164: Health Beyond Medicine—Social Factors Shaping Men's Wellness

Scot: We've talked in the past about social determinants of health. This is the idea that our health is impacted by things other than our own behaviors, such as how much money we make, where we live, our education level. And some of those things can't be changed in our lives. Does that mean we give up? No. It means that we've got to make the best with what we have. And today, our guest is going to help us better understand some of these issues men face and how she helps them overcome them.

This is "Who Cares About Men's Health," with information, inspiration, and a different interpretation of men's health. My name is Scot Singpiel. I bring the BS. You know our MD to my BS, Dr. Troy Madsen.

Troy: That's right, Scot. Excited to be here.

Scot: And he's a "Who Cares About Men's Health" convert, Producer Mitch.

Mitch: Hey there.

Scot: And joining us, Monica. She's a physician associate in the emergency room. She's a listener. She may have told some of her patients to check out the show. We need to find out about that for sure. And she's also another one of Troy's sisters. How are you doing, Monica?

Monica: I'm doing great. I'm happy to add to the little sister bunch here.

Scot: Troy, is this your last sister, or are we going to get a few more Madsen episodes out of this deal?

Troy: Well, we're going to have to draw from my brothers next if we're going to do that.

Monica: And delve into the sister-in-laws.

Scot: Monica, you're a physician associate, which is also known as a physician assistant, in the emergency room. And where you live, you see a huge range of situations that come into the emergency room. What I'm talking about, again, are these social determinants of health, whether it's economic status or where this person lives, and it's been kind of a passion of yours. So explain, first of all, what it is that you kind of see.

Monica: So I see a little bit of everything, especially as one of the advanced practice providers. We probably see 65% to 70% of the patients that come through the emergency department. A lot of them are kind of basic things like lacerations, pneumonia, basic abdominal pain. Really common is altercations, broken bones.

But I think one of the big things is someone will come in maybe after an altercation, like I said, and I'm sewing up their face, and we just kind of start talking a little bit about, "Hey, when you came in, your vital signs showed that you had really high blood pressure. Have you ever taken a look at this?" And this is often a man in his 40s and he's like, "Oh, no, I never go to the doctor." There's almost this point of pride, like, "Why would I go to the doctor to talk about my blood pressure?"

And so it's not until they have to come in with a broken orbital bone and a laceration that we actually have a chance to sit down and talk about some preventative health. And I always find that a great opportunity to kind of really dig into the real story, especially in the community where I live and work.

Scot: Yeah, tell us about that community a little bit.

Monica: So it's really fascinating. It's in the San Francisco Bay area, and I live and work in an area called Richmond. I think there was a famous movie actually, "Coach Carter," that came out a while back, kind of about a basketball team in Richmond. And in this area, the statement is made that a man is 80% more likely to be incarcerated than graduate from high school in this community.

Scot:Wow.

Monica:Yeah. So it kind of hit me. I'm like, "Wow, I'm entering a community where I can make a difference. I can see people and I can see them for who they are at the core, and I can really make a difference in their life." And so I just became very passionate about justice and realizing that justice spans everything, and especially healthcare.

So I've had some really incredible opportunities to sit down with patients one-on-one, and many patients who are currently unhoused, experiencing homelessness, living below the poverty line to actually talk about preventative health and, "Hey, you can actually make your life better just by making these little tiny changes." It always feels like a real honor and privilege to be a part of such a diverse community.

Scot: So if I'm understanding correctly, a lot of these patients come in, whether it's masculinity issues, "Oh, men don't go to the doctor," but they have to now because they have some reason that they had to go to the emergency room, or because they can't afford . . .

I mean, what do you think is the main barrier that people aren't getting this preventative care beforehand and they're seeing you for the first time where then you're able to actually have this conversation? Is it economic? Is it masculinity? Is it something else?

Monica: I'd say it's a combination of all the above. We do have some community clinics. In California, we have an insurance called Medi-Cal, which I actually think is a very good insurance, and it does allow patients access to primary care. However, our primary care providers are so overloaded, they're typically three to six months out in getting an appointment.

