Doctors understand that social determinants of health have a major impact on patients' wellbeing, yet they often are reluctant to address such issues with their patients.
Doctors have long known that patients’ health depends as much on life circumstances, such as being able to afford healthy food and decent housing, as any treatments doctors themselves can provide. Even so, many physicians are, for a variety of reasons, reluctant to ask patients whether they face such challenges in their lives.
But that situation may be changing, thanks to a growing focus on the importance of social determinants of health (SDOH) says Elaine Waxman, PhD, a senior fellow at the Urban Institute, a Washington, D.C.-based think tank, and former vice president for nutrition issues at Feeding America, a nationwide network of food banks.
Waxman is among a panel of experts who will discuss ways doctors and healthcare policymakers can address SDOH at the 2019 ACP Internal Medicine Meeting in Philadelphia.
Waxman notes that among the challenges to incorporating SDOH into medical care is recognizing when it is an issue, then knowing how to discuss it with patients. “Most doctors don’t mean to be insensitive to the challenges their patients face, they just don’t understand the extent of them because they haven’t experienced significant hardship in their own lives,” she says.
Moreover, it can be difficult to identify patients experiencing SDOH-related health issues by outward appearances alone. “When we see a homeless person we make assumptions about how they’re doing. But if someone has housing and is working, even if it’s a low-wage job, it’s easy to think things are better for that person than they really are.”
The solution, Waxman says, is for doctors to routinely screen for SDOH issues such as food insecurity, and get trained in how to talk about them so they feel less awkward in doing so. “Give them resources they can tap to address issues they may feel are outside their wheelhouse,” she says.
Similarly, doctors need information on how to help patients deal with the high cost of many prescription medications, another important SDOH, either through programs that can make the drugs more affordable, or managing the patient’s disease around the problems resulting from low incomes.
She cites the example of diabetic patients who skip meals at the end of the month when their Supplemental Nutrition Assistance Program (SNAP) benefits run out, but continue taking insulin, thereby risking hypoglycemia. “Some physicians will tell their patients, ‘if you know you can’t eat, that’s a time not to take that medication,’” she says. “It’s a matter of partnering with patients to address these problems, instead of patients feeling they have to manage on their own.”
When it comes to advocating for policy changes that can improve health-another topic the panel will discuss-Waxman says physicians can, and should, make their voices heard among elected officials and other policymakers.
“Doctors can speak up on issues where they feel comfortable, like helping policymakers understand that adequate food is a type of medicine or that poor-quality housing has a direct health impact,” she says. She points out that it was a physician who discovered and publicized the elevated lead levels in Flint, Michigan’s drinking water. “That proves physicians can make a huge difference in elevating the importance of a public health issue to a community,” she says.
Doctors around the country are starting to understand they need to think of themselves as just one part of a community-wide care team, Waxman adds. “You can’t just refer a patient out and hope that works,” she says. “If you really want to make headway in health improvements you’ve got to be actively engaged.”
This ACP 2019 panel, “Improving Individual and Community Health,” will take place on Friday, April 12 at 4:30 p.m.