How social interventions can be powerful medicine

One simple question can offer clinicians a powerful insight into the lives of their vulnerable patients. Asking, “Do you ever have trouble making ends meet at the end of the month” can help physicians identify significant barriers to restoring the health of their patients.

The link between the social conditions in which we live and health outcomes is well-known. However, health provider action to address the social determinants of health is an emerging area of practice innovation and research. This episode looks at what social prescribing looks like in action and what the evidence tells us about its effectiveness.

Drs. Mojola Omole and Blair Bigham speak with Janet Rodriguez, a patient at St. Michael’s Family Health Care Clinic in Toronto. She describes the profound impact social interventions had on her physical and mental health.  

They also speak with Dr. Gary Bloch, a family physician at St. Michael’s Family Health Care Clinic and a co-author of the analysis published in CMAJ titled “An Evidence-Based Guide to Social Interventions in Primary Care.”

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The CMAJ Podcast is produced by PodCraft Productions

Transcript

Dr. Mojola Omole:

Hi, I'm Mojola Omole.

Dr. Blair Bigham:

And I'm Blair Bigham. Welcome to the CMAJ Podcast.

Dr. Blair Bigham:

So Mojola, back when I was a paramedic, I always felt ill-equipped to help a lot of my patients who had more complex health problems, often some social challenges in the mix. And for a lot of my patients, all I could offer them was diesel and a ride to the ER. But then, as an ER doc, I also know that the emergency department is a revolving door. Often we call ourselves a social safety net of society, but we don't always live up to that expectation because we just don't have the time. If it's not an emergency, I tell patients that they just have to go home and follow up with their family doctor. But GP's don't have a lot of time either.

Dr. Mojola Omole:

Especially now with what's happening with how the pandemic has worsened things, GP's have a lot on their plate and they're not necessarily well-equipped or have it at their fingertips to be able to address social determinants of health.

Dr. Blair Bigham:

Absolutely. And you have a story from your surgical practice.

Dr. Mojola Omole:

Yes. So I had a patient who had advanced cancer in the sense of, they definitely were going to need surgery and have chemotherapy after. Usually, I see patients two to three visits before their operation, but, with this patient, it was more often because she kept on missing appointments. And it really hard to try and figure out what was going on with her. And only to find out that she had unstable housing. She was in a situation where she was in a rooming house and there was always issues for her in terms of people taking her things, her food. And that instability was not going to be helpful in terms of her being able to get the proper treatment that she needed.

Dr. Mojola Omole:

I was able to set her up with the social worker in the Oncology program, who was able to actually get her better housing and help her with some stability, some income supports, that I think was very beneficial to her in terms of her overall care. And I would say that, as a specialist, it's not something that we often think about is the social history. Oftentimes we kind of glaze over that part of our history-taking.

Dr. Blair Bigham:

Absolutely. I think everybody does because it takes a lot of time and in a lot of cases you just don't feel like you can do anything, even if you do collect that data. And today we're going to dive right into this topic. Dr. Gary Bloch and Dr. Linda Rozmovits co-authored an analysis 'Implementing Social Interventions In Primary Care', which was published November 8th in CMAJ. Here's Gary with a three bullet-point summary of his paper.

Dr. Gary Bloch:

First: social interventions hold the potential to fill a gap in our ability to address risks to health. And what I mean by this, is that after years of targeting biochemical and psychological risks, we are now learning to address the last major frontier: social environments. And we've known the evidence that links social conditions to health for eons. But we have shied away from addressing social conditions for our patients and that's changing. Second: social interventions are a new area of medical practice and this area is growing exponentially. So we've seen an explosion in the development and evaluation of programs that target social risks to health. And these programs address social risks in multiple settings at multiple levels, from individual healthcare interactions to community level health interactions. And finally: any health practitioner can engage in social interventions. So even solo practitioners or small group practices have the capacity to develop interventions like screening for social risk or developing databases of community resources to support patients.

Dr. Mojola Omole:

We're going to hear more from Gary later on in this episode. But before we do...

