Incorporating the Social and Structural Determinants of Health Into Clinical Practice

As physicians, we pride ourselves in our ability to be unbiased, objective observers. I think this edition of FP Essentials will test your ability to keep your personal experiences, political views, and cultural understandings from shaping how you view the evidence presented here. We live in a time when a person’s political affiliation often determines their response to inclusivity. I know that I have many friends and colleagues who saw the topic of this edition and had at least the passing thought that we need to stay out of social issues and just focus on health care. Whether you are an underrepresented-in-medicine physician or someone who groans every time someone mentions diversity, equity, and inclusion (DEI), I hope that you are willing to set aside your personal and political opinions on the issue and take the time to learn more about the evidence on this topic that profoundly affects the lives of our patients and colleagues.

Many of us now depend on value-based payment programs; pay-for-performance, accountable care organizations; and other alternative payment models for at least part of our income. These models incentivize physicians, practices, and health systems to improve the care and outcomes for their patients. Because the most vulnerable patients have disproportionately poor outcomes that bring down a practice’s averages, addressing barriers for these patients is the right thing to do both clinically and fiscally.

As a cisgender, heterosexual, White man, I thought discussions about serving diverse communities were something that impacted my patients, my community, and my colleagues but not me personally. Two years ago, that changed. With a move to Canada, I was suddenly an immigrant, a temporary foreign worker, and a foreign medical graduate. I have experienced what it means to have an uncertain immigration status. I encountered workplace abuse and wage theft that occur so often for marginalized people. I have seen the costs and inconvenience associated with not being able to establish a bank account, get a credit card, or obtain government services.

The first section of this monograph examines the risks of race-based medicine. The second reviews the social and structural determinants of health, how they impact patients, and how family physicians can impact these determinants. The third section looks at how to build a welcoming practice and diverse health care team. And, the last section discusses how to address health equity within your practice and community.

Even if you have frequently encountered these issues, I believe that the ideas presented here can improve your success in advocating for yourself, your patients, and your community. If many of these concepts are new to you, I encourage you to continue exploring and learning about how they are affecting the health of your patients. If you are unsure how to start exploring DEI, I suggest you learn more about implicit bias and how it impacts you and the institution you work within. The American Academy of Family Physicians has excellent resources on implicit bias at https://www.aafp.org/family-physician/patient-care/the-everyone-project/toolkit/implicit-bias.html

Ryan D. Kauffman, MD, FAAFP, CCFP, Associate Medical Editor
Family Medicine Physician
Erie Shores Family Health, Leamington, Ontario, Canada

Jason E. Glenn, PhD, is an associate professor of history and philosophy of medicine at the University of Kansas Medical Center (KUMC), Kansas City. He uses a translation science approach to make the history of medicine and science applicable to resolving local inequities of health and well-being. He examines the relationship between the production of biomedical knowledge and mass incarceration, the history of drug policy in the United States, the ethics and history of human subject research, the inequities in health research (especially for incarcerated populations), and the social and structural determinants of health.

Carla Keirns, MD, PhD, is an associate professor of history and philosophy of medicine and of internal medicine (palliative care) at KUMC. She leads education in ethics in the MD curriculum; practices palliative medicine, clinical ethics consultation, and mediation; and participates in community collaborations to improve the quality of care for urban and rural patients with serious and life-threatening illnesses.

Marial Alonso-Luaces, PhD, is an education associate professor in the Department of Family Medicine at KUMC and director of the Office of Student Engagement at the KU School of Medicine. Her work focuses on the intersection of education and health. She works closely with communities and urban schools in Kansas to develop a strong pipeline to the health professions. She serves as the head of the Structural Competency Thread for the medical school curriculum and leads the medical Spanish program. She provides educational sessions on language barriers, how to work effectively with medical interpreters, and how racism and bias affect access and quality of care.

Erin Corriveau, MD, MPH, is an associate professor in the Departments of Family Medicine, Community Health, and Population Health at KUMC. She is a practicing physician and university faculty educator. She is focused on our most vulnerable community members, working to ensure we reach them with appropriate information and provide support to meet their social needs. She has extensive experience in designing and implementing health programs to support rural, urban, and underserved communities.

Disclosure: It is the policy of the AAFP that all individuals in a position to control CME content disclose any relationships with ineligible companies upon nomination/invitation of participation. Disclosure documents are reviewed for potential relevant financial relationships. If relevant financial relationships are identified, mitigation strategies are agreed to prior to confirmation of participation. Only those participants who had no relevant financial relationships or who agreed to an identified mitigation process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

• Explain how using race-based medicine can increase health disparities.
• Choose appropriate, race-agnostic guidelines to drive clinical decision-making.
• Assess a patient’s social history using a socio-ecological perspective.
• Reframe individual patient health behaviors as the product of structural determinants of health.
• Determine how you can contribute to the education of learners who can help form a more diverse and equitable health care system.
• Improve patient outcomes by addressing health equity in your practice.
• Explain how addressing social, political, and economic health determinants can have a greater impact on health than acting on individual needs.