Medical Debt is an Important Social Determinant of Health — What Now?

First comes injury, then comes debt...

Medical Debt is an Important Social Determinant of Health — What Now?

The recent Chart of the Week from Danny Wongworawat, MD, and Maggie Shi, "Medical Debt is an Important Social Determinant of Health," rang especially true for me. As an orthopaedic trauma surgeon, for decades I’ve seen patients’ lives destroyed first by injury and then by debt.

This CORRelations post shows how even small increases in the percentage of people carrying medical debt results in large increases in premature loss of life, age-related mortality risk, and mental health harms. The source for the data in their graphic suggested that Medicaid expansion helped mitigate some of this problem, and the authors of that source article suggested that employers should offer paid sick leave and health savings accounts as employee benefits.

I have seen this scenario play out countless times going all the way back to my trauma fellowship in Nashville, Tennessee. I recall performing one amputation that year on a patient whose healthcare journey was a 4-year struggle marked by countless surgical procedures to save his leg. When I asked him, “Would you have done anything differently?” he responded, “When I got hurt, I was employed, married, and I wasn’t addicted to Vicodin. So, yes.”

In practice, we’re often insulated from the crushing pressures that weigh on our patients. Sometimes, patients will “act out,” lashing at everyone and transferring their issues onto the staff caring for them. In my experience, most patients in this situation withdraw and become apathetic. They isolate because they can’t find a way out, because their world is disintegrating and it’s too much for them to bear.

As surgeons, we must advocate for these patients.

When we see a patient facing this struggle, we might:

  • Point out that the path they’re on is destructive, but that there are alternatives
  • Help them take advantage of mental health resources and social services — don’t just tell the patient those are available, help the patient access them
  • Maintain a list of those resources so that it’s not a new (and time-consuming) experience for you and your team each time

Although it may feel awkward to bring up these issues, and it takes a little time, many times it’s only the surgeon who can help these patients start to get out of the deep dark hole they’ve fallen into, or, better still, avoid it in the first place.