I recently saw two different patients with type 2 diabetes mellitus, both of whose hemoglobin A1c values were above the limit of detection of our point-of-care machine. My medical training taught me to treat them similarly: titrate medications, assess and encourage “compliance,” recommend home glucose monitoring, and counsel on nutrition and exercise.
But one of those patients was Ms. G, a woman who had residual weakness and visual impairment from a stroke and lived in a food desert. It was not possible for her to look at nutrition facts or a glucometer, access healthy foods, cook for herself, or walk around the neighborhood. Her dependence on loved ones made her feel depressed, ashamed, and useless, which contributed to poor eating habits.
The other patient was Mr. B, a Congolese refugee who was diagnosed with diabetes during routine health screening upon his arrival to the U.S. He had low English proficiency and low general health literacy, and was overwhelmed by both a new diagnosis and a new country. The base of his diet was ugali, a maize flour carbohydrate that he could not imagine giving up — it was one of his few remaining reminders of his home and culture. He was also experiencing food insecurity since he had not yet gotten a work permit, and ugali is cheap and easy to make.
These are clearly not one-size-fits-all situations. In order to treat these patients successfully, we must assess and respond to the nuances of their social contexts.
A large and ever-increasing body of evidence shows that addressing health-harming social needs during our patient visits can significantly deepen our impact on their health. We know that 80% of health is determined by factors outside of the healthcare system, such as environmental and behavioral factors. In recent years, researchers have been turning that theory into action. Colleagues in Philadelphia, Chicago, and Boston, among others, have demonstrated effective models for screening and responding to social needs in healthcare settings. We are doing similar work at Dell Medical School in Austin, moving towards integrating social factors seamlessly into patients’ electronic health records. At a recent panel at the Association of Health Care Journalists Conference, I sat alongside scientists and advocates making a difference by linking health and geography in Austin, Atlanta, and across the country.
National organizations also recognize the benefits of addressing social needs in the healthcare setting. The National Academies of Sciences, Engineering, and Medicine released a landmark report on the topic in 2019. CMS has released their own Health-Related Social Needs Screening Tool. And earlier this year, CMS announced a new initiative, the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model, which incentivizes ACOs to address social needs and provides enhanced reimbursement for ACOs that serve higher-need populations.
But these ideas have been painfully slow to penetrate into daily clinician practice. As co-director of our school’s Primary Care, Family, and Community Medicine Clerkship, I have helped implement an innovative longitudinal curriculum that integrates social determinants of health and community engagement into learning cases. But our students are frustrated that their supervisors often aren’t ready to hear this knowledge. An internal survey conducted by Dell medical students found that over 60% of our students “sometimes,” “often,” or “always” faced dismissive attitudes about health equity from residents and faculty. We must move forward as leaders so that our learners do not feel they are ahead of us.
Here are three things we can do as individual clinicians to improve the care of our patients’ social needs:
Know the patient. This means knowing the patient as a whole person, rather than as a diagnosis code or problem list. It sounds obvious to most clinicians, but it is not always intuitive because we may be asking the wrong questions. The standard history and physical format has changed little in the last 60 or so years, but it’s time for an update. A task force of the American Medical Association developed a new format, the H&P 360, which has been shown to collect significantly more biopsychosocial information. Expanding and prioritizing our assessment of patients’ personal and social circumstances will help us improve diagnostic accuracy and implement more effective treatment plans.
Know the system. Unfortunately, in our complex, opaque, and inequitable healthcare system, it is not enough to know the person in front of us. We must also have intimate and exhaustive knowledge of the systems influencing patient care and the resources available. Being able to refer a patient to Meals on Wheels or to a tenant advocacy organization can have an equal or greater impact on their health than referring them to a medical specialist. Conversely, if we send the patient to the wrong imaging site or prescribe a nonformulary medication and accidentally bankrupt them, we may be doing more harm than good.
Work in an interdisciplinary care team. If the above two tasks sound impossible to accomplish within the time allotted for a patient visit, this third to-do is here to save the day. We can’t do this alone, so we must have an interdisciplinary team working together to address social needs. This may include social workers, community health workers, behavioral health specialists, patient navigators, and others. The key here is that the team must be well-integrated to be effective. We must break down hierarchies and silos and empower team members to help lead patient care, recognizing the unique expertise of each role. And we must advocate for payment models for all care team members that justly compensate them for their contribution.
Our healthcare system has a long way to go before it provides equitable preventive and proactive care for all, but the exam room is a place to start. Only by moving beyond the biomedical framework and individualizing care to patients’ social circumstances can we help patients like Ms. G and Mr. B achieve their greatest health potential.
Brandon Altillo, MD, MPH, is an assistant professor of population health, internal medicine, and pediatrics at the University of Texas at Austin Dell Medical School, and practices primary care internal medicine and pediatrics in Austin. He is a Public Voices Fellow of The OpEd Project.