EP. 142: A PRESCRIPTION FOR CONNECTION
WITH JULIA HOTZ
A journalist explores the power of “social prescriptions” — when health workers to prescribe community resources and activities such as art classes and swimming lessons — in improving our social, psychological, and physical health.
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Episode Summary
In recent years, it has become evident that loneliness is one of the most pressing public health challenges of our time — so much so that the US Surgeon General has labeled it an epidemic with far reaching consequences. The pain of isolation doesn't merely gnaw at our sense of belonging: it undermines our physical wellbeing, erodes our mental health, and places an invisible strain on communities. In this climate of ever widening personal and cultural divides, the collective call for deeper human bonds feels both urgent and universal.
Our guest on this episode is Julia Hotz, a journalist and passionate advocate for social prescribing, the practice of directing people to community activities and social support networks as part of their health care. She is the author of the book The Connection Cure: The Prescriptive Power of Movement, Nature, Art, Service and Belonging (2024), in which she argues that whether it's group classes, volunteer opportunities, or simply forging new friendships, true well-being is as much about our social fabric as it is about physical health.
Over the course of our conversation, we discuss the psychology of isolation and loneliness, the tangible health effects of loneliness, the historical societal forces that drive humans increasingly apart, the role of social media in connecting and separating us, and how patients and physicians alike can take proactive and creative steps in making human connection an integral part of living well.
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Julia Hotz is a solutions-focused journalist and author of The Connection Cure (2024) — the first book chronicling the science, stories, and spread of social prescribing. She helps other journalists report on the ideas changing the world at the Solutions Journalism Network.
For her insights on social prescribing, Julia has been invited to speak on podcasts, write for news outlets, teach in medical schools, deliver talks at TEDx, university symposiums, and international conferences, and advise health organizations like Walk with a Doc and Social Prescribing USA.
Before becoming a journalist, Julia worked as a teacher, bartender, pizza server, and summer camp forest ranger. She enjoys running, biking, hiking up mountains, riling up dance floors, budget traveling around the world, and building the longest road around Catan.
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In this episode, you will hear about:
• 2:50 - What social prescribing is and how it became Hotz’ focus as a journalist
• 5:32 - How loneliness became a crisis in the era of social media
• 18:46 - The ways in which social prescribing can change the conversation between doctors and patients
• 28:24 - The impact that our relationships and environments have on our physiological wellbeing
• 38:29 - How doctors and health care systems can leverage the power of social prescribing
• 45:00 - How social prescribing is beginning to find its place in the American healthcare system
• 56:03 - How social prescribing can bring a stronger sense of meaning into the lives of both patients and doctors
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Henry Bair: [00:00:01] Hi. I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Tyler Johnson: [00:01:02] In recent years, it's become evident that loneliness is one of the most pressing public health challenges of our time, so much so that the US Surgeon General has labeled it an epidemic with far reaching consequences. The paying of isolation doesn't merely gnaw at our sense of belonging. It undermines our physical wellbeing, erodes our mental health, and places an invisible strain on communities. In this climate of ever widening personal and cultural divides, the collective call for deeper human bonds feels both urgent and universal. Our guest on this episode is Julia Hotz, a journalist and passionate advocate for social prescribing, the practice of directing people to community activities and social support networks as part of their health care. She is the author of the book The Connection Cure: The Prescriptive Power of Movement, Nature, Art, Service and Belonging, in which she argues that whether it's group classes, volunteer opportunities, or simply forging new friendships, true well-being is as much about our social fabric as it is about physical health. Over the course of our conversation, we discuss the psychology of isolation and loneliness, the tangible health effects of loneliness, the historical societal forces that drive humans increasingly apart, the role of social media in connecting and separating us, and how patients and physicians alike can take proactive and creative steps in making human connection an integral part of living well.
Tyler Johnson: [00:02:43] Julia Hotz, thank you so much for joining us, and welcome to the show.
Julia Hotz: [00:02:47] Thank you so much, Tyler. So great to be here.
Tyler Johnson: [00:02:50] Most of the people who we have joining us on the program, just by nature of what we're talking about here tend to be medical doctors or medical professionals in some sense. You are certainly not the first journalist or author without a medical degree who we've had on the program, but you are a little bit of an exception to the rule. So to begin with, can you just talk to us a little bit about what do you do?
Julia Hotz: [00:03:12] Yeah. Well, much respect to all the health care providers. I cautioned at the beginning of the book. I am the furthest thing from a health or health care expert. I joke that, you know, my habits would probably make a lot of health care providers, you know, make their jaw drop. And, uh, I have some trouble with figuring out what insurance means. But all that said, you know, I'm a journalist. And specifically I do something called solutions Journalism, which is reporting on systemic solutions to widely felt problems. And before I was a journalist, I went to grad school studying sociology. Public health was really intrigued by the sort of epidemic of loneliness. You know, I'd sort of grown up culturally believing loneliness was something that affected older adults. It was synonymous with isolation. But actually, what I found was that this sort of pervasive loneliness, this lack of meaningful connection to other people and to oneself, is responsible for a lot of things that might mask as healthcare problems. There's associations between loneliness and depression, loneliness and anxiety, even more obscure connections like chronic pain and dementia. So I became really interested first in what was working to sort of systemically address loneliness. But it ended up being also an investigation into what's working to systemically treat depression, anxiety, chronic pain, ADHD, PTSD. And what I came across was this solution called social prescribing, which is the idea of having health care providers connect their patients to non-medical resources and activities. So that could be the resource front, could be, you know, food, housing support, job support, but it could also be an art class or a nature excursion or even working on a farm. And, you know, this comes from this pretty well accepted idea in health care that actually 80% of our health is determined by social, environmental, behavioral factors. And I really think social prescribing is this solution that responds to this fact that if we want people, if we want individuals to get better, we need to treat the environment in which they're in.
