The morning session continued with paper two, “Achieving the Quadruple Aim: Treating Patients as People by Screening for and Addressing the Social Determinants of Health” by Dennis Hsieh, MD, JD, of Harbor-UCLA Medical Center in Torrance, California, and its accompanying commentaries by Jocelyn Freeman-Garrick, MD, Highland Hospital in Oakland, and Robert Rodriguez, MD, of UCSF. This was intended as a case exploration in the possibilities of social emergency medicine. Dr. Hsieh, also a lawyer, reviewed some of the help-desk and coaching models for resource navigation for health-related social needs. Much of the discussion revolved around the dichotomy of formal screening for health-related social needs, which can generate data and targeted referrals, balanced with the process of understanding our patients’ social context to improve care, or what emerged as the “be a good doctor” paradigm. “Screening is really a matter of viewing the social history through a disparity lens,” said Nathan Irvin, MD, of Johns Hopkins School of Medicine in Baltimore, Maryland, “the conversation can humanize the patient.”

To begin the afternoon, attendees engaged the next case example in paper three, “Homelessness and the Practice of Emergency Medicine: Challenges, Gaps in Care, and Moral Obligations,” by Maria Raven, MD, MPH, of UCSF, followed by commentaries from Roberta Capp, MD, of the University of Colorado School of Medicine in Aurora, and Kelly Doran, MD, MHS, of NYU. Much of the discussion focused on unstable housing as a social driver to care, and there was a general sense that when people who are homeless or unstably housed come to the emergency department for food, shelter, or safety, it must be a “yes, and” situation. The social need should not, on the one hand, need to be medicalized into a chief complaint, but neither should it always be viewed as the only driver to care. The dichotomy lies between the observation of Hemal Kanzaria, MD, of UCSF, that, “We hear ‘chest pain,’ and everything else goes away,” and Dr. Goldfrank’s admonishment that “homelessness can be a ‘distracting injury,’ and every ED visit is an emergency from the patient’s perspective.”

The last discussion of the day began with paper four, “A Paradigm Shift to Interrupt the Bi-directional Flow Driving Community Violence,” by Thea James, MD, of Boston University School of Medicine, and its commentaries by Dr. Hargarten and Dr. Irvin. This impassioned conversation touched on all the ways that violence affects our emergency departments and communities, as well as how our emergency departments and hospitals affect the communities our patients comprise. We went upstream to economic opportunity and how the concept of anchor institutions can enhance job prospects for youth in our hospitals’ communities and downstream to the secondary prevention of violence interruption initiatives. Finally, reflecting on the distinction Dr. James drew between the emergency department treatment of survivors of the Boston Marathon bombing and the daily survivors of gun injury, Dr. Hoffman remarked, “Unfortunately, we can fall into the trap of looking differently at ‘innocent victims’ with whom we empathize, and other patients whom it’s easy to blame—reflexly or even subconsciously—for their own circumstances. Addressing and correcting this pattern presents an enormous opportunity for the bedside practice of social EM.”

Conference Sessions Day 2

The following morning, discussants dug right in on paper five, “Emergency Physicians as Community Health Advocates,” by Joneigh Khaldun, MD, FACEP, of Henry Ford Hospital in Detroit, and its companion pieces by Christopher Barsotti, MD, MA, of Southwestern Vermont Medical Center in Bennington, and Zachary Meisel, MD, MPH, of the University of Pennsylvania in Philadelphia. Speaking from her experience as executive director and health officer for the city of Detroit’s health department, Dr. Khaldun led the conversation toward how individual emergency physicians can influence “little p” and “big P” policy—acting in our emergency departments, hospitals, and hospital systems, testifying before lawmakers, or working with public agencies. As Dr. Hargarten noted, “We can leverage our leadership to do things differently, and we can recognize these different talents in our residents and students and encourage their leadership for bedside advocacy, at the community hospital, or on a larger stage, wherever their talents may lead them.”