What brought you in today?

Through my work in an internal medicine-pediatrics residency pathway focused on rural and under-resourced healthcare, I’ve been moved by the ways both rural and urban health are often characterized by patients’ difficulties in physically accessing medical services. 

Transportation challenges are a common reason for missed appointments, leading to unmet or delayed attention to medical needs. Extenuating circumstances, like the pandemic, exacerbate these problems. In an urban area, if a patient is unable to access public transport, their ability to attend an appointment is like that of a rural patient who must find a way to travel many miles. Other elements of the story—weather, time of day, physical terrain, travel companions—further complexify these equations. 

When we think of the question that often begins medical visits, “What brings you in today?” it’s almost reflexive to consider the motivation for the appointment as opposed to the mechanism of arrival: personal, friend, or family vehicle, bus, taxi or Lyft, train, foot, bicycle, etc. But the way a person arrives at an appointment can be closely related to their overall health. The same can be said for the time and work that it takes to arrive, and by this, I mean work as a function of the (broadly speaking) energy exerted in that time of travel. Was the trip stressful and what made it so? Is the travel so complex that appointments are missed, or important topics are forgotten? Further, getting to an appointment may not mean a patient also has the resources to access all suggested follow-up care. 

While “What brings you in today?” is a vital and open-ended question, “What was it like getting here today?” is also an important, open-ended, follow-up question that tells you about the patient’s travel and other support systems.  

Listening for travel barriers is a skill that can be built with the practice of narrative medicine, which, as Dr. Rita Charon has defined it, “is clinical practice fortified by knowledge of what to do with stories.” Narrative medicine teaches us to think of healthcare stories in terms of form and content, both the “How did you get here?” and the “What brought you here?” Narrative medicine also helps us learn to ask the follow-up question, “What was it like?” leading to further critical inroads to understanding a patient’s experience as we realize what more can be learned from a story. For instance, if a patient arrives seeming anxious, could this be a product of the conditions of their travel? A clinician communicating about access needs in more narrative ways could also help patients feel less stigmatized about stressful contexts and provide openings for healthcare teams to suggest resources to facilitate travel and communication about it, such as can be achieved by connecting patients with community health workers who are trained to help patients navigate their healthcare travel options. 

Consider the following tips to help support your patients’ access needs: 

1. Ask open-ended questions and listen closely to responses to learn how patients are traveling to their appointments and what this travel is like, so that its relevance to care can be assessed.

2. Keep a list of resources for medical travel to share with your patients and those in your hospital or clinic.

3. Contact local community health workers (CHWs) to support patient navigation of health-related resources and services. One great way to find CHWs is to communicate with your local Area Health Education Center (AHEC).

4. Utilize telehealth programs as options for both rural and urban patients with access limitations.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.