This past October, I met a bright and engaging man who had suffered a stroke. Luckily, a family member of his had recognized the symptoms he was having and brought him to the hospital. Unfortunately, the stroke had left him unable to use the left side of his body and, as a result, he required a wheelchair. I saw this patient as part of a clinical skills class where I had the opportunity to interview him and perform a brief physical exam.
For the interview, I administered the routine questions that I’ve been trained to ask: “Do you have any current or chronic illnesses? What past illnesses or surgeries have you had? Does your family have any history of heart disease?”
His answers fit the pattern that we’ve learned to watch for when it comes to risk factors for strokes. I recorded what he told me, and proceeded to ask another routine, yet important question: “What medications are you currently taking?”
His answer to this question gave me pause. He told me that he had been prescribed medicine to reduce his cholesterol and blood pressure, both risk factors for stroke. However, he had stopped taking them. When I asked why, he revealed he was uninsured and could not afford them.
This patient had been in hospital for weeks, and was receiving comprehensive medical treatment and rehabilitation. With the help of a social worker, he was in the process of applying for the Ontario Drug Benefit Program, as well as a housing unit that was wheelchair accessible. Still, his life after discharge would be significantly different than his life before the stroke.
The fact that he was unable to afford treatments which may have helped control his risk factors for heart disease remained in my mind for the rest of the week. Could his stroke and its resulting effects have been prevented or delayed?
Medical school taught me about the structure of Canada’s healthcare system and the social factors that affect health, but it is easy to lose sight of these concepts while absorbing the waves of clinical and scientific information that are needed to become a physician.
After interviewing this patient I thought about how the interplay of the healthcare system, social factors, and human biology all had a role in his health. It wasn’t just theory anymore; it was something that had a tangible effect. Had this patient been able to afford his drugs, would he have had this stroke? If there was a national Pharmacare policy in place, would he have been able to secure the cholesterol and blood pressure medications that he had been prescribed?
The answers to those questions either aren’t easy or are impossible to know. Patients will have different physiologies, illnesses, and treatment plans. However, all of us, individually and collectively, are affected by the policies of our healthcare system and other social factors (like our incomes, housing conditions, and cultural backgrounds). This early episode in my training served as a reminder that the complete picture of a patient needs to include not only their diagnosis and treatment, but also how their experience within the healthcare system and their community has affected-and will continue to affect- their health. In short, we always have to keep one eye on the upstream causes of what we end up seeing downstream in the hospital.