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Tuesday Nov 29, 2016

FPs Can Shape Social Determinants of Health Outside Clinic

Four little words guaranteed to make physicians slightly uncomfortable are "social determinants of health." Most of us know what social determinants are and recognize their importance, and often this understanding can decrease our professional frustration. For example, when patients fail to pick up prescriptions, I frequently remind myself that it could be because they had no way to get to the pharmacy rather than assume it was because of negligence.

But we don't always know how to address the root problems. 

Why should we care? Social determinants have profound impacts on morbidity, mortality and other health indicators, and at least one study has shown that they influence health outcomes more than medical advances.

Here is the truth: As doctors, and even more so as family physicians, we have an oversized influence in our communities. It can be hard to decide exactly how to wield this influence, but the power to shape our communities' social determinants of health -- the conditions in which people are born, grow, live, work and age -- rests heavily in our hands whether we use it or not.

Recognizing that we have power over more than just prescriptions is step one. Step two is remembering that with great power comes great responsibility. Finally, step three is figuring out what to do with this power. Here, I present some options for using it to make a difference when treating patients and through community leadership and advocacy.

Assess Your Patients' Social Determinants
Did you know that the question, "Do you ever have difficulty making ends meet at the end of the month?" has a sensitivity of 98 percent and specificity of 60 percent as a predictor for living below the poverty line? This is important because poverty is a risk factor for many health issues, including cardiovascular disease, various cancers, cancer mortality and suicide.

Thus, the first thing we can do is adjust our clinical decision-making to include poverty as a risk factor for disease, thus increasing appropriate use of primary prevention.

My hospital employs a social worker in the ER. She saves the hospital money by preventing unnecessary admissions -- enough, in fact, to pay for her annual salary in just three months of work. She also is a valuable resource for patients in innumerable ways -- from assisting them with insurance applications to connecting them with food shelters -- that help prevent future health crises. At least one primary care clinic in my area also employs a community health worker who performs these services.

Be a Resource for Your Community
My mayor also happens to be my landlord, and I know city council members on sight. This familiarity is one of the beauties of rural and small town America. It also allows me to be plugged into community development without much fuss.

Get to know your community leaders. They will keep you informed about local policy, and they may turn to you when a health perspective is needed. You will find yourself invited to speak on all manner of ordinances, or at least you will be made aware of meetings where issues such as protected bike lanes or school-based health centers are being discussed.

If this familiarity seems far-fetched, it may be because you find yourself in an urban environment. In that case, you are likely to be surrounded by other organizations, and getting to know groups that are already working to address public health and social issues is a great option. This could include your community's NAACP unit, the health department's community health improvement planning council or other community-based organizations.

Advocate on the Big Issues
This is perhaps the sexiest option on the list, so I understand if you skipped to here. The key to advocating effectively is to make it easy; if it is easy, then more people will do it and they will do it more often.

First, find a way to stay abreast of upcoming state or federal policy action. Sign up for a service such as the AAFP's Family Physician Action Network or a similar tool from your state chapter that tells you when important issues are on the docket. These resources may even include letter-writing campaigns such as the AAFP's Speak Out tool, which, at the time of this writing, included prewritten letters members can modify and send directly to their representatives in Congress on direct primary care accessibility, the Teaching Health Center Graduate Medical Education program and many more topics important to family medicine. All of a sudden, you will know what is going on, and it will be magical.

Second, ask your professional society to advocate for you. Let's say you really like school-based health centers, for instance. Submit a resolution asking your state academy to advocate for them if and when an applicable bill appears. One of our greatest skills as physicians is bringing the health perspective to bear on issues such as housing and food security. The 2015 Congress of Delegates was flush with resolutions that dealt with addressing social determinants on a systemic level, and I've never been so proud of my professional organization.

Third, understand that the social determinants of health are extensive and that you likely won't be a passionate expert on each one. Find a few you love talking about. This way, you will be fired up and excited when you advocate for them rather than bemoaning the time away from your charting.

For example, one issue that is important to me is bicycle safety and the built environment. I am proud to say that after several months of community organizing and testimony at city council meetings, Klamath Falls, Ore., adopted an Urban Trail Master Plan that includes protected bike lanes to the heart of downtown.

