Everyone on our unit seems to know Tina. Tina is a 50-year-old Black woman. She is single, has two kids and does not have stable housing, currently living with an abusive man in one of the poorest neighborhoods in Baltimore. She has nonischemic cardiomyopathy and has been admitted numerous times to the inpatient Cardiology service.
Each time, she is admitted for acute decompensated heart failure, diuresis aggressively to euvolemia, and discharged. She has not “tolerated” previous attempts to start guideline-directed medical therapy (GDMT), so the only heart failure medication she takes at home is an oral diuretic. “Behavioral issues” are flagged all over her chart: she has left against medical advice, has demonstrated “poor insight” into her medical condition, and has refused medications and treatments.
This admission is no different. When I first meet her, she is teetering on cardiogenic shock, twenty pounds above her dry weight, dry heaving and confused, her extremities cool. She quickly turns around with inotropic support and diuretics and is now doing a lot better. I’ve managed to convince the team to re-trial GDMT and we have her on a low-dose ACE inhibitor and spironolactone. The nurses on our floor have also taken a liking to her and have banded together to help care for her on her own terms. Tina is doing all of the things we are asking of her.
But what will the future look like for Tina? She has entered that unfortunate spiral in which all patients with advanced heart failure find themselves: recurrent and increasingly frequent hospitalizations, progressive decline, and seemingly no way out. One day on rounds, we discuss her options. A member of our team mentions offhand that she is obviously not a candidate for advanced therapies due to her “social issues” and her lack of adherence to prescribed therapies.
Every time I hear the words “social issues” in the hospital, I shudder and think about how loaded the phrase is. It’s a catch-all euphemism that physicians use to describe patients who face obstacles extending beyond their medical environment and into their social or contextual environment. These patients, like Tina, share certain characteristics: they are female, Black or brown, poor and live in socioeconomically deprived neighborhoods. Moreover, these patients with “social issues” do not qualify for advanced heart failure therapies such as left ventricular assist devices (LVADs) and heart transplants.
Indeed, this trend is supported by the medical literature. A recent study published in Circulation: Cardiovascular Quality and Outcomes found that women, Black patients, Latinx patients, Medicare and Medicaid patients, and those living in lower-income areas were less likely to receive LVADs than their more privileged white, male, insured counterparts living in higher-income areas.1 Likewise, another recent study published in Circulation found that a patient’s race influenced decision-making around selection for a heart transplant.2 Disparities also extend to outcomes related to these advanced therapies, as highlighted by a Circulation: Heart Failure study that found socioeconomic and racial disparities in outcomes after a heart transplant.3
In the face of such evidence, we must challenge the status quo on behalf of our patients with “social issues.” We must question the presumption that they are simply ineligible for advanced heart failure therapies. We must investigate the role that personal, social, and contextual factors have played in bringing them to the precipice of death from end-stage heart failure. We must ask ourselves how their lifelong experiences with racism and discrimination in the hands of healthcare providers affect their trust in us. We must ask ourselves which societal forces of socioeconomic oppression and structural racism make it difficult for them to obtain the care they need to live a better life. And finally, we must look inward and acknowledge the ways in which we as health care providers perpetuate racism and discrimination against them through our own words, discussions, and actions.
Most importantly, we must figure out how to right this injustice, so that we do not just take it for granted that patients like Tina cannot access LVADs and heart transplants. We need to determine what we must do to help these patients receive the same advanced interventions that their privileged contemporaries are offered. Everyone should have equal access to these therapies; our work as cardiologists, physicians and good citizens of our society is not done until the words “social issues” are banned from our lexicon and are no longer used to disqualify patients from receiving life-saving therapies.
- Wang X, Luke AA, Vader JM, Maddox TM, Joynt Maddox KE. Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes. Circulation. Cardiovascular quality and outcomes. 2020;13(6):e006284.
- Kuehn BM. Race May Influence Transplant Decision Making in Heart Failure: Studies Also Detail Disparities in Hypertension Diagnosis, Statin Prescribing. Circulation. 2020;141(8):694-695.
- Wayda B, Clemons A, Givens RC, et al. Socioeconomic Disparities in Adherence and Outcomes After Heart Transplant: A UNOS (United Network for Organ Sharing) Registry Analysis. Circulation. Heart failure. 2018;11(3):e004173.
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Andi Shahu is a resident physician in the Osler Medical Residency in Internal Medicine at Johns Hopkins Hospital in Baltimore, and will begin General Cardiology fellowship at Yale-New Haven Hospital in July 2021. He is interested in the intersection between cardiovascular outcomes, health equity and health policy. He is a member of the Council On Quality of Care and Outcomes Research (QCOR). He also loves traveling, writing, music and running. You can follow him on Twitter @andishahu.