Dr. Blair Bigham:

We're going to hear from a patient at his clinic, Janet Rodriguez, who became a patient at the St Michael's Hospital, Family Health Clinic in 2014. She says right from the start, she could tell there was something different about his practice.

Janet Rodriguez:

I thought this was unusual, but I also felt like right on. Like they want to know more than just which joint is aching, to want to know what is my situation after I leave this clinic.

Dr. Blair Bigham:

Our interviews with Janet Rodriguez and Gary Bloch are coming up right after this break.

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Dr. Mojola Omole:

Welcome back. In 2014, Janet Rodriguez was looking for a new family physician, two decades of living with severe rheumatoid arthritis resulted in constant pain and depression.

Dr. Blair Bigham:

Eventually she ended up at the office of the St Michael's Family Healthcare Clinic, and right from the start she could tell there was something different about this practice. And the first clue to that came from a question on her intake form.

Dr. Mojola Omole:

So Janet, how is this different from previous intake forms that you filled out?

Janet Rodriguez:

Well, one of the questions that was different is, "Have you ever run out of money at the end of the month?". And the answer for that in my case was yes, I was living on a disability income. And so that was really different, that they would ask a direct question about something that was so critical for me in my survival.

Dr. Mojola Omole:

So what did you first think when you saw that question?

Janet Rodriguez:

I thought this was unusual, but I also felt like right on they want to know more than just which joint is aching today. They want to know what is my situation after I leave this clinic, right? So I thought they want to know about how I'm getting by.

Dr. Mojola Omole:

Describe for us the situation you were in when you first came to the clinic.

Janet Rodriguez:

I was not well. At that time I was taking at least one depression medication. When I first came to the clinic, I had just had total knee replacement. I was still using a power wheelchair. I was in a lot of pain. I was pending to have a second knee replacement. So I was taking a lot of medications and I was having also to deal with a lot of financial issues.

Dr. Mojola Omole:

Were there other things that were going on in your personal life also that was contributing to your overall health?

Janet Rodriguez:

Yes. My mother had died.

Dr. Mojola Omole:

I'm so sorry about that.

Janet Rodriguez:

And so my father came to take care of me. And so a year after he was here, he himself got very sick and died.

Dr. Mojola Omole:

I'm so sorry to hear that.

Janet Rodriguez:

Yeah, I missed him. So because of... He was not a citizen, he was just visiting, people in the hospital took very good care of him, but it costs a high cost to my credit card. That was also another source of having that high level of debt, around $25,000. It was really significant. So yeah. And I was already on disability, so it was not an easy thing for me to deal with.

Dr. Mojola Omole:

Yeah.

Dr. Blair Bigham:

Going back to when you were first seeking treatment for the pain you were experiencing, what treatments were offered?

Janet Rodriguez:

Three things. First was a painkiller. So starting with your basic Tylenol, then Tylenol 1, 2, 3. All the way up to morphine, different kinds. But also because of my inflammatory disease, I was given anti-inflammatory medications, some nonsteroidal anti-inflammatory medication and also steroids. Both in pill form and injections and various types of disease modifying medication or DMARDs. And the new type of therapy called biologics is the medication that actually finally stopped the inflammatory process. And I was able to stop feeling pain in such an intense way, it started to really take the pain away.

Dr. Blair Bigham:

And despite that benefit, at some point you needed to go on disability. How did that affect you?

Janet Rodriguez:

It affected me in two ways. One was my identity part. We live in a society where everybody says, Hey, hello, how are you? And the next question is what do you do?

Dr. Blair Bigham:

Yes.

Janet Rodriguez:

And when you don't do anything because of whatever the reason, in my case, my disease... It really feels like your life has been taken away from you, your identity, the value that at the end of the month is represented with a number in your bank account. Suddenly it's like you're no longer that. You're no longer that worker - in my case, a translation manager. So it affects who you are, right? But then if you let it get to your mind, then it can really put you in a dark place. So, that was the personal mind side of it. But also the practical, tangible thing was that I had to pay my bills. I had accumulated debt. So not having that income from my work was really... It was really tough.

