i once saw a patient who came to the emergency room with injuries clearly related to domestic violence. Instead of offering a sympathetic ear and a blanket to cover her uncovered body after a seizure, her intake nurse rushed through a checklist designed to screen her for social needs. While looking at the computer screen, the nurse asked the patient a series of sensitive questions, including one about whether she had experienced domestic violence. The patient, feeling put off by the nurse’s impersonal manner, denied ever experiencing any abuse.
Primary care providers like me have come to realize in recent years that we need to ask patients about a variety of topics, including domestic violence and whether they have access to a refrigerator when we prescribe a medication that needs to be kept cold. But these efforts have manifested themselves in the form of a rapid screen-and-refer approach, where patients are asked to quickly fill out checklists about their social needs and then automatically refer them to social assistance agencies.
The “screen-and-refer” approach has become increasing popularity in hospitals and clinics across the US However, as I’ve learned, implementation is often flawed and overwhelms the very organizations intended to provide support. In the end, this well-intentioned but poorly executed system is not only ineffective, but also degrading – and even potentially harmful to patients.
When someone answers “yes” to screening questions, they are automatically referred to local community organizations such as food banks, housing agencies, domestic violence services, or non-emergency medical carriers. But most of the references go unused because of a lack of program capacity and funding And low patient interests in the social services offered. When people make use of the referral, the result is often that civil society organizations have to deal with overcrowded waiting lists and appointments. Some of these patients are in dire need of help, while others may have answered “yes” to a screening question but are unsure why they received an outreach they didn’t ask for. Perhaps even more alarming, it can also lead to “automatic referrals” for social risk factors increased depression when patients are screened frequently, but ultimately don’t get the help they need.
Healthcare organizations often praise themselves in press releases for meeting social needs by screening and referring more patients, while local organizations ranging from food banks to housing agencies are overrun and underfunded. In the process, those of us in healthcare are missing out on the opportunity to connect with our patients, hear their stories, and truly understand their needs. By reducing our patient interactions to the click of a button, we deny people the dignity and respect they deserve.
There are indications that a “narrative medicineapproach – where we take the time to listen to our patients and understand their stories – is a more humane and effective alternative. Narrative medicine is based on the idea that each patient should be treated as a person with an individual story to be understood, rather than a collection of symptoms to be screened for and assessed. In a randomized clinical trial, the narrative approach of community health workers has been shown to do just that prevent preventable disease events and generate a return of $2.47 for every dollar invested through personalized action plans and hands-on support.
In contrast, peer-reviewed research on the screen-and-refer approach often finds it ineffective And hard to keep up in primary care practices – despite striving to be more streamlined and efficient – due to poor implementation of software services, limited resources to develop and maintain community resource lists, challenges in matching referrals with patient needs, and inability to measure the effectiveness of referrals.
Resistance to narrative approaches focuses on legitimate concerns about time management. Too many providers are already struggling with unsustainable workload and burnout. One potential solution to this dilemma is greater adoption of community-based models of care, including multidisciplinary teams that include community health workers. As trusted frontline resources often drawn from the communities they serve, community health professionals act as a bridge between patients, caregivers, and social service providers. They accompany patients to medical appointments and serve as “translators” between time-bound healthcare providers and patients tired of the healthcare system. This work may include helping patients better articulate their social needs and working with health care providers to appropriately refer them to social service organizations when necessary. Numerous studies have shown that community health workers can help healthcare providers better address social risk factors and generate a positive return on investment for payers.
I recently experienced the benefits of this approach with a patient who had been to the emergency room multiple times for chest pain and hypertension. There was a clear social class divide between me and my patient in the exam room, as the patient answered my questions with one-word answers and passive consent. But once he met a community health worker who, like my patient, had also served time at San Quentin Prison, the patient immediately felt more comfortable talking about his blood pressure—and eventually admitted to his community health worker that he was functionally illiterate. and was nervous about being unable to read his medicine bottles. The health worker labeled a “sun” and “moon” pillbox so he could confidently take medication day and night, and the patient has since had no chest pain or uncontrolled blood pressure.
Returning to our roots in medicine means prioritizing meaningful socializing and empathetic understanding. It means taking a more nuanced and compassionate approach than assuming that social needs can be addressed with a quick click of the mouse, much like a lab order or prescription. As healthcare providers, we have a responsibility not only to treat our patients’ physical conditions, but also to address social needs that impact their lives. We can’t do that if we keep investing in a system that’s more focused on congratulating ourselves for ticking a box than solving our patients’ problems.
Sanjay Basu, MD, Ph.D., is a primary care provider, epidemiologist, and clinical lead at Waymark, a public benefit company dedicated to improving access to and quality of care for people receiving Medicaid benefits. He provides primary care, substance use, HIV and hepatitis C treatment to patients at San Francisco’s HealthRight360 Integrated Care Center for marginalized adults.