Opinion | Should We Ask the Questions If We Can’t Act on the Answers?

Now along comes something new that primary care is being asked to take care of.

A new initiative has come down to us from on high saying that we must ask our patients new questions to screen them for problems related to “social determinants of health.” As we all know, there are so many things that go into our patients’ health beyond the strictly biological — where someone lives, their job opportunities, what food they have access to, the quality of the air they breathe, and the safety of their neighborhoods, to name a few. So much is entrenched in our society, including disparities that have built up over generations.

We have always recognized — although it has come more to the forefront recently — how much these things can impact the patient, and how much good can be done by making them better. Numerous screening items are already built into our electronic medical record — questions across the full spectrum of the social determinants of health. We recognize that these can have an enormous impact on our patients’ lives, but once again we are faced with a conundrum, wondering whether asking all of these questions when we don’t have the resources to do much about many of them might not, in fact, be the right thing to do.

And how did this burden suddenly fall to the primary care practices? There are literally dozens of questions that can be asked, each one of which can open up an issue that is clearly related to our patients’ health and can negatively impact upon it, but far too often we have very little power to intervene to make a difference. True, awareness is critically important, and understanding these things about our patients can help us make sure we are doing the best we can to take care of them. But what we really need are resources — lots of resources. And more than just words.

Just discovering that my patient has food insecurity — that they often have to cut back on food to pay the rent or pay for medications — or that parents are skipping meals so their kids can eat, isn’t enough. As I’ve often said, it might not always be the best thing to ask a question for which the answer is something you can’t do anything about. Over and over, we’ve been asked to pose a lot of questions, often getting an answer that only leads to more questions, and then to answers for which we have no solutions.

I’ve written before about how universal screening for mental health issues when you don’t have enough mental health resources to take care of the mental health issues you uncover creates an incredible tension that may do more harm than good. It’s not that we don’t want to know, it’s that we want to have something we can do for all of our patients for everything affecting their health.

Regarding the rest of the social determinants of health, if I discover that they live in a neighborhood where it’s unsafe to go outside to exercise, what can I offer them — a new place to live? A gym membership? A bodyguard to go with them? If I discover that the air in their neighborhood has been made toxic by chemical plants and garbage dumps placed where they live because of implicit social injustices, what can I do about it — send them home with a respiratory mask? Make the city clean the air? Find them a new place to live?

I think the answer has to be that if we are going to screen, the people who are telling us to screen for these things need to give us some tools, some resources, some money, and some power. Demonstrating that our patients in certain neighborhoods don’t have access to fresh and nutritious foods should become a rallying cry for the institution, demanding far-reaching solutions.

We should marshal whatever we can to find ways to help lessen these problems. We’re never going to be able to wipe it all away, to clean up all of this mess we created, with a bunch of simple screening questions before an annual health visit. But perhaps we can use the data we collect, and the grassroots solutions that are presented to us to offer to the patients, to raise a clarion call that more needs to be done.

We shouldn’t be surprised that these inequities exist, or that they are hindering our patients, preventing them from being as healthy as they can be. But perhaps instead of just telling the primary care teams to screen, we should do this only when we been given the necessary resources and investments to do something about the answers we get.

These new initiatives always seem to fall upon primary care, the least resourced and understaffed practices within an institution. It strikes me as odd that we don’t ask for the screenings to take place in the more intensely resourced and higher-earning practices, the subspecialties and surgical practices throughout our institution, where there seems to be more and more support, more and more personnel there to help, and more and more customer services available. Perhaps if we spread this around, make this the responsibility of everybody, making it an institutional requirement instead of once again just putting this on the plate of the already-stretched-thin primary care practitioners, we’d be more likely to get something done.

Don’t get me wrong — we are never going to shirk away from this, because we always do what we’re asked. But maybe this time if we think it through, if we ask ourselves why we are asking, and demand that we be given something to do about it, we’re more likely to help our patients get the results we’re looking for.