Dr. Blair Bigham:

So you're challenged with pain. You're challenged financially. You're challenged with your mental wellness and then you show up at this clinic and they begin on their intake form by asking if you have trouble making ends meet and you say yes. So what happens next? What did they offer you?

Janet Rodriguez:

Well, all throughout the process, I started to learn that they were not just asking to complete their research or survey - that they were actually asking because they had a resource to offer me. They asked, for example, if I needed to see an income support specialist right on the clinic. Like my doctors are in one office, this income specialist is in another office on the same building. So I was able to see them and they had follow-up meetings with me just as much as you would have follow-up meeting with another therapist. And I was able to access, for example, help filling out forms... My tax forms, filling out my CPP disability forms. And that was a significant outcome. I was able to get more income. So it was like, you're going to the doctor. I have a fever. Sure. I can give you a pill for that. So in this case, it's like I'm having these issues that are affecting my health and they were able to say, sure, I have something I can give you. And they did.

Dr. Blair Bigham:

What was the impact of that financial counseling and legal counseling?

Janet Rodriguez:

Well, I was able to access more income and because of the debt that I had accumulated, you get the calls from the collectors that was also stressing me out. And they referred me to the Health Justice Program. Again is part of the Family Health Team. And this lawyer, they told me what my rights were, were the limitations. They also supported me in writing up a letter to explain my health condition and my situation. And I was able to slowly, not overnight, but slowly to be able to eliminate a couple of debts and have that not being a burden emotionally and taking up my sleep.

Dr. Blair Bigham:

I think at some point, all of us can imagine what having to deal with a chronic illness. And then on top of that, just the mental anguish of debt and having those constant conversations could have on you. Looking back now, where do you think your health would've been if you didn't receive these other types of support?

Janet Rodriguez:

I think I would be still dealing with depression, anxiety, and panic attacks because it wasn't just the, "oh my God, I'm sick in my diseases, degenerative condition that will get worse if untreated". The depression takes over your mind. I was not eating properly. I wasn't connected with community. So I think my outcome would not be as good as it has been so far.

Dr. Mojola Omole:

Can you tell me what life is like for you now?

Janet Rodriguez:

I feel more stable. When something happens, whether it's the pandemic, my family back home having a crisis, I don't crumble down to pieces. I now have a few tools in my toolkit. Talk therapy. I do my exercises. I schedule my fun. I schedule my tasks. This is from the CBI treatment that I went through. I have friends that I can talk to. I have friends here that are like my family, that I trust them. I can call them anytime. And if I need to, I talk to my doctor and they can support me. And if I need to there's medication.

Dr. Mojola Omole:

That's wonderful. Thanks very much for being with us today, Janet.

Dr. Blair Bigham:

Thank you so much, Janet.

Janet Rodriguez:

Oh, you're very welcome. I'm honored to be here.

Dr. Blair Bigham:

Janet Rodriguez lives in Toronto. She is a patient at St. Michael's Family Healthcare Clinic. She's also a member of the St. Michael's Hospital Family Healthcare Team’s social determinants of health committee.

Dr. Mojola Omole:

Dr. Gary Bloch is a family physician with St. Michael's Hospital and Inner City Health Associates. He's also a family physician in Toronto and, as we mentioned, a co-author of the analysis in CMAJ entitled 'An Evidence Based Guide To Social Interventions In Primary Care'.

Dr. Blair Bigham:

Janet is a patient at your clinic, but she's not a patient of yours. When you hear her story, how do you react? How does it make you feel?

Dr. Gary Bloch:

My immediate feeling on hearing her speak was sadness and respect for what she's been through. I've known Janet for a long time. And even through that time, I don't think I've really appreciated all the levels of complexity, the adversity, all the elements of what she has been through in dealing with her health issues.

Dr. Blair Bigham:

How many years has your clinic been operating with this social prescribing philosophy?

Dr. Gary Bloch:

We started developing explicit social interventions in about 2013. Although our clinic does have a long history of working to address the specific health needs of particular socially marginalized groups, right? So, but from the time of the HIV crisis, for instance, or as the substance use crisis emerged in the 1990s, our team was certainly at the forefront of those efforts. But this idea of focusing in very specifically on the social risks, the social conditions, and the social structures that impact our patient's health really started emerging in the early 2010s.

