SOCIAL DETERMINANTS OF HEALTH IN FAMILY MEDICINE RESIDENCY EDUCATION
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* Deborah S. Clements

Social determinants of health (SDH) are the conditions in which people are born, live, learn, work, play, worship, and age that impact health, function, and quality of life. Typically, SDH are categorized into 5 broad areas: health and health care, social and community context, education, economic stability, and neighborhood and built environment, with multiple subcategories in each. Only about 20% of the impact of SDH can be attributed to health and health care alone—things such as access, quality of care, and provider competency. The vast majority of health inequity and inequality can be ascribed to environment, social and economic factors, and learned healthy behaviors.1 These inequities lead to health disparities reflected as obstacles to health and a worsening quality of life for people across the country.

Family medicine is deeply rooted in the principles of caring for patients in the context of their family and community over time. As we prepare the future generations of family physicians, teaching these principles with a renewed focus on the role of SDH in wellness is critical to both the health of our communities and the future of our specialty.

A recent review of Accreditation Council for Graduate Medical Education (ACGME) residency program requirements showed that only family medicine training programs specifically require residents to assess community, environmental, and family influences on health. Other primary care programs either have no explicit requirements or focus predominantly on advocacy to address health inequity.2–4 In recognition of the importance of SDH, the recently implemented Clinical Learning Environment Reviews (CLER) requires that all residents be involved in addressing health care disparities at the clinical site where they are trained, but do not extend into the community.5 Even with this recent requirement, CLER data published in 2016 indicate only about one-half of residents are aware of the priority to address health disparities. Knowledge and implementation of community needs assessments fare even worse.

During family medicine residency education, renewed emphasis must be placed on learning about the communities where patients live and work, expanding attention to include population health and the evaluation of community health problems. Technology is now readily available to supplement the home visits and community activities already a part of a busy curriculum. Vastly improved access to publicly available databases through geocoding and partnerships with community-based organizations offer opportunities to enhance residency curriculum in a meaningful, impactful way. Incorporating asset-mapping activities into community medicine experiences allows residents to understand the strengths and resources of a neighborhood as well as the challenges patients may face in public transportation, access to healthy foods, and safe places to exercise. Additionally, tools that generate accurate satellite images can begin to give residents empathy for the barriers patients face in their daily lives and expand their ability to make thoughtful, informed care decisions and recommendations. Ideally, linking these resources to electronic health records will allow further personalization of patient care and a deeper understanding of community needs. Improving knowledge, skills, and attitudes around SDH through the use of advanced tools and community-specific learning activities can improve the care of all patients and contribute to addressing health inequities and inequality—principles at the heart of family medicine.

*   © 2018 Annals of Family Medicine, Inc.

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2.  ACGME Program Requirements for Graduate Medical Education in Family Medicine. [http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/8/Family%20Medicine](http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/8/Family%20Medicine). Accessed Jan 8, 2018.
    
    

3.  ACGME Program Requirements for Graduate Medical Education in Internal Medicine. [http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/2/Internal%20Medicine](http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/2/Internal%20Medicine). Accessed Jan 8, 2018.
    
    

4.  ACGME Program Requirements for Graduate Medical Education in Pediatrics. [http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/16/Pediatrics](http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/16/Pediatrics). Accessed Jan 8, 2018.
    
    

5.  Wagner R, Koh NJ, Patow C, Newton R, Casey BR, Weiss KB. Detailed findings from the CLER National Report of Findings 2016. J Grad Med Educ. 2016; 8(2s1): 35–54.