Like you, I'd like to think that the medical care I provide promotes healthy outcomes. However, I'm chagrined to learn that clinical care is estimated to account for only 10 percent to 20 percent of the modifiable contributors to health outcomes in a population.1 The other 80 percent to 90 percent of modifiable health factors are health-related behaviors, socioeconomic factors, and physical environment factors1 – things that typically fall outside the purview of what we think of as medical care. Consider that 80 percent to 90 percent to be public health issues or what are now commonly referred to as social determinants of health (SDoH).
Parenthetically, genetics is, of course, a major contributor to health outcomes. But at least for now, it is not a modifiable contributor to health.
So should we expand our repertoire in primary care and systematically screen for SDoH and make referrals when problems are uncovered? SDoH includes issues like housing instability, food insecurity, transportation problems, utility help needs, interpersonal safety, financial strain, employment status, family and community support, education level, a safe accessible environment in which to exercise, and substance use.
In this issue, in “A Practical Approach to Screening for Social Determinants of Health.” David O'Gurek, MD, and Carla Henke, MD, make the case for systematic screening and they identify several helpful tools. The article is even-handed, and the authors concede that the research supporting the benefits of adding this responsibility to primary care is limited. They also recognize that primary care physicians have more than enough on their plates these days and shouldn't be the ones to do the actual screening.
As a physician trained to believe in the biopsychosocial model, I find the concept of trying to modify patients' SDoH appealing. But as a physician who is well aware of the ever-expanding expectations of what I should be doing to provide “quality” care, I'm hesitant to take this one on. Does it make sense to medicalize issues like economic insecurity, social disparities, and unsafe streets? Isn't this really the purview of public policy, public health, and social work? Should we be employing social workers to help us guide our patients when their screening results shout “I need help”? Who will pay for that? Perhaps in the world of accountable care organizations, that is the way to go. But how do we prioritize, and how far do we go to address problems that often seem unsolvable? Which interventions will make the most difference? Finally, where is the research to support this effort?
Those are my musings as I struggle with the idea of introducing yet another screening survey in my practice and then knowing what to do with the abnormal results. Please read this important article, and let us know your thoughts as well.