Dr. Mojola Omole:

So I just wanted to... I just wanted to maybe step back because, for some of us, like the time I was community health doc is behind me. And so I just want to, maybe to our audience who might not be familiar with the social interventions and the interplay with health, if you can just give us like a little briefer on how that works.

Dr. Gary Bloch:

So, I will say, first of all, that we have known about the link between social conditions and social risks to health and health outcomes for a very long time, right? I mean, really that conversation goes back decades and even centuries, right? I mean, well back into the 1800's. What we haven't explored as intensely, traditionally, is what our role is as frontline health providers in dealing with those risks to health. And in terms of the range of interventions, I mean, there are interventions that we can carry out in individual patient interactions, right? And these range from simply asking our patients about their social conditions, taking a good social history, doing what we often call social screening to understanding where community resources sit that can help our patients, housing agencies, income, support agencies, social support agencies, etcetera, and building into our understanding of our team. The idea that there are these support agencies that can do really powerful work with our patients. To actually building new interventions into our teams.

Dr. Gary Bloch:

So these are things like in our team income security specialists, for example, that can do intensive work with patients specifically focused on helping them access income support programs, reducing debt, increasing financial literacy. And there are other interventions like that. And then there are real community level interventions. And what I mean by this is actually health teams that support, for example, community health workers that will go into communities that will work with community leaders and community groups to recognize community assets, to help build programs that deal with adverse social conditions and deal with condition that adversely impact health.

Dr. Gary Bloch:

And in some cases they even take, what's called a community development approach where they work with community is to build up structures of strength, to create new entities within their communities that sort of draw on those strengths and actually strengthen communities that have been traditionally socially marginalized. So this is really the kind of spectrum of interventions that have emerged. And a lot of this work while you can sort of trace back the genesis of this work probably to the early 1990s, there is just a huge amount that's been done in the last four to five years on this and that continues to grow. So it's quite an exciting area to be involved in.

Dr. Blair Bigham:

Gary, when I hear you talk about this, and when I hear about Janet's experience with the financial literacy and debt assistance, it makes me think that it's sort of the missing puzzle piece for so many people with chronic health problems. It also makes me think that it requires an awful lot of time to sort this stuff out and you have to have the resources to connect people to the right counseling, the right assistance. And when I think back to the family clinics that I've worked in as a resident or as a medical student, they're busy, they're very high volume. They're struggling to make appointments for people who want to get in quickly. How does the typical family clinic that doesn't have the same expertise and resources that your clinic have go about dealing with that questionnaire that Janet filled out that said, I'm having trouble making ends meet? How do they take that forward given how busy they are? How do they get those resources in place?

Dr. Gary Bloch:

So, I mean, this is a question I'm asked all the time, and I think it is very legitimate, right? That frontline physicians and other health providers say, we just cannot fit this into our lives. Right? And I totally understand that. And I want to be clear that, I mean, the work that we've done and what we've created in our team has built up over 10 to 15 years of very intensive work in this area. Right? It's a process of transformation. And so I think you need to start with what feels doable within the resources you have currently, and then kind of slowly build out piece by piece as you recognize the power and the importance of these interventions. So I often say like the number one starting point is simply asking about social issues, right?

Dr. Gary Bloch:

And for some people that can be a single question screen, right? So the one that I've talked about for years is do you ever have difficulty making ends meet at the end of the month, which I think Janet refers to as well. It takes 10 seconds, but if someone responds positively to that screen, meaning saying yes, they do have trouble making ends meet, that can open the door to a whole different level of conversation through which we can start to understand in a real way, the social conditions in which our patients live.

Dr. Gary Bloch:

And as we start to hear people's stories and start to hear the realities of their lives, I think that the sort of level of priority for these types of interventions starts to rise, right? It is very hard to hide away from realities. When it's our patients telling us the factors that truly impact their health in the deepest way.