And then I'll have social workers make that appointment for patients regarding their, like I said, hypertension or elevated blood sugar or whatever it might be, and then they miss the appointment.

When I talk to them, I'm like, "Hey, we got this appointment scheduled for you. Why didn't you go?" And so often, it's a number of factors that will come into play. I'd say more often than not, it's like, "Hey, I had this job come up and I had to work. I had to be there. I finally got this job."

Something else, which maybe is a little bit dismal to talk about, is incarceration, especially amongst the patients that I see. And when we're talking about continuity of healthcare, it's a really tough thing. If someone's incarcerated, suddenly there's this huge disruption in healthcare.

And I'll often see patients before or after they were incarcerated, and there's really no communication as to . . . You're like, "What happened with your blood pressure meds? What happened with your diabetes meds? This is missing."

I think kind of looking at the whole justice component, that's a real issue. I think they say 1 in 4 Black men will be incarcerated at some point in their life, and 1 in 6 Hispanic men, and it's 1 in 23 Caucasian men. My practice is primarily a very ethnically diverse community that I treat, and so I always find this a little bit of a challenge too. How do we work through this and provide the best care we possibly can when there's so much disparity?

Scot: When you first talk to these individuals, have they ever really talked about primary care before? Is this a discussion they've had with a physician at all, or are you really the first?

Monica: Occasionally. What we'll often do is search back through chart notes and you'll see other doctors or APPs who have seen the same patient, and they've gone through this very similar thing of trying to set up primary care for them.

And I find in a lot of cases we become the primary care. And when asked once again, "Why didn't you make this appointment?" it's like, "Well, the only time I could get here is 10:00 p.m. on a Saturday and I need a refill on my blood pressure medication." So the emergency department is over-utilized, and I'm sure Troy can attest to this.

I think for a long time I'd just get really frustrated with it, like, "Why are you misusing or abusing the emergency department?" But now I think more and more I've shifted my perspective on that and really seen it as maybe a privilege, an opportunity to teach and to talk, and to talk about preventative measures, and to talk about this podcast and say, "Hey, actually this is free. You've got your mobile phone here. Let's download it. And here are some fun episodes you can start listening to. Just put your health first."

When everything else is falling apart around us, then one thing we can really do is take our healthcare into our hands and make the most of it. So I think that that's actually been . . . I see it more as an opportunity now versus an annoyance.

Troy: And like Monica said, it is frustrating, quite honestly, to have people come in for primary care visits. But yeah, like she said, sometimes you realize they don't have other options and you do get to play a role that they just don't have in their lives, so you do have that opportunity.

I hear you talk though, Monica, and I think about a lot of the patients I've seen, and then I think about some of our episodes and about talking . . . For example, talking about sleep and me talking about getting a nice comfy sleep mask and Mitch talking about getting a nice silk pillowcase, we sound so elitist.

Scot:Right?

Troy:That's the hard thing. I think about a lot of the patients I've seen as well, and I'm curious where you even start these discussions.

Monica:Where do you start?

Troy:Yeah, like sleep. "Let's talk about your sleep." In some cases, they're just saying, "Wow, I wish I had a place to sleep that was a regular place I could go to, to sleep."

Monica:That's exactly it.

Troy:Things like that.

Scot: A place or . . . I mean, sometimes people have multiple jobs. They've got to work shift work in addition to day work. Where you happen to live might be loud and noisy and lots of light.

Troy: Yeah, where do you even start that discussion? I'm curious how you've brought these things up. Or are you just starting with, "Hey, let's get you in to see a primary care provider"? Is that where you start, or do you start diet? Do you start talking about other things? Mental health? How have you introduced that?

Monica: I mean, all of these are really great questions. I think the mental health component is a big one. It's something I've been thinking a lot about since I read this book on PTSD, "The Body Keeps the Score." I don't know if any of you have read that.

Mitch: Sure have.

Monica: Yeah. So they talk about often Vietnam vets and someone who will go to the emergency department complaining of chest pain or some physical ailment, when really they're there for mental health. The only time that many of these men are given real attention is when they're there complaining about a physical ailment.

