A Virtual Village

There are already several faces on screen when I join the Zoom call. I don’t recognize most of them, but it is only my 10th day at the community health center of my Primary Care rotation. The last person to join is the medicine resident, running over from a patient visit. I hear him through my earphones and through the workroom door; we are joining this meeting from our separate desks, masks briefly lowered as we lunch.

The resident begins: “Thank you all for hopping onto this Integrative Case Conference. Today we will talk about a patient with history of schizophrenia and diabetes who is well known to both the medical and behavioral health clinics. Recently she has been struggling to control her blood sugars.”

During my clinical year, I have met few patients with a disease that I had not already studied in the classroom. And yet, when I encounter the disease entities in real people, it feels as if I’m learning them for the first time. For example, I did not realize how difficult not only it can be for many people to administer insulin but also how much time primary care clinicians spend on troubleshooting medication regimens.

“She has regular visits by a home nurse, so we know she is taking her medications appropriately. So what we should do is increase her insulin dosing, but she hasn’t liked that idea.”

I’ve learned the first-line treatments, the grade A guidelines, but I haven’t learned what to do when a patient is not on board with what is recommended. The relationship between the medical establishment and everyone else feels especially fraught now, almost two years into the COVID-19 pandemic.

“She doesn’t have stable access to food. She receives food stamps, and sometimes goes to food pantries.”

Diabetes management as taught in the classroom focused on reduction of intake and restriction of certain foods. Managing diabetes in the setting of scarcity, I am less familiar with.

“And lately she has been missing her in-person appointments with the medical clinic. But we noticed that she attends most of her telehealth appointments with behavioral health. So we’d appreciate any thoughts from all of you about how we can best help her.”

The Zoom room immediately begins to respond. The clinical social worker wonders whether someone ever talked to the patient about the complications of poorly controlled diabetes. The quality improvement coordinator asks about telehealth at the resident clinic. They discuss working with the home nurse to discuss increasing the insulin dose. I’m losing track of the different titles in the room—there’s a recovery coach, a dentist, a pharmacist.

For 30 minutes, all these healthcare professionals brainstorm ways to better control this patient’s diabetes. But the conversation is quick to shift and morph to include other problems—ongoing smoking, psychotherapy, lack of transportation. When the exchange of ideas is at its quickest, it is easy to imagine a virtual round table around which representatives from each domain of health care have gathered, the patient’s life at its center. As they each offer their tools at hand, the plan begins to take form marshalling the resources available in the clinic network which, until this moment, have floated in siloes, invisible to each other. The virtual format suits the meeting well; each person appears on screen in a square of equal size and shape. Everyone gets to stay in their office where they can return to their separate days with a click. The logistic barriers to gathering an interdisciplinary team are much fewer now that the pandemic has normalized online meetings.

As I listen, many conversations that I’ve had with my classmates return to mind. At debrief sessions after rotations, we exchange stories about patients who were uninsured, poor, and isolated, and how the medical system did not do much to help them. The intense schedule of the clinical year is no doubt to blame for the new tiredness in our faces, but the hard edge in our voices as we process aloud what we are seeing—that sounds like a different kind of fatigue.

I have heard the same edge, but more pointed and worn, when working with the residents at the clinic, which is a federally qualified health center, providing care regardless of the patient’s ability to pay. Some said it becomes difficult to see patients who keep coming back with worsening outcomes, often because of social factors that remain unchanged.

But the residents were not alone in their exhaustion. An interview of 50 clinicians in Denver and Houston found that providing undocumented patients with suboptimal care contributed to professional burnout and moral distress.¹ Moral distress is a concept that was first described in the field of nursing; it refers to “the psychological distress of being in a situation in which one is constrained from acting on what one knows to be right.”² Having to tell patients that the one medication that may help them is out of financial reach, or being unable to get necessary labs because the bills are an unaffordable burden—these everyday occurrences take a toll. While the gap between the standard of care and the options available for most patients is something that providers face every day, it still must gnaw away at people who entered their professions to try their best to help people.

The discussion of social determinants of health has been a fixture in my medical school curriculum and, since the pandemic, public health has been among the most interest-generating topics on campus. We are encouraged to think about how individual health is shaped by our society and challenged to imagine more boldly what the physician’s role can be in advocating for their patient. While I have no doubt in the capacity of my classmates to rise to that challenge, this year we have witnessed the grueling hours that residents work and the superhuman effort it takes to do more than the bare minimum. I have wondered whether our aspirations to be doctors who care for the whole patient will survive after residency.

But at the Integrative Case Conference, I saw how tending to the whole patient—as in addressing the socioeconomic aspects of their lives shaping and shaped by their physical health—does not have to further stretch the capacity of overworked physicians. During the call, questions that would have gone weeks without answers—how to change the frequency of home nurse visits, how can we assist with food insecurity—were answered immediately. Not only that, but the meeting also identified problems that had gone unseen because of lack of time or perspective.

At the end, the quality improvement coordinator summarized the action items (e.g., contacting the home nurse agency, the community health worker reaching out to the patient about food insecurity). Just before the Zoom closed, she told the resident that he should reach out if he needed anything else. Even without this meeting, I’m sure if the resident had asked, she would have helped care for the patient to the best of her ability. But there is a distinct power to people coming together in a room, whether physical or virtual. It’s why the tradition of medical rounds continues.

All those patients my classmates and I talked about whose social barriers to care seemed insurmountable—they all would have benefited from the same kind of comprehensive attention. And if I had been able to see, or even join, the interdisciplinary team at work, I would have been less discouraged about the quality of care being provided. It remains true that there are social determinants of health that cannot be addressed with individual intervention alone. But as a medical student, at the entrance of a new profession, it is empowering to know that physicians can choose to work closely with other disciplines who have deeper expertise in the social barriers to care. I have spent most of medical school asking whether as a physician, I could possibly alter the course of health inequities in someone’s life. Equally important questions for me now are how to become a better team member, how to ask always whether there is someone who can advocate for my patient better than I can in this moment, and how to build a village of caregivers.