We must address social determinants of health

April 26, 2019

When physicians don't talk to patients about social determinants of health, they miss the bigger picture. 

Editor’s Note: Physicians Practice’s blog features contributions from members of the medical community. The opinions expressed are that of the writers and do not necessarily reflect the opinions of Physicians Practice or its publisher.

My organization, like many others engaged in population health, is focused on identifying, documenting, and addressing social determinants of health (SDOH). SDOH are things like food insecurity or homelessness that can directly impact patients’ health. The Center for Disease Control’s Healthy People 2020 grouped SDOH into five categories: Education, Health and Health Care, Economic Stability, Neighborhoods, and Social and Community Context. Although I am a primary care doctor, I do not routinely ask about most of these areas, other than health and healthcare. Even then, my focus is myopic and fixed on things like family health history and medication allergies. 

Think about the following questions about SDOH and consider when you last asked a patient about them.

Are you lonely?

Do you have any concerns about whether your water is safe to drink?

Are you concerned about safety in your neighborhood because of crime or violence?

Can you read?

Are you able to afford food?

Are you able to afford housing?

Do you have transportation to your job? The grocery store? The clinic?

Have you been the victim of discrimination?

The list of questions is extensive. While I adhere to the bio-psycho-social concept of medicine, I also have a laundry list of things to accomplish in a visit. I tend to stick to the things I have some knowledge or expertise in: antibiotics, interpreting lab tests, managing insulin, targeting high blood pressure. However, I am missing a bigger picture. Consider the following:

  • A patient with high blood pressure who cannot read the instructions for the DASH diet that I printed off for her

  • A patient who cannot afford the $3 co-pay for an antibiotic until his paycheck next week

  • A patient with diabetes who does not have adequate resources for food and relies on a food pantry where she has limited options to follow the type of diet recommended by diabetic education

  • A patient facing discrimination at work but is too afraid of losing his job and health insurance to complain

All of the above scenarios profoundly impact my patients’ ability to engage in lifestyle improvements, follow a healthy diet, take prescribed medications, and afford the care I provide. Even though I recognize that, I do not know about literacy classes in my community or what assistance is available to protect someone who claims discrimination in the workplace. We are fortunate enough to have care managers and social workers, but the need is greater than they can meet. 

Like all hard things, we can either stay passive because being active is difficult and time-consuming. Or we can learn more about what we can do, and then do it. We cannot fix or address all social disparities, but we can address some. What if tomorrow you asked three patients about some aspect of social determinants of health? What if you found out what resources were available in your community to address those needs? What if you did the same thing the next day and the next? 

 

As physicians, we have a unique window into our patients’ lives. They tell us things that they will not tell anyone else. Many factors of SDOH may be uncomfortable for people to discuss. We should use our privilege to ask those questions and find those answers.

Jennifer Frank, MD, is a family physician and physician leader in Northeastern Wisconsin and finds medicine still to be the best gig out there. Married with four kids, she is engaged in intensive study and pursuit of work-life balance.