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PE R S PE C T IV E Rethinking the Social History

BECOMING A PHYSICIAN

Rethinking the Social History


Heidi L. Behforouz, M.D., Paul K. Drain, M.D., M.P.H., and Joseph J. Rhatigan, M.D.

R esearch has established that


social environments affect
human health.1 Acknowledged
powerlessness or incompetence
in addressing these root problems.
Whereas biologic pathology may
as results of the complicated in-
terplay of individual factors with
a complex social environment.
social determinants of health — present specific targets for inter- For example, a proper social
including racial or ethnic back- vention, social or structural pathol- history of a “brittle diabetic” pa-
ground, occupation, and the use ogy is difficult to treat. tient may reveal a very limited in-
of alcohol and tobacco2 — also Since social problems affect come that precludes purchasing
influence the effectiveness of patients’ health and treatment healthy foods. Social isolation may
health care delivery.3 But other effectiveness, however, we cannot prompt excessive emotional eat-
social factors, such as the ability afford to ignore them in assess- ing, limited mobility may hinder
to afford medications, access to ments and treatment plans if we monthly visits to the pharmacy
transportation, available time, and hope to improve outcomes, reduce to pick up prescriptions, depres-
competing priorities, may influ- costs, and improve patient satis- sion or poor coping skills may
ence health outcomes even more. faction. Moreover, clinicians’ sim- thwart lifestyle modifications,
Although we believe that explor- ple acknowledgment of social family lore regarding “low sugars”
ing these issues constitutes an forces can strengthen their ther- may impede adherence to insulin
essential part of the medical ex- apeutic alliance with patients. regimens, and life with arthritic
amination, the most important Patients know clinicians cannot knees in a third-story walk-up in
and relevant social history ques- alleviate their poverty, but empa- a violent neighborhood may make
tions are rarely asked or acted on. thy and concern shown by a clini- prescribed daily walks seriously
Applying social science prin- cian who explicitly addresses it challenging.
ciples to medicine — a practice constitute powerful medicine. Adopting the social medicine
sometimes called “social medi- So how should we teach stu- framework, we revised our list of
cine” — enables us to contextu- dents and clinicians to explore social history topics in an effort
alize patient care to achieve more social determinants of health? to strengthen our therapeutic al-
sustainable and equitable health How can we encourage health liances, better contextualize pa-
outcomes. Social medicine eluci- care teams to explore social fac- tients’ diagnostic and treatment
dates how patients’ environments tors that influence health care plans, and improve health out-
influence their attitudes and be- delivery? And how should clinical comes (see box). Our topics ex-
haviors and how patients’ agency teams address these issues? tend well beyond the common
— the ability to act in accor- To start, obtaining a more ap- “TED” (tobacco, ethanol, drug use)
dance with their free choice — is propriate and comprehensive so- questions, encompassing six cate-
constrained by challenging social cial history can enable proper gories: individual characteristics,
environments. assessment of a patient’s social life circumstances, emotional
Physicians often see patients environment. Although many so- health, perceptions of health
with complex social situations as cial barriers exist between patients care, health-related behaviors, and
a burden — requiring extra work and providers, deliberate inquiry access to and utilization of health
that is neither reimbursable nor into the social environment allows care. Primary care clinicians may
central to our core clinical exper- clinicians to understand behaviors find that such a comprehensive
tise. Unfortunately, we inculcate such as nonadherence to treat- history is best obtained over mul-
these attitudes in trainees, implic- ment plans, missing of appoint- tiple visits, but we believe it is
itly and explicitly, perhaps because ments, or failure to fill prescrip- ideal to revisit these questions
of our discomfort with hearing tions not as products of ignorance annually; inpatient clinicians
difficult stories or our sense of or willful misbehavior but rather probably need to be more target-

n engl j med 371;14 nejm.org october 2, 2014 1277


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PERS PE C T IV E Rethinking the Social History

Common Current Topics and Proposed Comprehensive Topics for the Patient
ed but could, with training, ob-
Social History. tain similar relevant information.
Of course, clinicians should use
Common current topics
their judgment regarding the ap-
Racial or ethnic background
propriate timing of these conver-
Marital status and children
Occupation sations, since patients may need
Highest level of education to establish trust and rapport be-
Tobacco, ethanol, drugs (“TED”) fore sharing intimate information.
Seatbelt and helmet use To obtain proper social histo-
Firearms in the home
Victim of domestic violence
ries, clinicians could be trained
in basic and motivational inter-
Proposed new topics
viewing techniques and chal-
Individual characteristics
Self-defined race or ethnicity
lenged to examine their own bi-
Place of birth or nationality ases, since unexplored prejudices
Primary spoken language influence our ability to obtain or
English literacy act on important information. We
Life experiences (education, job history, military service, traumatic or life-­
also recommend that clinicians
shaping experiences)
Gender identification and sexual practices attempt to visit the neighbor-
Leisure activities hoods where the majority of their
Life circumstances patients live, since such experi-
Marital status and children ences can enhance clinicians’ so-
Family structure, obligations, and stresses
cial perspective and help them
Housing environment and safety
Food security understand their patients’ “health
Legal and immigration issues homes.” Such visits might inform
Employment (number of jobs, work hours, stresses or concerns about work) clinicians about people or ser-
Emotional health vices in their patients’ world that
Emotional state and history of mental illness (e.g., depression, anxiety, trauma,
post-traumatic stress disorder)
could be organized to help them
Causes of recent and long-term stress achieve better health and about
Positive or negative social network: individual, family, organizational the forces working against their
Religious affiliation and spiritual beliefs engagement in health-promoting
Perception of health care or harm-reducing behaviors.
Life goals and priorities; ranking of health among other life priorities
Personal sense of health or fears regarding health care In addition to learning how to
Perceived or desired role for health care providers obtain this social information,
Perceptions of medication and medical technology clinicians need to learn how to
Positive or negative health care experiences use it — specifically, they need
Alternative care practices
training in ways of developing
Advance directives for cardiopulmonary resuscitation
Health-related behaviors individualized care plans that
Sense of healthy or unhealthy behaviors take into account patients’ per-
Facilitators of health promotion (e.g., healthy behaviors among close social sonal and structural barriers to
contacts) good health.4 Using shared-deci-
Triggers for harmful behaviors and motivation to change (may be determined
through motivational interviewing)
sion-making techniques and ap-
Diet and exercise habits propriate pedagogical and coun-
Facilitators or barriers to medication adherence seling skills, clinicians can help
Tobacco, alcohol, drug use habits prioritize patients’ goals and em-
Safety precautions: seatbelts, helmets, firearms, street violence power patients to make lasting
Access to and utilization of health care
Health insurance status
changes to achieve self-identified
Medication access and affordability objectives. Increasingly, through
Health literacy and numeracy (may be ascertained with specific tools; e.g., shared-savings contracts and re-
“The Newest Vital Sign”) imbursement for care-coordina-
Barriers to making appointments (e.g., child care, work allowance, affordability
tion activities, clinicians will re-
of copayment, transportation)
ceive financial incentives to make

