Itt took two years and nearly 50 emergency-room visits for Dr. Ardeshir Hashmi to realize he didn’t need to prescribe pills for his 93-year-old patient’s excruciating chest pains. His patient needed ballroom dancing.
Ruth—a pseudonym used for privacy—hadn’t always been a frequent flier in the ambulance. In 2015, she began to feel suffocating in her rib cage. She would shake, pain, and call 911. Every two weeks, she arrived at Massachusetts General Hospital and received what Hashmi, then her geriatrician and now the chair of geriatric innovation at Cleveland Clinic, calls “the million-dollar workup.” It was an endless parade of white coats, stethoscopes, and negative test results. As he spoke to Ruth, Hashmi seemed baffled by the fact that the pain had subsided long before Ruth arrived at the hospital.
The pain actually dissipated as soon as EMTs reached her house. After countless conversations, Hashmi discovered that Ruth’s grandson had left for college right before the vicious chest pains began. The house was empty and dark. She didn’t have anyone else to take her to the local dance studio. She would not be noticed if she fell down the staircase. Ruth would recall that moment and feel the pain in her chest rise in panic attacks.
Her grandson could not be brought home by a mountain of antidepressants and painkillers. Hashmi would be able to refer her the geriatric-care management who would take her to dance ballroom, drive her in her wheelchair to jazzy swing and connect her with her music love and friends from the community center.
So he did. So he did. And then her habit of getting to the ambulance twice a month vanished.
Ruth was effectively given a social prescription by Hashmi. This refers patients to community activities such as a music performance, art class, dance class or volunteer activity to improve their mental and/or physical health. As chronic health conditions, an aging population, and declining mental health overwhelm the nation, prescription drugs are not the magic bullets they’re sometimes expected to be—and that’s particularly true right now, during a global pandemic and the greatest natural experiment of social isolation in history. Social determinants of health are a problem that doctors don’t have the tools to tackle. Is social prescribing possible?
A formal definition of social prescribing is necessary to begin answering this question. It is possible that the English have the greatest claim to it. Their National Health Service (NHS), the largest health system, has funded national social prescribing. The College of Medicine chair Dr. Michael Dixon is a leader in the movement of social prescribing in England. “I suppose I define it as anything that the patient and the link worker think will help get them to a better place,” he says.
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The link worker, Dixon explains, is a clinician who’s critical to the social prescription. Link workers act as community navigators; they spend time and energy getting to know a patient’s interests, motivations, and resources, and then together they co-create a treatment plan involving community activities tailored to these priorities. Unlike traditional doctors who aim to diagnose patients’ problems as quickly as possible, link workers find out “what matters to them, rather than what’s the matter with them,” Dixon said.
It can be anything you want to refer that addresses these issues. It can involve connecting with others via art, volunteer work, or nature. Sometimes it may involve learning to cook healthy meals and walking your dog regularly. “I don’t think we should be too precious about it,” he says.
Social prescribing is still an exception in America. Dr. Deb Buccino of MACONY Pediatrics, Berkshires, Massachusetts, is one advocate.
As part of CultureRx Initiative (a pilot program supported by Mass Cultural Council), Buccino provided social prescribing over the last two years. This initiative promotes engagement in arts, science and culture across Massachusetts. CultureRx ran only for two months until COVID-19 overtook all plans. This simultaneously increased the need to social prescribing, while also making it virtually impossible for people to get together or socialize.
Buccino pinpoints patients who would benefit the most from social prescribing. To her, these are kids who wouldn’t be able to go to the museum or arboretum otherwise. These kids might have issues with weight or anxiety, as well as depression. There may also be domestic violence or socioeconomic distress in their families. Buccino is convinced CultureRx, by seeking these people for social prescriptions can help build equity and a feeling of belonging in spaces culturally not welcoming to everyone.
Buccino introduces patients to her office’s care coordinator, who spends time learning about the family’s lifestyle and the child’s interests. There are many local options available, including a personal reception at Norman Rockwell Museum or a family pass for the Massachusetts Audubon Society. Mass Cultural Council offers transportation and additional tickets for children to bring along a friend.
