The Case for Advocacy and Social EM Training

As defined by Shafer “Social Emergency Medicine is a focus and initiative within Emergency Medicine that strives to impact the social forces that affect a population’s health with the goal of making patients and communities healthier.”[1]

According to the ACEP Social Emergency Medicine Section, Social EM has become an important emerging initiative, because EM physicians have realized the need to:[2]

• – promote the incorporation of patients’ social context into routine emergency car
• – serve as a central organizing point for emergency providers interested in the interplay of the emergency care system and social forces affecting both patients and communities
• – foster high-quality research and translate this research into best practices for the application of social determinants of health at the bedside and beyond
• – disseminate ED interventions that improve population health through emergency care informed by community needs with a focus on EDs that see underserved patients
• – propose, evaluate, and critique health policies that affect the social determinants of health of our communities, especially as they pertain to marginalized and vulnerable populations that frequently present to EDs for their care

These contextual forces that can affect a population’s health are often synonymous with the term, social determinants of health. Your patient’s health is not just affected by factors such as genetics, epidemiology patterns in the region, and patient demographics. Other contextual factors that play a role in the health of people in the catchment area of a hospital include laws and regulations at multiple levels of government, the economy, socio-cultural factors, technology, and ecologic patterns. According to the Institute of Medicine differences in these surroundings are directly related to how many health problems an individual has compared to another individual who lives in a different context.[3] Moreover, according to the Levitt Center the chief complaints and disease processes we see on any given day working in the ED are influenced by laws and regulations such as assault weapons, motorcycle helmets, farm hygiene regulation, and an anticompetitive pharmaceutical market as well as the forces of behavioral economics: human choices, health behaviors, and risk behaviors.[4]

According to IDHEAL when we think about how social factors affect someone’s health, some topics that come to mind are:[5] 

-alcohol use
-built environment
-drugs and addiction
-education and health literacy
-employment and financial instability
-food insecurity
-structural and personal gender-based violence
-housing security and undomiciled
-human trafficking
-immigration
-incarceration
-language and culture
-structural and interpersonal violence towards LGBTQI
-medical-legal needs 
-police violence
-structural and interpersonal racism
-violence (gun, gang, domestic, sexual, etc).

Are we aware of the health problems surrounding these issues? How does each of these impact our patients and the communities we care about? 

Advocacy in Emergency Medicine means pushing for changes in society to reduce patient barriers to access to healthcare and health-promoting activities and to minimize structural inequity. Doing so strives to make our patients healthier at baseline, more likely to be able to access primary and emergency care, and less likely to need the ED through good preventive measures. Advocacy also means leading our specialty through changes that adapt to a dynamic society and context. 

According to the Advocacy Handbook of EMRA, 2nd Edition, many factors have affected access to care for many patients in recent years.[6] Our opinions are valued in society and we, therefore, have the ability to shape policy. Emergency medicine has become one of the largest political action committees with an annual leadership conference in Washington, D.C., that brings the message directly to the representatives. State chapters have wielded powerful voices on numerous issues, from the opioid epidemic to the fight for fair coverage and network advocacy.”[6]

An emergency medicine physician may argue: “I work in a public hospital and I treat all my patients equally. I escalate delays in patient care to my superiors. I do this at lower pay than my colleagues at other hospitals. That is my advocacy.” It is laudable that we choose to work in a setting with many challenges. When we advocate for our patients to specialists reluctant to arrange follow-up and work to decrease ED boarding, we are advocating for our patients. But our voice can move beyond the four walls of an ED to positively impact the health of so many people if we work to ameliorate the social, administrative, and policy factors that impact the health of our communities. According to EMRA, Advocacy at all levels as we learn more about how legislation can transform issues facing us and our patients as emergency physicians, we may become more interested in advocating for policy at the city, state, and national level.[7]

By striving to become hospital administrators, lobbyists, policymakers, academic program directors, population health research scientists, leaders of civil society organizations, and leaders of government organizations working at the local, state, national, and global levels, we can often do more for our communities and populations than by seeing patients one-by-one in a clinical setting. We have a voice through national organizations, such as EMRA and ACEP, which allow us the opportunity to guide how our specialty interacts with patients and communities and dictate what is standard of care for patients in emergency departments across the nation. We can help create changes in the components of our health system to improve the health of populations and we can have a say in how our specialty adapts to dynamic changes within our society. 