Tyler Johnson: [00:05:38] Okay. So before we get to some of the specifics, in terms of both what it is and some of the stories that you relay and whatever about social prescribing per se, I want to back up for a for a minute and sort of set the stage for a moment. And in order to do this, I think it's important to think back, let's say maybe 15 years. So like kind of the end of the aughts and the beginning of the 20 tens, kind of right at the dawn of the social media era, as that was starting to become something that was really sort of integrated into people's lives. And I think it's easy to forget now that if you were paying attention to both the sort of popular press treatment of social media at that time, and also especially the advertising around something like Facebook or Instagram or whatever, there was this idea that we were right at the precipice of becoming the most connected worldwide community in the history of humanity. Right. It was like there were these very sort of touchy, feel good images about, like grandma video chatting in through some Facebook app or whatever to her grandchildren at bedtime to read bedtime stories. And so social media was going to connect us, and it was going to put us into community, and it was going to be, you know, there there was a little bit of a sense of a sort of a coming techno utopia that would be with us through social media.
Tyler Johnson: [00:07:20] So on the one hand, that's kind of the vision that was laid out for everybody 15 years ago then, now just over the last year or two. And you referenced some of this briefly previously. We have the US Surgeon General who is declaring that the 2020s, equivalent to the public health scourge of tobacco. From the 1960s and 70s and of course, before that. But that's when it sort of started to be more widely recognized is nothing other than loneliness. And you have everything, you know, from starting with at least as far back as Robert Putnam and Bowling Alone, and then going up through the Surgeon General's report on the epidemic of loneliness. I think there is this this recognition that loneliness has become a deeply threatening public health issue. And so, I guess the question that I want to ask more broadly is sort of what do you make of this? But more specifically, how did we get from there to here? Like, how did we go from a place where what we were promised was the most connected community of people around the world in history to a place where now we are declaring loneliness. As arguably the largest threat to public health, at least in the United States of America and in particular. How did all of this happen? Right coincident with the rise of social media?
Julia Hotz: [00:09:08] Oh, wow. These are two meaty questions I love it. Let's take the first one. When when did we see this decline? I argue in my book that it actually goes back way further. And social media I think, is the most obvious symptom. We'll talk more about that in a minute. But, you know, ever since the Industrial Revolution, technology has been displacing, yes, you know, our labor. And in some ways that's great. Life is easier now than it ever has been. But within that, I say we've sort of thrown the baby out with the bathwater. You know, there was a time in which everyone's job. Let's just start with our job. Everyone's job had a purpose that was very much connected to the whole of the community. This is why we still see this in last names like Baker or Smith or Taylor. And actually, I thought this was interesting. The word economy has Greek roots that refer to the management of a family unit. Nikos and Nomia. So where am I going with all this? You know, there was a time in which your job required you to interact with other people, and you really clearly saw the purpose of your job. But with the Industrial Revolution and increasingly so over time, that has been less true, I would say. There's a great late anthropologist, David Graeber, who talks about the rise of what he calls bullshit jobs, where, you know, people are just kind of serving this corporate cause that they don't really know about or understand. In other words, they can't easily see the effects of their job on the world.
Tyler Johnson: [00:10:53] Yeah. You know, this reminds me a little bit. I don't know if you've ever seen the original Pixar The Incredibles movie, but in that movie, one of the sort of central conceits is that you have this guy who is, in effect, Superman. He's named Mr. Incredible, right? But he's super strong and is a super hero. And, you know, whatever saves buildings from being knocked over and saves people's lives or whatever. And then because of a lawsuit, he has to go into hiding and, and hide his superhero identity. And so he becomes a worker at an insurance company, and he goes and has to work for this boss who's like, a quarter as tall as he is and who the boss clearly has no real talent. And really, the only two things that the boss cares about are that the pencils are. Exactly straight and parallel with each other and in the right order on the desk, and that all of the insurance claims get denied. And so literally, you have, in effect, Superman, who is relegated to this sort of faceless cubicle in a faceless building for a faceless company where he's supposed to just sit there and rubber stamp denied on insurance claims all day, every day.
Julia Hotz: [00:12:06] Wow. That is exactly it. And I mean, it's funny, and I'm sure listeners of this podcast can relate. Even the medical profession, like there was something called Once the Family Doctor where you literally went to people's homes, went to the families, you knew the whole family. And medicine was very much an interpersonal thing. And now and you could tell me if I'm wrong about this. What I hear is that it feels more and more like working in a factory. You have 15 minutes with the patient. There's all this sort of sort of bureaucracy that you have to navigate and administrative stuff that makes it harder for you to do the human connection stuff. So I think our jobs are one culprit, but I think with that, I also talk in the book about how the sort of displacement of labor to technology also created more time. And at first, this was this sort of utopia you're describing. You know, we had more public spaces. People were playing sports. Arts was flourishing because people had what they called leisure time. But then, as it usually goes, some people realized, well, we can actually create a market out of this leisure time.
Tyler Johnson: [00:13:19] Let's monetize it.
Julia Hotz: [00:13:21] Let's monetize it. Exactly. And like the most obvious place I think we see this is with sports. You know, it used to be that sports really were this common good. There'd be public fields, the YMCA. There were all these associations that really encouraged people to come out and play together. But then, you know, we had the rise of the sports industry and people saying, no, if you want to play golf, you have to pay $100 to go on this golf course. And if you want to go to a gym, people feel they have to look a certain way. They have to have the right equipment. So anyway, before this becomes just a rant about why we're all so lonely without getting into the solutions, I think it's a combination of these forces, and I really think social media is a symptom of the decline, sort of of the importance of community, even just in our economic life. Right. And to your second question, I get asked this a lot. I think social media, again, is this like easy culprit? You know, earlier this year, we had the surgeon general put out sort of an op ed arguing for warning labels on social media because of all this adverse effects on youth mental health. I would say a couple of things. While that might be true, I think if we're going to, you know, put warning labels on the bad thing and try to have people use the so-called bad thing less, we also need to invest more in the good thing. We need to invest in sports teams and access to arts and access to nature, opportunities to engage with nature. And I would also say, and I've learned this, I still am sort of on the Luddite side of things. Like I joked on a podcast last week that my most used app was clock for a long time. Like, I am not super on social media. But.