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Nurse Adrien Conklin acted as the office care coordinator for the pilot’s first year. For Jimmy, an 8-year-old boy who is kept private, she recommended tickets to go to see the production. The Little Mermaid With a friend. Jimmy was born to a difficult congenital condition. He was raised by his grandmother on a very limited income. Going to school was challenging. Even harder was making friends. Conklin called his grandmother a week later in order to check on his social prescription. His grandmother was delighted to tell him that Jimmy spent the entire time focused on the stage with his friend beside him. She had never seen her grandson so happy for so long.
“It’s such a small token, right? You think it’s just theater tickets. But what that really means to that family under stress …” Conklin’s voice, unwavering before, cracks ever so slightly. “He had an hour of pure joy.”
Both the patient as well as the doctor reap the benefits. Buccino describes feeling burned out, “like a broken record,” from repeating the same recommendations that patients never followed—like exercising regularly or eating vegetables with every meal. With social prescriptions however, it was easier to follow through. Family members were delighted to enjoy an afternoon at the theatre matinee or in the art gallery.
Buccino is a firm believer that social norms should be followed based on how much they are enjoyable. It’s like Willy Wonka giving out the golden tickets. “He just put that ticket out there to the general public, and it wasn’t all the rich people who got the reward. It’s fun. It’s free. It makes me smile, and it makes the family smile.”
It will take evidence to show that the benefits of social prescribing for patients translate into savings in healthcare costs for major payers. Social prescribing has been supported so far by several studies. Each study focuses on a specific aspect of the practice, while none can speak for its overall value.
A 2010 study, for example, was published in PLOS MedicineThe data was compiled from nearly 300,000 older people and showed that loneliness may pose as high a death risk as 15 cigarettes daily. The 2015 study found that the loneliness risk was as high as smoking 15 cigarettes per day. LancetA double-blind trial that randomized 1,200 individuals with early dementia to general health advice and an intervention including regular exercise, interaction with others, and controlled diet was published. The intervention actually improved patients’ cognitive function from their baseline level, while general health advice only slowed cognitive decline.
Some studies do not apply to seniors. A meta-analysis of seven arts-based treatments for cancer patients found that all participants reported better well-being and many also experienced less stress and anxiety. Many articles highlight the many benefits of time spent in nature. These include better sleep, increased mental health and lower blood pressure.
But there aren’t many studies of formal social prescription programs, and their effects are difficult to evaluate. It is difficult to determine if there has been an increase in purpose or connection. Until these gaps are filled, many doctors aren’t comfortable throwing their medical authority behind a formal social “prescription.”
One of these is Dr. Carla Perissinotto. As a geriatrician-scientist at University of California, San Francisco, she’s a firm believer in the connection between loneliness and poor outcomes. But she won’t wield her prescription pad against it until she sees a robust investigation into social prescribing’s effects and possible harms. “There are some studies that show the benefits of volunteering, and they give you very concrete directions: two hours a week is enough,” she said. “That’s something measurable, in the same way that I give doses and frequencies for medications.”
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However, for others the intuition behind social prescribing may be enough. Dan Morse, founder of Social Prescribing USA—an organization supporting the advancement of social prescribing in the U.S.—hosts online “happy hours” for advocates to build networks around social prescribing projects. From doctors to musicians at Midwestern hospitals to top-notch developers at Reddit or the National Institutes of Health, attendees include a variety of people. At a recent gathering, attendees nodded along as Morse said, “Just think what could happen if there’s 10 million more people volunteering in our country. If there’s 10 million more people going into nature, falling in love with it, and taking care of their places. If there’s 10 million more people finding their voice through the arts who are sharing their work and beauty with other people.”
This sounds so idyllic. It sounds long and tedious.
But experts agree it’s not impossible. Social prescriptions aren’t simply the doctor’s orders. In its collaborative delivery, social prescribing empowers patients to care for themselves and their communities without a doctor’s oversight.
In a suburb of Boston, Ruth—the elderly woman who experienced chest pain until she resumed ballroom dancing—sways in her wheelchair to the slow-slow-quick beats of a foxtrot every week. In the heart of Cleveland, Hashmi keeps a card from Ruth’s children that reads, “Thank you. It’s like we got our mom back.” Deep in the Berkshires, Adrien Conklin tears up when she remembers 8-year-old Jimmy watching a play.
“What is the health benefit of that?” Conklin answers her own question quietly. “He had a good day.”
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