Table 1 HTH Resident Focus Group Themes and Representative Quotations

Patient connection, insight, and clinical impact

Connection and meaning in work

He had just experienced the loss of his partner and I got to talk to him a lot about his spiritual beliefs…. and really his comfort in the whole disease process. We also got time to focus on his home situation. He took a lot of pride in the repairs that he did in his trailer, making sure that he was able to get around. We just really focused on a lot of aspects that you don't really normally get to talk about, which was very, very nice. (R1-P6)

…it was nice to be able to sit down for a couple hours and chat with someone about the human experience. Get to know somebody. I still remember my patient very well. (R1-P3)

I kind of let the patient talk and tell his stories, and when you let someone share their story you end up learning a lot more and in ways that you can't really gather just from asking direct questions…. So I just really enjoyed listening to his stories and kind of learning about his personality through his storytelling…. [HTH] gave me that opportunity to [write about a patient] and remember “Okay this is nice. I like doing it and it makes me remember all the good things about medicine and patient care and the humanistic side. That's why I think it's kind of a nice thing to do intern year. You start to lose sight of that. (R1-P5)

It was really nice to get to know a patient and not always be thinking about the next step for them. (R2-P2)

Insight about social context

I think he maybe enjoyed the experience of opening up more about his life and the experiences he had and how it influenced his approach to what he wanted in terms of treatment of his chronic disease and he ended up dying like two weeks after I completed this story. (R1-P5)

[She] had a lot of stories about the grit of her family members, and I got a sense of what she respected, and what her values were and what makes her tick, and how she might respond to medical recommendations in the same vein….I think getting a sense of what her values were and how she saw the world allowed me to better understand how to approach her care and how to make recommendations in a way that she would understand—and how to make the right recommendations for her. (R2-P5)

The thing that I got out of it the most was acknowledging how much somebody’s propensity to come to the hospital depends on their diagnosis and the stereotypes that go along with it. [My HTH was] with a person who had cirrhosis. He was a drinker, but not more than anybody that he knew…but he was really stigmatized for being an alcoholic despite having another serious liver disease [hemochromatosis] that was really the main culprit for his cirrhosis, not his drinking. His drinking just made his liver disease worse. He really had struggled with coming to the hospital because he didn’t want to be judged by nurses, doctors….(R2-P2)

[HTH] helped identify some risk factors …. He had worsening dementia…[leading to] a lot of inappropriate social situations where he would say these random things out in public to people that were way off topic and his wife had a really hard time dealing with that for a number of years before even a diagnosis was made. And then he was having afib, refractory to his ablations, so he was having congestive heart failure and that was landing him in the hospital multiple times as he would forget to take his medications. (R2-P4)

Clinical impact

The major takeaway I got from him…was that he felt like his psychotherapy was not helpful for him at all...he felt…it would be better with like a group scenario or just some sort of mix and match. So wouldn't be all on him.... And so I made the recommendation when I saw he no-showed his next one-on-one psychologist's appointment. And I felt like I knew why, because he didn't think it was helping him at all. (R1-P1)

From what I heard from the [inpatient] team…it was really, really helpful for their dispo[sition] planning. Because my patient was wheelchair bound, he was making a lot of modifications to his home and…it may have helped them hook him up some services to help make the improvements…sway their decision on rehab vs. home, because he seemed to have a lot of things at home that he may not have gotten at rehab. So it was really, really useful for them from that perspective. (R2-P1)

I remember one of my WWII vets, a 94-year-old gentleman who had a lot of health issues, I remember reading his [HTH note] [done by another resident] and what stuck out was that he was always happy with VA care and now he just wants to be happy and comfortable, which is reasonable for someone who is 94 years old. But I think before I saw that [HTH note], I was working him up pretty aggressively for certain things…. (R2-P1)

Clinical skill development

Social medicine learning

…that was actually one of the first times I actually had an extensive goals of care discussion with a patient, because we do a palliative care rotation as a second year, but I hadn't ever done a real conversation like that as an intern, by myself. So I felt a little bit out of my element. But I think what it helped me understand was that there were very clear ways of asking and identifying what [patients’] goals are and I think they're really closely tied to a lot of the social determinants …that was something that I think lasted with me and helped me…. (R1-P3)

I think it helped me be a good PCP [Primary Care Provider]. It helped me ask the sort of questions that probably don't often get asked of [patients] when they're in contact with the health care system. So I thought that was a good learning experience.... (R1-P2)

