Mnemonic Devices Can Finding the Sweet Spot When Caring for Vulnerable Patients Make you a Better Clinician! My Dean Schillinger MD, UCSF Professor of Medicine in Residence Neurons Chief, Division of General Internal Medicine Erase Director, Health Communications Research Program UCSF Center for Vulnerable Populations @ SF General Hospital Memory. Only Names Improve Cognition Common Social Vulnerabilities Vulnerable Populations Defined V iolence U ninsured L iteracy and Language Vulnerable Populations are subgroups N eglect of the larger population that, because E conom ic hardship/ food insecurity R ace/ ethnic discordance, discrim ination of social, economic, political, A ddiction structural, geographic and historical B rain disorders, e.g. depression, dem entia I m m igrant forces , are exposed to “greater risk of L egal status risks”, and are thereby at a I solation/ I nform al caregiving burden T ransportation problem s disadvantage with respect to their I llness Model health and health care. E yes and Ears S helter Schillinger 2007 1
What are We Up Against? 3 Mechanisms Whereby Vulnerability Reversing The Inverse Care Law is Associated with Poor Health “Access to and quality of healthcare is inversely proportional to the needs of the population” - Tudor-Hart, 1971 Schillinger et al McGraw-Hill 2017 Finding the Sweet Spot for Care of Vulnerable Patients Effective Intervention with Vulnerable Patients “ There needs to be a little Don Quixote in all health This approach uniformly practitioners… locked in allows a clinician to on the mission, undaunted by the navigate the social doubters and the half- distance and create the hearted ” human connection that underlies therapeutic • Fitzhugh Mullan, MD relationships 2
US Spends Least on Social Eliciting the Patient’s Story: Service Relative to Healthcare Reveals Hidden Treasures that Humanize Bradley BMJ 2016 Despite similar TOTAL spending, US is an Finding Resilience outlier in Social Safety Net Spending Religion Expertise/ Employment Social support & Network Intimates Laughter Institutions Energy & Enthusiam Navigate Life’s Difficulties Papanicolas Health Affairs 2019 Cultural Assets Entertainment/ Enjoyment 3
The First: always smiling, Laughing even. Gold sparkling from a tooth. Bejeweled with bling The Second: never sure of his age, Like epaulettes Either 93 or 88, From his favorite pastime: Reno with Maria His Louisiana birth certificate, Unable to read it, But he knows it bears false witness. Keeps his daughter's number safe: Pearline - on the inside brim “Somebody has to do something, and it's just Of his omnipresent incredibly pathetic that it has to be us.” Baseball cap. Jerry Garcia The Former: still alive TWO DEAD MEN TWO DEAD MEN ‘Cause he quit tobacco 25 years ago After being filleted open A POEM…. A POEM…. To plumb his heart. Proud of his medical survival skills, One: a refugee from Cuba. And grateful for his doctor. While smacking his big round belly, Always in white, The Latter: still alive Pregnant with hope and worry. Skin black and smooth, ‘Cause he quit smoking 25 years The other: tall, lanky, Fitting the mold from bottom to top: ago Happy and old. After being told his lungs are White leather shoes, A former ball player vanishing. White pants, In the West Coast Negro League. Owe my life to my doctor, White linen shirt, So he says and so he believes. Pitched for the Sea Lions Crowned with a Havana, Now chained to an oxygen tank, Until he threw his shoulder Of course. Not sure if it's worth it, Out of its socket, Anymore. And could throw no more. 4
Two Brothers, Resilient, Living in parallel, Struggling in parallel, Full lives behind them. Now both suddenly dead, How can it be Within days of each other. That these two men, Leaving behind their doctor Bedeviled by society Could become the favorites Of their doctor? What can fill the absences, When one is robbed of one's favorites And their love is lost? 5
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