Q&A: Doctor goes upstream to find root cause of patients' medical problems

09/09/2013 12:00 AM

09/30/2013 2:11 PM

Dr. Charlene A. Hauser, 31, who just marked her first year of practice at Sutter Health Group in Grass Valley, was featured in a new TED book titled "The Upstream Doctors."

TED books are electronic narratives that discuss innovative ideas and approaches.

For downloadable TED books, go here.

Hauser is part of a movement of "upstreamist" physicians – doctors who search for patients' life issues that may be triggering their health problems.

Explain a bit about the upstream concept and where it comes from.

There's a parable that's well-known in the health world: These good Samaritans come across a river and see children tumbling over the falls, drowning. So people start doing everything they can to save the children. They throw them life jackets, build rafts and pull them out of the water. They start to construct bridges, design nets and all sorts of devices to save the children. Then one of the rescuers leaves the group to head up the river. "Where are you going?" the others ask. "We are trying to save all these drowning children." And he says, "I'm going to find out who's throwing the children in the water and stop it."

So the concept is that going upstream is the answer?

Yes. We spend a lot of time in medicine trying to save people who are already drowning. And we need people to look at why they are drowning in the first place.

What are some of the factors affecting health that you might find if you look upstream?

The social determinants of health – the way everything around us influences our health: our environment, if we have clean water, clean air, places to walk, safety in our homes and in our jobs, exposure to violence, the stress in our lives. All those factors influence how sick people are. And it starts way before people end up in my office.

As an upstreamist, what do you do differently when a patient comes to you?

I spend a lot of time talking with the patients about some of the social and environmental issues that may be contributing to their problem. So rather than giving medication for their asthma, I would also be talking to them about what it is that's going on. What is the trigger? Certainly, up here, we have a lot of issues recently with the wildfires, and so we definitely saw more people complaining about eye issues, more breathing issues.

Do you have other examples of putting the upstream concept to work?

Patients may come in complaining about headaches, but the more you get into it, the more you find out that there's a lot of stress building up. They're having problems at work. They can't put food on the table. They are struggling financially. I had a patient just the other day, and the main thing I'm doing for him is having a social worker talk about various resources in the community to get his life a little bit more stable. Because, right now, he barely has a roof over his head and he's trying to provide for his family and so he also has the stressors related to housing insecurity and food insecurity. He's never going to heal from the infectious episode that he's having trouble with until we can address those conditions. Financial stressors compound the whole situation, and then you're pretty much looking at someone drowning in the river.

You made a switch from surgery, which was your earlier career goal, to primary care. Why did you do that?

When I was in medical school, I ended up getting a dual degree in public health and the M.D. at the same time. But I kind of put the public health on the back burner. I thought it was interesting, but I was more interested in disaster medicine. So I went into surgery and decided that I was really excited about operating on people and really fixing their problems. Of course, there are conditions that can't be fixed.

So I thought, I'm going to focus on what can be fixed. But then I realized while I was in my surgery internship that I wasn't actually fixing anybody. Of the patients I saw at the community hospital every day, about three-quarters were operated on for problems that were related ultimately to upstream issues. Things like smoking and obesity are contributors to a lot of problems that can have surgical complications. So are conditions like diabetes and certain cancers and gall bladder infections. So here I was, way at the end of the road trying to make a fancy raft to try to save a drowning person only to throw them back into the river. So I decided to switch to primary care, where I can use the public health focus and work a lot more upstream for patients.

There's a shortage of primary care doctors, so this is a good time to get into the field, yes?

Absolutely. We definitely need primary care doctors now more than ever. But beyond that, we need more upstream primary care physicians because issues happen before patients even make it to the office.

Do you see issues related to rural poverty in Grass Valley?

We see a lot of issues related to isolation. People live on big pieces of property, or far away from a neighbor, or who have distances to travel to get to a place with food or any sort of social interaction. They might not be able to afford a car. Or maybe they can't drive or they have a disability. Transportation really is a limiting factor out here. So the less interaction people have, the more isolated they are, the more depression they can have and the worse all their chronic issues can be.

How do isolation and depression relate directly to the chronic issues?

When people feel more depressed, they are less motivated to care for their own chronic issues. Maybe they don't take medications on a regular basis – or exercise or eat well, or focus enough on their own self-care.

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