Why it’s important for physicians to change the system [PODCAST]

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“What if I had access to real solutions? What if I had resources to provide to a person to help them overcome their problem? As a primary care provider with over 20 years of experience, I know viscerally that I will never “fix” anyone. I can teach, I can guide, I can comfort; but I’m never going to fix a single person. Still, I wish I had more to offer.

In my current iteration, I take care of people experiencing homelessness. Having spent much of my career taking care of people with homes, I’m currently grant-funded to care for people experiencing homelessness. The problems, I find, are not fundamentally different, but the phenotype, the manifestation of common, universal problems, such as social isolation, poor nutrition, insecurity, addiction, comes with sharper edges.”

Nancy Connolly is an internal medicine physician.

She shares her story and discusses her KevinMD article, “What if this physician had access to real solutions?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Nancy Connolly. She’s an internal medicine physician, and she wrote the KevinMD article, “What if this physician had access to real solutions?” Nancy, welcome to the show.

Nancy Connolly: Thanks so much for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Nancy Connolly: Yeah, so thanks very much for asking. I started as an infectious disease doctor in Pittsburgh and moved here in 2008 and started working in a primary care practice. For about 10 years I practiced primary care in a pretty conventional practice, seeing 20-plus patients a day and taking care of what they needed. About three years ago, I moved to the University of Washington to care for the homeless in our city. Homelessness is becoming a much bigger problem.

In the homeless population, we find a lot of addiction, a lot of mental health disorders, and a lot of lack of social connectedness, and it’s a different way to work. I’ve seen similar problems, but with a different phenotype, a different manifestation of the problems. It’s been a very interesting journey, and I’m looking forward to improving systems as I do this work.

Kevin Pho: So tell me some of the motivations that caused you to go from traditional primary care practice into treating the homeless population. What were some of the reasons behind that?

Nancy Connolly: Traditional primary care is pretty challenging these days, with having to see so many patients every day, and there’s so much that patients need that we simply can’t provide in the office because the infrastructure is not available. People suffer from loneliness, and there’s really not a lot you can do in a busy primary care practice to address that, and it impacts every single one of their physical, shall we say medical, complaints.

And so I moved over to see sort of what systems were available for other populations, offered by Medicaid and other public services, to help people. I also moved to escape the productivity-based incentives that we worked towards, and just to see a different system in a different population.

Kevin Pho: Now, can you take us through, say, a typical day, and perhaps, without getting into too much detail, some common scenarios and cases that you might see?

Nancy Connolly: We see a lot of people who are seeking rehab, and we see a lot of barriers to getting them there. I see quite a few people suffering the effects of withdrawal and intoxication, and it’s very hard to treat that, certainly at the street level. You need to have facilities. You need to have detox facilities and rehab facilities, and where we have those, we have a lot of barriers getting people to them. It’s not just physically driving them; there are intake procedures. There’s something called a substance use assessment that actually is like a two-hour interview that only certain people can do. So we see a lot of those barriers.

We also see abscesses and urgent care issues, and we can kind of get to know people and kind of meet them where they are and try to move them to the next step, but the infrastructure’s really lacking.

Kevin Pho: Before you treated this population specifically, you were in a traditional primary care practice. Did that prepare you for your current role?

Nancy Connolly: I think it really did. For people who have always treated the homeless population or the underserved, I think it’s often underexpressed or underappreciated exactly how similar the populations are. People really have the same problems. We all suffer at some level from loneliness. Vivek Murthy talked about this in his book, his great recent book, Together, and those problems are the same. They are just worse in people who are suffering from homelessness. Obviously, they’ve fallen to sort of the lowest rung they can get to. They’re at the end of their rope, hence no social connectedness, which is largely why they become homeless. But the problems, the medical issues, the psychological issues, are the same.

Kevin Pho: All right. So let’s transition into the KevinMD article that you wrote. It’s titled “What if this physician had access to real solutions?” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Nancy Connolly: Well, I saw a patient that day, and I see patients like this pretty regularly, who have interfaced a lot with the system through ERs or mental health hospitals or even primary care offices or jails or anywhere, social service offices. They interface with those offices, and they don’t get the care they need. The ER is the best example. ERs are incentivized to move people through quickly. So if someone comes in because of a cough, they’ll treat them with a chest X-ray and an antibiotic and get them out in 30 minutes, and that meets their criteria.

But if they were to look at that person holistically and say, “This person needs a home, or they’re going to come back to the ER,” or, “This person needs some other type of service, whether a counselor or a social worker,” and to connect them to that service, we would be serving people better. We wouldn’t be meeting the current demands of our systems, i.e. getting people through ERs quickly, but we would be helping our patients better.

So this particular patient had been in jail, had been in a mental health hospital, and hadn’t received those services, and so kept sort of coming back again and again to the system. Small things are addressed, but the big problem is never addressed.

Kevin Pho: So what’s preventing the emergency room from providing these services? Is it incentives? Is it a lack of budget and staff? What are some of the core reasons why these services can’t be provided?

