health of our communities. We should be systematically gathering information about our communities and using that knowledge in combination with our positions of privilege and power to advocate for fundamental changes at the policy level. I hope that we can continue to build a strong, cohesive movement and that EM can lead the way in the fight to eliminate health disparities.