An Introduction to Social Emergency Medicine

In September 2023, I had the privilege of speaking with Dr. Adrian Aurrecoechea about social emergency medicine. Dr. Aurrecoechea is the Director of Social Emergency Medicine at SUNY Downstate Health Sciences University and New York Health and Hospitals Kings County.

Portions of the interview have been edited and condensed for clarity.

Lin: Can you tell us more about how you define social emergency medicine (SEM) and what practicing SEM entails?

Aurrecoechea: SEM is a school of thought in emergency medicine (EM). Every EM physician practices SEM to an extent and on a spectrum. Borrowing from ACEP’s description, SEM is when an emergency provider “incorporates social context” into the practice of EM. With SEM, we think about the social context and incorporate what we’re able to do for patients in the emergency department (ED). We work with local communities to affect the social factors that bring people to the ED.

Lin: Why is SEM important and relevant to EM physicians?

Aurrecoechea: While some physicians believe their “black cloud” or “white cloud” affects volume, I would argue that what actually brings someone to the ED on any given day are social determinants of health. Many ED visits are inevitable, but some are avoidable. Often patients present to the ED when they can’t access another medical provider they need to access such as a specialist. They present to the ED when they don’t understand when they need to go to the hospital versus when they should go to a primary care provider (PCP) for a chronic issue. They may also present when something in the environment triggers a health problem or causes an injury and they’re forced to come to the ED because they don’t know where else to go for care.

When we’ve evaluated a patient and discharged them on medications, they may not be compliant with medications because of cost and access. Or they may not understand the need for medications and the need for taking these medications as prescribed because of health literacy. They may not be able to adhere to a medication regimen because of a lack of stable housing or because they’re having difficulty having their basic needs met and no amount of medication prescribing from the ED is going to fix this. As a result, all the work we’ve done with that patient in the ED may end up being futile. If we want patients to do what we’ve instructed is the right thing for their health, we have to consider what might be preventing them from doing the right thing.

Emergency physicians can address these social determinants of health through advocacy within the department and hospital and working with local governments to improve the health of communities. When we become involved in social determinants of health research or try to influence local and national policies that affect our patients, we can collectively influence the flow into our EDs and improve the health of our patients.

Lin: Why is SEM important and relevant to EM physicians?

Aurrecoechea: SEM is a school of thought in emergency medicine (EM). Every EM physician practices SEM to an extent and on a spectrum. Borrowing from ACEP’s description, SEM is when an emergency provider “incorporates social context” into the practice of EM. With SEM, we think about the social context and incorporate what we’re able to do for patients in the emergency department (ED). We work with local communities to affect the social factors that bring people to the ED.

Lin: How did you develop your niche and interest in SEM?

Aurrecoechea: Many medical students who choose EM, especially those who choose to train in a public safety net hospital in traditionally underserved communities, do so because it’s a unique setting where society intersects with the medical system. An ED visit is one of the few moments when a person living within the context of their society and environment interacts with the medical system and becomes a patient in a hospital, often for the first time. For many patients, this is their only interaction with the medical system. This gives the emergency physician a good sense of what’s going on in the community and how local laws and local factors affect a community. These things determine who needs the ED and I found this fascinating.

Our knowledge as EM specialists makes us well-suited to work towards the well-being of entire populations. This motivated me to advocate for marginalized communities and improve the context our patients live within. As a medical student going into EM, I became interested in public health from clinical shifts in the ED. I found that people are really affected by their social context. This is what drives who ends up coming to the ED, who goes to the primary care doctor and who sorts out their issues on their own at home. I sought a public health degree to acquire tools that would enable me to focus on identifying and treating social determinants of health through health programs, clinical guideline implementation and working with departmental and hospital administration. I wanted to influence policy writing, lobby for policy changes and research how to improve society at the community level. Through my interests in public health and population health, I was drawn to SEM because it fit well with what I wanted to do both inside and outside the ED.

Lin: Tell me more about where you practice EM and how you incorporate SEM principles into your clinical practice.

Aurrecoechea: I practice EM in East Flatbush, Brooklyn, New York at King’s County Hospital and SUNY Downstate Medical Center. If we consider Brooklyn, New York as its own city, not as a borough of New York City, it would be the third most populous city in the US. In the ED, I serve a diverse, international population. There’s variation in the social determinants of health affecting community members. In my patients, there’s a wide mix of incomes, education levels, legal status in the US and languages spoken. There’s also diversity in sexual orientation and gender identification. I serve a large Caribbean community. Some people are established in the US, some are here temporarily or visiting the US. Many of my patients speak Haitian Creole, many speak Spanish.

