Jennifer (Walthall) Sullivan, MD, MPH, Secretary of the Indiana Family and Social Services Administration, delivered the keynote address to members of the Indiana University School of Medicine Class of 2019 during the school’s commencement ceremony on May 10.
An alumna of the IU School of Medicine Class of 2000, Sullivan served as deputy commissioner for the state’s Department of Health prior to assuming her current role. Additionally, she was division chief for pediatric emergency medicine at Riley Hospital for Children and remains an adjunct clinical professor of emergency medicine.
The following is a transcript of her remarks:
We May Have it Backward – Social services, Social context and the Evolving Role of the Physician in Society
Nineteen years ago this girl from northwest Indiana was sitting in one of your seats. I was 35 weeks pregnant with my first baby, newly matched in a combined emergency medicine and pediatrics residency, and wondering what in the world I had gotten myself into. I suspect that I might be describing a couple of you today. I had spent my entire academic life waiting for this moment. Was I ready to be a doctor? YES!
Was I ready to be a mom? I hadn’t taken any training for that, so I wasn’t really sure.
Fast-forward 19 years. That 35-week promise of the future is now leaving for college. There is one thing I know – I would never have dreamed 19 years ago, barely able to get my gown over my gravid belly that I would be on this side of the podium with you and those who have supported you.
I have a recurring conversation with my soon-to-depart-the nest son that centers around the question – “What do you have left to learn?” In the case of my son, it’s almost incomprehensible how much I have left that I want to teach him. Does he know how to change a tire? Does he have adequate cooking skills in order not to go broke with Uber Eats? Your medical school faculty feel the same way about you – will you remember the “never misses” from physical diagnosis class, can you double check medication interactions in stressful circumstances?
I’m here to tell you that those things are very important and appropriately define our profession.
I can also assure you that you are well prepared. The Indiana University School of Medicine produces great doctors. Your residency programs will also teach you to do all the things you need to treat your patients at the cutting edge of medicine. You will work hard, you will laugh, you will cry, you will meet the people that will become your best friends for the rest of your life.
I really only want you to remember one thing I say today – the phrase social context. Ten minutes from now, some of you will see this as yet another responsibility of being a physician, some of you will be excited about this additional opportunity, and some of you will file it away to contemplate at a later stage of your career. But please remember this: social context. If you fail to consider this, your ability to serve as a vessel of good, your ability as a healer, may never reach its full potential.
Despite our historical path of learning, the most important thing you need to learn will be completely up to you. As you consider what lies ahead of you, I would suggest it may not be what immediately comes to mind. We may have it backward in the way we think about being doctors in the larger context of our role in the health of our society and I believe the future of medicine depends on embracing that change. Let me explain.
To become a true healer, you will need to learn to evolve and enlarge your identity as a physician. This means that in addition to writing prescriptions for critical medicines, or operating on patients to improve their lives, you must also have a better understanding about what people really need. It’s a basic premise that we all learned as Maslow’s hierarchy – being self-actualized is challenging if you are hungry, the ability to experience love is compromised if you aren’t assured of your safety.
So, I suggest to you that what you have left to learn is an understanding of something called social context. It’s what I believe we have backward. Doctors are really good at writing prescriptions for albuterol when we should also be able to write a prescription for a smoke-free car. Operating on a patient with a gangrenous foot from frostbite might solve the immediate problem, but without securing housing the underlying condition will worsen and, in isolation, our typical standard of medical intervention may actually contribute to that global worsening.
To the parents in the audience, this makes complete sense. It’s how we try to raise our children. We don’t wait until they are malnourished to give them food. We enroll them in school before they have educational deficits that impair their growth. We surround them with opportunities to develop socially and emotionally before there are problems. The role of the parent is to prepare children for life before independent life happens. What if we did that in health care, too?
I’d like to share with you a public health parable that illustrates this well. (I’ve taken some liberties to make it a little more modern.)
A superhero was fishing in the river when she noticed someone was drowning. The superhero was an excellent swimmer and pulled the drowning victim out to the safety of the shore. Shortly afterwards, the hero noticed another person in the river and saved them too. She noticed another and another. A crowd of people gathered and were cheering on as the hero pulled people from the river.
