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How One Doc Uses Cartoons to Address Social Determinants of Health

For Anita Ravi, MD, cartoons are more than just a series of jokes. Cartoons serve as a form of patient advocacy for Ravi, who uses art to depict the social determinants of health.

social determinants of health

Source: Thinkstock

By Sara Heath

- On social media and in the healthcare space, Anita Ravi, MD, is largely known for her patient advocacy and cartoon work depicting the social determinants of health (SDOH) for vulnerable patients and how providers must address those factors to support a better patient experience.

But in the PurpLE Clinic, a New York City-based federally-qualified health center (FQHC) at which Ravi practices family medicine, her patients know her for building trust and meeting both their healthcare and social needs.

Most of Ravi’s patients at the PurpLE Clinic have experienced some form of trauma, including sexual violence and human trafficking. This patient population experiences numerous social determinants of health, including homelessness, poverty, food insecurity, and other significant barriers to a healthy lifestyle.

“I went into family medicine mainly because I wanted to be able to work in women's health, particularly with people who'd experienced gender-based violence in whatever form that looked like,” Ravi said in a recent interview with PatientEngagementHIT.com. “That can include domestic violence, rape, or sexual assault, and particularly those who are interfacing with the criminal justice system.”

To tackle those demographics, Ravi had to complete extensive interdisciplinary medical training. During her residency, Ravi volunteered on Rikers Island at the women’s prison doing health education. Her volunteer work allowed her to gain skills working with underserved patients and tied together to help her start the PurpLE Clinic in 2015.

READ MORE: Using Social Determinants of Health in Patient-Centered Care

“A lot of the work that we do in the clinic is about re-earning peoples’ trust in a lot of different ways, primarily in the health care system,” Ravi said of the PurpLE Clinic, which stands for Purpose: Listen & Engage. “We do that through verbal and non-verbal strategies.”

For example, Ravi regularly meets people who are interested in registering at her clinic but are unsure if they can come because of the social determinants of health (SDOH) they face. While Ravi’s patients often experience numerous social barriers, one prominent example includes transportation barriers.

“The transportation piece is a huge one,” Ravi pointed out. “In general, we always ask why someone couldn't make the appointment, about what we could do better. But sometimes we don't spend enough time finding out how the people who did make it – well, how did they make it? What are they doing that's different or that's helpful?”

When Ravi started asking that question, she discovered that several patients were turnstile hopping in the New York City subway system.

In New York City, turnstile jumping has only just been decriminalized in February 2018. Previously, the offense could be met with arrest or another sort of citation, a major cause for concern for Ravi, who treats a number of patients with other legal troubles.

READ MORE: How Health Centers Measure the Social Determinants of Health

“You shouldn't have to risk arrest to make it to clinic,” she asserted.

Now, the PurpLE Clinic advertises access to metro cards that clinic staff will mail to patients. Ravi and her colleagues will also help set up rides for post-traumatic stress disorder (PTSD) patients who might be fearful of public transportation after dark. Uber and Lyft have been a boon for situations like this, Ravi stated.

Offering these amenities is a point of pride for Ravi.

“We wouldn't always think to ask about whether someone needs transportation help, but the fact that someone feels comfortable asking and that we can respond with a yes, those are all things that help earn back trust that might be lost in a lot of different ways within systems, within interactions with people who promised things for patients and then didn't deliver,” Ravi said.

Many of her patients have seen people in authority positions or family members hurt their trust or even break it, Ravi added. Broken promises have become something trauma survivors may come to expect, a fact that providers need to consider when treating this population.

READ MORE: What Providers Should Know to Improve Patient Access to Healthcare

The healthcare industry is currently falling short for these vulnerable patients, Ravi continued. She has her concerns for patients who intersect trauma survival and experiencing social determinants of health. The healthcare industry isn’t setting up sufficient safety nets to care for these patients.