Nancy Connolly: Well, I think the fundamental thing is that the system is not designed to provide it. The system is designed to churn people through quickly. The system is not designed to truly help people. And it’s not the fault of the emergency room per se; it’s the fault of the way we pay our emergency rooms. The way the system is funded disincentivizes people from taking the time to really discover what the real problem is and address it holistically, with a social worker or a counselor or connections to housing services.

Kevin Pho: Short of completely changing the systems and incentives, what are some paths forward? What are some tangible solutions that we can do to address these issues?

Nancy Connolly: Well, for example, as I stated in the article, one of the things that Medicare did a few years back was to create penalties for bounce-backs. If a patient was readmitted within 30 days, the hospital got dinged. They had a financial disincentive. And the hospitals then, and I was part of some of the groups that worked on this, tried to determine how to prevent people from coming back to the hospital. It involved creating safer discharges, and sometimes people stayed a little longer in the hospital while those were created. And so those kinds of things are helpful. I really think we need to fundamentally change our systems to incentivize healthy patients and not incentivize time spent with a patient or medications or radiology prescribed.

Kevin Pho: Well, I think that certainly applies to primary care. I think there are incentives, as you know, to see as many patients as possible, to do as many things as possible. We certainly live in a fee-for-service system. Now, is there anything that an individual emergency physician or urgent care physician can do in that short amount of time with a homeless patient to help alleviate some of the issues that you talk about?

Nancy Connolly: Well, I think I’m a big advocate for physician advocacy, and I think speaking out to the systems, to the designers of this, is an important role that we as physicians play. I know not everyone believes that, but I really think we need to speak up when we see things that aren’t right. When we see ourselves churning patients through so quickly, we need to speak up and say, “This isn’t right. We need to redesign our systems to really help our patients, not just run our systems.”

On an individual level, with a one-on-one patient, I think really all we can do is hold that patient’s hand, show them that we care, and encourage them to re-engage, not chase them away from systems. I think patients often are frustrated by their interactions and don’t come back, and then we lose our opportunities to help them.

Kevin Pho: I think that physicians speaking up certainly has some resonance, because that’s really one of the most powerful ways that we can change the system, and I have a lot of physicians, of course, write on KevinMD and appear on this podcast. What are some other ways that you recommend physicians speak up and use their voice? And can you share any stories or examples of physicians that you’ve come across who’ve done that?

Nancy Connolly: Well, last year I participated in a Doctors in Politics workshop at the Society of General Internal Medicine. I think doctors should run for office. I think doctors should write letters to the editor. I think doctors should write letters to their legislators. I think we need to change the way medicine is funded, and I think doctors play a big role in advocating for that. We’re listened to by the community. I mean, I’m impressed you have this podcast. You’ve obviously engaged full time in promoting physician experience and advocacy, and I think it’s such an important thing that all of us need to do.

Kevin Pho: Now, tell me some resources. You mentioned the Society of General Internal Medicine as one, that workshop. Are there any other resources that the physicians listening to this podcast can turn to if they want to express their voice?

Nancy Connolly: Doctors for America is an organization that, again, Vivek Murthy, our current surgeon general, started, I think eight, 12 years ago. Doctors for America is present in all 50 states, I think, with different chapters, and they offer op-ed writing workshops and advocacy opportunities. There are state medical organizations. I’m a member of our Washington state medical organization advocacy, and the American College of Physicians has an advocacy arm. So there are lots and lots of ways to engage.

We have something called the Washington Health Care Alliance, which actually coordinates the efforts of various different organizations and specializes really in watching the legislation. We’ve had some really great legislation go through our state this year, trying to get towards more of a universal health care system. So I think actively being aware of that and engaging with that is an important component of helping our communities.

Kevin Pho: We’re talking to Nancy Connolly. She’s an internal medicine physician, and she wrote the KevinMD article, “What if this physician had access to real solutions?” Nancy, I’m a primary care internal medicine physician myself, but I don’t have nearly the experience with the homeless population that you do. What are some tips and advice that you give me and other clinicians who may not have that experience with the homeless?

Nancy Connolly: Well, one of the most important things, I think, is to create a compassionate relationship. It’s not different from what we do with all our other patients. I mean, these patients often have a lot of distrust for our systems, sometimes very rational distrust. They’ve often experienced hard times. It’s showing them that we care about them and encouraging them to continue to engage. It’s very frustrating dealing with our system, for us as well as for them. And it’s assuring them that we really want to help in whatever way we can.

Kevin Pho: Are there any questions that we should be asking, or any phrases that you particularly say that would have resonance?

Nancy Connolly: I think just sincerely, from your heart. There’s nothing particular that I’ve learned, I believe, about how to speak. They’re like everyone else, the homeless people. And I think I saw so much addiction in my conventional primary care practice. It looks different, but addiction is a problem in our country, getting worse all the time, and it’s something we really need to address. We need to destigmatize. It’s a problem that affects really everyone, and so having compassion with that and understanding and helping people get the care they need is really just the most important thing.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Nancy Connolly: I think look at the systems. See where the systems are failing our patients. Do what you can to address the incentives and the metrics built into the system, to help change and make more resilient, better systems for the health of all our communities.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Nancy Connolly: Oh, thanks very much.

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