Some time ago, a new medical student attending my tutorial on public health and disease prevention brought up the risks of homelessness and the recent murders of two homeless men in Albuquerque. The comment was marginally related to the case we were discussing but reflected serious concerns of students and sparked an intense debate among them. After we condemned these senseless and brutal acts, we began to discuss the problem of homelessness. Is it a medical problem? We agreed that it is not quite like congestive heart failure or pneumonia, which have clear pathologies and pharmacological treatments. But the homeless do run higher risks for certain medical conditions like skin infections, mental illness, and environmental exposures, just as diabetics have higher risks for heart and renal diseases.
The students asked about my own experience with homeless patients, and I described a man I had seen the previous evening who was found intoxicated and unconscious on the sidewalk and brought to the emergency department (ED). As it turned out, that was the latest in a long string of similar visits to the ED by him. During a recent one, he had a subdural hematoma, so on this latest visit, we sent him for a CT scan, which fortunately was negative. I imagined this man would probably get a CT scan again if he presented to the ED unconscious with bruises or cuts on his face. On this visit he occupied one of our ED beds for more than 10 hours as he slept off his alcohol intoxication. In the end, he refused a shelter or an alcohol treatment center, and our team discharged him back to the street with a bag lunch.
I shared the story of this patient to help my students understand the complexities of the intersection between social and medical problems. We wondered if increasing access to health care, which the Affordable Care Act (ACA) encourages through insurance coverage, would provide better solutions to problems that the homeless experience.
The students did some research on the medical effects of homelessness for our next session. We learned that studies of homeless adults had documented the higher mortality of homeless adults compared with other adults in Toronto,1 Philadelphia,2 and Boston.3 Sadowski et al,4 in a randomized study of homeless chronically ill patients, found that interventions that provided housing and case management after hospital discharge had reduced subsequent hospitalizations and ED visits. Frankish et al5 discussed the public health and policy perspectives related to homelessness in Canada, a country whose health care system differs from the U.S. system, and found gaps in access to social support and medical care similar to those in the United States. While my students had great sympathy for the plight of the homeless, they wondered whether the provision of housing was a public responsibility or part of the health delivery system and how it might affect incentives for the patients to seek work. That discussion led to the larger question of the role of government in health care.
The role of government in health care is at the root of many of the arguments about health reform that currently focus on the ACA, but it also could be seen as a major factor in funding and eligibility for Medicare and Medicaid and in meeting future workforce needs. The questions that our discussions raised probably echoed questions being raised at academic health centers (AHCs) and universities around the country. Should health care be based on an individual relationship between a patient and a doctor, and should government’s role be to ensure the proper functioning of markets? Or should health care be considered a right guaranteed by the government, as is the case in some other countries? If health problems occur because of social determinants such as homelessness, smoking, and alcohol or drug abuse, who should be responsible for treating or preventing them? These are important questions, and my students would not likely encounter them in their future anatomy, biochemistry, or other basic sciences classes, nor would these questions appear on any of their exams. Even during their clinical rotations, the students would probably not consider alternatives to our current health care system. Instead, they would learn the tricks for navigating the current system.
I think we need to do more than figure out the workarounds for problems in our health care system. For example, it is time now, four years after its passage, to take stock of the ACA, what it has accomplished, what unintended consequences have occurred, and how it has altered our priorities in medical education and care delivery. I believe that we must now begin conversations about what we have learned about the ACA and other efforts at health care reform to help us understand where our health care system is headed and how the changes will affect what we teach, investigate, and practice at our AHCs. We will also need to engage our communities in these conversations, both internal and external. I hope that through such conversations we can influence the policy debate about the future of health reform.
With these goals in mind, we have created a new ongoing feature in the journal called New Conversations. In past years, Academic Medicine’s editor-in-chief has posed a Question of the Year each January and has invited brief essay responses to be published in a subsequent issue of the journal. Although I have looked forward each year to engaging with our readers on important topics through the Question of the Year, I believe that it is time to end that feature and expand the journal’s ability to engage with readers by introducing the New Conversations feature. I hope to stimulate our thinking about the most important issues facing the academic medicine community by periodically posing topics for New Conversations and publishing selected contributions about those topics by experts as well as members of our general community and the public. The first topic for New Conversations is, What are the present and future impacts of current health care reform efforts on medical education, health care delivery, and research at academic health centers, and what effects might such reforms have on the overall health of communities? Contributions may address a number of topics related to health care reform and advocacy for the health of all people, such as end-of-life care, reducing unnecessary care, workforce, patient safety, costs of care, and interprofessional teams. The ultimate goal of this first New Conversation is to help the academic medicine community become full participants in the critical conversations that need to occur to help all stakeholders make informed decisions about health policy and reform.
In this issue of the journal we are fortunate to kick off this feature with an essay from former Senator Tom Daschle.6 His perspective provides a valuable vision of our health care options going forward at local, state, and national levels, and the opportunities for AHCs to play an important part.
I believe that many of you also have perspectives, experiences, and ideas to contribute. Solutions that work in one part of our country may take root in other areas if we can know about, understand, share, and nurture them. In addition, I think it may sometimes be the questions you can raise that will be as important as the answers. I ask that you submit contributions to this first New Conversation, guided by the question stated earlier in italics, to be considered for publication in the journal. Please submit contributions through the journal’s online submission system, Editorial Manager (www.editorialmanager.com/acadmed), using the article type “New Conversations.” Submissions should be scholarly contributions; they must follow the journal’s regular submission criteria for Commentaries, Articles, Perspectives, Innovation Reports, Research Reports, or Letters to the Editor, depending on which of these formats you use for your submission. (For more information about those criteria, please see the journal’s Complete Instructions for Authors at http://journals.lww.com/academicmedicine/Pages/InstructionsforAuthors.aspx). Submissions will be peer-reviewed. I will be looking for submissions, on all sides of the issues, that are respectful and scholarly related to health policy and medical education, research, clinical care, or administration at our AHCs.
We will carry on the conversation outside the pages of the journal as well. Our blog, AM Rounds (academicmedicineblog.org), will feature a series of roundtable discussions related to the New Conversations contributions that are published in the journal. I also encourage you to discuss New Conversations on Twitter using the hashtag #AcMedConversations by offering your opinions, posing questions, and responding to the questions posed by your colleagues. We will be using the journal’s Twitter handle, @AcadMedJournal, to do the same. Our goal is to keep the New Conversations going throughout the year by using these channels.
Although the impetus for this first New Conversation is rooted in the current climate of health reform and its implications for AHCs in the United States, I believe that the perspectives of our international readers will be important in this conversation. In AHCs around the globe, physicians and faculty have valuable experience enacting and accommodating reforms in education, research, and patient care. I encourage our international readers to submit contributions to this first New Conversation to share their thoughts and experiences and thereby inform the debate here in the United States.
I will consider New Conversations submissions at any time—there is no deadline for submitting a contribution—though I will periodically announce new topics of focus for the feature. The current New Conversation will remain active through the 2016 U.S. presidential election, with the intention of preparing you to participate in debates about health care reform and policy, in your communities and with political leaders, as more informed and effective advocates for the health and health care needs of our country. After the election, I will announce the end of the current New Conversation and will introduce a different topic to be covered in the New Conversations feature.
Although we may not publish New Conversations contributions in every issue of the journal, we hope to have many contributions to share in the pages of the journal and beyond as this initial New Conversation unfolds. Whether you are interested in policies related to improved access to health care for the homeless through the ACA, as my students were, or you have thoughts on other topics related to the ACA or other efforts at health care reform to share, I look forward to your creative thinking, problem solving, and perspectives.
David P. Sklar, MD