Realizing Our Power: Advocating for Social Justice
Summer Institute Sarah-Anne Schumann
F. Daniel Duffy August 3, 2012
Social Justice
The new professional contract with society
The practice of medicine and delivery of healthcare are
morally relevant acts aimed at preventing or relieving human suffering in life,
liberty, and the pursuit of happiness
Moral Act of ProfessionPatient’s Predicament Vulnerable Frightened Unable to help self Dependant on others Low social status
Healthcare Professionals swear a public oath to: Be trustworthy Use specialized knowledge
and training for the good of the sick
Keep patients from harm to the best of their ability
Put aside self-interest for the good of their patients
Sulmasy D. The Rebirth of the Clinic: An Introduction to Spirituality in Health Care. 2006 The Georgetown University Press, Washington, DC.
Medicine’s Contract
PhysicianPatient
Community Medicine’s Contract
Professional
Society
Patient
The ABIM Foundation, The American College of Physicians Foundation, The European Federation of Internal medicine, Ann Intern Med & Lancet, March 2002
We make a personal commitment to improve the health of our patients
Devote our collective
efforts to improve the health care system for the welfare of society
Expanded Contract
A Just Society Assures equality of opportunity and
fairness Guarantees its members a fair share of
what is required for them to pursue their individual ends
Upholds the principle of “Just Sharing” of the “financial burdens of medical misfortunes equally by the well and ill alike, unless individuals can be reasonably expected to control those misfortunes by their own choices”
Smith, GP. Social Justice and Health Care Management: an Elusive Quest. Houston Journal of Health Law & Policy. 2009
Social Justice in HealthcareExamines the relationships between groups and individuals that influence the distribution of healthcare across society.
Advocates for the poor on an individual level and for solutions to the structural barriers that deny the poor access to affordable, adequate health care.
Justin M. List, MD, Medicine Resident JAMA 2011
Community Medicine’s Agenda
Marketplace Commodity
Social Determinants of Health
Physician
SocietyPatient
Social Injustice is a Cause of Disease
Lack of universal access to healthcare reduces the well-being and economic viability of the entire society.
Health status is tightly tied to education, financial status, healthy environment, and a secure social situation.Treating the disease of addiction mainly as criminal activity prevents effective research and treatment.Childhood poverty, neglect, and abuse threatens adult opportunity for life, liberty, and the pursuit of happiness.
Healthcare as a Market Commodity US society has come to view healthcare
as a market commodity Subject to supply and demand forces and
rationing decisions imposed by providers Medicine’s contract yields to “social good
and economic need” Individual wealth or privilege of
insurance rather than need of the patient determines the degree of participation in the US healthcare marketplace
Justin M. List, MD, Medicine Resident JAMA 2011
Charity Health CareIn the United States charity care or uncompensated care is health care provided for free or at reduced prices to the poor or uninsuredFaith Based Hospitals
Teaching Hospitals
Physician Generosity
Community Health CentrPublic Hospitals
Free (Mission) Clinics
Hospital Emergency Rooms
Charity Care in the US In 2004, 68% of physicians provided
charity care, down from 76% in 1996 In 2006, Senate investigators found
Many hospitals did not inform patients that charity care was available
Some for-profit hospitals provided as much charity care as some non-profit hospitals
Some non-profit hospitals charge poor, uninsured patients more than they did insured patients
Is Charity Care Social Justice?“Though it is sorely needed, charity care may in some ways perpetuate the unjust system that makes it necessary in the first place.
True social justice in medicine demands that physicians take the lead in advocating for systemic change.”
Justin M. List, MD, Medicine Resident JAMA 2011
Rudolph Virchow
“Doctors are natural attorneys for the poor … If medicine is to really accomplish its great task, it must intervene in political and social life…”
Community Health Centers
Access to Healthcare for the poor
Federally Qualified Health Centers: Part of the Solution Located in or serve a high need community (OK has 40 sites
currently, +6 fall 2012) Governed by a community board composed of a majority (51% or
more) of health center patients who represent the population served. Provide comprehensive primary health care services as well as
supportive services (education, translation and transportation, etc.) that promote access to health care.
Provide services available to all with fees adjusted based on ability to pay (OK 40% uninsured, 30% Medicaid)
Grant-Supported Federally Qualified Health Centers are non-profit health care organizations that meet certain criteria under the Medicare and Medicaid Programs and receive funds under the Health Center Program (Section 330 of the Public Health Service Act).
