Beyond the Stethoscope: Addressing the Social Determinants of Health

By Nikki Apana, ’20

For my uncle, no level of mental health treatment could cure his chronic homelessness. No number of visits to the psychiatrist could shield him from the physical and psychological trauma that accompany living on the street. Having witnessed the effects of homelessness on my uncle’s overall wellbeing, I became deeply committed to addressing healthcare disparities through medicine and public health.

At Stanford, I sought out courses that could help me understand my uncle’s experience and how to help. My frosh year I found a Cardinal Course that allowed me to combine my academic interests in public health and passion for public service: Social Emergency Medicine and Community Engagement. In the class, we discussed how socioeconomic status affects health status, and I got to see how these trends play out in the emergency room (ER) through a partnership with our partner organization, Stanford Health Advocacy and Research in the Emergency Department, or SHAR(ED).

The emergency room is a safety net. When people don’t have anywhere else to go, that’s where they end up. Sometimes emergency room patients come in for something as minor as a cold—or a serious condition after a minor condition goes unmanaged for a long time. The hospital ranks the severity of a patient’s condition on a scale of one to five, with one being the most severe. But the ranking says little about the social causes of their illness.

As a volunteer, I screened patients at the Stanford Hospital Emergency Department for social needs that could negatively affect their health. Some of the most common issues included the lack of affordable housing, difficulty accessing a primary care physician, high cost of childcare, lack of healthy food, and difficulty paying utility bills. At the end of each visit, I referred patients to local organizations to help reduce the burden of these needs on their overall health.

I valued providing patients with resources to help them cope with different pressures and reduce the frequency of their visits to the emergency room. However, in medicine there is still a disconnect between physicians and patients: ER physicians are there to only treat serious medical conditions, while patients want any treatment.

During one of my volunteer shifts, I was with a Spanish-speaking patient and a nurse asked if I spoke Spanish. I nodded.

“Oh great! Can you translate for me?” the nurse asked. Then she quickly rattled off a number of test results to me. “Her CT scans, blood test, and everything else look normal. Can you tell the patient that everything is fine and that she should just go see her primary care physician?”

I did as the nurse said. Then, the patient looked at me and asked, “Are you sure there’s nothing wrong?”

From an operational standpoint, the nurse was right; the patient should have gone to a primary care physician instead of the ER. But this patient was like many others in the ER who have never heard of a primary care physician or simply cannot afford it.

As I learned from a young age, addressing medical issues requires so much more than scrutinizing physiological symptoms and abnormalities. Access to healthy food, affordable housing, and high-quality healthcare all contribute to individual health and wellbeing and can prevent frequent visits to the emergency department.

After taking this Cardinal Course, I pursued honors thesis research on the barriers patients face in seeking healthcare—research that I plan to use to advocate for policies that ensure patients’ basic right to high-quality healthcare.

As I look beyond graduation, I hope to apply to medical school and become a primary care physician, with the knowledge that a state of complete health cannot be achieved without remediating the underlying social challenges that patients face everyday.

Nikki Apana, ’20, is a premed student studying human biology, with a concentration in race, ethnicity, social class, and public health. She is a Cardinal Service Peer Advisor, Community-Based Research Fellow, volunteer with SHAR(ED) and, patient health advocate with Cardinal Free Clinics. She is also involved with Kaorihiva, the Polynesian dance group at Stanford. Nikki is from Concord, CA.