The Public's Health: The Illusion of Clinical Success | Public Health Post

As doctors we have both had our fair share of patient success stories. A patient presents herself to our office or emergency room with a problem, we diagnose it, prescribe treatment, and the patient gets better. We can remember Lois who presented with vomiting, whom we diagnosed with gastroenteritis, treated and restored to health two weeks later. And Emmanuel who came to the emergency department with a cut on his forehead because he fell down the stairs. He was sutured up and the cut healed nicely. All clinicians have these stories. They are the reason why many of us went to medical school, to heal people, to make them better.
And yet, anyone who has worked as a clinician knows what often happens next. The patient who had gastroenteritis returns again a few months later, this time with shortness of breath that turns out to be influenza pneumonia. The patient who had the cut on his forehead returns this time with hepatitis. The reason for this, of course, is that both had common causes that were not dealt with when we, the physicians, dealt with the presenting complaint. Yes, the immediate concern was gastroenteritis, but the root cause was a refrigerator that went out when the electric bill wasn’t paid that resulted in contaminated food. That same root cause—poor living conditions—resulted in pneumonia transmitted from another unvaccinated resident in a densely populated house. For the patient who presented with a fall and a cut, and later hepatitis, his medical problems were all related to alcohol dependence that had its roots in adolescence.
These observations are all immediately recognizable to clinicians who struggle to identify and treat a root cause whose sources are often outside the medical system. And that is what makes root causes so powerful: they escape ready treatment and underlie a multiplicity of medical presentations. The same root cause can be responsible for a gastrointestinal or a respiratory problem, for an injury or a hepatic problem. This is why when we think of the causes of medical problems strictly from an organ-based perspective it is never enough. Because medical problems often do not arise in their end-organs; they are bodily manifestations of underlying issues.
What does this mean for the role of the clinician? Clinicians remain responsible for fixing the immediate problem, but must, we believe, eventually also grapple with the underlying concerns. The issues of inadequate housing, limited access to addiction treatment, poverty, and terrible neighborhoods are medical problems. But they are larger than any individual clinician caring for an individual patient. Clinicians can choose to be advocates themselves, voices for public health outside of the hospital or clinic, or they can advocate that their hospital or clinic embrace these issues with fervor. Absent that, our clinical success remains fleeting, illusory.
Michael Stein & Sandro Galea