Dr. Mojola Omole:

Some people who are listening could think, well, should this not be something a community social worker should do? Or community nursing should do? Why do you think physicians are best positioned to manage the social determinants of health?

Dr. Gary Bloch:

So we are often the very first point of contact for people. And it is that point of contact where we have the opportunity to identify social risk as early as possible. What we do with that knowledge really does depend on what we have in our team. So if we have social workers that have the capacity and have the time to work with our patients on these issues, absolutely. And ideally those people work very closely with us in our teams. We can go back and forth and sort of have a conversation about what to prioritize in terms of social risk, what will be realistic. But if we don't have access to those resources, we need to be able to do something, right? So what I suggest is that we just can no longer bury our heads in the sand when it comes to understanding and addressing social risk. We need to be ready to act on those risks. And if we don't have those external resources to refer to, honestly, it's got to come back to us or we're not going to see our patient's health improve.

Dr. Mojola Omole:

Very true. So what are some like some tangible examples or of interventions that let's say like family physicians and - both me and Blair are specialists so we have a bit of a bias - and that specialist can incorporate into their practice?

Dr. Gary Bloch:

So examples that have been looked at quite intensively are first of all, income support examples. So I mentioned earlier that we have income security specialists on our team. These are people that we actually fund through Core Ontario Ministry of Health Funding as health promoters, specifically focused on income. They're busy, right? I mean, I think that over the last year and a half, our two full-time health promoters have seen close to a thousand unique patients of ours to deal with their income security needs. It is not a particularly expensive position from a health systems perspective. It is one that is very powerful.

Dr. Gary Bloch:

We can also look to really interesting partnerships with other agencies that are interested in doing this work. And I think that probably the best study to those types of partnerships are what's called medical legal partnerships, where we partner with lawyers or legal aid clinics to provide facilitated referral pathways. I mean, often these are people that will actually come into our clinic and see our patients to deal with the myriad legal needs that people who are socially marginalized face. And it's these legal needs often pose significant barriers to people being able to deal with the social risks to their health. So those are some of the ways that I actually think are not hugely resource intensive, but can be very powerful. I think for a lot of those, you probably need a minimum of kind of small group practice or small interdisciplinary healthcare practice. And we've seen this done across Canada, the US, the UK, and other places.

Dr. Blair Bigham:

Gary, it sounds like the UK might be a couple steps ahead of us on this. How do we catch up? How do we get to where we want to be in an accelerated way, say five years or 10 years from now?

Dr. Gary Bloch:

So, I think there's a couple things the UK has that we don't. So first of all, they have really powerful networks of clinicians who are interested in doing this work. And those networks that become very strong advocacy forces within the healthcare system and within the social policy development system. For instance, as a group called Deep End GP's, which really just started as kind of a discussion group amongst physicians who are working in what they call the most deprived areas of the UK, but has evolved into a group that does education and also does a lot of government lobbying to shift the healthcare system. And I think partly due to their work, the other piece that the UK has that we don't yet have, is a real engagement of their healthcare system with this idea of social interventions, right?

Dr. Gary Bloch:

So their National Health Service is now funding interventions, like what they called Welfare Rights Advice Bureaus, which deal with income issues and also social prescribing interventions in a very big way, in many practices right across the UK. So it's that building of a specific community. And then the actual engagement of government agencies with this work that I think has allowed them to push forward in really big ways. I think all of that is possible in our context in Canada.

Dr. Blair Bigham:

Gary, you've inspired me to bring this lens to my practice. Thank you so much for joining us.

Dr. Mojola Omole:

Thank you.

Dr. Blair Bigham:

So Mojola, I hear Gary talk and I understand how his program is filling the gaps, but you and I are both specialists. We see patients once, twice. We don't really have very longitudinal relationships with people and we just don't have time for the things that he's describing. And I don't know. It makes me wonder if, am I a bad doctor for not focusing more on the social history when you come in with a broken ankle in the emergency department and I'm trying to flow the department and meet my physician initial assessment times? I don't know. Where does the responsibility lie or those deep social histories, and then doing something about what you hear?