The community I serve is affected by local violence. We see a lot of trauma in the ED, mainly from gunshots and stabbings. This community is historically underserved. A lot of people are low-income, some receive government subsidies, some do not. A large portion of our patients are homeless. There’s a wide spectrum of health literacy affecting what patients understand about their own health and medicine. We also see patients who struggle with substance misuse – alcohol, crack cocaine, cannabis, synthetic compounds. I practice in a very unique environment and for me, it’s an opportunity to make an impact in patients’ lives by addressing some of the social factors that influence why they come into the ED.

I really love the community I work in. The community and our patients are warm and welcoming. They often need help from us as medical providers and are very grateful for the care they receive.

Lin: In your practice, what are the most frequently encountered SEM issues and how are these issues addressed where you work?

Aurrecoechea: One is language barriers. Until recently, we were having challenges providing care to patients who speak Haitian Creole. Through advocacy, we addressed this in the greater hospital system where I work. We now have a live language interpreter for Haitian Creole. Previously, we were using language phones and found this was inadequate. Patients have found it easier to communicate with providers using a live language interpreter, as some things were lost in translation using the phone interpreter and there were sometimes technical difficulties. This is a step towards better language equity for our patients.

Another issue is drug and alcohol misuse. For patients with opiate misuse disorder interested in quitting, we partnered with our psychiatry colleagues and the Department of Mental Hygiene to create a protocol for starting patients on buprenorphine from the ED. Before, we referred patients to outpatient programs for initiating buprenorphine and stopping opiate use and would hope they made it to their appointment. We now have a workflow involving psychiatry seeing patients in the ED and getting them involved in a patient’s care earlier. This smooths the transition to outpatient treatment and has really made a difference. We’ve started a lot of patients on buprenorphine. This transition from oral or snorted opiates to a buprenorphine regimen has changed the way these patients live on a day-to-day basis.

Another issue is food insecurity. We established a program in the summer of 2020 in collaboration with Food Bank for New York City to give food boxes to our patients in need. This program ran for several years and we gave a lot of food to our patients. This is more of a bandaid approach in that it was something we could do in the ED to provide our patients with food immediately but wasn’t addressing the root causes of food insecurity. Moving forward, we can create something more sustainable through advocacy in our community and at the local and state government levels to create more food options and pantries in our community.

We also see a lot of incarcerated patients presenting in New York Police Department custody. With this population, we must be especially thoughtful about transitions of care and outpatient follow-up. At one of our hospitals, there’s a clinic dedicated to patients who are postincarceration. This is a fantastic resource for patients who have been incarcerated and gone through the penal system. These patients benefit from a better connection with the health system. A care manager aids patients as they navigate the health system and helps address social issues, health literacy and following up appropriately for specialty care.

Lin: For EM physicians interested in SEM but who have no background or training in this field, what are the first steps they can take to pursue this interest?

Aurrecoechea: There are easy initial steps an emergency physician who doesn’t identify as a SEM physician can take in the ED to begin their SEM practice. These steps include making sure discharge instructions are easy to read and in the patient’s preferred language, connecting patients needing services with a social worker or case manager and having one more conversation with patients before discharge to explain discharge instructions and ensure understanding with teach-back methods.

Outside of the ED, for EM residents, the first step would be to vocalize your interest to your program director and have them connect you with other attending physicians in your residency who are already doing advocacy work, working with the community or practicing SEM. SEM work can take many different forms – it can be research, advocacy at the community level or within the local, state and national governments. Residents can also involve themselves in the SEM sections of our national organizations – EMRA, ACEP, etc. These organizations also have sections dedicated to advocacy and health policy and can connect you with mentors. Residents can also become informed about the social determinants of health affecting their local community. A lot of communities have a community health needs assessment that has already been done through the hospital, health system or Department of Health. These are done so public health practitioners can understand a community’s health needs and social determinants of health. These needs assessments are usually a mix of quantitative and qualitative research and inform others about the social challenges facing a community. Residents can start with these assessments and do more research with colleagues – further clarifying findings, designing and implementing hospital or ED programs addressing these community needs.

Attending physicians in an academic setting can take an approach similar to the approach residents can take. A unifying thread in all of this is collaboration with colleagues. More voices tend to result in better advocacy and increase credibility with the local community and local government. If you don’t have access to a structured SEM program, often a good first step is to get out to meet the local community through participation in community events. This is especially useful if you don’t live in the community you serve. These events can include health fairs and community festivals. At these events, you can also provide education about health issues and ED visits.

To summarize, a good first step in pursing an interest in SEM is discussing social determinants of health with colleagues. The second step is understanding patients’ needs and community needs. Ultimately, implementing programming – doing something about these needs – is the third step and this can take many forms.

Lin: You have already touched on this in your earlier comments, but with what other organizations should an EM physician partner to develop social support programs? Who should an emergency physician reach out to?

