Health maintenance, disease prevention, and health outcomes once disease develops are all critically influenced by factors outside the scope of medical care as traditionally taught and practiced. Medical care is estimated to contribute only 10% to 20% to a person’s health, while nonmedical factors (such as health-related behaviors and socioeconomic and environmental factors) account for 80% to 90% of overall health. Medical care alone also plays a relatively minor role in health outcomes, again estimated to be between 10% and 20%. (Am J Prev Med. 2016; 50:129-135).
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June 2021These nonmedical factors are collectively referred to as the social determinants of health, defined by the World Health Organization as the conditions—shaped by political, social, and economic forces—in which people are born, grow, live, work, and age. These factors are called determinants because they determine access, or lack of access, to the crucial elements needed for health and for improving health once disease sets in—from basic living requirements (e.g., housing, food, safe drinking water, and transportation) to economic opportunities (e.g., education), to environmental security (e.g., safe homes and neighborhoods and clean air), as well as the larger structural issues within which these factors play out, notably with regard to issues of equity and justice based on race and gender.
Many of these determinants have long been incorporated into public health planning and initiatives. The more recent move into population-based health programs recognizes that improving health outcomes for and reducing costs of many of the most prevalent chronic diseases, such as diabetes and heart disease, rely on going “upstream” to address the context within which these diseases are seeded and take root before they head “downstream” as chronic illnesses seen in clinical care.
Even downstream, however, once a person develops an illness or needs medical care, it’s important to pay attention to social determinants to improve patient outcomes. Primary care is leading the way, but specialty care is also participating, as providers and healthcare systems become increasingly aware of the impediments to healthcare delivery and the high cost of not addressing factors, such as a lack of access to transportation, that can limit a patient’s ability to reach clinical care or adhere to treatment.
We want patients to show up for appointments, so we want to make sure they have adequate transportation. We want them to have great postoperative care, so we want them to have food security as well as clean and safe housing. I don’t think our field knows enough about how to assess our patients’ social determinants of health and then address their social needs. —David J. Brown, MD
None of this is new. Fundamentally, recognizing social determinants of health and incorporating them into healthcare delivery is about health equity. It’s about acknowledging and addressing all of the factors that determine the health, or illness, of a person. If COVID-19 did nothing else, it raised considerably the awareness that health equity is far from being achieved in this country, as illuminated by the disproportionate effect of the virus on minority populations (JAMA Otolaryngol Head Neck Surg. 2020;146:995-996).
“The COVID-19 pandemic raised people’s awareness that health disparities exist, and that these disparities are connected to the social determinants of health,” said David J. Brown, MD, associate vice president and associate dean for health equity and inclusion, and associate professor of otolaryngology–head and neck surgery at the University of Michigan Medical School in Ann Arbor.
Regan Bergmark, MD, a sinus and endoscopic skull base surgeon in the department of otolaryngology–head and neck surgery in the Center for Surgery and Public Health at Brigham and Women’s Hospital, Harvard Medical School in Boston, underscored the idea that the disparities associated with COVID-19 highlight the need for equity to be central to clinical care. Currently, she emphasized, the U.S. does not have a healthcare system based on the concept of a universal design in which the system works the same for everyone, but rather, it’s based on a system in which segments of the population have poor access to care, low quality of care, and often catastrophic costs associated with their care. “Health equity and attention to the social determinants of health need to be baked into routine practice,” she said.
At the Practice Level
What does it mean to bake social determinants of health into routine practice for an otolaryngologist? The first step is raising awareness about and recognizing the significant impact of social determinants on a patient’s health and health outcomes. Like other specialties, otolaryngology is taking a closer look at health disparities within the specialty and how social determinants impact patient care and outcomes.
Uchechukwu Megwalu, MD, MPH, associate professor and chief of the division of comprehensive otolaryngology and otolaryngology clerkship director in the department of otolaryngology–head and neck surgery at Stanford University School of Medicine in California, and colleagues recently published an article on the growing evidence of healthcare disparities and social determinants of health in otolaryngology (Out of Committee: Outcomes Research and Evidence-Based Medicine. Bulletin. AAO–HNS. Published April 26, 2021). They discussed and cited evidence documenting disparities in a number of otolaryngologic areas, such as head and neck cancer, pediatric sleep apnea, and hearing loss, along with the powerful influences of nonmedical factors (race/ethnicity, socioeconomic status, geography, and insurance status), on health.
Separately, in an overview of the social determinants of health for otolaryngologists published in Laryngoscope Investigative Otolaryngology in 2017, researchers found that social determinants had a major effect on patient health and healthcare use; however, their study also pointed to the need for more data on how these factors can be addressed within otolaryngology (Laryngoscope Investig Otolaryngol. 2017;2:187-193).
