Continuing Messages: Using the first Starfield Summit as a frame for discussing social determinants of health

Sara A. Martin, MSc
Harvard Medical School, Class of 2017
Pisacano Scholar, Class of 2015

The opinions and views expressed here are those of the author and do not necessarily represent or reflect the opinions of the Starfield Summit or its funders. This blog is not intended to provide medical, financial, or legal advice.

           Last year, over a hundred key policy makers gathered in the center of Washington D.C. last year for the first annual Starfield Summit.  The Summit was named after Barbara Starfield, a prolific primary care researcher who, as described at the Summit, “revealed that countries and areas with health systems that are primary care oriented have better population health outcomes, higher quality care, greater health equity, and lower costs.”

          At the Summit, United States policy makers visualized a system where primary care physicians could truly take care of whole communities as opposed to just their registered list.  The room dreamt of what this could look like, coming up with solutions that blurred the line between social and primary care, and tackled health where it started.  As one policy maker said, “the center of health care should be family and community, not the doctor.” 

          In the United States, places such as Iora Health are leading these attempts.  Through proactive outreach to patients, they are meeting patients where they are and often before they even know they need it.  For example, Iora Health has re-envisioned diabetes care to include a trip to the market.  There they can walk with the patient through the store, demonstrating how to read nutrition labels and giving tips for avoiding troublesome foods.  Other groups such as Health Leads allow physicians to practice social prescribing (e.g. recommending a knitting group for an isolated person), an idea gaining traction in the United Kingdom too.

          However, in the United States these “bright spots” remain anomalies; we are hindered by an insurance-based system that still leaves too many people without access to health care services.  As one policy maker and physician said, “It’s not a health system, it’s a wealth extraction system.”  We are also hampered by the most common financial model—fee-for-service—which pays us only for tangible services rendered.  It does not measure—or pay for—that which never happened: the woman who never got diabetes, the man who never had a heart attack, the hospital admission that was avoided.

          This year’s Starfield Summit (April 22-25) will focus on the social determinants of health.  It will move beyond the first Summit, from how healthcare can be shaped to have family and community at the center, to how family and community can shape health.  It is guaranteed to be an inspiring weekend, full of passionate movers and shakers for whom there is little question as to the importance of community within medical care.

          It is important, however, that the second Starfield Summit occurs within the context of the first Summit, using measurement, payment, and new models of care as a frame for discussions.  How can measurement, payment, and new models of care be changed and mobilized to improve social determinants of health?  Framing the conversation this way will help the primary care community to move past the bright spots to unlock the potential—and the power—of the medical community to help ameliorate the social determinants of health.

Healthcare reform: Growing a team commensurate with the challenge at hand

Elizabeth V. Looney, MD
Family Medicine Resident, Class of 2019
MetroHealth Medical Center, Case Western Reserve
Cleveland, Ohio
Pisacano Scholar, Class of 2015

The opinions and views expressed here are those of the author and do not necessarily represent or reflect the opinions of the Starfield Summit or its funders. This blog is not intended to provide medical, financial, or legal advice.

            In medicine, we are both victims and perpetuators of tribalism. From the moment we firstdeclare the desire to pursue a career in medicine, we are faced a stemming question: "Yes . . but what kind of doctor do you want to be?" Instantly conflated with an identity in medicine itself is a pressure to define that identity based on what we will not be doing. We grow from undifferentiated, pluripotent physician-hopefuls into specialized, distinctive tribes, oftentimes before we realize what is happening to us. The question then becomes: In this house so divided, how do we stand together as a healthcare team to address the global issues affecting us all -- namely, a higher functioning healthcare system?

            One of the answers which emerged from the discussion on Teams was that the de-tribalization of the medicine must start early on. Currently, as we "grow up" in medicine, we do so along a linear trajectory that floats further and further away from other specialties. We start early on to distance ourselves from the issues that seem to plague only other specialties, and become invested or divested accordingly. Why does this matter for those of us interested in reform? Because somewhere along the way, the bettering of our healthcare system has become a primary care issue alone. Our tribal mentality, then, is a major stumbling block to reform; each facet of medicine needs to pull their weight in order for us to be successful, because the system we are working in represents all of us. Undergraduate medical education and residency need to entail intentional training and teaching on the working together of medical disciplines to share not just a common vision for our patients, but for our entire healthcare system. From the moment our professional identities hatch, a shared responsibility for the future of healthcare should start to grow as well. 

            A further point that emerged from this discussion was that we need to not only reach out and embrace our specialty colleagues, but each and every member of the healthcare team. From our receptionists and MAs to the CEOs and administrators of our hospitals, we must first believe -- and then act on the belief -- that everyone has something to contribute. The work of creating a higher performing, more just healthcare system is simply not possible to accomplish without the support, camaraderie and expertise of each and every member of the healthcare community -- including our patients! Multiple examples were cited on the micro- and macro-levels of higher-functioning organizations that resulted from intentional involvement of every player with a stake in the game, not just the traditional leaders. The Patient-Centered Medical Home (PCMH) is one well-known example of this model, along with numerous original ideas that Summit attendees had witnessed in their own healthcare settings.

            So where does this leave us as primary care physicians? Looking at the Starfield Summit as a revamping of our game plan, our job is to be the initial leaders and galvanizers of the global reform team. Whatever level we are involved at -- from undergraduate medical education onwards, there are things we can do. From the Teams discussion, I offer two key points in sum:

We need to change the culture of medicine so that our very identities, rather than basedon distinction from one another, include early on a deeply held and shared, pragmatic commitment to making our healthcare system better.

We must believe that everyone in healthcare, in both the horizontal and vertical directions, has something to offer towards the reform movement. Once we are convinced of this notion, we must actively seek to involve representatives from as many of these sectors as possible. In doing so, not only do we cultivate buy-in and solidarity, but our approach is that much more likely to without critical blind spots and ultimately, effective.