Our Common Language in Social Emergency Medicine

As a member of the newly formed Social Emergency Medicine section of ACEP, you presumably have some idea of what is meant by social EM. You may have very specific interests in health literacy or incarcerated patients. You may have decades of experience in the field, or you may be just beginning to learn about this side of medicine. Our section already has almost 250 members, with diverse interests and backgrounds, but we all have a common interest in understanding how social factors affect our work in the emergency department. As our section establishes itself within the house of emergency medicine, we will spend time talking with our colleagues, supervisors, and students about what social emergency medicine means, and so it would be helpful to establish some common language to help in these conversations.

Contrary to many initial assumptions, the Social EM section is not tasked with organizing parties for ACEP. Social Emergency Medicine takes its name from Social Medicine, a field of medicine which traces its roots to the 19^th century when Rudolf Virchow famously responded to the typhus epidemic in Silesia (now Poland). His analysis led to strong criticism of the Prussian government for not addressing inadequate food, housing, and sanitation for the affected population.

A primary interest in social medicine is describing and understanding social determinants of health, including how the experience of one’s sex, race, culture, ethnicity, financial instability, immigration status, housing conditions, and many other aspects of one’s life, affect health. In emergency medicine, much of the interest and work on social determinants of health thus far has focused on community violence, homelessness, and humanitarian emergencies.

But the social determinants of health not only impact our patients’ health before they walk through our doors, they also affect how care is delivered to patients, and the contexts in which they try to heal. Many patients come to the ED as their primary source of care, only after negative interactions with other health providers. Provider bias has been shown to at least partially explain certain outcome disparities between different groups. For example, there is evidence that sexual orientation and the experience of bias by LGBTQ patients affects health outcomes. However, it is difficult to make evidence-based conclusions about the health outcomes of any particular group, if the group definition is not well established, not standardized, or varies over time. With Meaningful Use, the Center for Medicare and Medicaid (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have standardized how electronic health records should define and capture data on sexual orientation and gender identity (“SOGI”) which in the future will hopefully improve our ability to measure and address health outcome gaps in these patients.

What we choose to address and prioritize as a specialty is also a social and political process. Human trafficking involves recruiting, harboring or otherwise detaining people for the purpose of labor or service through the use of force or coercion.  The explicit advocacy on the part of emergency physicians has led to improved education for providers of all specialties to be able to recognize potential victims of human trafficking, in its many forms, and methods to offer safety and resources to victims.

As specialists on the frontline care of ballistic injuries, many emergency physicians find ways to reduce the incidence of gunshot injuries in their communities. Hospital based violence prevention programs (HBVIPs) can help mitigate the downstream impact of interpersonal violence.

As a specialty that sees all persons in society, and perhaps disproportionately the most vulnerable members of society, emergency physicians are particularly well-positioned to be able to understand, identify, and address the most impactful social, economic, and political threats to our patients’ lives and health. On the frontline of emergency medicine, we all grapple with our patients’ experiences from substance abuse to domestic violence, homelessness to transsexual identity. As many of these issues overlap and interact with each other in different ways for different patients, the concept of intersectionality comes into play. Intersectionality is the idea that there are overlapping and interlocking mechanisms of social stratification.

Social emergency medicine requires us to go beyond the biological basis of disease, and understand the social, political, and economic contexts in which diseases develop, as well as the ways that we as providers and the health system around us identify and respond to those processes. To achieve optimal outcomes, we must account for these factors, and in many cases address them, as they can be just as important for achieving health as any prescription we write or referral we make. Learning how to optimize our care as providers for all of our patients is part of the mandate of social medicine. A common language to describe social emergency medicine and the social determinants of health is the first step toward understanding how all these factors impact our patient’s health. And ultimately, acknowledging and addressing these factors can help us all become more effective emergency physicians.

Laura Janneck, MD, MPH, FACEP and Luis Lovato, MD, FACEP