SAN DIEGO -- If doctors open their eyes, they would see "hard-to-reach patients" in their offices every day, said Noah Nesin, MD, vice president of medical affairs at Penobscot Community Health Care in Bangor, Maine, speaking here at the American College of Physicians' annual meeting.
In medicine, the term "hard-to-reach" encompasses socially and economically isolated patients as well as those with access problems due to geography. It includes LGBTQ (lesbian, gay, bisexual, transgender, and "queer") individuals, the homeless, the undocumented, those with mental illness or substance use disorders, sex workers, and other vulnerable people, he said.
Such people may be seeing physicians but, for a variety of reasons, major health-related problems and risks are never addressed, and thus their health never improves.
Addressing Painful Childhoods
In describing the millions of people struggling with substance use disorders, Nesin said, "We don't do a very good job [with] this hard-to-reach population, which I would argue is hard to reach largely because we don't want to reach them."
In one study, 94% of primary care providers missed or misdiagnosed alcohol-abusing patients, said Nesin. Only one in six patients speaks to their doctors about their drinking problems, and only one-fifth of those with opioid use disorders are getting treatment, he said.
Physicians often also neglect a valuable resources in understanding patients's health risks. The 10-question helps identify traumatic experiences (physical neglect, criminal activity, drug abuse) tied to subsequent adverse outcomes including alcohol abuse, early pregnancy, memory loss, and suicidality.
Higher ACE scores are also associated with higher rates of lung cancer, obesity, liver disease, auto immune diseases and heart disease, Nesin noted.
Out of fear, implicit or explicit bias, embarrassment, a lack of self-efficacy and very often a lack of time, clinicians avoid conversations that could yield important information about problems affecting patients' health.
For a patient, just having someone hear their story and acknowledge a trauma they've experienced -- and their resilience in surviving it -- has "an enduring benefit," even for patients with post-traumatic stress disorder, he said.
Eliminating Physician Bias
Nesin noted that physicians, like the rest of the public, have their own biases that have negatively affected care for hard-to-reach patients, particularly those with substance use disorders.
Only 2.2% of U.S. physicians have gotten waivers from the Drug Enforcement Administration allowing clinicians to prescribe buprenorphine/naloxone for treating opioid use disorder, according to a 2015 study from the . This included 16% of all psychiatrists and 3% of primary care physicians.
Roughly 30 million people live in counties without any access to bupenorphrine, the study noted.
"I've also heard people, administrators and physicians, talk about 'those people' in their waiting rooms," speaking of people with substance use disorders. They're concerned about about the financial impact of serving these patients and the chaos they may bring.
Physicians are also highly susceptible to burnout -- over half of family physicans have symptoms -- which can lead to feeling less empathetic to patients with addiction problems.
"Lacking empathy is not a good place to start when you're treating [substance] use disorders," he said.
While physician burn-out has no simple solution, with regard to time pressures, Nesin recommended hiring scribes, coders, standardizing work flows, and delegating tasks that don't require clinical decision-making to a medical assistant.
In the early 1990s and 2000s pain was seen as the fifth vital signs, "I'd argue that we need to shift to suffering as the fifth vital sign and that we have the tools to do that if we decide to undertake it."
Dynamic Problem Solving
A second speaker at the ACP session, James O'Connell, MD -- an assistant professor at Harvard Medical School, president of the Boston Healthcare for the Homeless program and author of -- gave a real-world example of the isolated patient population.
While working at a shelter clinic during his residency in the 1980s, he saw a patient "Jack" who, despite scabies and heavy drinking and smoking, had normal vitals. The patient said he was fine. Initially, O'Connell agreed but on a second visit, he took an x-ray and discovered an imminent public health crisis: "Jack" had multi-drug resistant cavitary pulmonary tuberculosis.
With 900 people coming into the shelter each night, O'Connell and his colleagues knew they needed to take action. They determined that some 60 other homeless people in contact with "Jack" needed treatment -- which involved four medications each day for 18 months.
O'Connell said they went into "third-world mode" to find a way to reach these individuals all over the city.
What the staff soon recognized is that homeless people live very ritualized lifestyles. For example, several men went to a certain bar each afternoon. So, O'Connell gave the TB medications to the bartender who confirmed which patients had received the treatments. They also contacted a barbershop where a cluster of homeless men got coffee each morning. The barber also gave the men their treatments and follow-up.
When many of the people living in the shelter moved outside, because they thought the shelter was now a place where people get sick, O'Connell and several nurses rode their bikes around the city to find patients. After 18 months, they had given all but three of the 60-odd people the complete treatment.