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Doctor's Orders: A Social Prescription For Health

Hotz is a solutions-focused journalist.

Last month, a viral video explaining an MIT neurosurgeon's decision to quit the field unearthed the many frustrations that millions of fellow medical professionals have been facing for years.

The most obvious is burnout. One survey found more than half of U.S. Doctors experience burnout, and that numbers were highest among doctors in emergency medicine, internal medicine, ob/gyn, and family medicine. Another study weighing physician guidelines with current patient demands suggests it would take primary care doctors 26.7 hours per day to see an average number of patients.

Recent pleas diagnose the culprit as moral injury -- described, in another viral essay, as a phenomenon in which health workers are forced to cast their ethics aside, and put the hospital's business needs over their patients' needs. During the pandemic, eight in 10 doctors experienced moral distress, according to one survey, and another article suggested more than 70% of emergency physicians agreed: "the corporatization of their field has had a negative or strongly negative impact on the quality of care and on their own job satisfaction."

But beneath the surface of burnout and moral injury, something else is happening in medicine: a phenomenon in which doctors, strained for time and resources, often can't treat the root causes of their patients' suffering.

The MIT neurosurgeon compares this phenomenon in his patients to fixing a house with a leak in the roof. Just as tearing out the moldy drywall and installing a brand new wall does little to stop the underlying leak, cutting out bulging discs and installing titanium spine rods does little to treat what's often the root cause of the patient's pain. Regardless of the surgeries he can perform, the doctor says the patients who best recovered were the ones who had healthy lifestyles, stress coping mechanisms, and good social support.

Which begs the question: why can't doctors prescribe those medicines, too? Why can't prescriptions include activities that help patients find ways to cope with stress, move their bodies, spend time outdoors, and find deep and lasting relationships?

Around the world and in the U.S., more health workers are mobilizing around this mission through a rapidly spreading practice called social prescribing -- a practice through which health workers refer patients to nonmedical resources or activities that aim to improve their health and strengthen their community connections. Instead of asking "what's the matter with you?" social prescribing asks patients to consider "what matters to you?" and invites medical professionals to help them get there.

The practice responds to a basic fact: Up to 80% of our health is determined by the environments in which we live (social determinants). To survive, we need basic resources -- clean air, trees, nutritious food, shelter, and money. And to thrive, we need sources of joy, meaning, and relationships -- reasons to wake up in the morning, things that make us feel healthy, connections to what matters to us.

And so, by prescribing patients activities like cycling groups and art classes, and resources like food, legal support, and transportation, social prescriptions help patients meet these basic and psychological needs -- improving their ability to manage their own health problems and boost health outcomes across the board.

The practice began in the U.K., the world's first nation to create a minister of loneliness, an issue made more dire after the National Health Service estimated one in five doctors' appointments are made for nonmedical, purely social reasons. This creates more pressure on doctors, who then have less time to see patients with medical issues, in a system already struggling with staff shortages, long backlogs, and pervasive burnout.

And so, to free up doctors' time, social prescribing is often done with the support of someone like a link worker -- health professionals whose job is to listen to the patient, understand what matters to them, and connect them to community activities and resources accordingly.

"I find amazing organizations not because I look on Google, but because I walk around my neighborhood, and understand who's in the community." says Gay Palmer, one of the U.K.'s first link workers. In other countries, the link worker role is handled by social workers, health coaches, or even volunteers.

"There's a lot of tears and frustrations being pulled out [in that first conversation], so all I've got to do is listen, translate for the [doctors] what's going on, and help them understand why [the patient] has had these frequent attendances," Gay says.

This sort of translating and redirecting has proven to be effective; studies associate social prescribing with a reduction in the total number of doctor visits and emergency department visits, hospitalizations, and healthcare spending -- all of which alleviates pressure on the system.

It's no wonder surveys have found a majority (59%) of general practitioners in the U.K. Believe social prescribing can reduce their workload.

And yet, more than just giving doctors more time to focus on patients with clinical needs, social prescribing can help remind doctors of their own needs, and reasons for practicing medicine in the first place.

That was true for Ardeshir Hashmi, MD, the endowed chair for Geriatric Innovation at Cleveland Clinic, and one of the first adopters of social prescribing in the U.S. His first go at social prescribing came when he was at Massachusetts General Hospital, where he met "Ruth," a 93-year-old patient who came to the emergency department every 2 weeks with chest pains.

"Everyone thought, 'Oh my god, it's something with her heart, her blood vessels,'" he explains. But when Hashmi learned her chest pains were gone by the time she arrived at the hospital, he also learned the root cause of her pain: she was lonely.

Her grandson -- her main social support and ride to ballroom dance lessons -- had left for college. The solution? Arranging for a geriatric case manager to take her to ballroom dancing again.

"Wouldn't you know it, all of these emergency department visits disappeared! It was just as simple as that."

When Hashmi arrived at the Cleveland Clinic, he became determined to make that kind of socially determined, patient-led care the norm. He established a patient council, which recommended clinicians invest in 90-minute conversations with patients, and "prescriptions" based on those conversations. Then, with community partners and a software platform, clinicians prescribe local connections, like walks at the local arboretum or home visits through an art center.

The result has been hundreds more patient stories like Ruth's, Hashmi says. And yet, he believes the benefits aren't just for patients; they're also for healthcare professionals.

To remind him of the value social prescribing can hold, Hashmi keeps the card Ruth's kids sent him on his desk, with an encouraging message: "Thank you for giving us our mom back."