Aurrecoechea: If affiliated with a medical school or EM residency, these organizations are natural partners. Collaborating with physicians from other specialties can also be effective. For example, if violence is bringing patients to the ED, then partnering with the trauma surgeons to brainstorm how to help the community avoid some of these visits and advocate for the community can be effective. Nearby schools of public health with resources and interested students/faculty would also be good partners for addressing social determinants of health in the community and ED. Other organizations include food banks and community organization that provide clothing, shelter and legal support. A way to find these organizations is to search on the internet “community-based organizations” or non-profit organizations in one’s local area. In some places, faith-based organizations are very prominent and effective. If this is true for your area, partnering with faith-based organizations doing charity work would also be useful.

Partnering with hospital or health system administration and local government is also effective. Working with these groups often requires research on the challenges affecting the local community. Evidence supporting what the problems are and potential solutions is needed. For example, if you pilot a program in the hospital and collect data showing efficacy, the next step would be to speak with hospital administration to make the program a permanent part of the hospital structure. Working with social work and case management within the hospital is useful when implementing programming and when trying to streamline transitions of care.

Also, there are community boards and leaders outside of local governments who meet to discuss the problems a community is facing and this is another group of people to reach out to. Sometimes these groups are led by religious leaders or local business leaders. Additionally businesses within the community may be interested in collaborating with emergency physicians and hospitals for community advocacy because this is good publicity for the business. I encourage physicians to be creative with available resources and to not automatically rule out any group or organization as potential collaborators. Consider collaborating if the partner organization is well-meaning and cares about the health and outcomes of a community.

Lin: Tell me more about SEM training for residents in your program.

Aurrecoechea: During intern orientation month, interns participate in a one-day session on advocacy and SEM. Interns learn about the basics of SEM, trauma-informed care and social/demographic-specific resources available to our patients at our hospitals. We also guide our new interns on a community leader-guided walk to learn about the neighborhoods where our patients live and work. We visit and interact with leaders from community-based organizations that provide social safety net support to people living in the communities we serve.

Residents in our residency participate in mini fellowships such as global health, ultrasound and SEM. SEM mini fellowship residents attend quarterly meetings led by residents or attendings to discuss social challenges affecting our local community and what we can do to address these challenges. We discuss relevant medical literature – ideally from EM literature – describing protocols and programs that have worked. Some residents also engage in SEM research to meet their residency research requirement. The projects I mentioned earlier – giving out food boxes, bringing in in-person language interpreters, establishing a buprenorphine program – were all resident-led. Resident-led projects are supported by a group of physicians who serve as mentors.

We also regularly have SEM didactics as part of our weekly EM conference. Junior residents are often responsible for these didactics and are mentored by SEM faculty or senior residents in the SEM mini fellowship. Additionally, through involvement in the resident union, Committee of Interns and Residents (CIR), our residents have advocated to hospital administration for things that have led to more resources for our patients. Through CIR, our residents connect with other residents including psychiatry, internal medicine and Ob/Gyn residents who care about the wellbeing of our community, addressing the social needs of our community, social medicine and population health. Our residents interested in SEM have also collaborated with medical students and like-minded residents and attendings from other specialties through the Diversity, Equity and Inclusion division within our medical school.

Lin: What are ways an EM physician can participate in SEM outside of their institution and outside of their local community?

Aurrecoechea: One way to participate outside the institution is through community outreach and engagement. This involves partnering with community organizations and stakeholders to identify social determinants of health impacting patients and brainstorm how to address these challenges. Another way is to advocate for policy change with other EM physicians and health care providers from outside the institution. Advocacy in the form of writing can be op ed pieces, blog posts and writing members of Congress. Advocacy can also be done in person by travelling to local and state governments or to Washington, DC to speak with government leaders.

Working with colleagues from outside one’s institution in conducting research to build SEM’s evidence base is another way to participate in SEM. Educating colleagues outside of the institution about SEM’s importance is something else you can do. Framing discussions as how addressing social determinants of health can prevent unnecessary ED visits is a more digestible way to introduce SEM concepts.

Participating in media outreach is a great way to being attention to challenges facing a community. Doing this can sometimes be difficult as often our employers don’t want us to interact with the media without some coaching. But you can connect with hospital administration and hospital public relations or media relations for guidance in preparing to talk with the media about patient care. This guidance doesn’t necessarily have to impede your message. Instead, by working with your hospital, you can send a unified message through the media that benefits patients and also shows the hospital in a positive light. Finally, another way to participate and advocate is through political involvement.

Lin: Do you have any final thoughts?

Aurrecoechea: I’m really excited and glad that we’re talking about these issues. Hopefully, through this interview, we can influence and inspire people to practice SEM. There’s a spectrum in the degree to which EM physicians practice SEM, but every EM physician practices SEM in one way or another. Some practice it a little and some practice it a lot. Ultimately, it’s not possible to address the needs of your patients without thinking about their social stressors and social factors bringing them to the ED.