FLAT LINES AND THE HUMANS THAT BRING THEM BACK TO LIFE

Elizabeth Shaw, MD

Flat lines are generally ominous signs in medicine. A flat line on a cardiac monitor represents a dire situation, but offers no hints about the underlying cause. Similarly, a flat trend line showing consistently subpar performance on a clinical quality measure is both troubling and unrevealing. As we learn early in medical training, a flat line is not a shockable rhythm.

These difficult situations highlight another truth in medicine, which is that the solution is to treat the patient, not the problem. When the cause of the pattern on the screen or the graph is unknown, it is critical to focus on the humans and stories behind the data and let them guide our actions. As a family physician at a federally qualified health center, I recognize that personalizing care for individual patients drives quality. Safety net providers know that anticipating barriers and molding care to our patients’ individual needs improves outcomes. In my role as Medical Director of Quality Improvement, I have learned that this same commitment to customized care on the population level is a powerful driver of health equity as well.

Perplexingly, breast cancer screening rates at my health center have defied years of improvement efforts tailored to overcome the most troublesome barriers for our patients. For example, when patients shared that transportation to off-site imaging centers was a hurdle, we responded with taxi vouchers and ride-share credits. Acting on feedback that scheduling mammogram appointments was cumbersome, we collaborated with our main imaging centers to reserve appointment blocks and now provide appointments to patients directly. In order to help our many Latinx patients feel comfortable accessing care outside their medical home, we recently partnered with a bilingual, bicultural nurse case manager to provide extra outreach and reminder calls to our shared patients. Despite these well planned strategies, patients’ high noshow rates for mammogram appointments persist, and our trend line for breast cancer screening has remained level.

In late 2022, faced with a flat line and dwindling options, we decided to try something completely different. For the first time in history, we took a chance and offered mobile mammography to patients at our health center facilities, with generous support from Partnership Health Plan of California. We had long suspected that removing the challenges associated with off-site mammography could be successful, but we lacked access to a local mobile mammography unit in Marin and we worried about the complexity of bringing an outside service into the community. To our amazement, over the course of two days, we provided over 80 screening mammograms to health center patients. This amounted to nearly three times the number of women successfully screened in the reserved mammogram slots at our largest off-site imaging center in 2022. Beyond the numbers are the compelling stories of the women who were screened, several for the first time in their lives. Patients at both events shared profound gratitude, at times through tears, for the opportunity to access needed screening in a way that actually removed barriers, not just masked them. Yet again, we were reminded that equitable access to care happens when systems of care strive to conform to the needs of patients, and not the reverse.

In the weeks since these pilots occurred we have navigated responses from the local community. On one hand, we are learning from concerns shared by our local imaging centers about the technology used at the mobile events and the lack of continuity this approach creates around abnormal results. On the other hand, we have watched a wave of interest build around the possibility of a local mobile mammography unit, including attention from potential funders. Most importantly, we hear patients continue to share enthusiasm for this new approach and ask when “the bus” might return for their mothers, sisters and daughters.

Challenging the status quo to deliver care effectively is the daily work of those of us who serve the most vulnerable patients in our communities. However, we know that pilots are merely launching points and that true progress has to be sustainable for all involved. After all, when a flat line regains hopeful movement, it is usually due to the heroic efforts of a coordinated team with a shared goal: to save lives. I feel hopeful that we can come together as a health care community in Marin to do just that.

Dr. Elizabeth Shaw is a Family Physician and the Medical Director of Quality Improvement and Assurance at Marin Community Clinics. She obtained her medical degree from the University of California, San Diego and completed residency at the Ventura County UCLA Family Medicine Residency Program. She also serves on the Board of the North Bay Chapter of the California Academy of Family Physicians.