Boston: Codman Square Health Center Medical services
Include dental and behavioral health, residency programs
Open until 9 weekdays for primary care
Urgent care 7 days a week Community Services
Fitness center Teen center Job/computer training Food Pantry Farmers Market Charter School
Chicago’s Urban Health Initiative“DELIVERING THE RIGHT CARE IN THE RIGHT PLACE AT THE RIGHT TIME”
Wuhan, China
Tulsa:Morton Comprehensive Health Services Program highlights
Transportation PAL clinic Multiple options for
specialty care referrals Example of limitations
of safety net
Now that the Summer Institute is ending, what do I do next?
Power, Privilege, Advocacy
The non-self serving influence of healthcare professionals to foster social justice in health care
Power without Love……is reckless and abusive; love without power is sentimental and anemic. It is precisely this collision of immoral power with powerless morality which constitutes the major crisis of our time”
Martin Luther King, Jr.
Love and Social Justice Justice validates the dignity of the
human person Love is the “driving force” behind
justice A spirit of love, humaneness, and
compassion in medicine and healthcare will minimize human suffering and maximize social good
The social good allows attainment of the “good life.”
Power and Social-Justice Power can correct the inequities
Without power there can be no justice, Without justice inequities between the haves
and the have-nots can not be fairly resolved Power must often be exercised coercively
through appropriate laws and policy Laws must rest on moral reasons that the
public in whose name they are enacted could be expected reasonably to accept
The Cost of Healthcare Privilege Professional education Self-justification of inequity – “I rose above
it” Rationalization - specialty procedures
“deserve” a higher price than primary care or cognitive specialty services
Status quo – our practice overhead is not under our control
Widening wealth-poverty gap in the U.S. leading to more working poor and uninsured individuals and demand for more charity care
Financial Self-InterestA social-justice framework requires that physicians speak out against the forces that continue to make meaningful, truly universal health care unattainable, even when to do so temporarily contradicts their own financial interests.Do the Right Thing
Don’t obtain screening exercise electrocardiogram testing in asymptomatic individuals and at low risk for coronary heart disease. (ACP)
Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. (ACP)
Don’t do imaging for low back pain within the first six weeks, unless red flags are present. (AAFP)
Don’t do imaging for uncomplicated headache. (ACR)
Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. (ACP)
Five Things Physicians and Patients Should
QuestionAAAI, AAFP, ACC, ACP, ACR, AGA, ASCO, ASN,
ASNC
Support the Affordable Care Act“The Affordable Care Act seeks to increase access to high-quality, affordable healthcare for all Americans.
Three aims: better care for individuals, the community, and making it all more affordable. “Michael Maxwell, MD, OU-Tulsa Alumnus
Advocate by Speaking Up“What we do know is that those of us with insurance pay for those without, access to care in many areas of our country, even some areas of the Tulsa region, is no better than that in third world countries, the quality of care is widely variable throughout the country. We know we can do better. This [ACA] law is a good start. Now if we can get out of our own way by fostering a spirit of cooperation, collaboration and innovation, we canpull off something great.”
Michael Maxwell, MD, OU-Tulsa Alumnus
Exercise Political WillPassing the ACA, enduring the misrepresentation of its purpose and content as “Obamacare,” and the Supreme Court’s upholding its legality demonstrate the enormous political will necessary to bring the United States into the company of every other high-income country to assure that every citizen has adequate access to affordable healthcare.
Free Our Society from Charity Care Demonstrates a fundamental respect
for human dignity Frees healthcare professionals to
spend more energy on patient care, instead of balancing charity care with making ends meet in practice
Bedlam can focus on excellent care for vulnerable patients and education of the next generation of professionalsJustin M. List, MD, Medicine Resident JAMA 2011
Next steps: ACHIEVING HEALTH EQUITY IN THE MOST CHALLENGING ENVIRONMENTS
1. Critical thinking
2. Critical communication
3. Critical emotions
4. Critical actions
Critical Thinking: Stay Informed! Medical Education Futures Study: social mission of medical
education Bi-weekly newsletter: www.medicaleducationfutures.org/newsletter
Oklahoma Policy Institute: issue briefs, email alerts www.okpolicy.org/
Health Affairs: eTOCs www.healthaffairs.org/
Health Begins (clinicians addressing social determinants of health) healthbegins.ning.com/ [email protected]
Critical Communications Generous Listening Shared Decision
Making Learn Spanish!!! Speak up!
Op eds Opportunities to speak
Schools Churches Community centers
Critical Emotions Keep a journal Record patient stories Talk to colleagues Self-care: “This is
your life” Exercise Relaxation/vacation Friends, family Healthy eating
Critical Actions: Advocacy Individual: patients Groups:
Specialty choice Practice location
Systems: speak up when you see flaws in the system, innovate! Primarycareprogress.org Narrative Matters
www.healthaffairs.org/NM.php
OU-Tulsa Center of Excellence
for Bioethics and Social Justice in
Healthcare