Educating otolaryngologists on these issues is fundamental to addressing them in clinical care. Across clinical care, graduate medical education to include social determinants of health is under discussion. Some are calling it a “call to act” and offering specific key principles for implementing curricula focused on social determinants across all specialty groups (Acad Med. 2018;93:159-162). Some underscore the fact that the Accreditation Council for Graduate Medical Education (AGCME) has required health disparities education for residents for many years, and yet its inclusion in curricula is far from widespread (JAMA Netw Open. 2020;3(8):e2013097).
So, what’s being done in otolaryngology? General guidance is found in the preamble to the most recent ACGME program requirements for graduate medical education in otolaryngology–head and neck surgery, published in 2020: “Graduate medical education develops physicians who focus on excellence in delivery of safe, equitable, affordable, quality care; and the health of the populations they serve.”
Teaching clinicians to focus on the safe delivery of care with an eye to quality is foundational to healthcare delivery. Focusing on equitable and affordable care may be less tangible within the clinical context—and keeping an eye on the health of populations served is even more opaque. But the growing evidence on the impact of addressing social determinants of health and, in doing so, addressing health equity, is making these elements more tangible and less opaque for the clinician.
We should focus our educational efforts to influence health outcomes at levels above individual interactions. Risk for disease begins well before our patients see us in the clinic. —Carrie L. Francis, MD
Teaching Residents and Fellows
The inclusion of social determinants of health in otolaryngology residency/fellowship post-graduate curricula is currently spotty throughout the country. Of the experts who provided comment for this article, none saw an intentional effort to incorporate these determinants into the curriculum at the organizational level.
“I think individual departments are picking up the mantle and doing some teaching on their own,” said Oneida Arosarena, MD, professor of otolaryngology–head and neck surgery and associate dean for diversity and inclusion at the Lewis Katz School of Medicine at Temple University in Philadelphia. She added that a lecture on social determinants of health and bias in medicine is offered yearly at her institution, and the subject is also regularly included in journal clubs. She would like to see it included in the curriculum, however, and thinks it would fit nicely into the section on medical ethics or quality improvement.
In linking social determinants of health to a quality improvement issue, for example, she cited the importance of determinants such as access to transportation and health insurance as significant influencers of healthcare delivery. “This is both an ethical issue and a quality improvement issue for outcomes,” she added.
Dr. Brown would also like to see implementation of curricula on social determinants at the organizational level for residents and fellows. The GME program at his institution is one of nine in the country currently participating in a pilot program as part of the ACGME Pursuing Excellence in Clinical Learning Environments: Quality Improvement in Health Care Disparities Collaborative to develop and implement health disparity curriculum. The curriculum developed at his institution included four components: social determinants of health and social needs, impact of systemic racism on healthcare, cultural humility, and use of quality improvement techniques to evaluate healthcare disparities. The two big components seen in most of the other eight participating programs, he said, were the social determinants of health and social needs component and the cultural humility component.
Three otolaryngology residents participated in the first year of the program, he said, adding that the program is entering its second year soon.
Dr. Megwalu would also like to see a general overview of health disparities included in the curriculum, with specific examples on how social determinants of health affect health outcomes in otolaryngology. “This would hopefully encourage [residents and fellows] to consider these factors when recommending or discussing treatment plans for patients,” he said. He also thinks that training in implicit bias would be helpful so that clinicians learn to recognize and address unconscious thoughts and attitudes that can negatively impact the care of disadvantaged patients.
Carrie L. Francis, MD, associate professor in the department of otolaryngology–head and neck cancer and associate dean of workforce innovation and empowerment, faculty affairs and development, at Kansas University Medical Center in Kansas City, Kansas, also would like to see training that addresses bias and racism, as she sees social determinants through the larger lens of structural determinants. “I agree with health profession and public health scholars who describe these forces [social determinants] as structural determinants of health, as they’re rooted in social and political structures and policy that are tied to the many “-isms” that exist in society,” she said.
She emphasized the importance of educating residents, fellows, and faculty on structural factors that result in inadequate access to and delivery of healthcare services in many minority and marginalized communities. “We should focus our educational efforts to influence health outcomes at levels above individual interactions,” she said. “Risk for disease begins well before our patients see us in the clinic.”
This call for a more proactive approach to healthcare, and to expanding focus to populations of patients, is one that Dr. Bergmark would also like to see. “We need more collaboration across surgical and medical fields and across healthcare systems to improve access to care at a population health level,” she said. For example, she wondered whether a coordinated effort could help lower the rates of delayed presentation of head and neck cancer, perhaps by increasing insurance rates, given the better survival in patients who present with lower stage cancer. She also questioned what a more coordinated approach would do for increasing HPV vaccination rates. “We should measure ourselves based on our outcomes, and increasingly these include regional population health data in our outcome metrics,” she said. “Some of these efforts will include increased focus on health policy and social issues.”
