“I was terrified, and my foot was in so much pain,” said Mrs. C as I began our interview. There was a blood clot that had turned her toe blue. She went on to describe her history and briefly mentioned that she did not have medical insurance. With her pain now gone after a few days in the hospital, the anxiety of the financial burden of her stay was now at the forefront. In addition, her new diagnosis of antiphospholipid syndrome would require her to be discharged on a new medication—warfarin. After nearly losing a toe from an arterial clot, our patient had more than enough merit to ponder this new change. Our attending began to counsel her on the need to have follow-up appointments for regular blood checks. Unfortunately, it had been some years since she had seen a primary care provider, and she was uncertain of how to navigate this unique situation. I then informed her about our local student free clinic, an opportunity she happily accepted.
As I talked to the front desk staff to schedule her appointment, I could not help but be reminded of the important interplay of the social determinants of health and the overall well-being of the patients we care for as physicians. These societal factors significantly influence a patient’s ability to care for themselves and extend far beyond what we do in the clinical setting. Some elements included in social determinants of health are socioeconomic status, education level, unique demographics, housing stability, employment status, and social support systems. Each aspect contributes to the overall well-being and has been shown to influence health outcomes. As physicians, we must be engaged with our patients’ specific needs and connect them to the proper resources.
For example, in the case of our patient, her income and socioeconomic status played a pivotal role in her access to care. Her medication requires close follow-up due to the risk of hemorrhage. In fact, patients with low socioeconomic status have been shown to be more likely to experience bleeding events while being treated with warfarin. Possible explanations for this include a lack of adequate medical visits or poor medication adherence. In the interest of patient safety, the care team needed to strongly emphasize to our patient the need for stable follow-up appointments and assist her in identifying possible options.
One fundamental component of the social determinants of health is adequate access to a primary care physician. By serving as the gateway for comprehensive continuity of care, these physicians play a pivotal role in maintaining the well-being of a patient. With proper access, patients are more likely to receive adequate preventative health screenings, vaccinations, health education, and decreased burden from their chronic conditions. Primary care physicians also serve as patient advocates, demystifying the ever-complex medical system, particularly for those with low education levels. The loss of continuity of care has been associated with increased specialty, urgent, and emergency care usage.
Low socioeconomic status significantly hampers the ability of patients to not only find a primary care provider but also provides barriers to maintaining continuity with their physician. High health care costs, including insurance premiums, deductibles, and other “surprise” expenses can deter patients with limited resources from seeking out adequate care. Ultimately, this could result in delayed time to diagnosis, worsening of chronic conditions, and the use of emergency rooms as a last resort for acutely presenting problems. Moreover, patients with low financial resources also struggle with flexibility for time off work to attend their medical appointments, keeping them stuck in a vicious cycle.
Our patient is one of many caught in this never-ending storm of obstacles, just one major health problem away from a potential financial catastrophe. In our case, she had chosen to forego medical treatment for her toe pain for two whole days before coming to the emergency room due to her limited resources and work responsibilities. Even when she had improved clinically, her first thought revolved around how she was going to afford her hospitalization and how she was going to afford follow-up care for her new long-term medication. Her overall experience caused her more undue stress than necessary, particularly when compared to a patient with more flexibility in their finances. The barriers present for those with lower socioeconomic status in general can cause chronic stress. This has been correlated to physiological dysfunction, such as an increased risk of vascular disease.
Addressing low socioeconomic status and other social determinants of health is a multifaceted issue. Physicians can be at the forefront of this, collaborating with community organizations and policymakers to bring about positive change in our patients at both the individual and community levels. Advocating for policy changes can help tackle the issues faced by income inequality. For instance, expanding Medicaid programs could help mitigate barriers to establishing care with a primary care physician and improve health outcomes.
At the grassroots level, community-based outreach organizations will also be pivotal in helping to address gaps of care present in low-income populations. Free clinics like St. Vincent’s can serve as a safety net for uninsured patients. Programs targeted at nutritional assistance and education can help uplift patients and their respective families. Physicians and other providers could partner with these organizations to offer free health education, health screenings, and even on-site services. These additional efforts outside of the traditional clinical setting can help empower our communities and mitigate the negative effects of the social determinants of health.
My experience in taking care of Mrs. C reminded me of the important role physicians have in caring for the overall well-being of our patients. While we have the power of the prescription pad on our side, we also have the knowledge and capabilities to bring about long-lasting change. The challenges from this patient encounter have cemented this ideal within me. Moving forward, I plan to continue assisting patients in navigating the unique obstacles placed in front of them. Furthermore, I plan to seek out further opportunities to work with the local community to tackle unique issues.
In summary, the social determinants of health play an unquestionable role in the lives of the patients we serve. These issues can be tackled by helping our patients individually and engaging with the community’s stakeholders to bring change at the population level. Indeed, taking these crucial extra steps could potentially bring about a more equitable health care system that serves all patients. As I continue my medical education, I am committed to integrating the lessons learned from this experience into my future practice and partnerships with community organizations.
Christopher Huy Doan is a medical student.