Julia Hotz is a solutions-focused journalist based in New York. Her stories have appeared in The New York Times, WIRED, Scientific American, The Boston Globe, Time, and more. She helps other journalists report on the big new ideas changing the world at the Solutions Journalism Network. Hotz is the author of The Connection Cure, published by Simon & Schuster, from which this piece was excerpted.

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Pharmacy Prescriptions Delayed After IT Outage

Pharmacies are warning of delays in issuing prescriptions in the wake of the global IT outage, with "slower than usual" service as they cope with backlogs.

Patients waiting for medicines are being told that emergency cases will be prioritised, as the health service attempts to deal with the fallout from the chaos on Friday.

Nick Kaye, the chairman of the National Pharmacy Association, said: "As pharmacists recover from last week's IT outage and catch up on the backlog of prescriptions, we expect service in some community pharmacies to be slower than usual today.

"Please be patient with your local pharmacy team if you are visiting them, as they may still be prioritising emergency prescriptions from their local GP surgeries as well as experiencing increased demand as services return to normal.

"As ever, community pharmacies have worked hard to provide support for those who need them during this period."

GPs have warned of continued delays this week as a result of the backlog.

The British Medical Association (BMA) said the IT chaos had forced doctors to cancel appointments on Friday, which would have an impact into this week.

Mondays are normally the busiest days for doctors' surgeries.

GPs said the start of this week would be particularly stretched because many patients who should have been dealt with last week would now need attention.

Dr David Wrigley, the BMA deputy chairman, said: "Friday was one of the toughest single days in recent times for GPs across England. Without a clinical IT system, many were forced to return to pen and paper to be able to serve their patients.

While GPs and their teams worked hard to look after as many as they could, without access to the information they needed much of the work has had to be shifted into the coming week."

Dr Wrigley said GPs had been "pulling out all the stops … to deal with the effects of Friday's catastrophic loss of service" but said the loss of the EMIS patient record system had caused "a considerable backlog".

He added: "Even if we could guarantee it could be fully fixed on Monday, GPs would still need time to catch up from lost work over the weekend, and NHS England should make clear to patients that normal service cannot be resumed immediately."

An NHS spokesman said: "Systems are now back online, and patients with an NHS appointment this week should continue to attend unless told not to."

The outage was caused by a faulty software update produced by CrowdStrike, a cyber security company, for PCs running Microsoft Windows.

The problem is estimated to have affected 8.5 million devices worldwide. On Sunday, Microsoft released a recovery tool to aid the repair of PCs that use Windows.

CrowdStrike has issued a fix for the bug in the software update, although George Kurtz, its chief executive, said it would take "some time" for systems to be fully restored.

Asked whether the Government would be launching a review into what had happened, the Prime Minister's official spokesman said: "We keep resilience under constant review."

The spokesman added that the Government has set out its plans to better protect public services and the third-party services that they use, including through a Cyber Security and Resilience Bill to "ensure that more essential digital services than ever before are protected" by putting regulators on a stronger footing.

"Clearly this case is one to learn the lessons from," the spokesman said. "There are lessons that we should ensure are learned from this particular incident."

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Optimizing Opioid Prescriptions After The ED To Reduce Opioid Overdoses, Misuse

New research aims to help reduce the quantity of unused prescription opioids after emergency department visits and lessen the risk of opioid misuse and overdose. The study is published in CMAJ (Canadian Medical Association Journal).

Overprescribing is linked to opioid misuse and overdose, with household supplies of opioids associated with an increased risk of overdose, as many people do not dispose of unused medications safely. In Canada, more than 7500 people died of opioid overdoses in 2021, and more than 68 000 people died in the United States in 2020 from these drugs.

A team from the Network of Canadian Emergency Researchers conducted a study at 7 emergency departments (6 academic tertiary care hospitals and 1 community hospital) in Quebec and Ontario to determine the ideal quantity of prescription opioids to control pain in patients discharged from emergency departments and reduce unused opioids available for misuse.

"As higher quantities of prescribed opioids are associated with higher quantities of consumed opioids, it is important to adapt opioid prescription practices to patients' analgesic needs for specific acute pain conditions while minimizing the number of unused opioid tablets that can be diverted or misused," writes Dr. Raoul Daoust, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur-de-Montréal, and the Department of Family and Emergency Medicine, Université de Montréal, Montréal, Quebec, with coauthors.

The study included 2240 participants, with a median age of 51 years, who were asked in 14-day diaries and follow-up phone interviews if they filled their prescriptions, how many pills of opioids they took (converted to 5 mg morphine per tablet), and if they filled any new prescriptions. Half of participants received a prescription of 16 tablets or more, and 63% of these were not used. Consumption of opioids was low, half of patients consumed fewer than 5 tablets, and consumption varied significantly by type of pain condition.

"The authors suggest that clinicians could adapt prescribing quantity to the specific condition causing pain, based on estimates to alleviate pain in 80% of patients for 2 weeks, with the smallest quantity for kidney or abdominal pain (8 tablets) and the highest for back pain (21 tablets) or fractures (24 tablets), and add an expiry date for use (e.G., 3, 7, or 14 days). Furthermore, since half of participants consumed even smaller quantities, pharmacists could provide half this quantity (partitioning) to further reduce unused opioids available for misuse.

"Opioid prescribing requirements to minimize unused medications after an emergency department visit for acute pain: a prospective cohort study" was published July 15, 2024.

Research: https://www.Cmaj.Ca/lookup/doi/10.1503/cmaj.231640

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