Dr. Mojola Omole:

I think that we say we don't have time but, as Janet pointed out, it was just one question that was asked. So I think oftentimes the issue is that we don't have at our disposal the answers to those questions. So if someone is telling you that they're struggling with income, we don't like, I'm like I wouldn't... Before this podcast, I wouldn't know where to go. And so I think for me, the change that I'm going to make in my practice, is being able to have some resources for patients. Whether it's the immigrant patient, the refugee patient, or just any patient in terms of things that do affect their outcome. And as we know, social determinants of health.

Dr. Mojola Omole:

So I do think we have the time for it, but it's just having, what do we do next after it. Having those connections would make it easier because you're like, okay, you know what you've mentioned this, this is a number I can give you of someone to talk to, to help with this situation. That adds an extra for five minutes to each patient that we see. And we don't need to do that for every patient.

Dr. Blair Bigham:

And maybe that doesn't have to happen in the emergency department or in the clinic. Maybe that can be like, you've said a phone number, a social worker, an advisor, someone who they can call the next day or the next week, but at least get them plugged in somehow. Mojola, how easy is it for you to hook someone up with a social worker? `

Dr. Mojola Omole:

If the person is an inpatient, very easy because we have social workers on the floor. If it's someone that I'm seeing in my clinic, that's never going to be in the hospital, I don't even know where to start with that. I don't have that easily accessible to me. I'm sure there are different agencies that are out there and different community health programs that can help people, but it's just knowing of those and being able to refer patients and clients to those services.

Dr. Blair Bigham:

So our takeaways here: start small, just ask one or two questions about social context and thinking about my emergency shift last night, I probably don't even need to ask. There's probably a lot that I gather just from my interaction with people without explicitly asking and then finding a way to connect them to social services. The social worker in the ER works nine to five and I usually work evening shifts. So after that, I just don't even, I don't even have a phone number to give them, but I'm sure our department could come up with some system where we could get people plugged in the next day or the next week. It sounds like a lot of the benefits that Janet experienced, they happened over time, right? It wasn't a single intervention.

Dr. Mojola Omole:

Mm-hmm (affirmative).

Dr. Blair Bigham:

It happened over months. So maybe I can take the pressure off myself a little bit and just try to get the ball rolling.

Dr. Mojola Omole:

I think the first step for all physicians and allied health is to find those resources in the community that exist and being able to have a list of them, so you have somewhere... Something to type in, to pull up and to be able to assist your patients. And it is just asking the one question that affects your discipline and maybe for someone who deals with a lot of fractures, it's can this person do... Could they access disability? You know, that would give them more money. Because oftentimes people like, well I can't take time off work. We heard a lot of that during COVID of why people were going into work sick because they financially cannot afford to be off work. We do not realize how I'm much people in our society, in Canadian society, are living paycheck to paycheck. And if part of that paycheck is missing, it is a huge burden on their family and people will sacrifice their health before they'll sacrifice feeding their family.

Dr. Blair Bigham:

Absolutely. It makes me realize how ill-equipped I am as a physician to help people in areas that might make even more of a difference than a prescription or a splint or the medical side of things. I'm sure if we had a social worker on today's episode, they'd tell us that they're just as busy as we are. But I do think that they bring such a unique expertise to the healthcare setting. We probably need a lot more of them.

Dr. Mojola Omole:

Yeah, and I think what Gary has done in his paper is outlined for us some simple interventions that even though it's for primary care, that even specialists can do in terms of being able to optimize the health of their patients.

Dr. Blair Bigham:

Absolutely. It is a good How To guide. Great launching pad.

Dr. Blair Bigham:

And that's it for this episode of the CMAJ Podcast. Let us know what you think. Leave us a rating or a review on Apple Podcast or wherever you get your podcast.

Dr. Mojola Omole:

Also, please share this episode. Rating, reviews, and sharing episodes are the best way to make this podcast easier for others to discover and enjoy. So we really appreciate it.

Dr. Blair Bigham:

This episode was produced by Podcraft Productions. I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole. We'll be back in exactly two weeks. Be well and thanks for listening.