1278 n engl j med 371;14 nejm.org october 2, 2014

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PE R S PE C T IV E Rethinking the Social History

appropriate referrals to both insti- three subspecialists, and a refer- Attention to the social forces in
tution-based and community- ral to outpatient rehab — and our patients’ lives would allow us
based resources and to commu- has to contend with the eviction to provide better and less costly
nicate effectively with social notice, unpaid utility bills, and care to patients with the most
workers, community health work- isolation that await him at home? complex conditions and situa-
ers, lawyers, therapists, counselors, Trainees could learn how to tions — thereby increasing satis-
and other service providers. assess patients’ literacy and health faction among both patients and
For example, an individualized literacy and how to deliver infor- caregivers. Failure to attend to
care plan for a woman with dia- mation using well-established ped- these forces will perpetuate the
betes might include referrals to a agogical techniques. They could cycle of poor outcomes, high
food pantry and farmer’s market practice motivational interview- costs, and dissatisfaction among
for purchasing fresh produce; re- ing techniques using role playing our neediest patients.
ferral to a community-based walk- and learn, in real clinical set- William Osler said, “The good
ing program, where neighbors tings, how to motivate and em- physician treats the disease; the
help her up and down the stairs; power patients to engage in health- great physician treats the patient
sending prescriptions to a phar- promoting behaviors. Audiotaping who has the disease.” To be able
macy that delivers medication to or videotaping of history taking, to treat the patient, a physician
her home; referral to a medicolegal counseling, and care-planning must ask the right questions and
group for contract assistance con- activities can provide opportuni- know how to act on the answers.
cerning her unsafe housing situ- ties for giving feedback and hon- Disclosure forms provided by the authors
ation; and referral to a commu- ing skills. Clinicians-in-training are available with the full text of this article
nity health center that holds group can be taught how to enhance at NEJM.org.
meetings where she can build re- shared decision making, create
From the Division of Global Health Equity,
lationships, explore new explana- individualized care plans, and Department of Medicine, Brigham and
tory models of disease, and learn work effectively in teams — all Women’s Hospital (H.L.B., J.J.R.), the Divi-
from others’ stories of illness and principles that we believe should sion of Infectious Diseases and the Medical
Practice Evaluation Center, Department of
coping. For the most challenging be incorporated into the U.S. Medicine, Massachusetts General Hospital
“nonadherent” patients, a struc- Medical Licensing Examination5 (P.K.D.), and Harvard Medical School
tured home visit by medical team and the Accreditation Council for (H.L.B., P.K.D., J.J.R.) — all in Boston.

members would be ideal. Graduate Medical Education and


1. Marmot M. Health in an unequal world.
Medical education curricula American Board of Medical Spe- Lancet 2006;368.2081-94.
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this approach. Students and resi- cies. If we gear training toward a nants of health: the solid facts. Geneva:
World Health Organization, 2003.
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structured home visits and pa- understanding patients, clinicians adherence to medical treatment: a meta-
tient care mapping exercises to will gain tools for developing analysis. Health Psychol 2004;23:207-18.
4. Farmer PE, Nizeye B, Stulac S, Keshavjee
better understand all the places, therapeutic plans that take into S. Structural violence and clinical medicine.
people, and directives that pa- account patients’ complex social PLoS Med 2006;3(10):e449.
tients must negotiate in seeking environments. 5. Haist SA, Katsufrakis PJ, Dillon GF. The
evolution of the United States Medical Li-
better health. What happens, for We hope that the teaching and censing Examination (USMLE): enhancing
instance, when a patient with assessment of such an approach assessment of practice-related competen-
low literacy is discharged after a will foster a new generation of cies. JAMA 2013;310:2245-6.

hospitalization with new prescrip- clinicians who provide more per- DOI: 10.1056/NEJMp1404846
tions, orders to follow up with sonalized and appropriate care. Copyright © 2014 Massachusetts Medical Society.

n engl j med 371;14 nejm.org october 2, 2014 1279


The New England Journal of Medicine
Downloaded from nejm.org by XIAOMING HUANG on July 9, 2017. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.

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