It is hard for me to look at the world without my stethoscope. That’s not to say I lift it to my eyes to see through, or my vision magically clears when it hangs around my neck. Rather, I have been indoctrinated to view the world as a physician. I have been trained to think through problems first by identifying the symptoms and then asking what are the underlying diseases associated with these symptoms that need treatment. I have learned that you can always cover up a cough (the symptom) with a syrup or pill, but it’s only when you diagnose the pneumonia (the underlying disease) and treat it with an antibiotic that you will actually cure the problem.
One of the core principles of this training is that a good history is often all you need to diagnose a problem. Your physical exam is simply to reinforce what you think is going on; at its best, you may never have to order a lab test or x-ray to make a patient healthy.
Yet I often wonder if the art of listening to our patients has been lost. As researcher, I often think I get my best ideas from listening to patients. As a young impressionable pediatric intern in 1996, I remember asking a family what had changed recently after their child had a catastrophic asthma attack landing her in the intensive care unit. The family talked about the cat they had gotten in response to the mice they found in their daughter’s bed. It was the eureka moment for me in my career because in this case the symptom was the asthma attack and the underlying disease was an unhealthy home.
Since then, I have devoted much of my research life to thinking through ‘housing diagnoses’, whether it’s poor housing quality, such as what happened to the child, or unaffordability, such as when people have to pay more than half of their income on rent leading to awful trade-offs with food, or instability, like homelessness, or having to move two or more times in a year (near homelessness).
In my experience, under asthma is often a housing quality diagnosis, under failure-to-thrive is a housing affordability diagnosis, and when a child fails to meet key developmental milestones underneath is a housing stability diagnosis. In each case, the usual clinical treatments of breathing medicine, nutritional supplements or in-home developmental services have limited effectiveness unless we address underlying disease: housing.
That’s why I have enjoyed coming back again and again to the Eleven Principles for Creating Health, the recent report from the Creating Health Collaborative. The enlightened report challenges us to relearn what we should have learned in medical school: listen to our patients so they can be healthy.
Last month I co-wrote an article that looked at neighborhood-level interventions to address child poverty and improve opportunity and health. It was a way to think through housing location as a diagnosis and focus of treatment. While writing it, it became clear that place is defined as much by people as geography. The first stage in any “place-based” strategy would be community engagement, and community leadership building. It is only through listening to community members as partners can we begin the first steps in achieving health equity.
But listening is a hard thing to measure. It is not as sexy as ordering a genomic sequence or high resolution MRI. Yet in my work I have learnt that we need to operate with principles of inclusion, to have “an inclusive definition of community”, as the report says. It is essential to have our patients as partners in creating health, to acknowledge and then rebalance the power dynamic. All too often we let textbooks define success or “cure” without asking the patient what their goals are. Again, as the report says, we need let the community define what matters – and that’s what should be measured.
I could go on and on about the other principles in the report but my over-arching reflection is that the future of creating health lies less in developing a new technology and more in remembering what Sir William Osler said: “Listen to your patient, he is telling you the diagnosis.”
- Megan Sandel
Megan Sandel, MD MPH, is an Associate Professor of Pediatrics at the Boston University Schools of Medicine and Public Health, the Medical Director of National Center for Medical-Legal Partnership, and a Principal Investigator with Children’s Health Watch. She is a nationally recognized expert on housing and child health.