And it definitely did help become an exercise for myself not only to get to know the Vet[eran]s, but… to navigate these questions that could have been more awkward … if they've never shared these things…. It was good for me to have that conversation. (R1-P4)

I am on an inpatient cardiology unit now and it makes me think a lot about how we sort of need to get on board with what the patient would like more. We do various procedures and we can run a lot of diagnostics and it’s easy to get very mechanical about it without seeing the greater objective. But what [HTH] allowed you to do, in an [inpatient] context where I can’t usually do this, is in a methodological way get a sense of who this person was and what matters to them and what the next steps will look like for them. (R2-P3)

What struck me most about this project was how difficult it was to complete it…I was finally able to find the right place and time to interview my patient. And then she was so resistant to giving me details, I had to come back several times to get her full story. She would either get tired, or say you know what I just want to eat right now would you mind coming back later? And I think that highlights the importance of doing this for people, for these Vets, because oftentimes you do uncover these really important details…and it’s hard to find these really important details in the chart, in a good place, and it’s hard to get these details from them, when you are busy and they don’t want to talk, or for whatever reason. So, I think it’s great to have these really concise and loaded stories right up front in their chart to be able to access in terms of “what is their story, what is their social history, and what are the important things about them and their medical history that we should know about, that we don’t always ask about?” (R2-P5)

The history is just hard and sometimes impossible to flush out with your actual patient. And a lot of us do inpatient medicine and the social aspect is ever-present but also very hard sometimes to get especially with cognitive impairment and it requires digging through the chart but also talking to family members, other people, and this was really good to learn how to really spearhead that—definitely have something really concise that everyone can go back and reference for the future—and also actually taking the time to reach out to family and understanding the context. (R2-P6)

Reflection on the physician-patient relationship

…being a good PCP I think entails— and it is really, incredibly hard— having a really good sense of what is happening with your patient in a bunch of different respects. A lot of that falls within the medical context but a lot of it also falls under…disparities and social determinants of health. So I feel like in that sense doing this type of exercise where we're kind of forced to go really, really farther in depth than I think I've done for any of my clinic patients …forced me to think about how much I actually know my patients. Do I really know them that well at all? I may know their medical problems but do I actually know who they are? That's what I think, not just because of this project but it did help facilitate it. Just to take a little bit more time and like get to know people. (R1-P3)

Now that I am a little more efficient, I can ask more personal questions. And I think that makes a huge difference for me. I feel a lot more satisfied in the work that I’m doing just knowing the patients a little but more and feeling like a doctor who cares about somebody, versus somebody who is just trying to get through the process. (R2-P5)

Connection with other learning experiences

Morning rounds are like: “get stuff done” and afternoon rounds are like: “How are you? Who are you? What's going on?….it helps form alliances with the patients, it makes it more enjoyable for us. And I don’t know if I can say it's because of HTH that I do that. But it's nice and it's a similar sort of aspect. (R1-P1)

…for me, this was also kind of influenced by an attending I worked with shortly after, but whenever I feel like I am struggling to get a medical history out of somebody, I skip everything and go to their social history first. Because a lot of times if you can figure out what they did, or what they use to do, or who they live with…they see that you are listening to them…and when you flip back to your more medical questions, the conversation can sometimes be easier when you know who they are as a person. And you don’t have to ask the bajillion questions of HTH…. (R2-P2)

Structural barriers to the practice of social medicine

Systems barriers to patient expression

The patient that I interviewed … was a little bit taken aback by someone who asked the in-depth questions that we asked as a part of…an in-depth social history. I don't think anyone had ever really done that for her before….no one in the health care system had ever asked her those questions. (R1-P3)

[After] explaining to him what the purpose of my interview was…he gave me a furrowed brow and then asked me “So what is this really? Are you here to sort of talk about my symptoms and management plan more, or what?” And so that was kind of awkward. (R1-P4)

Systems barriers to resident elicitation of social context

I think that something we always are limited by is the amount of time we have with people. (R1-P5)

And it was a nice exercise, and I think it was refreshing in the fact that it was a time where you could just take a step back from the daily chaos, of getting things done, rounding, and notetaking, whatever it might be, and actually connect with someone, which is somewhat of an idealistic viewpoint of medicine.... But in that respect … it did remind me that: “oh yeah, there's this whole other part” after the other 70 percent that I had to do. (R1-P4)