“I buy a pack on Sundays and we eat one every night.”
My patient, a 63-year-old woman seeking treatment for diabetes and hypertension, sat across from me shifting in her seat. She looked down at her hands and waited.
Five minutes before, we had reviewed her blood pressure readings from the past few clinics. Today it was 165/100. We had discussed whether or not she was taking her medications, all 3 of her antihypertensives, as prescribed. She was, she told me, taking them all. We had started talking about her fingersticks, given that her A1c was elevated at 9.8%. I had asked her what she had eaten for dinner the night before and she had responded, “Hot dogs.” I asked, “Why hot dogs?” and she looked at me and said, “Well, my grandson lives with me and he likes hot dogs. It’s what I can afford, and he likes it, so on Sundays I buy a pack and we each eat one every night until they are gone.”
She paused just for a moment before saying almost to herself, “It’s what I can afford.” Then she waited, looking at her hands nervously.
In that moment, I saw all my years of education, training, certifications, and exams. My diplomas on the wall. My congratulatory letters for passing my internal medicine and then my endocrine boards. They meant nothing then because I had no response that would help my patient. After 9 years of training, and now 2 years into professional life, all I knew how to do was change her medications. But I realized it wasn’t the best thing to do.
That seminal moment forever changed my understanding of what it meant to be an educated physician. The curricula at medical schools continue to change, but there remain some persistent holes and silos of information that never connect, often to our patients’ detriment. For decades medical education has lagged in providing nutrition instruction for students; I was one of many trainees who was not taught this critical information. The topic of the social determinants of health has now made its way into many a medical school curriculum but most often in the form of singular lectures or seminars scattered among the years of training. My own medical school education had included topics such as poverty, literacy, and domestic violence. However, they seemed like islands by themselves, and on the wards the task of addressing pertinent social issues was quickly handed off to the social worker assigned to our floor.
The intersection of nutrition and the social determinants is where my patient stood all those years ago, and I had no compass to direct me on how best to help her. I did not know what food insecurity was or how it affected my patient. I had no knowledge of the resources in my community that could have provided assistance. I didn’t know how to guide her to better food choices when she had limited resources. In this patient, I saw that I was unable as a mature provider to address all of her needs through simply identifying and discussing them. I could change her medications, or add more, but I could not address what was wrong.
In the years since, I have sought to fill my own holes in knowledge and taught my students how to bridge those gaps in patient care so they are better prepared than I was at the end of training. I encourage robust appreciation for and connection with community agencies that address people’s nonmedical needs, such as food insecurity and domestic violence. Today I am as prepared to recommend healthy food options on a budget as I am to add another antihypertensive. That intersection of addressing medical and nonmedical needs is always my target now that I have a compass of my own.