Physicians in social emergency medicine are examining how changes in social elements change patients’ experience in the emergency department—the emergency department is more frequently used as a primary provider as private health insurance coverage declines, for example.

To find out more, ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, recently spoke with Harrison Alter, MS, MD, emergency physician and associate chair of research at Highland Hospital, Oakland, California, and executive director of the Andrew Levitt Center for Social Emergency Medicine, about what social emergency medicine is, how it differs from public health issues, and how it can give emergency physicians a different perspective on what affects patients who come through the ED.

KK: So, what is social emergency medicine?
HA: We conceive of social emergency medicine as an exploration of the relationship between social forces and the emergency care system, and how together these two influence the lives of our patients and their communities. We are primarily a research institution because social emergency medicine is young, but we also do some direct services and a little bit of advocacy.

KK: What types of programs do you have in place that you think are most impactful to the EM community?
HA: We’re participating in several large-scale projects. Probably our biggest is Doug White’s HIV and Hepatitis C screening program [at Highland Hopsital]. He’s a co-investigator with three other sites in the HIV testing trial, which is exploring the most effective and efficient way to target screening of emergency department patients and HIV. He’s also spearheading a novel hepatitis C screening program. We’re a site for a large-scale study exploring the relationship between the context of alcohol consumption and intimate partner violence—does it matter whether you drink at home, or drink on the street, or drink at a bar? We have a lot of gun injury work going on. I’m a member of the advisory committee of the National Medical Council on Gun Violence, and we have, I think, at least three ongoing research projects exploring the phenomenon or epidemic of gun violence in this country.

KK: I’m amazed at the number of different projects you’re involved in. For those who don’t know—and I didn’t know—social emergency medicine seems like a public health focus for emergency medicine, including research and impactful societal programs. Would that be a fair statement?
HA: Actually, I wouldn’t say that. There are distinct differences between the way public health and social emergency medicine approaches problems. I think it can be summarized in the difference between emergency medicine and almost every other branch of medicine. If you’re an internist, you treat hypertension and diabetes and asthma. In the ED, we treat chest pain and difficulty breathing. We see the world from the patient’s side and from the experience the patient is having, and we then translate that into a diagnosis and care plan. I think that makes emergency medicine in many ways distinct from most every other branch of medicine.

In the same way, social emergency medicine is distinct from public health. Public health is very disease focused. They want to prevent waterborne illness. They want to vaccinate against a specific disease. Some of Doug White’s work is very public health oriented. I view social emergency medicine as more grounded in the patient experience: “I’m experiencing violence in my community. What does that mean to me? I’m experiencing a lack of ability to exercise my free will. What does that mean?” Social emergency medicine will help the patient translate that into a diagnosis and care plan.

KK: With population health management, chronic diseases are managed for a large population. With social emergency medicine, you’re looking at the lifestyle choices and social implications of the environment of the EM patient. Whether it’s gun violence or perhaps motor vehicle safety, it’s much, much more patient safety focused about their environment than it is disease management as in public health.

HA: I think that’s true; that’s a great way of looking at it. We do have a program evaluating the use of health coaches in the emergency department. We assign a young person from our community who has received considerable training in community health outreach work to a patient with diabetes or hypertension. They develop a six-month longitudinal relationship around managing the patient’s disease. Even when we do take on a chronic disease, we do it from the patient, environmental, and ecological perspective.

KK: This is the societal impact that emergency medicine can have on a population, how they’re navigating through their lives, but not necessarily how their family doctor is taking care of their diabetes.
HA: I think that’s exactly right.

KK: I’m getting there. My level of understanding is improving as we talk; you’re making progress.
HA: I lack an elevator pitch. It’s a personal failing, and one I’ve been working on.

KK: I don’t think you need one. It probably requires, perhaps, a cup-of-coffee conversation like this one. It’s not so easily described. I think a good conversation really clears that up.
HA: I was fortunate to have an atypical education in public health at Berkeley, where I got a master’s of science, rather than a master’s of public health (MPH). That encouraged me to dig deeply into a specific topic of interest as opposed to the more broad-brushed MPH.

KK: Are there specific programs now in social emergency medicine or for the emergency physician who’s interested in getting more education?
HA: We had about two and a half hours of abstracts at the SAEM [Society for Academic Emergency Medicine] annual meeting last year. ACEP doesn’t yet have anything going, but I’m looking at trying to initiate an interest group.

KK: You should start a Section. ACEP staff can help you get started.
HA: Interest is growing. Last year’s SAEM was such a gratifying experience, and now the Stanford Department of Emergency Medicine actually offers a fellowship in social emergency medicine. This is really starting to grow, and it’s been very gratifying.

KK: Regarding the Stanford fellowship, how long is it, and how many do they take per year?
HA: They take one per year, and they prefer a stint of two years. However, with the right advanced training, they’ll take you for one.

KK: I’m sure you’re a little lonely right now, but that means you’re a trailblazer, which must be exciting.
HA: I want to reinforce, this isn’t anything I’ve invented. I may have coined the term, but when I started the Levitt Center, I reached out to the six or eight people who were publishing the papers I wished I’d written. This kind of work has been going on for generations in emergency medicine. You need only to put Bob Lowe, Rob Rodriguez, Jim Gordon, or Karin Rhodes into your Google Scholar, and you’ll see the work being done.

KK: So, maybe this is the time to truly distinguish social emergency medicine for what it is and recognize its distinct, specific, and narrow focus that can help our patients differently than the broad stroke that public health programs generally use. Can you tell us about Andrew Levitt?
HA: Andy was the research director at Highland when I was a resident. From the early 1980s through the early 2000s, he was the stalwart research director for this venerable department, and he was one of the early engines behind the development of emergency medicine research. Also, through his work at Highland and other places, he was extremely committed to community well-being and worked for the under-served for his entire career. When Andy died, his family wanted to recognize that dual role: his contributions to emergency medicine research and his commitment to society at large. We proposed social emergency medicine as a vehicle to recognize Andy’s contributions and commitment.
They went for it right away. In 2009, they used a portion of his estate to endow the Levitt Center and give us an inception grant to get things started. We’ve grown into a million-dollar organization—at this point, I think we have approximately $1.4 million. It was an act of faith on their part, and it was an act of devotion on ours. It turned out much better than we could have expected.