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Social History Is Part of Medical History

By Dr. Charlie Preston
. 1 Comment(s)

The Center for Disease Control’s (CDC) latest report on health disparities drives home a point that many people are already aware of: income and education impact health. Physicians understand this relationship better than most people, but still, we don’t understand it well enough.

The income and education chapter’s first set of graphs examine the demographics of not completing high school, a phenomenon the authors call “high school noncompletion”. The link to ill health is shown in another series of graphs, in which rates of disability (ill health) are compared between adults who didn’t graduate high school and adults who did. The data show that there are 2 times as many instances of disability in the non-completers as there are in the graduates, 24% to 12%, respectively.

Yet most physicians don’t think about high-school graduation as a medical problem—or, as a health disparity. But data show that in 2009, the percentage of Hispanic adults who failed to complete high school was more than 4 times greater than whites, 39% to 9%, respectively. For Blacks, the number was slightly better, but still twice the level of whites.

Such alarming figures beg the question: what are physicians doing to improve high school graduation rates amongst minorities? Are we even doing anything? The superficial answer is somewhat depressing-- a quick search of Pub Med using the term “high school noncompletion” yielded just 7 results, none of which described any programs or interventions. To be sure, there are many people who are working on this in education, but my suspicion is that very few are working on it in medicine.

What can a physician do about high school noncompletion? To be honest, there isn’t very much guidance. Neither the US Preventive Services Task Force nor the US Community Preventive Services Task Force feature website links for recommendations on adolescent education. But one idea for an intervention could be as simple as the clinician giving a 15 second message about the importance of staying in school, targeted specifically to minority patients. Steven Woolf, a prevention expert, suggested that integrating social change into patient care will require practitioners to establish social milestones for patients and then collaborating with community partners to find solutions.[1] With the advent of medical records, he continued, physicians could even monitor social situation as another “vital sign”. There are no doubt many possibilities.                                                                                             

The bottom line is that the social determinants of health, the umbrella where income and education fit underneath, are increasingly being recognized as major contributors to death and disease. In fact, Healthy People 2020, the US government’s official prevention goals, recognized the tremendous importance of social determinants, and included it as one of 42 topic areas-- on equal footing with cancer and heart disease. Physicians should heed this trend. For too long they have glossed over the patient’s social history, where subjects like unemployment and school truancy are mentioned. When I was a resident, training at a busy community hospital, my attending would often ask me to skip the social history entirely in order to save time. Besides, they often argued, social problems were for social workers, not physicians.

It is time for everyone in the medical community to think about problems in the economy or in the education system as not just somebody else’s problem, but rather, as our problem, especially as physicians and caretakers of health.

[1] Woolf SH. Social policy as health policy. JAMA. 2009 Mar 18;301(11):1166-9.

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  1. Sam Dugo

    I think James Vanderbeek made a similar remark in time weekly.

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