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Broadening the Agenda

Posted By John Muench, Friday, September 11, 2015


This is the first of several blog posts preparing readers for the upcoming CFHA Annual Conference in Portland. Click here to register for the conference.

We Portlanders like to claim New York Times columnist Nicholas Kristoff as one of our own, despite the fact that he grew up outside our fair city, in Yamhill, Oregon, surrounded by farmland and lumber mills.  We’re proud that Kristoff takes on global social injustice issues such as human trafficking and poverty.  Occasionally he writes stories about his hometown. In a recent column ("U.S.A., Land of Limitations?” NYTimes 8/8/15) Kristoff related the story of a Yamhill friend, Rick Goff, who died in July of heart failure at age 65. 


Death of heart failure at 65. When I hear such stories a petty voice peeps up in the back of my mind trying to calm my own fear of approaching 65 by attributing Rick’s early mortality to behaviors and choices that would, of course, never affect you or I. Rick must have chosen to smoke, use drugs, be inactive, and/or not take those heart failure medications as prescribed, straightforward problems that perhaps we could have addressed with good patient education and motivational interviewing. 


Kristoff reminds us that it’s not so simple, that  "too often the best predictor of where we end up is where we start.”  He relates that Rick’s mother died when he was 5, that his father was alcoholic, and that Rick mainly raised himself and his three siblings.  Rick dropped out of school by grade ten, was divorced twice and raised two children on his own. Kristoff encourages us to look at these problems as neither simply biologic, nor social, nor psychological, but a complex stew of all three, because "the best metrics of child poverty aren’t monetary, but rather … how often a child is beaten, how often the home descends into alcohol-fueled fistfights, whether there is lead poisoning, whether ear infections go untreated.” We know now that such early family dysfunction translates directly into poor adult health.


Rick did, indeed, stop taking his medicines shortly before he died.  According to Kristoff, Rick felt the need to help a friend in a jam and didn’t have enough money left to buy his own medications that month.




I’ve grown tired of watching similar scenarios play out in the urban community health center where I’ve worked for many years.   Too often we see adults in our exam rooms whose real problems are lack of education, poverty, addiction, and homelessness that began with inadequate nurturing during their formative years, or as Kristoff would say "too little being read to and hugged.”  By the time they hit our exam rooms, these problems have grown far bigger than my PCP tools can handle and it often feels like trying to empty the ocean with a thimble.


We’re learning.  Broader team-based care, we know, can better address patient psychosocial issues. Over the past ten years we’ve welcomed case managers, social workers, and psychologists as partners into our medical homes; it feels like there has been progress.   But still, I meet "Ricks” whose problems seem so heavy that neither they themselves, nor I, nor a whole team of people can lift them by the longest of metaphoric bootstraps.  The hopelessness that arises is compounded when we think of the children at home, children who are highly likely be caught up in the same cycle of poverty and disempowerment.


This is why I’m excited about our upcoming CHFA conference. There is beginning to be a critical mass of researchers, healthcare providers and policymakers (including at least one influential newspaper columnist) who understand that exam room decisions and relationships are important, but so are the larger environments that affect patients once they go home from the clinic - environments that are physical AND psychological AND social.  There is a growing consensus that the triple aim can’t possibly be attained until we address this cycle of biopsychosocial illness begun in early childhood. And we’re nearing a critical mass that can translate this understanding into resources that will help us find and implement better, more comprehensive healthcare.


I can think of no better group to explore these issues than the CFHA membership that has pushed at the edges of biopsychosocial since George Engel coined the term in 1977.  We’ve seen enough to know that medications and counseling are necessary, but sometimes not sufficient to fix the problems that begin with adverse childhood experiences.  It’s up to us to explore the hard, complex questions, and to go home with new ideas to test.  I’m looking forward to our conversation in Portland in October.  A hearty welcome to all trailblazers.


John P. Muench, M.D., M.P.H. 

Although a native of West Michigan, Dr. Muench has worked at the OHSU Richmond Clinic since its opening in 1995.  He completed a National Research Service Award fellowship in 2001, receiving a Masters in Public Health Degree focusing on diabetes screening, and continues to study systems processes for screening in primary care.  Currently an associate professor at OHSU, he serves as the Director of Behavioral Medicine for the Department of Family Medicine, director of the SBIRT Oregon Primary Care Residency Initiative (focusing on alcohol and drug screening), and as the OHSU representative to the clinical oversight group at OCHIN, an electronic health record service shared collaboratively with other safety-net clinics.

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Natalie Levkovich says...
Posted Friday, September 11, 2015
Great piece! The blog does not explicitly mention ACEs and the substantial body of research that now gives us a clear framework for action, but it certainly gives a very real and human face to the issue. I too am excited that CFHA and Oregon planners have made this a central thread in the conference program. Thanks Dr. Muench for elevating the conversation on this complex and critical issue.
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