Realizing Our Power: Advocating for Social Justice

1. Realizing Our Power: Advocating for Social Justice Summer Institute Sarah-Anne Schumann F. Daniel Duffy August 3, 2012

2. Social Justice The new professional contract with society

3. The practice of medicine and delivery of healthcare are morally relevant acts aimed at preventing or relieving human suffering in life, liberty, and the pursuit of happiness

4. Patient’s Predicament Vulnerable Frightened Unable to help self Dependant on others Low social status Healthcare Professionals swear a public oath to: Be trustworthy Use specialized knowledge and training for the good of the sick Keep patients from harm to the best of their ability Put aside self-interest for the good of their patients Moral Act of Profession Sulmasy D. The Rebirth of the Clinic: An Introduction to Spirituality in Health Care. 2006 The Georgetown University Press, Washington, DC.

5. Medicine’s Contract

6. Community Medicine’s Contract

7. We make a personal commitment to improve the health of our patients Devote our collective efforts to improve the health care system for the welfare of society Expanded Contract The ABIM Foundation, The American College of Physicians Foundation, The European Federation of Internal medicine,Ann Intern Med & Lancet, March 2002

8. A Just Society • Assures equality of opportunity and fairness • Guarantees its members a fair share of what is required for them to pursue their individual ends • Upholds the principle of “Just Sharing” of the “financial burdens of medical misfortunes equally by the well and ill alike, unless individuals can be reasonably expected to control those misfortunes by their own choices” Smith, GP. Social Justice and Health Care Management: an Elusive Quest. Houston Journal of Health Law & Policy. 2009

9. Social Justice in Healthcare Examines the relationships between groups and individuals that influence the distribution of healthcare across society. Advocates for the poor on an individual level and for solutions to the structural barriers that deny the poor access to affordable, adequate health care. Justin M. List, MD, Medicine Resident JAMA 2011

10. Community Medicine’s Agenda Social Determinants of Health Marketplace Commodity

11. Social Injustice is a Cause of Disease Health status is tightly tied to education, financial status, healthy environment, and a secure social situation. Treating the disease of addiction mainly as criminal activity prevents effective research and treatment. Childhood poverty, neglect, and abuse threatens adult opportunity for life, liberty, and the pursuit of happiness. Lack of universal access to healthcare reduces the well-being and economic viability of the entire society.

12. Healthcare as a Market Commodity • US society has come to view healthcare as a market commodity • Subject to supply and demand forces and rationing decisions imposed by providers • Medicine’s contract yields to “social good and economic need” • Individual wealth or privilege of insurance rather than need of the patient determines the degree of participation in the US healthcare marketplace Justin M. List, MD, Medicine Resident JAMA 2011

13. Charity Health Care In the United States charity care or uncompensated care is health care provided for free or at reduced prices to the poor or uninsured Faith Based Hospitals Physician Generosity Teaching Hospitals Free (Mission) Clinics Public Hospitals Community Health Centr Hospital Emergency Rooms

14. Charity Care in the US • In 2004, 68% of physicians provided charity care, down from 76% in 1996 • In 2006, Senate investigators found • Many hospitals did not inform patients that charity care was available • Some for-profit hospitals provided as much charity care as some non-profit hospitals • Some non-profit hospitals charge poor, uninsured patients more than they did insured patients

15. Is Charity Care Social Justice? “Though it is sorely needed, charity care may in some ways perpetuate the unjust system that makes it necessary in the first place. True social justice in medicine demands that physicians take the lead in advocating for systemic change.” Justin M. List, MD, Medicine Resident JAMA 2011

16. Rudolph Virchow “Doctors are natural attorneys for the poor … If medicine is to really accomplish its great task, it must intervene in political and social life…”

17. Community Health Centers Access to Healthcare for the poor

18. Federally Qualified Health Centers: Part of the Solution • Located in or serve a high need community(OK has 40 sites currently, +6 fall 2012) • Governed by a community board composed of a majority (51% or more) of health center patients who represent the population served. • Providecomprehensive primary health care services as well as supportive services (education, translation and transportation, etc.) that promote access to health care. • Provide services available to all with fees adjusted based on ability to pay (OK 40% uninsured, 30% Medicaid) • Grant-Supported Federally Qualified Health Centers are non-profit health care organizations that meet certain criteria under the Medicare and Medicaid Programs and receive funds under the Health Center Program (Section 330 of the Public Health Service Act).