So I think as a healthcare provider in the emergency department, I've tried to go beyond the presentation. I always think it's such a great experience and such a privilege to see these patients who are coming in with one physical complaint, but really there's so much more behind it.

Scot: What are some of the health issues in general? Mental health, we've discussed that a little bit, but you can throw that in there. If I had to say what are the top three, top five health issues that are most prevalent among men who fall victim to some sort of social determinant of health, whether that's housing instability, inadequate insurance, they don't have enough income to really pay for the healthcare system, or other issues, what do you see?

Monica: So probably the top three are elevated blood pressure, so hypertension. The second one would be diabetes which has gone unrecognized for a very long time. We often automatically check a blood sugar, and that's the first time that someone realizes they have diabetes. And the third one that really affects the community I work with is asthma. Asthma is really an issue.

Troy: What do you think causes all . . . What's the root of this? Like, the social determinant. I know it's hard to put a finger on. Do you think it's just the diet, the air quality, the lack of access to healthcare in their younger years? Do you think it's modeling adults in their lives and their health habits? What is it that really leads to this?

Monica: I mean, it's probably a combination of many of those things. I think access to healthy food or even just the knowledge of eating low fat, low salt, greens, and just eating healthy, right? That's just something that I don't think a lot of people really think about.

Scot: Or have ever been taught, really.

Monica: Yeah. And that kind of comes into the modeling component. So what are your parents eating?

Scot: What's available in your environment? There have been times I've been in cities traveling for whatever reason, and if you're in the downtown area, it's hard to find healthy food.

Monica: It's really hard. And even walking through the supermarkets, the most accessible foods are those that are very processed or fried. I mean, it's so much cheaper to go to McDonald's than it is to a vegan restaurant, let's say. It's so cheap. I mean, French fries and burgers are so, so cheap.

Scot: Although not as much anymore, but point still taken.

Monica:Yeah. I mean, relative to healthy food, right? So how can we increase accessibility and even desirability of healthy food? I think that's a lot of it too. It's almost like two and two aren't put together. There's a huge disconnect.

Troy: I was going to say, too, as you talk about this, I think about med school. I went to Johns Hopkins and it's in East Baltimore in one of the more dangerous neighborhoods in the country just in terms of violence there, and the disparity there is remarkable. You've got this world-famous institution.

I remember my first day there I walk across the street and there are burned out, boarded up row houses, but the two restaurants in the neighborhood were . . . It was a place called Mama Mias, which was just a greasy fast food place, and then Popeye's, which is greasy chicken. That was it. The grocery store, we had to get on a bus to go down there to Safeway.

They call them these food deserts and you just have places where there's just not a lot of healthy food available. Even if you wanted to go to a grocery store and buy it, there just aren't great options unfortunately.

Monica: It just isn't there, yeah.

Scot: What's causing the asthma? Is it the environment, or what's causing that?

Monica: Yeah, I think a lot of that is environmental. I think a lot of it does start when children are young and there's a lot of smoking in households. And then, of course, just being inner city. There's known higher rates of asthma amongst African-American patients and of inner city patients.

When I was working in Oakland, we actually started a full initiative at one of the hospitals where I was working that just focused on asthma and African-American patients, which was actually a really cool preventative program we had. So when someone would come in with first diagnosis of asthma, we'd get them in this program right away and just talk about getting on the preventative medicines and rescue medicines and how to reduce risks with asthma, specifically being around smoke.

Troy: Yeah. And then air quality.

Monica: Air quality is huge, right? I know you experience a bit of that in Salt Lake too.

Scot: Troy and Monica, I have a question for you. And we'll start with Monica and maybe, Troy, you can jump in since you also have worked in the emergency department.

After you see somebody and you start having some of these initial health conversations, if you want to help them get primary care and they don't have the finances or the time or the insurance to do it, what are some suggestions you give to them to try to get primary care after they leave your care?

Monica: I mean, our social work team is really big both in Richmond and Oakland, and they're actually really good at following up with our patients. So we'll actually go to the extent of making the appointment for patients. And in fact, our social workers will often check in later to see if they actually made that appointment. So that's probably the best.