Finally, remember a few simple rules when you advocate:

  • Make sure you identify yourself as a constituent, because an opinion from a potential voter hits close to home for public officials.
  • Forge a positive relationship so decision-makers will seek your advice. You are the health expert and they know it, and the more they hear from you the more they will rely on your opinion.
  • Have an anecdote to back up your data. Personal stories are more memorable and leave a stronger impression than just numbers. 
  • Have an ask. Don't just present information; ask them to do something specific.

And remember that although in-person encounters are powerful, and emails and tweets are easy, a phone call might be your most efficient route to change. You will probably talk with staff (who, by the way, are supremely important), and your five-minute investment is likely to make some noise in the office.

So there we have it. A whirlwind tour of the social determinants of health, why they are worth addressing, and how to take action. For more ways to effect change, check out the CDC's Tools for Putting Social Determinants of Health into Action.

If you come away with nothing else, remember that as family physicians, we have a unique perspective on social determinants of health, as well as the social power to do something about them. We have a responsibility to use that power, and we should use it well.

Stewart Decker, M.D., is the resident member of the AAFP Board of Directors.


It is a difficult time for family physicians. Clearly our physician and medical education masters have been important for our training, but their excesses are compromising the health of our nation and our patients.

It is our duty as FM docs, because of our scope and perspective and distribution, to point out that collapsing domestic discretionary spending is the result of accelerating health care costs - especially since 2008. Spending already high and increasing for so few in so few locations is compromising outcomes.

Massachusetts Budget Changes 2001 to 2014

Non Health Down 3.6 Billion

-22% Mental Health
-31% Public Health
-12% Education
-11% Human Services
-14% Infrastructure Housing and Economic Development
-13% Law and Public Safety
-50% Local Aid

37% increase in Health Coverages up 5.5 billion

As health care consumes ever more, there is less remaining to invest dollars in the places where health outcomes are shaped.

The compromise is worst where we family physicians make the most difference - where all other specialties are less to least likely to be found.

The real determinants of health outcomes are being compromised as health care cost increases devour state and federal budgets. Clinical interventions do very little anyway as people factors, environments, situations, genetics, do far more. Attempts to micromanage physicians have made matters worse, and the worship of measurement involves a small subset of clinical intervention for little real impact at all.

True health determinants such as behaviors, environments, situations, social determinants can be boosted by investments in people and in the people to invest time and effort in people.

The impact may be much worse in most of the US states and practices and hospitals that are less well off in 2700 counties where we are 24% of the workforce and no one else is more than 6%. The impact has been devastating to small practices, small hospitals, and care where needed.

Even worse, pay for performance schemes compromise practices and hospitals where care is most needed to the greatest degree, the ones already paid least over the past 30 years of aberrant designs that have created 2621 lowest physician concentration counties - where Americans are most fed up by design.

Posted by Robert C. Bowman, M.D. on November 30, 2016 at 12:26 AM CST #

"Why should we care? Social determinants have profound impacts on morbidity, mortality and other health indicators, and at least one study has shown that they influence health outcomes more than medical advances."

Very true, but now we have MACRA, which was specifically designed to punish financially those physicians who still give of their time and effort to care for patients with unfavorable social determinants. The AAFP lobbied long and hard for this miserable bill and was ecstatic when it passed

Does the Board of Directors have any understanding of how many of us feel that the Academy sees us as the enemy and is out to destroy us?

Posted by RSW on November 30, 2016 at 06:58 AM CST #

Much of the problem today is that "health care" is often equated with "health insurance coverage". We need to revamp the entire system and start before health insurance ever becomes a need. The money they are taking from other systems like mental health and public health etc is just being spent on trying to fix catastrophes that should have been prevented in the first place through health education and better social support systems. What do health departments even do today? They need to do more in communities. Social work needs to align with hospitals and nursing homes and doctor offices and schools. We need to bring all these services (nutrition, transportation, medication access, food access, transportation, etc) together as one unit instead of creating divisions between the services. Many patients may lower their costs and use of health care dollars if we could easily get them more support in other ways.

Posted by Jennifer Hollywood on December 01, 2016 at 11:53 AM CST #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.