Sarina Schrager, MD, MS, WMJ Editor-in-Chief
Health outcomes are predicted by a complex interplay between genetics, health care, and social factors. Outside of genetics, the factors that contribute to health are called social determinants of health and account for up to 80% of health outcomes.1 The University of Wisconsin Population Health Institute’s County Health Rankings and Roadmaps measured the effects of different social determinants of health throughout the country and found that health behaviors account for 30% of the variation in outcomes, clinical care accounts for 20%, social and economic factors account for 40%, and physical environment (ie, where you live) accounts for 10%.1
It follows, then, that medical care alone has a relatively small impact on overall health and health outcomes.2 Other social determinants of health—such as access to insurance, poverty, food insecurity, and healthy neighborhoods—account for a large variation in overall health, and government policies can influence these factors.2,3 A recent systematic review and meta-analysis of 38 randomized controlled trials found that there are health benefits from interventions to affect early childhood experiences, improved health insurance, and income support; but most of the trials included in the review were underpowered to detect changes in health outcomes.3
So, where does this leave clinicians? We work in hospitals and clinics, but to most effectively improve our patients’ health, it makes sense for us to also work to influence policy. The idea of clinician advocacy is not a new one, but it is unclear for many where to start—how to learn advocacy skills and how and where to apply them.4 However, there are many opportunities for those who wish to get involved. Common forums for clinicians to hone their advocacy skills include affiliations with medical societies, many of which have professionals on staff to offer guidance and support; leadership roles within health systems; and membership on boards of directors for local organizations.4 Clinicians can advocate at different levels as well, ranging from helping a patient get a disabled parking permit to advocating for patients and polices within organizations and health systems, or talking to legislators about issues like Medicaid expansion.5
Several papers in this issue of WMJ discuss issues related to social determinants of health and highlight topics where clinicians could advocate on behalf of their patients, including health of refugee populations, firearm safety, proximity to coal-fired power plants and more
The paper by Petrassi et al describes an educational intervention to improve knowledge of factors that influence the health of refugees and cultural competence.6 The intervention, which included a lecture and 3 small-group sessions, improved clinician knowledge but did not affect cultural competence. The authors conclude that further work is needed. Balza et al conducted focus groups with refugees to assess their barriers to care.7 Unsurprisingly, access to transportation, language barriers, and not feeling respected were obstacles hindering refugees’ ability to receive excellent care. At the system level, clinicians could advocate for improved health care for this population.
In their excellent commentary, Stiles et al present ways health systems and hospitals can advocate for reduction of firearm-related deaths and injuries.8 The authors outline several different approaches clinicians and health systems can use to decrease the number of people injured or killed by guns. A Florida law banned physicians from asking patients about firearms. The law was repealed in 2017, but a subsequent survey of Florida physicians found that only 40% routinely asked about firearms during clinic visits.9 A national survey of family physicians suggested that formal training in firearm safety improved clinicians’ comfort level when asking about firearm safety during clinic visits.10 These examples suggest that clinicians should advocate for more firearm safety education.
Advocating for health equity for vulnerable populations is another area where clinicians can effect change. In their review article, Ellis et all suggest that professionals must work across disciplines and social sectors to address the effect of racism and discrimination on the health of Milwaukee’s African American population.11 The study by Schiefelbein et al evaluated all adults diagnosed with pancreatic cancer in Wisconsin between 2004 and 2017.12 They found that non-Hispanic Black patients were significantly less likely to receive treatment or have surgery than non-Hispanic White patients—inequities that affect survival. In another study, Lor et al conducted a chart review looking at documentation of pain treatment and found significant differences between the way White patients are treated for pain compared to Spanish- and Hmong-speaking patients.13 These papers provide examples of clinical and community settings that may benefit from policy change.
For those who wish to get involved in advocacy efforts, there are resources available locally, in specialty-specific arenas, and nationally. For example, the AMA has available curated resources for physician advocacy (www.ama-assn.org/health-care-advocacy), and the Wisconsin Medical Society (www.wismed.org/wisconsin/wismed/Advocacy) and the Wisconsin Pharmacy Society (www.pswi.org/Advocacy) are two organizations that provide resources for those who wish to advocate on behalf of specific legislation. These are just a few resources and guides available to clinicians to help them learn about advocacy and find a venue for their advocacy goals.
If we wish to optimize health and health care for our patients beyond the clinic, working to impact policies that affect social determinants of health is a great place to start.
- Hood CM, Gennuso KP, Swain GR, Catlin BB. County Health Rankings: Relationships between determinant factors and health outcomes. Am J Prev Med. 2016;50(2):129-135. doi:10.1016/j.amepre.2015.08.024
- Magnan S. Social determinants of Health 201 for Health Care: Plan, Do, Study, Act. NAM Perspect. 2021:10.31478/202106c. doi:10.31478/202106c
- Courtin E, Kim S, Song S, Yu W, Muennig P. Can social policies improve health? A systematic review and meta-analysis of 38 randomized trials. Milbank Q. 2020;98(2):297-371. doi:10.1111/1468-0009.12451
- Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: what is it and how do we do it? Acad Med. 2010;85(1):63-67. doi:10.1097/ACM.0b013e3181c40d40
- Haq C, Stiles M, Rothenberg D, Lukolyo H. Effective advocacy for patients and communities. Am Fam Physician. 2019;99(1):44-46.
- Petrassi A, Chiu M, Porada K, et al. Caring for refugee patients: an interprofessional course in resettlement, medical intake and culture. WMJ. 2022;145-148.
- Balza J, Tsering S, Dickson-Gomez J, Hall T, Kaeppler C. Understanding barriers to care for refugee patients: lessons from focus groups. WMJ. 2022;141-144.
- Stiles M, Hargarten S, Lauby M, Peterson N, Bigham J. Preventing firearm-related death and injury: a call to action for Wisconsin health systems and the Wisconsin Hospital Association. WMJ. 2022;74-76.
- Hagen MG, Carew B, Crandall M, Zaidi Z. Patients and Guns: Florida Physicians Are Not Asking. South Med J. 2019;112(11):581-585. doi:10.14423/SMJ.0000000000001035
- Thai JN, Saghir HA, Pokhrel P, Post RE. Perceptions and experiences of family physicians regarding firearm safety counseling. Fam Med. 2021;53(3):181-188. doi:10.22454/FamMed.2021.813476
- Ellis J, Woehrle L, Millon-Underwood S, et al. The effect of racism and discrimination on the health of Milwaukee’s African American Population. WMJ. 2022;121(2): 132-140,144.
- Schiefelbein AM, Krebsbach JK, Taylor AK, et al. Treatment inequity: examining the influence of non-Hispanic Black race and ethnicity on pancreatic cancer care and survival in Wisconsin. WMJ. 2022;77-85,93.
- Lor M, Koleck TA, Lee C, Moua Z, Uminski JE. Documentation of pain care and treatment for limited English proficiency minority patients with moderate to severe pain in primary care. WMJ. 2022;86-93.