Tyler Johnson: [00:15:14] So I just have to say that as the resident Luddite on our podcast, I am with you in solidarity. Just for the record.
Julia Hotz: [00:15:22] Yes. I love it, I love it. But you know what I will say, what I've learned from connecting with other journalists is that for some people, particularly if you're super marginalized, if you live in a community where you know you're the only person who belongs to a certain identity or racial group, maybe you have a disability that prevents you from being able to leave your house as much as others. I do think it can be good for certain people in certain contexts for a certain amount of time. I'm just generally pretty averse to like blanket statements on is something good, is something bad? When I and I really think even, you know, for able bodied people, social media can provide an important source of connection and purpose. It just can't be the only source, I would say.
Tyler Johnson: [00:16:11] Yeah, I see where you're coming from. I mean, I like the formulation you offered earlier, which is, as I understand it, to say that it's not that social media is the thing that is causing loneliness. And it's not that social media is the problem itself per se, but rather that social media, in effect, is one proffered solution to the problem of loneliness, which is imperfect and which can, in some important and paradoxical ways, can actually exacerbate the very problem that it's trying to solve. But nonetheless, if you mistake the imperfect solution for the problem that it's trying to solve, you can spend all of your time critiquing the imperfect solution when what is really needed is to, yes, acknowledge that that solution is imperfect and is not going to solve the problem of loneliness. But what is really needed is to address the problem itself, which is loneliness writ large. Not social media per se.
Julia Hotz: [00:17:09] Amen. You know, that is so well said. And it also has me thinking about. I recently watched this great documentary called Join or Die about the work of Robert Putnam, who really is an expert on this. And I mean, his work predates mine by several decades. But he points to the rise of TV as being a factor in the rise in loneliness. And I think you could even go back further and say the rise of any kind of entertainment. I do think it's true that our sort of entertainment has become more and more individual over time, like at least with TV. Sure, you are in your household, but you were watching it together. Maybe you had your family members joining you. And I think in the future, my gosh, you know, your buddies are not your buddies, but your geographical neighbors in Silicon Valley have thoughts that maybe they'll be a future where we're headed to these sort of AR VR headsets and entertainment will become even more individual.
Tyler Johnson: [00:18:10] Yeah, I think this is the moment that I like, move to the woods and start reprising Henry David Thoreau at Walden Pond, just for the record.
Julia Hotz: [00:18:18] Yes, exactly, exactly. So all this to say, I think this has been a temptation that's been true throughout history, which leads me to me to believe that, you know, there's not so much we can do to stop that force. Clearly, people want entertainment, but what we can do again is invest in the other thing, make it as culturally cool to, you know, go out in the woods like Henry David Thoreau or join an art class as it is to be a TikTok star?
Tyler Johnson: [00:18:46] Yeah. So, you know, I think just as we are leaving this larger point and to reflect on what you were saying, I mean, I think it is important to recognize that humans, to some degree have always, at least insofar as they had discretionary time, have always wanted to be entertained. Right. And if you think, for example, about Aldous Huxley's book Brave New World, the Soma dispensers in that book, I don't know that they would use the word entertainment. But the point is that a lot of, you know, some people have argued that at least in the United States, Brave New World is a much more prescient book than 1984, because just the way that sort of America is wired, we were never going to allow ourselves to be subjected to a tyrant who sort of came down with an iron fist, but that we could be subjected to our sort of enslaved to our own appetites, as happens in Brave New World, where there is no need for an iron fist. Right? Because it's just sort of flaxen cords or whatever you want to say, because people are willing to be enslaved to their own appetites. Right. And I think that if you if you think about we've both referenced Robert Putnam's work, but if you think about Neil Postman and his book, I think Entertaining Ourselves to Death or something to that effect, that's kind of the idea, is that it's not so much that we have a new drive to be entertained, but rather that the changes in technology and of course, we now have many things that Neil Postman couldn't have even commented on directly because they didn't exist when he wrote the book.
Tyler Johnson: [00:20:21] But we have so much more efficient ways of being entertained. Right. In effect. And again, not that social media doesn't have good effects, but it's just to say that social media is a way to be entertained endlessly. Endless scrolling is just that, endless. And if you think about, you know, carrying around a cell phone in many ways, a cell phone, that's what a cell phone is. It's like a soma dispenser that you carry around with. You charged at all times so that it is always available to give you what amounts to that little soma hit, so that it is the the ubiquitousness and the efficiency of the Soma delivery system that has changed. More than that, we now have some new or different drive to be entertained. But okay, enough of that. So I do want to get more directly to sort of the stories you tell and the thesis of your, of your writing. So in order to facilitate that, I want to start by talking about what I think. You know, I have thought a thought a lot recently about what is it that we think doctors do? Sort of like what is the societal understanding of the role of a doctor? And as I've thought about that question, I come back again and again. As funny as this might sound, to believing that the quintessential example of what a doctor is supposed to do is strep throat. Now, that may sound strange, but let me tell you what I mean. There are multiple aspects to the way that strep throat works that I think are really important for us to highlight, because they reflect, I think, much of the way that we think about medicine.
Tyler Johnson: [00:22:00] If you think about a kid who has strep throat, basically they wake up one morning and oh my gosh, their throat is just on fire and they have a fever and they're tired and they just they just feel terrible, right? So then you go to the doctor and of course, the doctor does the one thing that every kid knows that doctors do which is has you open your mouth big wide say ah and then they stick a tongue depressor in there. They can see your throat, then they swab it. Then they send the swab for a test that will be done in like an hour. And then the test comes back. And if in fact you have strep throat, then they have a very specific algorithm for prescribing antibiotics. And then best of all, you take the antibiotics and you get better. So if you think about that story, there are so many elements to it that I think are really important. So first off, the problem is a easily identified foreign thing that is invading into your body. Then the second thing is that it has this very noticeable set of symptoms that come to you immediately, and that you can't help but notice. The third thing is that when you go to the doctor, there is an easily accessible, easily reproducible, and easily doable way of getting the biopsy, if you will, or taking the swab that is of making the diagnosis. Then the answer comes back very quickly. It's very clear yes or no. And then if you have it, best of all, you get this one particular prescription for this one thing, and almost immediately you start to feel better.
