Recently, we have seen a massive push to identify social determinants of health in healthcare systems. Infectious diseases doctors already see the effects of social determinants of health in patients, often leading to a combination of frustration, helplessness, activism and advocacy. On first blush, it seems unfair to ask doctors and healthcare systems to bear the brunt of these social determinants. Beyond that, it certainly is an opportunity for healthcare systems to collaborate with community and social partners to make it better for patients. I have heard both terms, structural determinants and social determinants of health, and my research on the difference led me to this wonderful document published by the World Health Organization. The difference is clearly pictured in the schema shown above. Structural determinants of health are the structures – social position (race, gender, ethnicity), education, occupation, income), while the social determinants include both the structural determinants and the intermediary determinants – living and working conditions, food accessibility, behaviors and biological factors, and psychosocial factors. As someone who now spends substantial time working in a patient-centered medical home for patients living with HIV infection in an urban safety-net health system, I know that we work to reduce the impact of intermediary determinants, but there is much less we can do to reduce the impact of structural determinants.
While I recognize the importance of assessing a patient for these determinants of health and documenting them in the medical record while making a plan to address them, I have struggled with where they belong in the presentation and the note. Like everyone else, I was trained to introduce a patient with age, gender, race, ethnicity, and pertinent past medical history in the leading sentence during presentation on rounds and in the written notes in the medical record. Sometimes, sexual orientation, country of residence and insurance status and other pieces of information are added in there.
This year, I have had some time to reflect on how we do this and what may be a better way to do this. The pros for staying with this approach are no one is surprised when you present a patient or when the person reads your note in chart. Priming the recipient of this information about who the patient is might help the recipient process the information in context of who the patient is. As for cons, this approach might make the recipient stereotype the patient or induce implicit biases in the recipient upfront, even before the recipient has had a chance to process the medical information on the patient, which in turn might bias the subsequent assessment and care plan. Another con is that with increasing collective awareness of race, gender, ethnicity and other structural determinants of health, we now know that they are way more nuanced than was originally thought. For example, there are at least seven or eight descriptors for gender, and there are preferred pronouns. In this modern world in which physicians span four or five generations and have as many permutations and combinations of political and other views on these topics as possible, some of these details may be more distracting from the medical information, at least for some. Moreover, the vast majority of these sociodemographic identifiers are not modifiable.
After much thought, I started omitting them entirely in the leading sentence, documenting them in the social and personal history, and listing structural/ social determinants of health as one among the list of problems – for example, problem #1: HIV, problem #2: Diabetes, problem #3: Structural determinants of health, etc. I’m sure I will iterate this some more in the near future. Where do you list them in your notes? Where do you think they belong? I would love to hear your thoughts.