If there's someone I'm really worried about, I'll actually oftentimes circle back with the primary care doctor later on to make sure that they made it in. So I think that's probably the best way. Just a quick phone call. I'm really big on follow-up phone calls with my patients.

Like I said, most of them do actually have phones. I'm able to give them a call and make sure they got in and just kind of check in, and so that's probably the way. It's just follow-up. And I think in an emergency department, that's often lost, but it's something I've probably learned from our dad. He was a pediatrician. He made a lot of follow-up calls.

Scot: So then do you just make the argument to them that, "I know that this is going to cost you some money and time is really, really precious to you, but it's really a good investment"? I mean, is that the argument you make, or are there also programs that can help pay for that or . . .

Monica: Yeah, for sure. I mean, in California, yeah. I can't speak to other states, but I know with our Medi-Cal program, pretty much anyone that needs healthcare can get on Medi-Cal if they fall within a certain income, or below a certain income.

Medi-Cal is fantastic for patients living in San Francisco. They have access to UCSF. Our patients have access to specialty care in an area called Martinez or at Highland Hospital that's pretty well known in Alameda County. So yeah, there's actually really good access there.

And I think a lot of patients don't realize that they have that, and they'll come to the emergency department because that's the only choice they have initially. But our social workers are really good about getting patients connected with Medi-Cal and then establishing that follow-up care.

Scot: Right. And then, like you said, just even following up, it sounds like many of these individuals are just like, "Wow, somebody cares."

Monica: Yeah.

Scot: So then when you follow up, that . . .

Monica: Yeah, I think a quick phone call goes a long way.

Scot: Yeah. How about you, Troy? Is there anything here in Utah that you're aware of? How would you handle this situation?

Troy: Yeah. I think like Monica said, I've utilized our social workers a lot, and what you really find is kind of like what she said too. Even in Utah, most people are going to qualify for some kind of insurance. They're going to qualify for Medicaid, and a lot of people just don't even know they qualify or they've never applied or looked into it. It hasn't been a priority. They just, again, come to the ER for their care, and in the ER you treat everyone regardless of their insurance status. So that's always an option.

And then, also, I think some people when they get on the healthcare exchange, the healthcare.gov site, I think they're surprised at just how inexpensive some of these plans can be just depending on their income level.

So those have been the big things. And again, for us, it's been more social workers in the ER who are incredibly valuable for helping people, number one, set up follow up appointments, and then number two, apply for these things and know what their options are.

Scot: And for somebody that hasn't gone to the ER, can you contact one of these social workers without going to the ER? How would you get in that way? Does that make sense?

Troy: You really can't, unfortunately. Yeah, you'd have to go to the ER to contact them, but most hospitals have financial counselors, so you could always contact a hospital and say, "I would like to see a primary care provider, but I don't have health insurance. Can you set up an appointment for me?" And then they would probably say, "Yeah, and let's get you in touch with a financial counselor who can explore your health insurance options with you." So that's often what happens as well.

Scot: Mitch, do you have anything? You've been very quiet.

Mitch: As someone who has been underinsured, as someone who has actually used the Medi-Cal system when I was working in Ventura where I was fully employed and still was not making enough money to be insured, I spent almost a decade being unable to get any sort of routine medical care.

I mean, it's not just me. There was a study recently done by the Commonwealth Fund that has two out of five Americans right now are underinsured, period. You see a lot more in the south. You actually see a whole lot within the White population and people under the age of 35, and that was my experience.

My primary interaction with health was an InstaCare if I was bleeding during work hours, and an ER if something had gotten beyond terrible that I just couldn't wait until morning.

And it's a terrible place to be. Even with some of the systems that are out there for people, there are a lot of gaps. I ended up being one of those people where either I had to quit the job or quit the education program that I was in at the time to get myself some benefits, or I didn't meet those poverty standards. I didn't meet those financial standards.

It becomes really hard to prioritize anything but work and where your rent is coming from and . . .

Scot: Survival.

Mitch: Survival, yeah. Absolutely. Mental health goes out the window and everything. I don't have an answer for it, I'm just a guy on a podcast, but I cannot tell you how much it has meant in the last two, three years to get insurance, to be able to take an active role in my health and not have it be such a herculean task or to make it so difficult to be able to get a primary care provider, etc.

