Thread by @gradydoctor

1/
There are things that happened that led to things that happened that led to things that are happening. If you don't want to call it by a name, just describe it.

And instead of it feeling like some pressured mandate, look at it the way we look at all things.

As history.

2/
History.

Not something designed to make someone else feel ashamed. Not a wagging finger or even a quest for moral distress. Just the things we do when we care for patients. We ask questions.

About the things that happened.

3/
That led to things that happened.
That led to the things that are happening.

You know?

And this is necessary to know. Not just "the in thing." But just a thing that we need in our arsenal to do a good job caring for human beings.

You know?

4/
A patient comes in with severe uncontrolled high blood pressure. They also had COVID recently. And known challenges with substance use.

The patient was seen once or twice in the ER with elevated BP. Never got a follow-up in clinic.

But why?

5/
Was it fear? Being irresponsible? Ignorance?

Instead of answering that, let's explored the things that happened. That led to the things that happened. That led to the things that are happening.

The patient doesn't have stable housing. They live outside most of the time.

6/
The shelters are full. And limited due to social distancing. And the best ones aren't keen on folks with active substance use.

So why can't they just get a job? Try harder? Gef off the bad stuff? So that they can take their medication.

And control their blood pressure.

7/
Good questions.

This makes me think of this person I knew once who struggled with addiction and mental illness (which, as it turns out, this patient had, too.) That person I knew turned to family. Who provided a soft place to land.

And soft places often involve resources.

8/
And sometimes resources come from resources that led to resources. Or they come from opportunities for resources that led to opportunities for resources.

This patient did not have that.

In fact, this patient came from a fractured family. Which happens a lot.

9/
Their father was incarcerated. First for "disorderly conduct" and later for a probation violation. The "disorderly conduct" was when he corrected an officer who called him "boy. "

2 incomes became 1. Mom set out to make things better. She worked as a domestic.

And saved up.

10/
She tried to buy a house. In a better neighborhood with better schools. With new books and sidewalks.

Her credit was good, too.

But not good enough for them to let her buy where she wanted to buy. And the law said this was okay.

So she bought what she could.

11/
In a resource-poor neighborhood that remains just as resource-poor to this day. Where the patient grew up.

Yup.

The patient didn't go to college. It wasn't really talked about at this school. And finishing wasn't even coveted.

So they didn't even graduate.

12/
They got a job and worked. Hourly, low-paying but a job. And along came a spouse and children of their own. Which was a lot.

Some days they felt sad. Like so sad that it was hard to do anything. And they quelled those feelings with substances. Because that's all they knew.

13/
And because "mental health" wasn't even talked about. Kind of like college wasn't at that school in the neighborhood that was the only one the bank said Mom could join.

So yeah. That was tough.

But then Mom aged and got sick. And she needed support. And help.

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And, though she had worked her whole adult life as a domestic, social security didn't provide many resources for her.

Oh. Did I mention?

The Social Security Act of 1935 excluded domestics and agricultural workers. Which excluded Mom.

Yup.

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So resources that could've built generational wealth went to caring for the generation before.

Oh. And since we're here, the GI Bill, which created lots of opportunities for generational wealth building through things like home ownership and education, was also challenging.

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Because segregation laws and things like dishonorable discharges rendered them useless for some folks.

Folks who looked like this patient.

So the patient got arrested in the 90's for drug possession. New laws made the punishment harsher. And the sentence longer.

Yup.

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So after being convicted of a felony and having a substance use disorder and having an untreated mental illness and no family support, that made it hard to work.

Impossible? No.

But hard? Yeah.

There were some things that happened that led to some things that happened.

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That led to some things that are happening.

Yup.

So now, here this person is before me and my medical student. And sure, I can and will teach them how to manage the high blood pressure. And I can make some teaching points about COVID, too.

I can and I will.

But.

19/
The rest of the history is relevant, too. The things that happened that led to the things that happened that contribute to the things that are happening now.

Not just to check a box. But because these are human beings and we signed up to care for them.

Full stop.

20/
And if you're even in medical school, there's a chance that, just maybe, some of those doors closed to this patient and their mama and their daddy and their mama and daddy before them, may not have been closed to you.

Maybe.
Maybe not.

But data suggests there's a chance.

21/
So listen--if you don't want to call it by a name? Don't.

Just know this:

There are things that happened that led to things that happened that led to things that are happening.

And these things affect health.

Regardless of what we call them.

#healthequity #teachDEI