Julia Hotz: [00:23:30] Yes.
Tyler Johnson: [00:23:30] So I think that all of us have this kind of like innate desire for medicine to work like that. We want that to be what it's like when we go to see the doctor for anything. And yet much of the work that you do in your writing is to complicate that narrative and all of its various aspects and factors. So can you talk a little bit about why most of the way that medicine is actually practiced does not conform to that sort of archetypal example that we want that all of us sort of want to hold near and dear.
Julia Hotz: [00:24:08] Oh gosh, we are so simpatico on this. I use almost the exact same analogy in the in the book to like explain. I think why there is this disconnect between, you know, what people think sickness and health are. Because you're right. Like strep throat is for many of us, the first encounter we have with the health care system. And it would be very reasonable for us to assume that sort of any kind of pain we feel in our bodies, like we do when we first have strep throat, has sort of a biological origin, first of all, can be diagnosed easily based on what the pain is, can be treated easily, and you'll feel better, like there's no reason to question that. But we know that most of the most common health issues we experience, lifestyle and sort of psychological illness are not as simple as strep throat. In other words, there's not a not a simple test you can run and say, yep, that's where you know the anxiety lives in your throat, or that's where the, uh, you know, I don't know, the depression lives. And yes, it's true that there are treatments. There are pharmacological treatments, just like antibiotics that can alleviate some of the symptoms. But the root cause is much more complicated. And how do we know this? I mean, look, nobody's talking.
Julia Hotz: [00:25:39] We have a strep throat epidemic. People are talking about how we have, you know, diseases of despair and addiction epidemic, a loneliness epidemic, which leads us to believe the increase in this over time is not just random and genetic. It has to do with the way that we live. So that's one thing. And yeah, I mean, I want to be careful with how I talk about that because of course, if you are somebody who is depressed or is dealing with chronic pain or whatever it might be, your symptoms feel real and painful like they do with strep throat. But what I'm suggesting is, and this is borrowed, by the way, from a wonderful psychologist, kind of coined the mother of mindfulness, Ellen Langer, who suggests that we think about pain of any kind a little bit differently. And what she says is that nobody, for example, is in chronic pain 100% of the time. Nobody is depressed 100% of the time. Nobody experiences debilitating anxiety 100% of the time. And so she asks us to reflect on what is it about our environments that cause us to feel these symptoms more intensely? And if we realize, for example, that and gosh, I'm a perfect example of this with my back pain right now, like ever since I emailed you before this saying, hey, I have some awful back pain, I slipped a disc in disc in my bag.
Julia Hotz: [00:27:10] I might not be able to, you know, stand up. I'm standing. And I don't feel the pain right now because I'm so locked into this conversation with you. And so where am I going with all this? I think that's what social prescribing asks us to do instead of focusing on, just like, what's the matter with you? Tell me about your symptoms. Tell me where it hurts. Kind of like the checklist of questions that we sort of culturally have come to expect from doctors. It asks us to think about what matters to you. When do your symptoms feel less? What makes you feel healthy? And based on that answer, doctors and buoyed by, you know, lots of data supporting this can actually prescribe people an activity or a resource that connects to that sort of sense of joy and meaning and belonging. And this is not woo woo, right? Like there is so much data supporting that nature is really good for our health. It has all these physiological benefits. The same with engaging with art. The same. Of course, we know with moving our bodies and having, you know, kind of some kind of cause we can serve and feeling belonging with others. All of this stuff really is medicine.
Tyler Johnson: [00:28:24] Yeah. So my mind is brought to think about two things here. So the first one is that I want to bring up this really interesting study, but actually even more sort of than the study, a particular reaction to the study. So let me tell you what I mean. So there is this really interesting study that was done a number of years ago by Jennifer Temel and colleagues in Boston, where. So this was done in an era when palliative care was much less well integrated into medicine than it is now, though there is still a long ways to go to have it fully integrated in the way that it would ideally be, but nonetheless, it was even much less integrated at that time. So what Doctor Temel and her colleagues did was that they randomized patients. Very simply, patients with incurable lung cancer into one of two groups. So in one group, the doctors who were taking care of the patients could consult a palliative care doctor whenever they felt it was appropriate. And they could do that early or late or, you know, basically whenever something came up where they thought they needed a palliative care doctor's help. In the other group, the patients were referred as a matter of course, as part of the study to a palliative care doctor. Basically as soon as they were enrolled.
Tyler Johnson: [00:29:34] So the question was not about access to a palliative care doctor. It was just about when and how did you get referred and how routine was the referral versus something that you had to, you know, ask for especially. And what was 0% surprising to anybody who has worked in oncology care and knows about palliative care doctors, is that the people who were in the group that was referred as a matter of course up front, did better in many ways in terms of their quality of life and the control of their symptoms and some of those things that, as I say, I think is in effect, you know, would not surprise anybody who really knows what they're talking about here. But what was surprising was that the group that was referred as a matter of course, up front, also lived statistically significantly longer than the group that was referred at the discretion of their medical oncology team. And just to be clear, I'm not talking you know, sometimes you get sort of a statistical anomaly where it is quote unquote, statistically significant. But you look at the numbers and kind of roll your eyes and think, well, that doesn't really mean anything. But this was not that. This was like a real deal, actual meaningful. Meaning what we call a median overall survival advantage.