And I sometimes wonder if that is one of the things that also plays in when you look at some of these different populations. I mean, underhomed for sure, but we're talking two out of five Americans, period, are uninsured or underinsured.

And so it's not just this worst-case scenario, but if you're working two jobs, if you're doing shift stuff, etc., it becomes really easy, especially as men, to just be like, "Eh, I've got to keep working, got to keep surviving. Who cares about their health? Because I don't. I can't. I literally cannot."

And I was always terrified, even sitting in waiting rooms with my head bleeding during one particular concussion I had, that I would be stuck with a bill I could not afford.

Yeah, I don't know what to do about it, but it is important to at least educate and understand, right? When we say, "Oh, hey, there's an obesity epidemic in this country," we immediately assume that it's because everyone is eating a whole bunch of fast food. We don't look at the systemic things like is there even healthy food around? Can the person afford healthy food, etc.?

And so I just, I would really urge people to educate themselves about some of these issues in their own communities, because even with . . . God bless Medi-Cal, because I had quite a few medical emergencies happen in my short stint in California. But without it, I don't know what I would've done.

Monica: Yeah, that's fascinating. I read this book "Just Mercy" by Bryan Stevenson. It's a really great read, but something he said is the opposite of poverty is not wealth but justice, and I think that's something I think a lot about. As you were talking, Mitch, it just made me really think about where's the justice in not being able to just access decent healthcare, decent food? And how do we find that? Like I said, it's not just wealth. It just goes so far beyond that.

How can we deliver high-quality healthcare in resource-poor settings? It's a question I've asked myself for 14 years now as I've been in this career. And I try to do it on an individual basis, but how do we extend this and reach more people in general?

So that's a great question for even the three of you in this podcast. You're trying to reach as many people as you can, as many men as you can through this, and making their health a priority, but how do we reach even more?

Troy: Yeah. But it's a great point, Mitch. I think, Monica, obviously you're talking about major health disparities and significant issues there. But then there's also, again, the group like Mitch. I think a lot of us have been in that situation at one point or another. When I was in residency, I had really crappy health insurance.

Scot: Isn't that ironic?

Troy: It was ironic, and I thought about that. I'm like, "I'm a physician." Number one, I was making minimum wage as a physician, which is the crazy thing about being a medical resident. But I'm like, "I'm a physician and there are so many people I'm seeing in the ER who have so much better access to healthcare than I do." So there is that also that component of it as well.

I think it's easy for us to talk when we have great health insurance. If you work for the University of Utah, you're going to have great health insurance. It's easy for us to talk about, "Hey, go see a sleep expert. Go get a sleep study." But for so many people, that's completely inaccessible. It is not at all feasible.

Again, that's an interesting statistic, just the underinsured component and how that factors into just our lack of access to what we might need for our healthcare.

And yeah, it's a challenge. You see it in Salt Lake City. I'm not in Oakland, but in the ER I've cared for a large population of unhoused patients and immigrants and people who are suffering from the same thing. Maybe not to the degree that Monica's seeing in Oakland and Richmond, but you see it everywhere, and certainly we have all those same issues in Salt Lake. I'm sure every medium and large and even rural communities are facing that as well. So it's a challenge everywhere to some degree or another.

Scot: As we begin to wrap this conversation up, I wish that we could wave the magic wand and make healthcare fair and just for everybody. As Monica said, it's a justice issue. But unfortunately, as the rest of the world or us even try to work to make it more equitable, we have to live in the environment we have to live in.

So what kind of final thought would you have for somebody who is struggling to afford healthcare, that doesn't have the time to get healthcare, or any of these issues we discussed? What could they take away from this to try to make things a little bit better, to make the best out of the situation that one has? Think about Mitch 10 years ago, for example, as an instance. What would you recommend?

Monica: Yeah. In that situation, look at the small things, right? We can get basic labs. I think, for instance, when you're going to the emergency department, just understand, "Hey, is my kidney function normal? Is my liver function normal?" It'd be great if someone could just get those basic labs, and there always is a way to at least get started on whatever medication you may need to be started on. And try to stay compliant if you can.

