"You know, doc, I can't afford a $15 medication."
Sitting in front of me was a young grandmother. She had several issues—obesity and hypertension among them. She made approximately $670 a month, with most of that going to her rent. Whatever was left had to pay for everything else: food, medications, traveling to doctor's appointments—and she wanted to be able to buy birthday gifts for her grandchildren.
I had suggested she start taking an additional blood pressure medication.
"Do you want me to come see you for my appointments? Or do you want me to take this new medication?" she asked me. "I can't afford both the bus to your office and the new medication."
"What am I supposed to do?" she asked anxiously.
I wanted her to be able to do all of those things: take all her medicine, keep her doctor appointments, and buy birthday gifts for her grandchildren. She needed a new care plan.
This story has stayed with me a long time. This event actually occurred before social determinants of health became a prominent part of our national health policy discussion, but the social determinants have impacted outcomes since the first surgeries in ancient times.
As physicians, we are trained to consider a patient's education, cultural background and income level when providing treatment and care. We adapt our approach based on our understanding of the patient's environment.
But when we talk about addressing the social determinants, one thing is often left out—communication—as well as how we engage with our patients in the modern age.
Our ability to communicate effectively directly affects a patient's care access and quality. Extensive research has shown the benefits of effective communication on patients' health outcomes.
But upwards of 70% of health outcomes are driven by factors beyond healthcare. For example, one study found that 5.8 million people in the U.S. delayed medical care because they did not have access to transportation. And it's estimated that one-third of adults with chronic illnesses underuse their prescription medication due to cost concerns. Yet they fail to share this information with their physician, a clear gap in patient-provider communications.
If we don't know how to reach and engage patients outside of the doctor's office, in a manner that fits both their lived experiences and cultural backgrounds, then we cannot provide the care they need and deserve.
Our patient communications strategy needs to mirror our mindset when we are in the examination room: adaptive based on our understanding of the whole patient.
Many patients cannot wait on the phone for half an hour or more, or be available during traditional business hours. They work double shifts; they work nights; they are family caregivers. An email full of medical terms, jargon—or even English—might be meaningless. The traditional one-size-fits-all approach to patient communications doesn't work (and if we're honest, it never truly did).
Today, we need to communicate with patients in the same way we communicate with family and friends, taking into consideration a range of factors such as working hours and preferred language.
It might be an after-hours email, or a series of text messages sent throughout the day, or a scheduled video conference. We might even end up using a combination of communications channels, timings and languages to address the patient's range of needs. With 97% of Americans owning a cellphone, we have the tools to meet the vast majority of patients where they are.
Only when we tailor our approach to each patient and truly engage them beyond the exam room—in ways that fit their lifestyle and experiences—will we be able to unlock patient needs between visits and close gaps in care.
Furthermore, every patient touch point—whether it's billing or clinical in nature—can play a role in deepening our understanding of the patient. Providers who recognize this, and synthesize the often-disparate communication touch points, will thrive in patient-centered care.
As for the grandmother on a tight budget? We were able to reduce the number of medications she needed and found lower-cost alternatives so she could travel to her check-ups and afford her prescriptions. And she did buy those birthday gifts.
