It 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. He needed to prescribe ballroom dance.
Ruth—a pseudonym used for privacy—hadn’t always been a frequent flier in the ambulance. But beginning in 2015, a tight, suffocating pressure in her rib cage would leave her shaking, aching, and dialing 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. Hashmi was baffled as he talked to Ruth about the pain that had receded long before she arrived at the hospital.
In actuality, that pain had dissipated the minute EMTs arrived at her home. After countless conversations, Hashmi discovered that Ruth’s grandson had left for college right before the vicious chest pains began. She was alone in a dark, empty house, and no one would drive her to the neighborhood dance studio anymore. No one would even notice if she took a tumble down the stairs. And when Ruth remembered that, pain would blossom in her chest in the fluttering crescendo of a panic attack.
No mountain of painkillers and antidepressants could bring her grandson home. But Hashmi could refer her to a geriatric-care manager who would drive her to ballroom dance again, accompany her as she swayed in her chair to jazzy swing, and reconnect her with her love of music and her friends at the community center.
So he did. And her twice-a-month ambulance habit vanished.
Hashmi had, in effect, written Ruth a social prescription, in which a clinician refers a patient to a community or cultural activity such as an art club, music performance, dance class, volunteer activity, or nature walk in order to bolster their mental and 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. Doctors have very few tools to address the social determinants of health. Could social prescribing be part of the solution?
To begin answering that question, social prescribing needs a formal definition. The English might have the best claim to creating it, since their National Health Service (NHS) is the only major health care system that has funded social prescribing nationally. Dr. Michael Dixon, a pioneer of the social prescribing movement in England and chair of the College of Medicine, keeps the parameters broad. “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.
The actual activity referral can encompass anything that addresses those issues. Often it involves connecting to others through art, volunteering, and nature. Other times it might include learning how to cook nutritious meals or regularly walking the dog. “I don’t think we should be too precious about it,” he says.
For now, social prescribing remains the exception, not the norm, in the U.S. One advocate is Dr. Deb Buccino, a pediatrician at MACONY Pediatrics in the Berkshires in western Massachusetts.
Buccino has delivered social prescribing for the past two years as part of CultureRx Initiative, a pilot program funded by Mass Cultural Council, which promotes public engagement with arts, science, and culture throughout Massachusetts. CultureRx ran for only two months before COVID-19 smashed through all plans like an asteroid, simultaneously amplifying the need for social prescribing while making it impossible to gather or socialize.
Buccino identifies the patients she believes would most benefit from social prescribing. To her, these are kids who wouldn’t be able to go to the museum or arboretum otherwise. They might struggle with their weight, or with anxiety and depression. Their families may be experiencing socioeconomic distress, polysubstance abuse, or domestic violence. In seeking out these patients for social prescriptions, Buccino believes CultureRx can build equity and a sense of belonging in cultural spaces that have not always been welcoming to all community members.
Buccino introduces patients to her office’s care coordinator, who spends time learning about the family’s lifestyle and the child’s interests. She offers a menu of local selections, ranging from a personalized reception at the Norman Rockwell Museum to a yearlong family pass to the Massachusetts Audubon Society. Mass Cultural Council provides transportation and extra tickets so kids can bring a friend.
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Nurse Adrien Conklin acted as the office care coordinator for the pilot’s first year. She recalls one 8-year-old boy (called Jimmy for privacy) for whom she prescribed tickets to see a production of The Little Mermaid with a friend. Jimmy was born with a painful congenital defect into a family struggling with substance abuse, so his grandmother raised him alone on a limited income. School was hard. Making friends was even harder. When Conklin called a week later to follow up on his social prescription, his grandmother was thrilled to report that Jimmy had spent an entire hour intently focused on the stage, with a friend sitting beside him. It was the first time she had seen her grandson genuinely happy in a long time.
“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.”
Benefits radiate from both the patient and the doctor. 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. But with social prescriptions, follow-through seemed to be more successful. Families were thrilled to spend an afternoon in the art museum or at the theater matinee.
Buccino believes adherence to social prescriptions comes from how enjoyable they are. She feels like Willy Wonka doling out the golden ticket. “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.”
Still, convincing major payers to reimburse clinics and community groups for social prescribing will require a body of evidence demonstrating its benefits for patients translated into financial savings for the health care system. So far, social prescribing is supported by a patchwork quilt of studies, each making a point about a singular aspect of social prescribing, but none able to speak on its value as a whole.
For example, a 2010 study published in PLOS Medicine including data from over 300,000 elderly individuals found that loneliness can present as great a mortality risk as smoking 15 cigarettes a day. And in 2015, the Lancet published a double-blind study that assigned 1,200 adults with early dementia to receive either general health advice or an intervention involving regular exercise, social interaction, and a controlled diet. The intervention actually improved patients’ cognitive function from their baseline level, while general health advice only slowed cognitive decline.
Other studies are not specific to older adults. In a meta-analysis of seven arts-based interventions for cancer patients, all patients reported improved well-being, and many experienced reduced stress and anxiety. A myriad of articles present the benefits of spending time in nature: better sleep, improved mental health, and reduced blood pressure, aggression, and obesity, for example.
But there aren’t many studies of formal social prescription programs, and their effects are difficult to evaluate. How does one measure increased purpose and connection, or the severity of a depression that might have been? Until these gaps are filled, many doctors aren’t comfortable throwing their medical authority behind a formal social “prescription.”
Dr. Carla Perissinotto is one of them. 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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For others, though, the intuition behind social prescribing is 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. Attendees range from physicians to music therapists at Midwestern clinics to big-shot developers from Reddit and the National Institutes of Health. 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.”
It sounds idyllic. And it sounds like it would take a long, long time.
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.”