Many residents who choose Emergency Medicine as a specialty, especially those who choose to train in a public safety-net hospital, do so because of a unique setting where society intersects with the medical system. An ED visit is one of few moments where a person, living within the context of their society and their environment, interacts with the medical system and becomes a patient in a hospital, often for the first time. 

This type of work-environment attracts humans who wish to practice medicine clinically in a setting where federal law requires “anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay” [8]. Naturally, many clinicians who choose Emergency Medicine as a clinical specialty are equally well-suited to work for the wellbeing of entire populations motivated to advocate for marginalized communities and improve the context we live in. Many of us practice in the field of public health and many of us obtain advanced degrees to gain the tools to focus more on identifying and treating these social determinants of health through program and departmental administration, writing policy and lobbying for policy changes, and researching how to improve society at the community-level and beyond.

We can and should be well-versed in the medical knowledge AND also be knowledgeable about the social factors our patients must deal with every day and the detrimental effects this can have on someone’s health in order for us to provide a better standard of care in emergency medicine. With our non-clinical time, we should be advocates for our communities and use our skills and training to persuade stakeholders in influential positions to support meaningful changes that improve the health of hundreds to thousands of patients and non-patients in the communities we care about. 

Here is one view of the health system. In the periphery, you see contextual factors that affect the health of a population. The health system inputs are governance and organization, financing, and resource management. Populations interface with healthcare services and public health activities in different ways depending on the equity, efficiency, effectiveness, and responsiveness of those services and activities. The outcomes of a health system can be sorted into and measured as health, financial protection, and user satisfaction [9]. A physician is only one part of what influences a person’s health outcomes, and sometimes not at all. 

By understanding how contextual factors play a role in someone’s health through a GME and CME curriculum of social EM and advocacy, we can target our advocacy to change policies and practices within any part of the health system we identify to be influencing the health of our communities in a negative way. The patient-doctor relationship is not the center of the health system; many things affect the health of populations. So, it behooves us as healthcare providers to understand ALL the factors that contribute to the health of our communities and know what factors our patients face so that we may adapt our practice accordingly and function as a collaborating component of the health system of which we are part.  According to Dr Tedros Adhanom Ghebreyesus the WHO Director General, health equity equals better health outcomes for all our patients, and health equity is a human right.[10]

Today, the residents with whom I work are incredibly compassionate and invested providers during the COVID-19 pandemic, a tragedy for our community here in Brooklyn. We organize civic action and institutional change in our hospital, our community, nationally, and internationally as a popular ice cream company stated to “take concrete steps to dismantle white supremacy in all its forms” [11]. We want to see positive change for our communities and we want to learn how to advocate for these communities to ameliorate the social factors that negatively affect health. We want to learn how to do so at different levels of administration and policy and through effective community interventions. 

There is a strong case for emergency medicine residents to take opportunities to learn more about social emergency medicine and advocacy during the PGY2 and/or PGY3 years and take time as a senior resident to put this learning into practice through an elective practicum experience. The deaths of George Floyd, Breonna Taylor, Elijah McClain, and too long a list have reminded our institutions that we must all undergo continuous growth to assure we promote intersectional equity. Emergency medicine training should not be an exception. All of society can do better to promote the protection of human rights and promote equity of health outcomes. We as emergency physicians can either pat ourselves on the back feeling self-satisfied or we can continue to learn to do better for our patients. 

The 25-year-old Yemeni Arabic-speaking patient in the case above with the mandible fracture in NYPD custody is discharged and taken to the local precinct. 

How much of what you said in English and with the Standard Arabic translator (different from the patient’s Yemeni Arabic dialect) did the patient understand? If not much, does he know anyone who can translate the discharge instructions to Yemeni Arabic? Can he read and write? When will he get home from the precinct? What will he eat and drink until then? How did his jaw get fractured and were there any witnesses to identify any assailants? Can this patient navigate our legal system to demand justice for being assaulted? What will happen to this patient after he leaves the ED in NYPD custody? What are the ways we can advocate on his behalf beyond the friendly smile we gave him on his way out the door?