Shortcomings often relate to the overarching structure of most clinics, Ravi stated. For example, nearly all of the patients she sees will struggle or be unable to arrive for their slated appointment time. These patients need to take care of their children, work in their jobs, attend other appointments, get to court on time, or meet with their lawyers.

Ravi knows this in advance and structures clinic times around that knowledge. She also ensures clinic policies do not penalize patients facing an onslaught of social issues.

“Some practices have policies that if a patient has three missed appointments, a provider gets reprimanded, or if patients arrive 30 minutes late, providers can't see them and they need to reschedule,” Ravi noted.

“I understand that from a practice management perspective, but if we actually want to be able to connect to people who always get missed, those are the kind of policies that we have to work around,” she continued. “We must think about how we can deliver care for people when those rules can't apply.”

Ravi has also designed the clinic environment to meet the unique needs of her specific patient population. Patients feel a lot of guilt for their social needs, Ravi has found. Part of delivering compassionate care is alleviating that guilt.

For example, the clinic is often one of the few places patients can charge their cell phones. After hearing patients apologizing for asking to plug in their phones, Ravi created charging stations that prompted patients to charge their phones. Charging a phone is a simple task, Ravi reasoned, and patients shouldn’t feel bad for needing that service.

During patient interactions, Ravi noticed patients apologizing for not wearing underwear or other situations patients perceived as embarrassing. But Ravi didn’t think those patients needed to be embarrassed – maybe they only had one pair of underwear that needed to be cleaned. Maybe it was bothersome, or the patient didn’t have access to undergarments.

“Now I change the language in how I talk about it with people,” Ravi said. “I say, ‘Okay, and if you just want to undress from the waist down, and you can put everything on the side.’ I don't want to imply societal pressures anymore. I'm trying to be as respectful or sensitive as possible, and you just have to learn and do better each time.”

Just like patients often feel guilty about the social assistance they need, they can often feel unhinged about the fears they harbor. Ravi works to normalize those fears by assuring the patient that others have the same feelings.

“I have found a lot of people will say, ‘There must be something wrong with me. I just don't feel comfortable going out at night,’” Ravi offered as an example. “Or ‘I have problems with my memory. For some reason, I'm just forgetful all the time. Just ignore me, and that's probably why I missed this appointment.’ And then, as they're articulating, they're telling me different symptoms of likely PTSD.”

Ravi has reframed her patient-provider communication in these instances from reactive to proactive. Instead of comforting a patient who is upset by her symptoms of PTST, Ravi frames those feelings as normal from the onset.

“I'll say, ‘you know, sometimes when I talk to people, they tell me that they are feeling crazy because things that they used to remember they don't remember anymore,” Ravi explained. “I ask everyone, ‘Have you ever felt that way? Are those things that you feel?’ The more I can couch things as ‘this could be normal’ and ‘hey, maybe you're having this too,’ the more patients know that it's okay to be able to talk about something like this and we can work through it.”

Ravi also has concerns that social policy frameworks for safety nets will still miss her patient populations. As noted above, she works with a very unique population that has niche needs. Most of these needs are not measured in clinical quality measures, even though Ravi must report CQMs as an FQHC.

“Every time, I'm like, ‘Oh no. I'm going to get in trouble with certain quality measures because I didn't ask about X, Y, and Z,’” Ravi said. “It's a balance between external pressures of what is measured as far as quality of health care delivery and what patients are telling you they need and how they need it.”

Ravi will do what she can to report on CQMs without harming the patient. For less complex patients, Ravi will work on CQM reporting. She’ll also put her reporting in context, so the patient knows why she is asking her certain questions.

But the fact of the matter is that many of these CQMs are not applicable to her patients. When Ravi treats a patient who is overweight, CQM reporting calls for her to counsel the patient on diet, exercise, and a healthy living plan. She’ll do this where applicable, but in other areas that’s not only unhelpful, but it can be reductive of a patient’s difficult circumstances.