Tyler Johnson: [00:30:52] Meaning, as I said, that they lived longer. But what's really interesting to me is that I brought this up one time, or I was in a meeting, a sort of a clinical case meeting with a number of other doctors. And we're talking about a patient with lung cancer. And this study came up. And what was really interesting is that as soon as it came up, there was a sort of a senior doctor in the room who raised their hand and said, you know, the results of that study are are sort of misleading, and that's not a real effect. And probably it just had to do with the fact that the people in the who were referred early just had more time with another doctor or a person they could talk to or whatever, but it's not a real effect. But the thing that's so interesting about that, to me, is the very idea that even if that were true, that that somehow negates the effect or something, because then let me let me have that, bring that, bring me to my second story, which is this. So, you know, as most medical trainees do, I spent about ten years where I was in my medical, the clinical part of my medical training, where I was being constantly supervised and constantly evaluated, and I was constantly working with mentors, both, you know, clinical and otherwise.
Tyler Johnson: [00:32:01] And as I think back about that time and the time that I spent with these clinical mentors, there are two mentors in particular that come to my mind very strongly. And one of them was the kind of person who, whenever I worked with them. And when I think also about this person's impact on my life and career, sort of in broad strokes, this was the kind of person who saw more in me than I saw in myself, who believed in me more strongly than I believed in myself, and who had a more expansive vision for what I was doing and what I could be than I had. And then there was this other person who I also worked with, who was consistently critical and demeaning, and who clearly did not believe that I had the makings of a great doctor and who insistently told me so. And who treated me in a diminishing way? Very consistently over the course of of our time working together. But the thing that is so interesting to me about this is that I have recognized in retrospect, I still sometimes have interactions with both of these individuals, and I have recognized in retrospect that when I see the first individual, I can feel it in my body.
Julia Hotz: [00:33:25] Right?
Tyler Johnson: [00:33:26] My muscles loosen. I can almost feel my blood pressure drop. Like I just I sort of feel easier, looser, happier, whatever you want to call it. On the other hand, if I have an interaction, even still with the other person, I can feel involuntarily, my jaw clenches, my muscles tighten. I can almost feel my blood pressure, like there is a physiologic response on both ends of the spectrum. And, you know, it's one thing if this is a person that person that you work with for however long, and then you move on and you know, whatever, it's a thing you can talk about in retrospect, not that big of a deal. But on the other hand, if you think about having a relationship or a set of relationships like that, that maybe our relationships at work that are never going to end, that are that are just the way it's going to be in the long term, or even more so. Those are family relationships, let alone if this is like an intimate partner or you know, someone, one of your siblings that you live with or your parents or what have you. And so I guess what I'm trying to say is that I think as as doctors, what we often want to say is, well, I believe in evidence. But what we actually mean by that in many cases is I believe in evidence, as long as it's evidence of a pill or, you know, something like that.
Tyler Johnson: [00:34:44] Because, again, the response of that doctor who was in the meeting that I was talking about earlier that like, well, if it's just more time to spend with that, that's not a real thing. Well, how is that not a real thing? Of course that's a that's a real thing. I mean, that's just as real. Like a if you're living longer because you have more people spending more time with you or caring about you more, that doesn't make the extra time that you have less valid or less real or less beautiful, right? I mean, it's just that it's coming from a different place, right? And, but but I say all of this to say, I mean, the only thing that I ever received from either of these mentors was words. And yet those words had a very real, unmistakable, and I would say undeniable physiologic effect on me, which is just to say that I think that as doctors, we often underappreciate or misunderstand or simply don't recognize at all the fact that this entire host of very complex social and cultural and familial and emotional and psychological factors have an impact on our health and the health of health of our patients. That is relatively easy to miss.
Julia Hotz: [00:35:58] Right. Oh my gosh. Wow. So much to unpack there. Well, first of all, I mean, just kudos to you, as you know, a doctor being able to acknowledge that. And I do think I mean, I'm biased, but most of the doctors I talk to would say the exact same thing that our environments, including our social environments, the people we interact with, really do matter on a physiological level. And gosh, I wonder in reference to the, you know, second person, I wonder if there's almost like a cognitive dissonance where here we have medical professionals in the US who work so hard, you know, go through all these years of school and residency and training and papers and research and long hours and overnights and all of this kind of like unwilling to accept, I don't know, maybe more primed to expect that because the journey to get here was so hard. The solutions have to be complicated. And, you know, pharmaceutically based and rigorously researched. And look, I think I want to be very clear. I think that pharmaceutical innovation is wonderful. It's done so much, I'm sure, in your field particularly, you know, my dad had a pretty rare cancer. And I am so grateful for all of the pharmaceutical innovations that helped him. But I don't understand why it has to be either or. And wouldn't it be so much simpler? Wouldn't it save millions of dollars in R&D and patents and safety and side effects? If more people in the medical profession and it's not even you, but more health insurers, our system as a whole could acknowledge that the very intuitive things we know to be true. That being around kind people, activities that stimulate us, the same sort of medicines that our evolutionary ancestors needed, that there is a place for this too. So amen to all of that. And that is my goal with this book and this social prescribing movement. It's not to say, you know, forget all the other kinds of medicine. It's to be able to more easily prescribe activities and resources that connect us to the virtues that we know to be very physically and psychologically good for us.
Tyler Johnson: [00:38:29] Yeah. So, I mean, I think there's nothing mutually exclusive about these two parts of medicine, right? I mean, there's no there's nothing about social prescribing that has to crowd out pharmacologic therapy when and where that's appropriate. Having said that, though, I also think it's important to recognize, right. Like so I think a lot for example about the diagnosis of depression. So I remember when I was for the first time studying depression formally as part of medical school. And I'm not a psychiatrist, obviously, but when we studied in medical school, I learned for the first time about this thing called the Dsm-v. And the Dsm-v is sort of the diagnostic Bible of psychiatry. It's how you it's the thing you go to if you're trying to figure out if a person meets the criteria for a particular psychiatric disorder. But what I think is very interesting, if you think of sort of a spectrum of diagnostic certainty and precision, the Dsm-v is on the opposite end of that spectrum from that example of strep throat that we mentioned earlier. Right. Whereas with strep throat, you do a single test and then you say yes or no, the person has or it doesn't. With the Dsm-v, oftentimes for many of the diagnoses that, you know, there's no blood test you can do for depression, there's no biopsy that you can perform. And so instead it is, well, they have to meet, you know, 1 or 2 of these major criteria and 3 or 4 of these minor criteria.