Building on the quality improvement aspect of including social determinants of health in the curriculum, Dr. Brown said that a key connection for residents and fellows, as it is with all clinicians, is the impact on what providers care about—clinical and surgical outcomes. “We want patients to show up for appointments, so we want to make sure they have adequate transportation. We want them to have great postoperative care, so we want them to have food security as well as clean and safe housing,” he said. “I don’t think our field knows enough about how to assess our patients’ social determinants of health and then address their social needs. Therefore, I believe [social determinants of health] should be a part of the curriculum so people at least have awareness and maybe we can move toward some more action about what we can do as otolaryngologists.”
Developing Postgraduate Curricula Focusing on Social Determinants
A scoping review of social determinants of health curricula in post-graduate medical education by Canadian researchers provides some information that may be useful for creating a curriculum in this area (Canadian Med Ed J. 2019;10:e61-e71). All 12 studies included in the review were from the United States and represented curriculum on social determinants of health developed in departments of internal medicine (n=4), pediatrics (n=4), family medicine (n=2), or multiple departments (n=2). The investigators found that 78% of the curricula improved participant-related outcomes, including improved screening for social determinants of health and referral to support services. Based on recurring themes found among the curricula that led to these improved outcomes, the investigators designed a set of recommendations for the development of postgraduate social determinants of health curriculum (see “Design Elements of a Curriculum on Social Determinants of Health,” below).
Examples of particular postgraduate curriculum may also help. An educational tool first published online in 2013 in the Journal for General Internal Medicine, called the “Social Determinants of Health Fast Facts” (www.sgim.org/File Library/JGIM/Web Only/SDH/Social-Determinants-of-Health.pdf), may offer a model to build a low-cost and effective tool for graduate medical education, as was done at the University of Pittsburgh Internal Medicine Residency Program. Investigators at Atlanta’s Emory University developed an experiential module to introduce internal medicine residents at an academic safety net hospital to social determinants of health and health disparities (MedEdPORTAL. 2017;13:10647).
Another strategy may involve including social determinants of health in curricula through consortia-type residency education models in which residents learn online from programs taught by faculty from across the country. Several such consortia exist in otolaryngology and present an evolving way to consider and deliver residency education, as highlighted in a recent article (Otolaryngol Head Neck Surg. 2020;163:70-74). Brett T. Comer, MD, residency program director and associate professor in the division of rhinology and anterior skull base surgery in the department of otolaryngology–head and neck surgery at the University of Kentucky in Lexington, and senior author of the study, said incorporating social determinants within this consortia style of learning would be wonderful if properly executed. “A consortium concept might allow otolaryngologists from different settings to teach and discuss the specific disparities they encounter, while allowing learners to see common themes that occur,” he said.
Design Elements of a Curriculum on Social Determinants of Health
| Format | • Longitudinal exposure through postgraduate training to enable repeated exposure to elements within the program. |
| Content | • Vary content based on the needs of the community. • Use multiple sources (e.g., resident and community needs assessments, local expert opinions, literature reviews). • Include at least a basic introduction to social determinants of health: what they are, how they impact patient care and health outcomes. • Other content could include resources relevant to the socioeconomic status of the patient, patient–provider interaction issues, leadership and health advocacy, interprofessional collaboration, and project management. |
| Learning Activities | • Include multiple types, such as patient or community exposure for hands-on learning supplemented with classroom-based or independent learning. • More rigorous programs may include a resident research or advocacy project. |
| Evaluation Methods | • Comprehensive evaluation methods should be used and should target objectives aimed at participant outcomes, as well as patient-, program-, and academic-related outcomes. |
Source: Canadian Med Ed J. 2019;10:e61-e71.
Integrating Social Determinants into Practice
Raising awareness of and recognizing the social determinants of health and how they are linked to health outcomes is the first step toward advancing better healthcare for all otolaryngology patients. Education is critical to this movement, and determining how to integrate social determinants into the otolaryngology clinic will require careful thought. Among the key questions will be how to define the role of an otolaryngologist in screening patients for factors such as access to transportation, housing, and food. Once screened, what does the otolaryngologist do with that information—what systems are in place to help the otolaryngologist refer patients to the resources they need (CMAJ. 2016;188:E474-E483)?
“This is uncharted territory for most of us,” said Dr. Francis. “Awareness is important, but not enough.” Calling for innovative ways of thinking on how otolaryngologists can evaluate and intervene on the social/structural determinants of health, Dr. Francis underscored the need for otolaryngologists to use their expertise and tools to support community needs and partner with leaders and scholars outside the specialty to learn about programmatic successes in this area.
Mary Beth Nierengarten is a freelance medical writer based in Minnesota.