The elderly man in the back row stood up. I was five minutes into a 30-minute talk about heart disease that Sunday morning at a local church. He asked a simple medical question. I, in turn, responded with a routine answer that all of us physicians give. He appeared confused, but accepting, then sat down. I paused briefly, caught off guard by his demeanor.
It was clear that my routine answer was anything but routine for him. For me, the exchange was a reminder that we in the medical field can sometimes be out of touch with the communities we serve, overestimating the degree to which patients are able to make sound health decisions for themselves.
Over the last three years during my internal medicine residency at the Johns Hopkins Bayview Medical Center, my colleagues and I have visited a dozen congregations in the Baltimore-D.C. area with one goal: promoting health through community education and engagement. I assumed it to be a simple task.
But it turns out, it's not necessarily something that comes naturally. As physicians — especially physicians in training — we learn to become great "disease treaters," focusing on the minutiae of a particular ailment. We learn to diagnose diseases, understand the pathophysiology and recommend treatments. We offer all of this knowledge to patients and then send them back into the community to fend for themselves.
What happens when they go back where there's no one to check on them?
With the growing prevalence of chronic diseases in our aging population, physicians need to recognize that they play a limited role in regard to disease management. Patients and/or their support systems must follow through with the directions and know where to turn to for help. The ability to understand and navigate through the health world is called "health literacy." Low health literacy has been shown to be associated with poor outcomes. In the past, a home visit by the physician would offer great insight into a patient's health literacy: How are medications managed? Is their home safe? Because I had the good fortune to participate in a residency where home visits still occur (a rarity for programs today), I appreciated how these visits can provide a more complete picture of a patient, but I'm often left wondering about the community in which they live and the resources they have access to.
Some communities may have doubts about and mistrust toward the medical field, as they are still wary of a history in which some populations were experimented on without their knowledge. I have learned that people within some communities do not want to feel like a "charity" case, nor are they able to open up during a temporary, one-time visit. Trust can be built over time when a genuine commitment is demonstrated, however.
One solution: physicians could aim to integrate with the communities they serve. For example, regular visits to religious congregations like those I've been doing provide an excellent opportunity. In most religious congregations a group of adults gather regularly with a sense of trust and community and concern for each other. However, to be pulled off successfully, the medical-community partnership has to be established carefully. And, the agenda of the medical community must be spelled out and align with the agenda of the congregation.
It should be noted this is not a one-way avenue of learning. By having physicians go out into the community, they, too, will learn valuable lessons — the community's concerns, needs, traditions and values. What does a community know about pneumonia? About advance directives? Having physicians do more than simply treating a disease and engaging with their community neighbors helps them take on their "new" role of health promoter more effectively.
As a physician who finished residency one year ago, the knowledge I have gained from working with nearby communities has been priceless. It has revealed the great gaps we have in medical management today, reignited the passion I had entering medical school that was nearly forgotten, and impacted my professional identity in a positive way. These gains cannot be achieved by most traditional medical residency training alone; curriculums emphasizing community health partnerships must become a priority if 21st century medicine is to prevail.
In today's age of chronic disease management issues, medicine must reaffirm its position in society and resurrect the notion that it is a public trust and exists to serve people, not diseases.
Dr. Panagis Galiatsatos is the assistant chief of service for Johns Hopkins Bayview Medical Center's Department of Internal Medicine. His email is firstname.lastname@example.org.
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