On September 14–15, 2017, 50 thought leaders were invited by ACEP, the Emergency Medicine Foundation, and the Andrew Levitt Center for Social Emergency Medicine to Dallas for Inventing Social Emergency Medicine, a consensus conference to establish the intellectual underpinnings of this growing field, which incorporates social context into the structure and practice of emergency medicine.
Funded by the Robert Wood Johnson Foundation (RWJF), the conference drew from a broad range of leaders, representing at least 16 emergency medicine programs. Some participants had been involved in emergency medicine almost since its birth, including Lewis Goldfrank, MD, FACEP, of New York University (NYU) Medical Center in New York City, Jerome Hoffman, MD, FACEP, of the University of California, Los Angeles (UCLA), Stephen Hargarten, MD, MPH, of the Medical College of Wisconsin in Milwaukee, and Edward Bernstein, MD, FACEP, of Boston Medical Center, among others. Thanks to the Levitt Center’s Lynton Scholars program, two medical students and four residents attended. There were seven alumni of the RWJF Clinical Scholars Program and five current fellows from its legacy program, the National Clinician Scholars program. Two board members from ACEP—Stephen Anderson, MD, FACEP, and Jay Kaplan, MD, FACEP—attended the entire session, as did several ACEP staff members.
Conference Sessions Day 1
There were five prepared papers, each with two prepared commentaries, all circulated to the participants in advance of the meeting. Each half day focused on two such sets, with the last session oriented to the future. The discussions ranged widely, incorporating the full ecology of social emergency medicine, from bedside practice to emergency department and hospital re-engineering to address social determinants of health, to working for leverage in communities and populations. The conversation was remarkably inclusive—49 of the 50 participants took the microphone at least once.
The opening discussion built upon paper one, “Principles of Social Emergency Medicine,” by Dr. Goldfrank and Jahan Fahimi, MD, of the University of California, San Francisco (UCSF), with commentaries by N. Ewen Wang, MD, of Stanford University School of Medicine in Palo Alto, California, and Suzanne Lippert, MD, of Kaiser Permanente in Oakland, California. Among many incisive observations made during this session, a comment by Lia Losonczy, MD, a critical care fellow at Maryland Shock/Trauma and author of one of the conference’s most-cited papers, seemed to sum it up. Reflecting on the task ahead, Dr. Losonczy remarked that clinicians often turn a blind eye to social needs because we don’t feel equipped to address them. She added, “With the right tools, they will be emboldened.”
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.”
The final hours of the program were dedicated to establishing research priorities for the burgeoning field of social emergency medicine. Conference organizers and others are actively distilling these themes and priorities into a summative chapter to accompany the conference proceedings in a publication.
Inventing Social Emergency Medicine was a beginning, meant to be a small group of people engaging in debate and discussion about an unformed area of inquiry and activism, one that is busy but lacks cohesion. That cohesion is what is changing, post-Dallas. Social emergency medicine is developing some internal logic of its own, and its principles and ideas are beginning to cohere. We invite any interested readers to join the Social Emergency Medicine Section or the Social Emergency Medicine Interest Group and roll up their sleeves in the creation of this maverick new field.
Dr. Alter is associate chair for research in the department of emergency medicine at Highland Hospital—Alameda Health System in Oakland, California, and executive director of the Andrew Levitt Center for Social Emergency Medicine