Tyler Johnson: [00:39:49] And if they meet this and they don't meet that and whatever, whatever, then you can make the diagnosis. But then I think the utility of this becomes greatly complicated by the fact that a lot of the people who end up having to use the Dsm-v, sort of in real life, are primary care doctors who are enormously pressed for time and who this is, you know, sort of on the border of their expertise to some degree. And yet they're trying to use these very subtle and complicated lists of, you know, sort of syndromic diagnoses to make a diagnosis. And so I guess the question that I would like to ask is this. Let's say that you have a person who is a primary care doctor, and for whatever insurance or network or whatever reasons, they don't really have the facility to refer a patient to a psychiatrist. But they think to themselves, you know, they look at the diagnostic criteria and they say, look, this patient clearly meets the diagnostic criteria for depression. And so then they think, okay, well, I'm going to consider an Consider an antidepressant some kind of a pill, but I would also like to try it out. I'd like to look at what social prescribing might look like here. What might that look like in that kind of a scenario?
Julia Hotz: [00:40:55] Great question. I think you're totally right. My best friend who you know works in pediatrics, said almost a version of exactly this during the pandemic, when she saw a teen who, you know, met all the markers for depression disorder. She does what her clinical guidelines tell her to do. And of course, for, you know, you take a Hippocratic oath for that patient who wants relief. You do want to give them something that day to help them feel better. So you most likely prescribe an antidepressant. And it's worth saying here that this is an old study, but I think it's something like 79% of all antidepressant prescriptions are written by primary care, I think, for this reason. And of course, you know, my friend and you and other primary care doctors. You don't have two hours to sit down with that person, and most likely you don't have all the time in the world to sit down with that person. Tell me about, you know, your childhood. Let's Google some community activities you can join. No. So in the UK, where social prescribing got its start, it's typically not the primary care physician who does the actual social prescription. They're the ones who might signal, hey, I think this person could use a social prescription based on these symptoms. But then what happens is they bring somebody else on staff in the UK, they call it a link worker who actually has an hour to get to know, okay, what matters to this person? You know, the tagline in social prescribing is not what's the matter with you, but what matters to you, what matters to you.
Julia Hotz: [00:42:30] Number one, really make that person feel listened to. And two, what is prescribable and desirable in this community? You know, let's say you love cycling? Okay, great. I know a group that meets on Tuesdays at 10 a.m.. It's perfect for your age group. You don't have a bike. That's okay. They'll give you a bike, that sort of thing. So in most cases, a position called the link worker does this. And the UK I mean it's kind of this chicken and the egg thing because, you know, they have a public health care system and a government that really believes in the evidence behind social prescribing. They actually fund the position of the link worker in primary care networks. So we think, oh great, it'll never happen here in the US. But what the second part of my book goes into is to say that, look, even if we don't have link workers, other healthcare systems have gotten creative about this. Some have on site social workers, some have partnerships with community organizations, and some have developed these sort of robust online systems that sort of enable the facilitation of the social prescription.
Julia Hotz: [00:43:38] I think in the US we see it more in community health care settings because that's where that infrastructure already exists. For example, in my book, I go to Rutland Community Health, where I meet someone who had been struggling with stress and insomnia, who gets prescribed, you know, this nature course. So in other words, I think for most primary care physicians in the United States, it's going to take some time and creativity to be able to actually do this. But I think it actually starts with the same question. I mean, what matters to that prescribing office? Maybe, you know, for example, at the Cleveland Clinic, there's a wonderful and interesting botanical garden that exists near there. And so they have a partnership now between the Cleveland Clinic and, you know, botanical Gardens, where, you know, that legwork of what is prescribable when do you know these groups meet? Some of that is already taken care of. So I think it's going to be this thing where slowly, over time, we're going to see more of these local models emerge. We're going to keep building that evidence base, and hopefully we'll get to a point like it has been in the UK, where positions like link workers can be more systematically funded. But I do think in the meantime it's possible.
Tyler Johnson: [00:45:00] I want to just observe here an irony, which I just think is interesting, which is that if I had a patient who like, let's say they really liked biking and I found that out, and let's say that for whatever, you know, health reasons, what they really needed was to get out and exercise more. I mean, I'm sure, okay, fine, that there are probably, you know, super mega, ultra elite mountain bikes and road bikes where you can pay 10 or $20,000 for them, or probably even a lot more than that. But my point is, you can get a very not just serviceable, but like a nice mountain bike or road bike or commuter bike or whatever for 1000, $1,500, what have you. And yet what is so funny is that at least as far as I am aware, there is no way that I could go to an insurance company and say, hey, my patient needs more exercise. So I bought them this nice road bike and I want you to reimburse them for the road bike the insurance company would like. What are you saying? We're not buying a road bike for your patient. You know, I don't care how much exercise they need or whatever. And yet, there are patients that I take care of as a medical oncologist where I prescribe therapies that, at least according to clinical trials, have. Yes, maybe it is a statistically significant, but it is still nonetheless a clinically only marginally noticeable benefit. And yet, sometimes insurance companies will pay tens or hundreds of thousands of dollars to allow us to administer those drugs and yet would totally balk at the idea of paying for, you know, a road bike or whatever else. And it's not again, I, you know, heaven knows that we need to rein in spending in our health care system, but it just is an interesting statement as to the kind of evidence that I think we look for and the kind of interventions kind of again, back to the point about the study from Jennifer Temel that we are willing to accept are really effective based on a very particular kind of evidence.
