A patient with chronic back pain may also be struggling with worry about how she will pay her rent or find nutritious food in her neighborhood. Her primary care physician might not have become involved in the latter concerns in the past, but that is changing as the concept of well-being shifts.
Many physicians and medical researchers now consider a patient's socioeconomic background, known as social determinants of health (SDH), to be as important as medical symptoms in health outcomes. The authors of an editorial(www.annfammed.org) in the March/April issue of the Annals of Family Medicine argue that practices can and should use such socioeconomic data when consulting patients and recommending treatment. Jennifer DeVoe, M.D., D.Phil., a practicing family physician and health services researcher at Oregon Health & Science University, and Andrew Bazemore, M.D., M.P.H., director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, were the lead authors.
"There is mounting evidence to suggest that SDH influence health outcomes more than medical care," the authors wrote. "Even so, attempts to address SDH in medical care settings have been limited and, for the most part, ineffective."
- Authors of an editorial in the March/April issue of the Annals of Family Medicine say physicians can use socioeconomic data to address an individual's health.
- Electronic health record systems must change to integrate such data, the authors wrote.
- Two companion articles in the same issue debate whether physicians should be more engaged with social factors in their practices.
For instance, factors specific to an individual such as race, income, obesity, and use of tobacco, alcohol or drugs are a strong predictor of health. From a population health perspective, low income at the neighborhood level may be associated with higher rates of low birth weight, infant mortality and sexually transmitted diseases.
But many electronic health record vendors have not yet incorporated space for social data into their platforms, and the vast majority of primary care practices lack processes for capturing and integrating such data, Bazemore told AAFP News.
Bazemore noted that the real challenge lies not only in data integration and use, but also making practice transformation efforts attentive to the social determinants that shape patient and community health. In addition to more information about individual patients, practices would benefit from tools that assess the needs of panels and communities.
Physicians who are aware of patients' struggles with domestic violence, housing, food shortages or substance abuse, for instance, can have more successful dialogues with them that may lead to better health, he said.
"At the very least, knowing such information permits greater understanding of the challenges each patient faces in pursuit of health, and allows the family physician to be a better connector of patient and community resources," Bazemore said. "A family physician shouldn’t be expected to overcome a patient's housing instability, lack of healthy food or poverty, but awareness of these issues can help them identify the resources they need, and create engagement on both sides into problem solving at the individual and community levels."
Tracking SDH data might be delegated to another professional in a practice rather than become another responsibility for a physician.
"Integrating and acting on SDH data shouldn’t fall on the physician alone, but rather on a broader primary care team, and it won’t happen without continuing payment reform to build and sustain that team," Bazemore said.
Two companion articles in the same issue debate whether physicians should be more engaged with social factors in their practices.
"Expanding the role of primary care physicians … toward addressing evidence-based prevention screening and interventions is feasible if the health team is expanded," Arthur Kaufman, M.D., vice chancellor for community health at the University of New Mexico Health Sciences Center, wrote in one of the companion articles(www.annfammed.org). "Perhaps the most significant addition to the team are community health workers who spend more time addressing the SDH than do other team members."
But not all physicians are convinced primary care physicians should take on social factors. Another writer argued that physicians are already struggling too much with clinical care demands.
"Anyone proposing any new responsibilities for primary care clinicians must be unaware of the degree to which most of them already feel overworked, stressed and discouraged," Leif Solberg, M.D., associate medical director at HealthPartners Medical Group, wrote in a counterpoint. "Much of this workload and stress comes from all of the expectations that have especially been added for primary care physicians since I began doing patient care 43 years ago."
Solberg cited the high rate of burnout among physicians and their reports that work leaves little time for family. He supports collection of social health data but questions whether innumerable social determinants can be addressed well in primary care practices that lack experience in such matters when qualified social service agencies are struggling to do so.
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