After a while our hero was exhausted and realized she would not be able save all of the drowning people. When the hero got out of the river, dried off, and started to walk away, the onlookers cried out, “Where are you going?”
The hero answered, “I am going up stream to keep all these people from falling in the river.”
This parable illustrates where we find ourselves in medicine – not able to save all of the drowning people despite being excellent swimmers. We have to determine effective strategies and then implement “up stream.”
I have the honor to do a really amazing job for the state of Indiana – I administer social services and health care for over 1.5 million Hoosiers as the Secretary of the Indiana Family and Social Services Administration. Everything from Medicaid to mental health and addiction to early childhood education falls in my portfolio of responsibility. I also continue to work clinically in the emergency department every Tuesday because that experience, paired with the public health parable informs and influences every single thing that I do in my government role. Let me give you a concrete example of how:
Just a few months into my current role in state government I cared for a young child who came into the emergency department with unrelenting seizures. After the child was stabilized, I sat down to talk with her mother about what might have prompted this event. I found out that it had been many months since her last seizure. Medicaid coverage for her seizure medication had briefly lapsed and she had missed four days of medicine because the out of pocket cost was too high without coverage, prompting this completely unnecessary, very costly, and potentially life-threatening complication. I hugged the mom, told her about my job, and promised her that her daughter would be ok, and I would also make it my personal mission that she would be able to navigate our complex system and meet her daughter’s needs in the future. I went back to work the next day to my executive staff meeting and uttered a phrase that is now the hallmark of Wednesday mornings at the Family and Social Services Administration – “Hey team, I saw this kid last night. We’ve got some work to do.”
Not only do we have work to do in health care, we have work to do in how we take care of people – how we become healers and experts in social context. You may be asking yourselves why I think this is important. Let me tell you.
Our comparative developed nations spend nearly exactly the same amount of money on the combination of health care and social services programs as we do in the U.S. So why do they enjoy different outcomes in important markers like infant mortality, cardiovascular health, and cancer survival? I call this the “2/3 : 1/3 paradox.” The U.S. spends 2/3 of our combined health care and social services budget on health care and 1/3 on meeting social needs like food, housing, transportation, and child care. In contrast, our counterparts have flipped those proportions. In essence, those successful nations have figured out that meeting a person’s social needs first is not only more effective for health outcomes, it’s also far cheaper. They are buying health, not health care.
Social context determines 80% of health outcomes in society. 80%. The work we do within the traditional confines of medicine only affects 20% of health outcomes. This means two things: we have to do that 20% extremely well AND we must become part of a bigger system that prioritizes a healthy environment and early recognition of unmet human needs of our patients. To do this cost effectively we must be creative and expand the definition of what health care does. In Indiana this is beginning to emerge outside the traditional halls of medicine in really exciting ways.
Area Agencies on Aging are regionally designated providers of social services, traditionally for the aging population. A short time ago, the new director of the Ft. Wayne agency decided that they may have been looking at social service delivery incorrectly. What she noticed was a group of frail, vulnerable, elderly people attempting to navigate two highly complex systems simultaneously: the health care system and the social service system. Her idea was to combine the two by making social service delivery part of health care. It literally meant turning their historical delivery model upside down.
The current way most aging individuals enter the social service system is when they have exhausted their resources in the health care system, which, as you might suspect, is the most expensive way to take care of people. It is also a great way to guarantee that people need to be sick before they receive help. What this agency pitched to the insurance companies in northeast Indiana is that it might be better for these individuals to start in social services and thus decrease or even avoid much of high cost health care because their needs are already met. Any idea what happened?
When they looked at the cost comparison, their social service programs cost $13/day on average whereas comparable health care costs were $4900/day. Rather than being an add on, this Area Agency on Aging became the entry point for the health care continuum, helping vulnerable patients achieve outcomes that meet their needs and don’t break the bank.
This helps us change the 2/3 : 1/3 paradox. We are designing this very thing at FSSA now and changing the way we deliver our services so that instead of making people individually navigate a series of complex, isolated systems, we instead focus on understanding people and make our programs work for them.
