Family Physician Urges Residents, Students to Consider 'Social Determinants' of Health

The practice of family medicine has moved from a strictly clinical to more of a community-oriented mindset during the past several years. This shift in focus will require family physicians of tomorrow to forge closer partnerships and alliances with community-based health organizations to provide the best possible care to their patients. That's according to Steven Woolf, M.D., M.P.H., who delivered the keynote address during the 2011 AAFP National Conference of Family Medicine Residents and Medical Students here on July 29.

Woolf, a professor of family medicine at Virginia Commonwealth University in Richmond and director of the university's Center for Human Needs, urged residents and students to "get outside of the box and think beyond the clinical setting when caring for patients." This will require a "partnership between what we do in the clinical environment and what exists in community health," Woolf said.

When forging alliances with community health organizations, family physicians need to think about the social determinants of health -- outside factors that have a profound influence on a patient's health and well-being, according to Woolf. Family physicians are familiar with the role of medical care as it determines health outcomes. As a result, they sometimes "fall into the trap of thinking that is what really determines the health of our patients," said Woolf.

"But we also know that personal behaviors, like tobacco use and diet, are very important," Woolf said. "In fact, 38 percent of all deaths in the country are attributable to poor health behaviors."

He listed five degrees of influence that play a dominant role in determining a patient's health status:

According to Woolf, health care at home is probably the easiest to envision. For example, possible obstacles to care a patient with diabetes may encounter at home would include whether a prescription gets filled or whether the patient can get to the pharmacy. "Can the patient understand the instructions?" asked Woolf. "What is in the home environment that affects diet?"

Most modifiable exposures fall into the realm of personal health behaviors, said Woolf. He cited a study from 1993 documenting the leading causes of death in the United States based on behaviors instead of disease category. According to that study, tobacco use was the No. 1 cause of death, followed by diet, activity patterns and alcohol use.

"The point is these risk factors are a very big deal if you want to save your patient's life, help them to live longer and have a better quality of life," said Woolf.

He also addressed the effect of socioeconomic factors on health. For example, the death rate for a person with diabetes who has not graduated from high school is three times the death rate for someone with diabetes who has attended some college, according to Woolf. That ratio is even wider between college graduates with diabetes and a person with diabetes who has not graduated from high school, he noted.

Family physicians can play a key role in mitigating and even overcoming such factors, Woolf said. One of the first objectives for family physicians is to "understand the living conditions patients face when they leave our office or when they leave the hospital," Woolf said. "What is the social and environmental context they are going back to? How does it affect treatment plans?"