Patient Engagement
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Stay in Your Lane? Clinicians vs. SDOH (05:19)

Should physicians stay in their lanes when it comes to things like behavior change and social determinants of health (SDOH)? Or do they have a duty to reach out beyond clinical work?

“I appreciate the thoughts of staying in your lane,” says Duke adolescent medicine PCP Charlene Wong, “but in my own clinical practice, I can’t do that.” A big part of Wong’s job is talking with patients about their social history to pinpoint the emergence of risky behaviors. “I see it as a huge opportunity to intervene at a critical point and life stage,” she says.

Wong appreciates having other team members with social and behavior expertise available, too, such as at a Medicaid clinic she works at. “They’re not available all the time; they’re covering a huge panel of clients themselves,” she notes. “Until we’re able to have some more of those teams that are in place, consistently, I see my role as doing that.”

Stepping outside one’s lane is particularly importantly when connecting people with behavioral health care. “A lot of my patients are struggling with depression, anxiety,” says Wong. “If you’re not able to work on that simultaneously [e.g., with physical activity], the sustaining of any change you’ve achieved is going to be much harder.”

Roy Rosin, Chief Information Officer for Penn Medicine, says that physicians should stay in their clinical lane and let other experts do the non-clinical work.

Rosin describes Shreya Kangovi’s IMPaCT initiative, which identifies, hires, trains, deploys, and manages community health workers. The populations IMPaCT serves have poor relationships with the health care system, says Rosin. They are more likely to interact productively with people from similar backgrounds. “What these community health workers do is remove friction,” he says. “They understand [not only] what are those goals, but what’s standing in the way of those goals — how do we get rid of those things?”

“There is absolutely no way that the clinician can, in the period of time allotted, manage [patients’ SDOH needs],” says Rosin. A patient may not be able to deal with their health until they have stable housing, for example. Community health worker programs like IMPaCT can successfully intervene here; a clinician cannot. “Friction that has to be removed from the system goes well beyond the clinical setting,” says Rosin. “It’s so much work.”

Peter Ubel, Associate Director of Duke Health Sector Management, adds to Rosin’s point that clinicians have limited time. “In the 15 minutes you’re with a patient, you have to maximize what you can do for them, given your background and your abilities, and you want to work with a team of people who can help complement what you can and can’t do best,” he says. However, he believes physicians should be in multiple lanes.

“As physicians, we’ve gained insights into parts of humanity and society, and we’ve got esteem, respect, money, and power,” says Ubel. “If we’re just staying in our lane and thinking 15 minutes at a time with patients” rather than using that status, then that’s not enough, he says.

Ubel mentions pediatrician Jill McCabe, who ran for state office. “Why did she run for office? Because she saw what lack of Medicaid coverage did to her patient population,” he says. “That jumping out of a lane I’d really like to see. And when we’re in our own lanes, we can share the lane with a lot of other people, too.”

From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.

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