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[In response to increased dependence on oil from unstable countries] EEN began to create the “What Would Jesus Drive?” (WWJDrive) educational campaign in February 2002 to help Christians and others understand the relationship between our transportation choices and these three major problems – human health impacts, the threat of global warming, and our increasing oil dependence.

Evangelical Environmental Network

Remember those WWJD bracelets. Folks wore them as a reminder to act “right” when no one was looking. The letters stood for “What Would Jesus Do?” and the presumption was that in every given situation there was a “Godly” answer. Of course, placing yourself into the mindset of a person who lived 2000 years ago to establish a course of actions in a given modern-day situation led to some strange speculation. What Would Jesus Do when confronted with pork? Is veganism the established Jesus-like diet? This person can site scripture to say it is. It also leads to some creative marketing. On ETSY are several pages of handmade items embossed with the official WWJD query. One “ladies T” substitutes the letter “D” for the “J” allowing one to substitute The Donald’s thought process for those of the Other Big Guy.

In 2002 a group of creative and and liberal soles asked themselves “What would Jesus drive?” This was a time immediately after the trade towers went down. The national narrative was being shaped and it was understood that our purchasing of oil from the Middle East was a proximate source of terrorist funding, bad for the environment, and bad for our health. Their solution?  Drive smaller and more efficient cars. Not SUVs. Unfortunately, the opportunity to invade an oil rich country seemed much more the Jesus-like answer to some:

God told me to strike at al-Qaeda and I struck them, and then he instructed me to strike at Saddam, which I did, and now I am determined to solve the problem in the Middle East. If you help me I will act, and if not, the elections will come and I will have to focus on them

George W. Bush. 2005

Why the walk through memory lane? I was sent a copy of the Alabama Department of Public Health’s transportation survey (found here). Groups from every county in Alabama who care for the poor and underserved were interviewed and to a group they coalesced around a single theme -Transportation for poor people is terrible in Alabama. Agency after agency identified between 25% and 50% of their clients have to rely on friends, strangers, or don’t keep health care appointments at all because of a lack of affordable transportation. Most counties in Alabama have no public transportation; for example in Marion County:

The hospital is not aware of any other transportation entities available to patients in this area, with the exception of one called “Tommy’s Taxi Service,” consisting of one elderly man and his personal vehicle, which they have known patients to use to get back and forth from their dialysis appointments. These dialysis appointments represent one of the largest challenges to patients without reliable transportation access, due to the necessity of attending multiple times per week.

Multiple agencies including this “for profit” entity suggested that churches are the answer:

Finding a way to involve the churches and other faith-based organizations in this area with the issue of non-emergency medical transport would help a lot of people in this area, and could be done by scheduling specific pick-up points and times at regular intervals. However, issues with reimbursement and assumption of liability are most likely the largest roadblocks to developing this type of solution.

So, Jesus might drive a passenger van and make scheduled stops to keep Alabamians from having to budget tax dollars for transportation. Perhaps He would work on His followers in the legislature to create and fund an effective bus service. I’m betting He would just heal the poor, sick people in Alabama. Alabamians who drive SUVs could take their turn being sick for a while.

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Me: This patient was admitted 10 times in the last year. She needs a good doctor to help her use the system better

Resident: Dr Perkins, she goes to the emergency room because she is an addict. And that is when she is taking her psych meds and not hearing the voices. She’ll only take the pain meds and won’t take any medicine for her diabetes or her blood pressure because they are (air quotes) poisoned (air quotes) 

Me: Don’t you want a challenge?

Resident: Her psychiatrist won’t tell us what medicine she is on or even whether or not he is actually seeing her. Claims it violates the (air quotes) doctor-patient  (air quotes) relationship. And don’t get me started about her drug problem. She has been kicked out of every treatment facility within 50 miles and there is ONLY ONE of them that take Medicaid, anyway. 

Me: Don’t you want a challenge?

Resident: Dr Perkins, don’t do this to me. Let me just refill the diabetes medicine that she won’t take…

Medicine in general has not historically functioned effectively outside of the here and now, meaning we try to fix broken people.  There is a parable that is often used to illustrate the problem with this approach, the parable of the babies in the river. In the story a village mobilizes to deal with a crisis (babies are found floating in a river) and the town folk eventually take on saving babies as their purpose. Finally, the story goes, someone suggests going upstream to determine where the babies as being put into the water. Delivering care to those suffering from complex illness in an academic health centers as I do is much like living in that village. We find ourselves pulling people out of the water meanwhile wishing someone could go upstream and fix the problem. Academic medicine has put together a list of things called the Milestones that our doctors should be willing and able to do. One of these suggests that family physicians should be willing to take that walk upstream and stop the babies from being put into the water in the first place.

The most complex patients do not simply need blood pressure and diabetes medications. Those who are “really sick” typically have multiple poorly controlled chronic illnesses, multiple physicians, and expensive care-seeking behaviors, and no primary care because they do not see a reason to add “one more doctor” into the mix. Also these are people who have problems with housing as either they tend to be impoverished from their illness or they suffer from illness as a consequence of their poverty. They lack access to healthy foods because they tend to live in food deserts associated with poor neighborhoods but also tend to require specialized diets that cost more. They also are more likely to have sought and receive disability and so must live on a fixed income. In addition these patients may have suffered from access to an over exuberant healthcare system and suffer the after effects of having had multiple surgeries and having been on multiple medications with serious side effects,

Atul Gawande wrote of a physician who focused on caring for these complex patients (information and link found here). Caring for these complex patients requires practice based resources such as timely access to clinical services and coordination of services, knowledge of community resources such as housing and healthy food, and a clinical quarterback. The payment structure, although changing, has not changed sufficiently to reward practices that “look upstream.” In addition, medical students and residents come from a model where “the here and now” is rewarded both financially and professionally so they are not looking to move “upstream.” For us to get healthier, our doctors need to be able to focus on the stream AND look upstream as well.

In our training site, we are working on create an nurturing and supportive environment that will allow us to care for these patients. Our hope is that we will allow our complex patients to receive better, more effective care.  Our hope is also that it will provide a lab for our students and residents to see that by partnering with the community, providing “non-medical” things such as housing and appropriate dietary information, and improving access to resources they can care for these patients in addition to providing care for the rest of the community. We will start building this “Chronic Disease Medical Home” annex to our patient centered medical home. I will use this space on occasion to  discuss our progress. Wish us luck!

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