Gosh, it's hard, right? I mean, just thinking about the little things that we can do. Let's say we take healthcare, actual medicine, completely out of it. What little things can I do to be a little healthier every day? Drink more water. Hopefully most people have, at least in the United States, some access to clean water.

Just thinking a little bit more about the food, incorporating a few more vegetables or whatever it might be. It's tough, though.

And hearing Mitch's story, I think I was really struck that this is the majority of the patients I see. There are a lot of patients who are below the poverty line, but then there's a huge chunk of patients who are just kind of this in-between state and a lot of them come in and they're scared about the bill that they're going to incur from the ER. And it pains me.

Scot: Or just even the doctor, like if you go into a primary. Mitch has mentioned on the show, any time he went into primary care, he was like, "What are they going to find and how much is that going to cost me? And am I going to even be able to do anything about it then?"

Monica: Yeah. I think also just on an own individual basis, what can we do once we've reached this point where we have enough capacity to think about others? What little sacrifice can we give? Can we have just a little bit more pity, a little bit more empathy? Can we all be justice fighters? If we have anything to give, can we all just be an ally for the underinsured, for the unhoused, and for those that just don't feel seen?

So I think that's a lot of where it comes from too. So many people think that problems can be fixed without any cost to themselves, but actually stepping up as individuals to look out for those in need.

I really appreciated Mitch's story and him coming from this place of . . . Now he's in this position where he sees healthcare as a privilege, which I think is kind of fascinating, when it really should be a right. Can we all just fight a little bit more for this to be a right for everyone?

Scot: Troy, do you have any final thoughts on this issue?

Troy: I love what Monica said about just having more empathy. And I think maybe for a lot of people listening, I think for myself, obviously I'm not facing these kinds of disparities and I feel incredibly fortunate and grateful for that. I've taken care of many, many people who do face those disparities, and there have been times in my career where I roll my eyes and I see the person come in for a refill on their blood pressure medication or some primary care thing and I'm like, "Seriously? Why are you using the ER for this?" And then I realize I need to have more empathy for the situation they're in and the challenges they're dealing with.

I think on a larger scale, not just as a physician, but just as someone who sees, again, the obesity statistics or the issues we see with heart disease and diabetes, just recognizing the challenges these individuals are facing and having empathy for them, and hopefully in the process looking for solutions and looking for ways that maybe we can help to address this larger disparity issue.

Scot: A couple things I pulled away are some of the themes that kind of come up on this podcast. Is there just something you can do, just a little something, to make things a little bit better?

Like Monica said, can you incorporate a package of frozen vegetables into your grocery list every week? Can you maybe be active if you're not active? If you're not doing a physical labor job, can you be active for an extra 5, 10 minutes a day?

And then there are programs out there and sometimes it takes a lot of work to find them, and you have to do some digging, but see what might be available in your area.

Isn't there a number, Mitch, here in Salt Lake City? And I would imagine it's in other states too. Like 211 that will connect you with resources? Something like that. I'm going to have to look that up.

Mitch, do you have any takeaways?

Mitch: One of the small things that everyone can do even if you are in a place where you do have access to healthcare, that you are able to be healthy, and it's an easy thing for you to do, is to kind of educate yourself about some of the issues in your community and what programs are available in your community.

Scot: It's 211, by the way. That will help you . . .

Mitch:It is 211?

Scot:Yep. If you dial 211, they can help connect you with community resources.

Mitch: Yeah. So just as someone who might have access, take the time to educate yourself about some of the problems and finding places where you can support, whether it means signing a petition or writing your senator or whatever that is.

But just recognize that some of the health problems that we have in this country with your neighbors, with your friends, etc., might not be because of their bad choices, but kind of because of some of the social determinants of health that are impacting them.

Monica: Yeah, I really like that.

Scot: If you have any thoughts or you have found yourself in a situation like we've discussed, and you are able to figure something out, we would love to hear from you. You can reach out at hello@thescoperadio.com. Thank you for listening, and thank you for caring about men's health.