Julia Hotz: [00:47:06] Yes. This is the other big like roadblock that most in the US health care system. See, I do have good news, though. And the good news is that, uh, well, okay, let's let's just start with insurance companies, for example. Like, you know, my mom is a therapist, and she rails and rails about how frustrating it is when she's on the phone with insurance companies, you know, trying to Trying to get them to cover more sessions for her patient. And to your point, yeah, all these like very seemingly insignificant factors like, well, how many sessions and what kind is the pill and is it covered? You know, that's really, really frustrating for everybody involved. It's frustrating for the patient who doesn't know if they're going to get coverage. It's frustrating for the, you know, the healthcare provider who has a million other patients they have to see. But here's an interesting incentive for these insurance companies. If you know there is some thing that doctors can prescribe now that would show that, hey, this is actually going to save you money over time. This is going to lead a person to have a healthier lifestyle that's then going to, you know, prevent them from requiring more medication and therapy down the line. Well, then that makes a lot of sense. And an example of where we see this more mainstream is in the way certain insurance providers, particularly Medicare, are starting to cover gym memberships, right? Like, my parents are in their 70s and they get their gym memberships covered by their insurer.
Julia Hotz: [00:48:42] And why is that? Well, an insurance company might reason this. You know, $50 a month gym membership is probably going to be cheaper down the line than my dad's. You know, five blood pressure medications and XYZ. But where I was really going with that is the really good news, is that now more insurance companies are starting to see that same relationship with art. So in new Jersey, for example, where I grew up, the insurance provider Horizon Blue Cross Blue Shield has agreed to cover up to six months of arts prescriptions, sort of facilitated through this local performing arts center, Njpac, for people at risk of overspending on their insurance. And they just finished up this pilot. It went super well that they just got another grant from actually the National Endowment of the Arts to expand it. And I just think there you go. You know, sure, it's maybe not the same exact method we'd use for medications, but now we're seeing more and more evidence that engaging in these healthy behaviors really does, you know, do well for our health over time and at a population health level, can prevent all kinds of diseases. So it's like if you build it, they will come. Like, I know it's probably hard for most healthcare providers listening to this to ever think that their insurance company would do this, but some already are. And, you know, I believe that it's only going to continue because what we're doing now is not sustainable, right?
Tyler Johnson: [00:50:20] Yeah. You know, I think that the broader critique that I think you're writing and this discussion levels is just how narrow we have become as a medical community in defining what open quote health. Close quote means. Right. I think we have developed this sort of unacknowledged and often unaware sense that health can be reduced to quantifiable things like blood pressure and weight and BMI and cholesterol and whatever. And this is not to question the importance of those things. And heaven knows that I'm in favor of preventative health and using those to prevent strokes and heart attacks and everything else. But just to give you an example of what I'm talking about. On Sundays I go to church, and sometimes in church I'm sitting there, even though I'm in church with my sort of doctors or podcasters or thinkers, whatever had on. And I look around at the congregation And I think, oh my gosh, like how many things are going on here that are good for a person's health a la you have Okto or Nonagenarians who are interacting with five year olds, right? And sharing stories of how things were way back when. And then you have the, you know, 50 year old who's recognizing the science fair prize of the person in junior high, and the person in junior high is just glowing with pride because some random grown up at the, you know, congregation told them how great they thought that their accomplishment was. And you have, you know, people helping each other with each other's kids, and you have people who, you know, some little ten year old who's going up to play a piano solo and everybody acting like it's the best thing since, you know, Davies Hall or I mean, whatever, right? But the point is that like, that is health.
Julia Hotz: [00:52:19] Yes. Yes.
Tyler Johnson: [00:52:20] Much more so than a blood pressure or a cholesterol number or whatever, like that embodied sense of being in community with other people who you love and who love you. And obviously, of course, I'm not saying that's the only place, but I'm just saying that, like, whatever that looks like for you, like whatever your people are, whatever your community is, whatever it is, you know, the thing is that gets you up in the morning. But the point is to say that like that is health. And while nobody is asking doctors to abandon looking at blood pressure or cholesterol or BMI or whatever of those things, what I am saying is that I think that medicine actually becomes more meaningful and our practice becomes more robust and helpful when we start to envision health as more of a holistic enterprise and less as a set of numbers.
Julia Hotz: [00:53:13] Oh my gosh. Amen. Pun intended to like all of that. I'm so with you. I mean, first of all, it's so funny. I that's like one of my favorite debates. One time my friend and I literally debated for eight hours about, has organized religion done more harm or good for the world? And I'm team good for all the reasons you say. And let's be honest, even if it's not a formal, organized religion, I would argue that cycling groups and art classes and you know, your cooking clubs like these do have some of the same elements of belonging. I think that organized religion does.
Tyler Johnson: [00:53:52] Yeah, right. I mean, back to that. You know, we have referenced this multiple times, but there is a reason that Robert Putnam's book was called Bowling Alone precisely because he was talking of all things about bowling clubs.
Julia Hotz: [00:54:04] Right, exactly, exactly. So I think that's true. Like, these things have extreme medicinal value. If you want to write a church prescription. I am all I'm all about that. But seriously, I mean, I also think it matters on an individual level. I probably said this three times, but the shift from what's the matter with you? I have high blood pressure to what matters to you. I feel most alive and connected and good and energized when I'm in church on Sunday. I think that when people direct themselves and their behaviors in terms of what matters to them, they actually do feel healthier. And I don't just think this, I know this, this is what this book is all about. I mean, when people made that shift from treating the symptoms of disease to actually creating lasting sources of health, well, what do you know? Not only did their symptoms of disease reduce, but they also felt healthier. And it went beyond something that they'd have to take for two weeks, two times a day. It was actually a major change in their life. I'm just grateful for you recognizing that having a sense of meaning is so, so important not just for your patients, but I think also something we haven't talked about is the way that this helps the health care providers feel so good, too. One person said to me who participated in an arts prescribing pilot in Massachusetts, they said that I never get to prescribe beauty in someone's life. You know, most of my day is writing scripts for blood pressure medications, antidepressants, and so on. But to be able to prescribe beauty and to be able to have that patient come back and be able to tell me about it and have their face light up and see in their body language that they actually are feeling better. That's why I got into this field.