Because of this I have incredible optimism for the future of our profession! You probably hear every day, the EMR is not patient-centered, the health delivery system is broken, the burden of student debt is too high…but I believe that there is no better time than now to be a physician. We have reached a tipping point and you – each one of you – are the answers to making it a better time to practice medicine than any time in the past. I promise that when you look for these important things you need to learn next, you will find there is so much good change happening in so many corners of medicine. We just have to decide together to build and sustain solutions.
As we near the close our time together, I’d like to share ten pieces of wisdom that I’ve acquired in my career that I think will serve you well and help you in your quest to becoming a social context-driven physician:
First, some tips on doctor-ing:
1) Sit down. The conscious act of being humble and at eye level makes a patient feel like the 3 minutes you spent with them were a lifetime.
2) Don’t lie. Ever. There’s no such thing as a one-time liar. Don’t lie about someone’s prognosis, don’t make up data when you don’t know, don’t cover a mistake. Full transparency is the new standard in medicine and holding that truth allows our profession to remain respected and revered.
3) Always listen. When they ask you if you want to watch the video, look at the picture, or see the diaper, your answer is “Yes.”
Part b) When families or patients ask you to speak to their loved ones, the answer is an equally enthusiastic, “YES.” Every single time. This meaningful and engaged listening is the glue of the doctor-patient bond.
4) Ask one more question. When you are certain that you have a diagnosis or a plan of treatment, ask yourself what you are missing. I have backed into life-saving moments of clarity with this cognitive forcing strategy more times than I would like to admit.
5) Don’t confuse treating pain with treating suffering. We have to do both. The prescription for suffering is connectivity, kindness, and equity. The prescription for acute pain is intranasal fentanyl. They are not the same.
For your consideration, I’d suggest that even more important than doctor-ing tips are tips on human-ing:
1) When you are no longer capable of having a real conversation with non-doctors at dinner, you need to take a vacation. Or read a book. Or re-discover a hobby. Life is too short to spend all of your time telling medical stories.
2) On the other hand, tell your medical stories. Debriefing is one of the best ways to maintain the ability to care about people and still be able to go back and do it all over again. Also, be aware your stories can change the world. I often say in the world of public policy influence, “Data matters, but stories convince.” Save your stories – their power is immeasurable.
3) Don’t overinflate your place in the world. It is very rare that you single-handedly save a person’s life. Don’t let those moments inflate your ego, just be grateful for your team and your training. At the same time, it is equally rare that you single-handedly hurt people. Don’t let those moments send you into irreparable despair. We have come a long way in medicine and know that we are not divine.
4) When you get down, don’t blow it off. The risk of addictions, suicide, and broken relationships are not a joke in medicine. I would much rather every single health care provider have a personal therapist on day #1 than lose anyone who felt like these things are a weakness. The second part of this rule is that when someone is acting differently than you are expecting or behaving differently than they have been in the past, your first question should be, “Are you OK?” Then you should wait patiently for the answer. Again, the risk of addictions, suicide and broken relationships are not a joke in medicine.
5) Write your mission statement. I’m not kidding. Start it today. The only way to know the difference between failure and success is to have a roadmap of your values and goals that you can check as the foundation for everything that you do. I would suggest starting with what you would want someone to write on your headstone when you die. Mine is: “She was a warrior for good.”
What this all means to me is a daily opportunity to connect with people. To offer a piece of myself to them and then offer what I learn from them in turn to others to make something better. Despite everything else you might do in medicine, the expertise and kindness you impart to each and every patient that sits in front of you, is the most important thing to them in that moment and will help you frame the way you shape your path forward – hopefully with social context in mind.
What you begin today is the one of the hardest, most important, most meaningful things that we ask anyone to do. You are now the new parents of health care – and I challenge you to take it on with a willingness to be the voices for the voiceless, warriors for good, and the manifestation of the sacred bond that lives between doctor and patient to make sure the place of medicine in society is moving forward rather than backward.
We all have much to learn together – and we are ready.