Zoe,* a 35-year-old law student, often missed and rescheduled appointments for her toddler Elias.* I have supervised Elias’ visits with the residents since his first newborn visit 2 years ago. Although I have only seen them with the residents, Zoe identifies me as their primary care physician and has always scheduled Elias’ visits during my teaching clinics. I have examined this cute little guy at every visit and thought I knew this family well.
I knew that Zoe and Elias were struggling because of the issues we discussed at every visit: finishing law school 90 miles away, struggling to maintain her breast milk, and single motherhood. Zoe’s tired face showed determination despite her challenges. Little Elias, in a loose diaper, always clung to Zoe’s tiny frame, a fact that initially made me think he was simply on the small side. Despite multiple no-shows, we gathered enough data to construct a disappointing growth trajectory. Was it failure to thrive or constitutional small stature? Medical advice typically consisted of dietary counseling aimed at boosting calories and more frequent follow-up.
Recently, I recognized Elias’ name on a resident’s schedule. Anticipating their typical tardiness, I asked the front desk to register Elias regardless of arrival time. When they came a little late, they were quickly ushered into to an exam room. The resident reported that although Elias had normal development, his weight remained below the first percentile.
I entered the exam room to a smiling and active Elias eating corn puffs and smearing their cheese powder on his mother’s face and clothes. As he climbed on and off her lap, Zoe greeted me cheerfully, oblivious to Elias’ mess. Zoe was disheveled and wearing a stained dress that was thin enough to be a nightgown. While noticing her matted hair, Zoe explained that she now allowed him to eat anything he wanted because she felt that any calories were better than none.
The room then filled with a noxious diaper smell. Zoe, who kept talking, failed to produce a diaper bag. As there were no diapers in clinic, I asked the parents of my next patient, a 6-month-old, for a diaper. They donated one and, fortunately, it fit. Elias soiled this one too and another replacement was issued. As I cleaned Elias again, Zoe said his diaper bag might be in the car.
These minutes with Zoe and Elias made me realize I did not know Zoe and Elias as well as I had thought. I knew that Zoe was a single parent in law school, but what did I really know about their lives? Did they have enough food? Was there money for diapers? Did they live in a safe neighborhood? Today I needed to learn more about them.
What I learned from Zoe alarmed me. They had moved repeatedly and had been staying with multiple family members for the past several months. Zoe’s mother lived nearby, but she lacked many resources. Zoe used her law school loans to survive, but “it gets really hard sometimes.” Worried about Elias’ future, Zoe began to cry and expressed worry that her son would be disadvantaged because of his small size. I offered to connect Zoe with social resources and she immediately accepted. Although hired for a subset of our managed care patients, I asked our nurse coordinator, a very caring and resourceful person, to help. After we conferred, I guiltily exited the room to supervise a trainee perform a procedure while Elias awaited a vaccination.
I looked for Zoe and Elias as soon as the resident’s procedure was completed. They were in the care coordinator’s office receiving the address of an emergency shelter for overwhelmed parents and other information. I handed Zoe a food assistance form and gave her money in an envelope for parking. Zoe thanked me for “always looking out” for her, saying “You are the best doctor.”
I reflected: how could I be the “best doctor” when it took me 22 months to seriously consider the effect of their social situation on their health? How could I be the “best doctor” when I just learned (via an EHR alert) that Zoe has Crohn’s disease and recently underwent a repeat colonoscopy? I didn’t even know if Zoe attended her own primary care visits. I thought I was a patient-centered family doctor—why wasn’t I practicing whole person care?
Poverty, food insecurity, and housing insecurity are serious problems affecting millions of Americans, and Chicago populations are at particular risk. As a full-time student and single parent, it should have been obvious to me that Zoe and her child were at significant risk of food and housing insecurity, yet I had not considered these possibilities until it was staring me in the face. How did I miss this family’s distress and need?
The American health system trained me to focus on a biomedical model and write prescriptions; it did not encourage me to expand to a biopsychosocial lens when caring for patients. Social determinants such as finances, public safety, education, transportation, healthy food, clean water, and stable housing are incredibly important, but I am a cog of the clinical machine that does not allow sufficient time for such matters. I felt ashamed for not looking out for them more, and for maintaining the status quo rather than recognizing this family’s vulnerability.
Before I left, Zoe asked, “Dr Figueroa, do you think I am homeless?” I held her gaze, “Zoe, I think you told me your housing has been very unstable. We call that ‘housing insecurity’ and that is a form of homelessness.” Zoe answered, “Yes, that is true.” As we hugged, I told her I was going to try harder to help. She smiled and thanked me.
