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Viewpoint
April 3, 2020

The Role of Physicians in Addressing Social Determinants of Health

Author Affiliations
  • 1Boston University School of Public Health, Boston, Massachusetts
  • 2London School of Hygiene and Tropical Medicine, London, England
JAMA. 2020;323(16):1551-1552. doi:10.1001/jama.2020.1637

To a large degree, health is shaped by the conditions in which people are born, grow, live, work, and age, collectively termed the social determinants of health.1,2 US public and health care professionals care about improving health outcomes. Compared with other high-income countries, the US spends significantly more per capita and in total on health care.3 Yet through chronic underinvestment in some of the conditions that most influence health, such as social services, education, physical environments, and access to healthy food, progress has been undermined, with lower-than-average outcomes across a range of health indicators, including a recent decline in life expectancy.

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    4 Comments for this article
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    Alone we are merely drops. Together we become a creek, then a river, then a flood that covers the world with justice.
    David Egilman, MD | Brown University
    "There is a power that can be created out of pent-up indignation, courage, and the inspiration of a common cause, and that if enough people put their minds and bodies into that cause, they can win. It is a phenomenon recorded again and against in the history of popular movements against injustice all over the world.”
    ― Howard Zinn, You Can't Be Neutral on a Moving Train: A Personal History of Our Times
    CONFLICT OF INTEREST: None Reported
    Physicians' roles in addressing social determinants and the need for human services
    Edward Schor, MD | Stanford University
    As noted in the article by Maani and Galea , there is little that physicians can do individually to address social determinants of health. The impact of external factors adversely influencing the health of individuals and populations are a reflection of the inequities and consequent disparities of our society, and will only be remedied by major social and political changes. Individual and groups of physicians can advocate as concerned citizens for those changes.

    However, physicians can address social determinants of health for their individual patients in two ways. First, they can identify personal and social circumstances
    that already are affecting their patients’ health and health behaviors and intervene, largely through referrals to support services in the community. Second, and more directly, physicians can anticipate the increased social needs that their patients’ illness and/or treatments will create and select interventions to minimize those needs for human services and initiate referrals in advance of those needs. Ill health can lead to diminished functioning, diminished financial resources and disrupted family and social supports. For example, physicians can anticipate that patients suffering a stroke may need home care, environmental modification, psychological services, transportation and other supports they did not require prior to their illness. Similarly, an ill caregiver for a patient with complex health problems can trigger a cascade of additional service needs within a family. Also, when there is a choice of treatments, the impact on the patient’s personal and financial situation should be considered as decision-making is shared. Being aware of how changes in health and the choice of treatments can determine functional health status and social service needs and acting proactively to address and/or minimize those needs should be a core part of medical care and ultimately of social policy.
    CONFLICT OF INTEREST: None Reported
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    Whose Job Is It to Produce Health in the United States?
    Stephen Bezruchka, MD, MPH | School of Public Health, University of Washington
    As our health has declined absolutely and mortality has risen, where has public health been? Asleep at the switch I argue. The 1988 IOM report on the Future of Public Health said public health should focus on assessment, policy development, and assurance. But comparisons with other countries were left out so by 2018 some 35 nations had longer lives in what I call the health Olympics. This is according to the U.N. which presents the United States in the best light; not counting Taiwan (not a UN country), or Monaco, (and other small populations). If we were to eradicate our leading cause of death, heart disease, we still wouldn't be the longest-lived nation. We are dead first among rich and some not so rich nations.

    Physicians care for individual patients. Who cares for all of us? Not the federal government. Although a bill has been introduced (H.R. 6561, "Improving Social Determinants of Health Act") it almost certainly will not become law.

    Since the public doesn’t understand health as distinct from health care, everyone needs to work together, especially in the COVID-19 era, to improve U.S. health by addressing Social Determinants of Health. That includes all health care workers.
    CONFLICT OF INTEREST: None Reported
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    Social Determinants of Health and Medical School Curricular Reform
    Trevor Hunt, BA | Brody School of Medicine at East Carolina University
    To the Editor:

    In a recent Viewpoint, Maani and Galea discussed the role of physicians in addressing the social determinants of health (SDH) [1]. We concur with the authors’ proposal that reforming medical education is an essential step in encouraging physician engagement with SDH if meaningful change is to be achieved. However, key aspects of current medical training models and student motivations may cripple efforts for reform if not carefully considered.

    Medical school curricula are designed according to guidelines published by organizations such as the AMA, LCME, and NBME. Students must complete classes and in-house
    examinations, but their attention is often fixated on the looming obstacle of USMLE Step examinations. Thus, an alternate curriculum runs parallel to the formal institutional learning objectives, consisting of non-accredited online resources geared towards content tested on Step 1 and 2 [2-4]. Step 1 is currently the primary metric residency program directors use to stratify applicants [5], though it will soon move to Pass/Fail scoring. Step 2 is remaining scored and will likely become the new focus for students and program directors alike.

    Efforts to reform curricula will be largely futile until educational content deemed important by students is no longer driven by licensing examinations. Even the most adept student is still presented with more information than they can realistically master, so time must be allocated preferentially to “high-yield” subjects,  namelythose tested heavily on Step examinations [2]. Thus, other topics which are still crucial to the modern practice of medicine, including SDH, are often sidelined during training. This current model of allowing multiple-choice examinations to dictate which content is most important is a dangerous precedent.

    Two solutions may help to properly implement SDH into curricula in a manner that will encourage students to give the topic the attention it deserves. In the short-term, Step examinations can shift their content distribution to include more SDH-related questions. This was recently done for other marginalized content like biostatistics and professionalism, establishing the possibility. Ultimately, fewer students would neglect to learn about SDH if they viewed it as a high-yield topic for Step examinations. In the long-term, schools can commit to admitting more diverse applicants as the authors suggest (1). Diversity must be extended to educational backgrounds, being inclusive of those with degrees in the humanities and social sciences. Ideally, these students will be predisposed to increased knowledge about and interest in SDH and will not sideline the topic as readily.

    References

    1. Maani N, Galea S. The Role of Physicians in Addressing Social Determinants of Health. JAMA. 2020;323(16):1551-1552.
    2. Farber ON. Medical students are skipping class in droves — and making lectures increasingly obsolete. STAT. https://www.statnews.com/2018/08/14/medical-students-skipping-class/ Published August 14, 2018. Accessed May 25, 2020.
    3. Colleges AoAM. Medical school year two questionnaire: 2017 all schools summary report. March 2018. https://www.aamc.org/system/files/reports/1/y2q2017report.pdf
    4. O'Hanlon R, Laynor G. Responding to a new generation of proprietary study resources in medical education. J Med Libr Assoc. 2019;107(2):251-257.
    5. Committee NDRaR. Results of the 2018 NRMP Program Director Survey. Washington, DC June 2018. https://www.nrmp.org/wp-content/uploads/2018/07/NRMP-2018-Program-Director-Survey-for-WWW.pdf
    CONFLICT OF INTEREST: None Reported
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