Rethinking the social history.

R has established that social environments affect human health.1 Acknowledged social determinants of health — including racial or ethnic background, occupation, and the use of alcohol and tobacco2 — also influence the effectiveness of health care delivery.3 But other social factors, such as the ability to afford medications, access to transportation, available time, and competing priorities, may influence health outcomes even more. Although we believe that exploring these issues constitutes an essential part of the medical examination, the most important and relevant social history questions are rarely asked or acted on. Applying social science principles to medicine — a practice sometimes called “social medicine” — enables us to contextualize patient care to achieve more sustainable and equitable health outcomes. Social medicine elucidates how patients’ environments influence their attitudes and behaviors and how patients’ agency — the ability to act in accordance with their free choice — is constrained by challenging social environments. Physicians often see patients with complex social situations as a burden — requiring extra work that is neither reimbursable nor central to our core clinical expertise. Unfortunately, we inculcate these attitudes in trainees, implicitly and explicitly, perhaps because of our discomfort with hearing difficult stories or our sense of powerlessness or incompetence in addressing these root problems. Whereas biologic pathology may present specific targets for intervention, social or structural pathology is difficult to treat. Since social problems affect patients’ health and treatment effectiveness, however, we cannot afford to ignore them in assessments and treatment plans if we hope to improve outcomes, reduce costs, and improve patient satisfaction. Moreover, clinicians’ simple acknowledgment of social forces can strengthen their therapeutic alliance with patients. Patients know clinicians cannot alleviate their poverty, but empathy and concern shown by a clinician who explicitly addresses it constitute powerful medicine. So how should we teach students and clinicians to explore social determinants of health? How can we encourage health care teams to explore social factors that influence health care delivery? And how should clinical teams address these issues? To start, obtaining a more appropriate and comprehensive social history can enable proper assessment of a patient’s social environment. Although many social barriers exist between patients and providers, deliberate inquiry into the social environment allows clinicians to understand behaviors such as nonadherence to treatment plans, missing of appointments, or failure to fill prescriptions not as products of ignorance or willful misbehavior but rather as results of the complicated interplay of individual factors with a complex social environment. For example, a proper social history of a “brittle diabetic” patient may reveal a very limited income that precludes purchasing healthy foods. Social isolation may prompt excessive emotional eating, limited mobility may hinder monthly visits to the pharmacy to pick up prescriptions, depression or poor coping skills may thwart lifestyle modifications, family lore regarding “low sugars” may impede adherence to insulin regimens, and life with arthritic knees in a third-story walk-up in a violent neighborhood may make prescribed daily walks seriously challenging. Adopting the social medicine framework, we revised our list of social history topics in an effort to strengthen our therapeutic alliances, better contextualize patients’ diagnostic and treatment plans, and improve health outcomes (see box). Our topics extend well beyond the common “TED” (tobacco, ethanol, drug use) questions, encompassing six categories: individual characteristics, life circumstances, emotional health, perceptions of health care, health-related behaviors, and access to and utilization of health care. Primary care clinicians may find that such a comprehensive history is best obtained over multiple visits, but we believe it is ideal to revisit these questions annually; inpatient clinicians probably need to be more targetBECOMING A PHYSICIAN