Tyler Johnson: [00:56:03] Yeah. So in a really important way, I feel like this kind of brings me around as one of the hosts of the podcast Full Circle to really what we are getting at in the podcast in the first place. I you know, when we launched the podcast a number of years ago, the the impetus for doing so was to try to figure out what is behind the epidemic of burnout and what we can do about it, and what I think has been unquestionably true, that we have recognized as we have gone through the podcast, is that because of many complicated systemic factors, corporatization and bureaucratization and changes in technology chief among them, what we have recognized is that many people in medicine have lost touch with the deeper existential core of the practice in favor of coming to feel like very well trained machinists for very complex machines. Now, to be clear, I heaven knows that I am grateful for machinists and anytime my computer or iPhone or whatever breaks, I don't know what I would do without them. That said, though, that is not generally why people go into medicine. People do not generally go into medicine because they want to fix the machine of the human body, even if that's a useful metaphor in some contexts, but rather they go into it because they want to be part of the sort of existential work of relieving human suffering. And I think this is important to bear in mind, because I think actually that these are two sides of the same coin, in the same way that we have limited the idea of what health means to a set largely of quantifiable variables. I believe that we have also thereby inadvertently narrowed what it means to be healers, narrowed what it means to be a doctor. And I actually think that that is much of what lies beneath this sense of malaise or ennui that is currently plaguing much of modern medicine.
Julia Hotz: [00:58:21] Oh, absolutely. It's I mean, it's in your podcast's name. I mean, the doctor's art. I don't know if that's an allusion to Hippocrates saying there's, you know, there's an art and a science to medicine. And just as important as the surgeon's knife is the listening ear. You know, something like that. But I think you're absolutely right. And I actually think that that is a big driving force behind why social prescribing has spread to 32 countries around the world, and to more and more parts of the US. You know, it's funny, as you're describing this sort of machine analogy, I will tell you that doctors in England, of course, but also doctors in Singapore, doctors in the Netherlands used almost that same exact analogy to describe the frustration that led them to consider social prescribing. You're right. Nobody goes into this field to be. I like that word machinist. But, you know, I think that just as much as social prescribing can help the patients, I argue in the book that for providers as well, this can help you sort of reconnect to that sense of meaning. I'm sure you're familiar. You mentioned you've read a lot of essays. One that I was particularly taken with is this idea of moral injury in healthcare. Right. And I'm sure your listeners are familiar with this, but moral injury was originally used to reference the way that soldiers in World War two had these symptoms that sort of resembled depression and anxiety after having witnessed Acts being forced to commit acts really that transgress their values.
Julia Hotz: [01:00:12] And so what you're left with is sort of this. Yeah. Moral injury. The work you do violates your morals. And in 2018, I believe there was this viral essay that said this is happening in medicine too. This is why doctors have some of the highest rates of anxiety and depression, you know, increased rates of suicide very tragically. I think a lot of it has to do with the way that the field often doesn't set you up to honor your morals, honor the sacrifices you made to enter this field, to treat the whole of a person. Instead, I think the system, you know, it makes it easy to be a machinist. But I do think that social prescribing is an antidote to this. And there are surveys suggesting that doctors, by and large, support this. I mean, after you get over the initial hurdle of, wait a wait a minute, how am I going to have time to do this? And what are the insurance companies going to do? I think once we get over those hurdles, this could be sort of a balm to the moral injury that so many people are experiencing.
Tyler Johnson: [01:01:22] So as one final wrap up question, let's say we have a person who's listening to this and they feel like the call to action, they're like, yes, I want to go out and do that. But then they think to themselves, well, okay, yeah, sure, that'd be nice. But here I am in my primary care clinic or whatever kind of clinic, and I, you know, how am I really supposed to do that? Like, if there was a person who wanted to do this but didn't know how to get started, what would you tell them?
Julia Hotz: [01:01:45] Great question. Well, first of all, I'd say they should immediately join what's called Social Prescribing USA. And this is a network, a coalition led by a primary care doctor of people, sort of in the social prescribing space, doctors, social workers, community groups who have a shared goal to make social prescribing mainstream in healthcare by 2035. And there, you know, they have webinars, they share the latest research. They share resources. Hey, this is what I introduced to my practice. Let's see how it works for you. So I'd say that's a great resource. I'd also say on my website social prescribing. There are other resources of, you know, questions that you can ask your patients of different groups. If you're in the US, that you can prescribe patients to. Some off the top of my head, for example, are the wonderful park network that has some really great resources on how you can start to prescribe time and nature to your patients. Another is the Arts on Prescription Field Guide, created by researchers at University of Florida. There are other groups, such as walk with a Doc, which is a a network of over 500 chapters of physicians who have started clubs to literally walk with their patients once a week. In other words, there are plenty of templates and resources out there, and I think it does start with asking, you know, what matters to you. It's not like overnight you're going to overhaul your practice and be able to prescribe, you know, to offer social prescriptions as easily as other kinds. But maybe there's a small slice of this. Maybe you have a really good partnership with a university that's interested in arts prescriptions or nature prescriptions or a community group. I would say to start there and don't just take it from me. Take it from the actual MDS who have started to do this.
Tyler Johnson: [01:03:37] Well, Jules Hotz, we are so grateful both for your generosity in taking the time to join us on the program today and also more broadly for the important work that you are doing for our field, a field that we love so much and that we, we believe really only stands to gain because of the way that you are trying to shift the paradigm of the way that we think of health and healing. Thank you so much for being with us, and we've been grateful to have you on the show.
Julia Hotz: [01:04:03] Thank you for. Gosh, you've left me with so much inspiration and thank you for spreading this important message.
Henry Bair: [01:04:13] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show. Available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [01:04:32] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [01:04:46] I'm Henry Bair.
Tyler Johnson: [01:04:47] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
To learn more about how you can get involved in the social prescribing movement, Julia recommends visiting Social Prescribing USA and socialprescribing.co.
