Beyond the Advocacy Track

Michael Khouli is a 2013 graduate of the Emergency Medicine/Pediatrics Residency Program here at Indiana University.  Seeking to extend the curriculum offered by IUEM through the advocacy track, Michael is developing an MPH curriculum for the residency while acquiring the Master’s in Public Health, himself.  Here’s how he got there:

“Medicine is a social science, and politics is nothing else but medicine on a large scale.”

           -Rudolf Virchow

The first time I thought about becoming a doctor, I was in Mexico.  I met a man with an obviously broken and infected hand asking for money, and I thought it seemed a relatively easy matter to treat him if only there was a physician to take care of him.  So I became a doctor.  I wanted to care for the underserved nationally and internationally, those people literally no one else would treat.  A lot of doctors probably have a similar story.  However, as I pursued my training in pediatrics and emergency medicine, I realized that many patients are underserved, not because of a lack of geographic access to a physician, but rather because of socioeconomic barriers to accessing that care effectively.  In the emergency room, I work with a disproportionate share of disenfranchised patients, serving as the healthcare safety net for America.  Rewarding as it is, I sometimes feel like the boy with his finger in the dike, dealing with the end result of a broken healthcare delivery model without having the wherewithal to address the factors that lead to preventable poor health.  I can provide medical care for the same intoxicated homeless patient for the third time this week, but I can’t provide him a home or social support to turn to instead of a bottle.  Yet many cities have initiated programs to do just that, with good results, reduced ER visits, and lower public cost overall.  Moreover, I have recognized that what really impacts our health and quality of life is not the latest antiplatelet drug or statin-de-jour.  Rather, public health initiatives often offer greater benefit at less cost, whether it has been through vaccination campaigns, potable water and sewage systems, removal of lead based paint and gasoline from the market, or adding fluoride to water supplies.  My emergency care for trauma patients matters, but legislation for stricter highway safety regulations keeps them from being trauma patients in the first place.

I chose to become a physician a decade ago to care directly for patients, unencumbered by the ambiguities and uncertainties inherent in broader healthcare policy initiatives.  Nonetheless, as I was forced to deal with the effects of those policies on my patients and myself on a daily basis, I realized that I could not simply ignore them and still do my job well.  Caring for patients requires physician advocacy and engagement in that public process.  Traditional residency training often neglects this aspect of patient care.   How do I partner with local interests in the community to establish a free clinic in an impoverished neighborhood?  How do I get funding for such a venture?  How do I establish liaisons with healthcare networks and systems in other states or countries to improve accessibility and coordination of care?  How can I understand global health to translate successes abroad to solutions at home?  How do I interpret epidemiological trends to understand and address socioeconomic and behavioral dimensions of health?  How do I engage with legislators to address these issues?  What kind of model will truly improve patient access to basic care so that their health does not deteriorate to a condition requiring emergency care?

I think many physicians, myself included, would struggle to even begin addressing such questions, and there are no easy answers.  IUEM already offers a strong and unique advocacy curriculum that offers many opportunities to understand and explore such public health issues.  To further develop such skills and interests, we are now partnering with the Fairbanks School of Public Health to offer the unique opportunity for residents to take formal MPH classes.  This program is set to launch during the next academic year.  Flexible and online classes will allow the residents to mold their curriculum within the demands of a full resident schedule.  In the ER we have ample firsthand experience of the consequences of broad public health problems.  Traditional medical training teaches us to treat those consequences.  My hope is that through our new public health curriculum, we will be able to address the deeper causes underlying those consequences to the relief of our overburdened ERs, our individual patients, and the public as a whole.  As ER physicians are increasingly asked to be all things to all patients, public health becomes a natural extension of our already broad scope of practice.

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