19. Boston: Codman Square Health Center • Medical services • Include dental and behavioral health, residency programs • Open until 9 weekdays for primary care • Urgent care 7 days a week • Community Services • Fitness center • Teen center • Job/computer training • Food Pantry • Farmers Market • Charter School

20. Chicago’s Urban Health Initiative“DELIVERING THE RIGHT CARE IN THE RIGHT PLACE AT THE RIGHT TIME”

21. Wuhan, China

22. Tulsa:Morton Comprehensive Health Services • Program highlights • Transportation • PAL clinic • Multiple options for specialty care referrals • Example of limitations of safety net

23. Now that the Summer Institute is ending, what do I do next?

24. Power, Privilege, Advocacy The non-self serving influence of healthcare professionals to foster social justice in health care

25. Power without Love… …is reckless and abusive; love without power is sentimental and anemic. It is precisely this collision of immoral power with powerless morality which constitutes the major crisis of our time” • Martin Luther King, Jr.

26. Love and Social Justice • Justice validates the dignity of the human person • Love is the “driving force” behind justice • A spirit of love, humaneness, and compassion in medicine and healthcare will minimize human suffering and maximize social good • The social good allows attainment of the “good life.”

27. Power and Social-Justice • Power can correct the inequities • Without power there can be no justice, • Without justice inequities between the haves and the have-nots can not be fairly resolved • Power must often be exercised coercively through appropriate laws and policy • Laws must rest on moral reasons that the public in whose name they are enacted could be expected reasonably to accept

28. The Cost of Healthcare Privilege • Professional education • Self-justification of inequity – “I rose above it” • Rationalization - specialty procedures “deserve” a higher price than primary care or cognitive specialty services • Status quo – our practice overhead is not under our control • Widening wealth-poverty gap in the U.S. leading to more working poor and uninsured individuals and demand for more charity care

29. Financial Self-Interest A social-justice framework requires that physicians speak out against the forces that continue to make meaningful, truly universal health care unattainable, even when to do so temporarily contradicts their own financial interests. Do the Right Thing

30. Don’t obtain screening exercise electrocardiogram testing in asymptomatic individuals and at low risk for coronary heart disease. (ACP) Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. (ACP) Don’t do imaging for low back pain within the first six weeks, unless red flags are present. (AAFP) Don’t do imaging for uncomplicated headache. (ACR) Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. (ACP) Five Things Physicians and Patients Should Question AAAI, AAFP, ACC, ACP, ACR, AGA, ASCO, ASN, ASNC

31. Support the Affordable Care Act “The Affordable Care Act seeks to increase access to high-quality, affordable healthcare for all Americans. Three aims: better care for individuals, the community, and making it all more affordable. “ Michael Maxwell, MD, OU-Tulsa Alumnus

32. Advocate by Speaking Up “What we do know is that those of us with insurance pay for those without, access to care in many areas of our country, even some areas of the Tulsa region, is no better than that in third world countries, the quality of care is widely variable throughout the country. We know we can do better. This [ACA] law is a good start. Now if we can get out of our own way by fostering a spirit of cooperation, collaboration and innovation, we can pull off something great.” Michael Maxwell, MD, OU-Tulsa Alumnus

33. Exercise Political Will Passing the ACA, enduring the misrepresentation of its purpose and content as “Obamacare,” and the Supreme Court’s upholding its legality demonstrate the enormous political will necessary to bring the United States into the company of every other high-income country to assure that every citizen has adequate access to affordable healthcare.

34. Free Our Society from Charity Care • Demonstrates a fundamental respect for human dignity • Frees healthcare professionals to spend more energy on patient care, instead of balancing charity care with making ends meet in practice • Bedlam can focus on excellent care for vulnerable patients and education of the next generation of professionals Justin M. List, MD, Medicine Resident JAMA 2011

35. Next steps: ACHIEVING HEALTH EQUITY IN THE MOST CHALLENGING ENVIRONMENTS • Critical thinking • Critical communication • Critical emotions • Critical actions

36. Critical Thinking: Stay Informed! • Medical Education Futures Study: social mission of medical education • Bi-weekly newsletter: • www.medicaleducationfutures.org/newsletter • Oklahoma Policy Institute: issue briefs, email alerts • www.okpolicy.org/ • Health Affairs: eTOCs • www.healthaffairs.org/ • Health Begins (clinicians addressing social determinants of health) • healthbegins.ning.com/ • Sarah-anne-schumann@ouhsc.edu

37. Critical Communications • Generous Listening • Shared Decision Making • Learn Spanish!!! • Speak up! • Op eds • Opportunities to speak • Schools • Churches • Community centers

38. Critical Emotions • Keep a journal • Record patient stories • Talk to colleagues • Self-care: “This is your life” • Exercise • Relaxation/vacation • Friends, family • Healthy eating

39. Critical Actions: Advocacy • Individual: patients • Groups: • Specialty choice • Practice location • Systems: speak up when you see flaws in the system, innovate! • Primarycareprogress.org • Narrative Matters • www.healthaffairs.org/NM.php

40. OU-Tulsa Center of Excellence for Bioethics and Social Justice in Healthcare