“When I know that some of my patients are living out of cars, living out of subways, staying at friends’ houses; when they're deciding between food, transportation, clothing, or something nice to wear to a job interview, it feels inauthentic to just put a sentence saying I ‘counseled’ on these things,” Ravi said.

clinical quality measures
Ravi uses cartoons such as this to depict the dissonance between patient social needs and clinical quality measures.

Source: Anita Ravi, MD

If she could, Ravi would lobby policymakers to make CQMs more inclusive to all patient populations. The system currently applies to maybe 80 percent of people, she said, but they haven’t caught the edges.

But it’s those edges who Ravi says are most vulnerable.

“I push back a little sometimes. I'll put that sentence in, but I'll also put ‘as it applies to the person,’” she explained. “If it doesn't apply to the person, then I do my best to document it in a way that's reflective of that circumstance for somebody.”

But Ravi wants to see options where she talked about therapy with a patient or talked about trauma. After all, trauma is associated with many of the factors assessed on traditional CQMs – weight gain, smoking, and other less healthy behaviors.

Using cartooning as patient advocacy

All of Ravi’s experiences in the healthcare industry has led her to her most commonly-known form of patient advocacy – cartooning.

A public health fellowship through the VA and Robert Wood Johnson foundation, research out at Rikers Island, and an internship with the Sesame Workshop on Sesame Street got Ravi thinking about health, underserved populations, and the way providers should be communicating with them. In the midst of all of this, Ravi was drafting some children’s books and drawing informal cartoons.

But when preparing more formal research presentations, Ravi found that those informal cartoons were some of the only things that helped her make her point in a way that made sense to her.

“I thought to myself, ‘I don't know how to better convey this than with like a two-panel, random stick figure,’” she recalled. “I did it in a very safe space first, where I would maybe show my colleagues or my friends that I really trusted, and be like, ‘Is this crazy? Is this okay?’"

Low and behold, Ravi’s colleagues didn’t think she was crazy, something she says was essential for her continuing with the cartooning. Through the cartoons, Ravi has been able to illustrate how providers need to approach different interactions with unique and underrepresented patient demographics.

Ravi is a self-proclaimed non-artist – “obviously, it’s very clear,” she said – but that’s often the point. Using rough stick figures and few panels help her meet all patients where they are, regardless of race or sex.

“I didn’t want to be in a space where people would look at my work and not see themselves in it,” Ravi explained. “The use stick figures is very deliberate because I didn't want people to feel like they couldn't associate, put themselves in that position or couldn't see themselves being in one of those roles. I try to make them as simple and as straightforward as possible so that they can translate as widely as possible.”

The cartoons have expanded beyond demonstrations of patient-provider interactions.

“Now I think of cartooning as a form of advocacy, so I try to think of every possible way that the work I do could be used in that way to really shift culture,” she explained.

For example, Ravi recently completed a few cartoons pertaining to the above-mentioned clinical quality measures issues. The cartoons are supposed to take a complex issue – whether quality metrics are truly beneficial to the patient – and simplifies them so they make sense.

Now, Ravi is turning her medical artwork on its head, asking her patients to draw so she can learn more about them.

“Sometimes I'll ask the patient, ‘can you draw what you see when you think about going to the doctor?’” she noted. “It's so fascinating to see the things that people draw. They'll draw big needles with blood coming out, and I realize, ‘Okay. Well, that explains to me you're terrified to see the doctor.’"

Ultimately, these drawings will identify the issues Ravi needs to address with her patients. Patients with a fundamental fear of the doctor, or who have concerns about making it to the doctor on time, or who face other mental or physical barriers to care will often show their hands during these drawing sessions.

From there, Ravi can begin addressing the issue, always with the fundamental principles of empathic listening.

“I'm sitting at this intersection of primary health, with delivering primary health care in a setting of people who are really experiencing chronic PTSD,” Ravi concluded. “The merging of those two things changes how you practice medicine. It changes how you answer questions. And it changes the things to normalize when you're talking to somebody.”

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