I have felt ashamed and worried for this family since Elias’ last visit. I have thought about the additional history that might have been pertinent and left multiple messages inquiring about their status. I want Zoe to receive more support so she can flourish as a person, mother, and future attorney. This support is critical to upward mobility and financial stability and will allow Elias to have access to a good education, healthy food, and safe living conditions.
After multiple attempts, I finally reached Zoe and learned that their situation had stabilized significantly. Concerned by my intervention, Zoe became worried that Child Protective Services might be alerted, and reached out to her law school mentors for support. They confided that they were also worried about her. Waitlisted for housing, Zoe was also finally able to secure her own apartment. She stated that the impetus for her abrupt move had been threatening behavior by Elias’ father—Zoe was out of contact with him and was planning to file a restraining order. Meanwhile, Elias’ appetite had improved and I wondered if his poor weight gain was related to her high stress level. We ended the call on a high note and agreed to a weight checkup in the upcoming weeks (which they attended!).
I suspect that if I knew more about my other patients I would find more like Zoe and Elias. In my 11+ years at University of Illinois, Chicago, I have never studied our patient population closely enough to know how many are affected by food and housing insecurity, racism, violence, or poverty. Sure, we distribute surveys asking about educational level, but I have never asked what we do with them. Do we use these data for anything other than fulfilling an accreditation requirement? Can’t we build a system that knows more about our patients’ lives and addresses these health determinants?
My complacency with our current health care system has motivated me to more deeply incorporate social factors into the health care of my patients. Engaging the community and establishing partnerships can help me better understand the housing, food, education, and other social determinants that affect whole patients, whole families, and whole populations. Although it took me nearly 2 years to see Zoe and Elias in this light, I am committed to advocating for them and my many other patients with similar circumstances. Our entire society cannot be healthy until our vulnerable patients like Zoe and Elias are treated as whole people.
Evelyn you are not alone in your in missing those initial signs. Often in the hurried day we forget to ask “How did you get to the office today?What type of work do you do? Where do you live? Is it your home or do you rent?” We seem to think that this does not affect the patient patient visit but it does. if you take two buses and walk up the hill to the office pushing a stroller, you are going to be late. Thank you for sharing.
I too am learning how the social-environmental determinants of health affect our patient population from a new perspective. As a current Public Health Masters degree student, I am starting to see the many “other” factors that affect our patients and the so many other “new” questions to ask that don’t fit into the traditional clinical model. It’s very enlightening but also presents new hope on we can best serve our patients. I’m happy to hear that things are turning around for the better for Zoe and Elias but it’s only the beginning.
You are an amazing doctor. This situation that occurred is just an eye opener for those who really care about their patients regardless to how long it took to recognize the severity of what Zoe was going through you took action immediately. Your compassion for patients first then your profession second is what makes you amazing. There’s only a few who is genuinely compassionate about their patients and you’re one of them
I admire you so much, as always
Evelyn this is a great example of “walking the walk” as we “talk the talk” of social determinants of health. Thank you for putting your personal example out there for the rest of us to learn from.
As a retired public health nurse and proud graduate of UIC College of Nursing, dealing with the patient’s every day reality and environment are so important. When health care professionals see patients only in the clinic or hospital, it makes it much harder to know what the patient is dealing with on a regular basis. The fact that you are now more sensitive and aware and plan to assess further in the future, is good. Thank you for sharing this meaningful story and caring so much about your patients. Best wishes to Zoe and son.
Thank you for taking the time to read, reflect, and for providing support.
Such a great ‘case study’. Thanks for sharing. Best to you, Zoe and son.
Thank you for sharing. I think it puts medicine in perspective as I have a primary care Geriatrics office. I frequently have nurse practitioner students who I have visit the patient first and then I go back in with them and also asked a history in front of them and then we discussed the patient after. I have the luxury of being in a private practice and having multiple alerts from the office staff and back office medical assistants who may alert me to concerns and issues. The student and I have found it very eye-opening after the student has done the history and evaluation if the question is asked what can I help you with today or what can I do for you today as a way to redirect our focus away from what we think is best for the patient and what they have the biggest concerns about. I have to admit the social issues are the biggest concerns and require the most intensive interactions and support which are difficult in a teaching environment especially but so important for the student to understand ‘so if that were you what would you want your physician to do.! Remember it’s not our agenda!