. . . partnership is such an important theme of the NAM report. It is also an essential component of the broad-er work we must all do to address the social determinants of health. I firmly believe that medicine, particularly academic health centers and their associated medical schools, plays a key role in addressing SDOH. However, this is not medicine’s work alone, and we should lean on our partners whose skills and experience complement our own, and sometimes surpass ours.
This past November, I gave grand rounds at Dell Medical School Department of Medicine on the Social Determinants of Health (SDOH). My talk centered on the recommendations of the recent National Academy of Medicine “Integrating Social Care in to Health Care” report (NAM Report).1 We followed the presentation with panel discussion that included a multi-disciplinary group of leaders talking about opportunities to advance health leveraging team based approaches and community partnerships. The panel included Barbara Jones, chair, Department of Health Social Work; Jewel Mullen, associate dean for equity; Bill Tierney, chair of population health; and Keegan Warren-Clem, Medio-legal Partnership, who was also a member of the NAM Report Consensus Panel.
We did this special portion of the grand rounds because partnership is such an important theme of the NAM report. It is also an essential component of the broader work we must all do to address the social determinants of health. I firmly believe that medicine, particularly academic health centers and their associated medical schools, plays a key role in addressing SDOH. However, this is not medicine’s work alone, and we should lean on our partners whose skills and experience complement our own, and sometimes surpass ours.
Medicine most naturally thinks of this work as what we can do for individual patients in our care. The team-based care approaches like those of the Patient Centered Medical Home or multi-disciplinary team rounds in the acute care setting are “go to” models. Though there are many important members of the health team, social workers are expert in understanding and addressing the social determinants of health. “A social worker starts where the person is and helps identify what matters most to each person. That’s essential in building a health system that places value on better health outcomes based on each individual’s needs.”
Dell Medical School is taking the team-based approach further by making structural change in the medical school. It is a bold and a first-in-the-nation approach that established a Department of Health Social Work in the school alongside Medicine, Pediatrics, etc. The work of the Department (Department) is “Advancing the Role of Social Work as an Agent of Health Care Transformation” led by Barbara Jones, a distinguished, senior social work researcher and educator from the Steve Hicks School of Social Work who was also a member of the post-Grand Rounds. The faculty in the Department is involved in all four pillars of the school’s mission. In addition to being an essential part of the team for the clinical care models and to conducting research, they also drive the interprofessional education for the medical students.
While I am proud of the cutting-edge work of Dell Medical School and peers across the country who work to build or strengthen teamwork and partnerships to address the social determinants of health, a question we received following the Grand Rounds presentations has stuck and pushed me to question the physician/medicine centric approach that predominates. The question came from Dr. Aliza Norwood, about whom I wrote in a previous column on medical education approaches to SDOH—“if we know that social influencers have more impact on health than medicine, then shouldn’t social workers be the team leaders for our most vulnerable patients instead of physicians?” She shared with me later that “the idea I was trying to convey is that I don’t think social workers should necessarily always be the lead, but for patients who have outsized barriers to health that are heavily influenced by their lived environment and social circumstances, it is incredibly difficult for a primary care physician to take the lead and address the patient’s health in a 15-minute visit, and that for many more patients than we realize, social work should be at the forefront. The result of a physician-led model in these cases is waste (ie, prescribe meds the patient can’t afford)…and higher medical costs (for the patient who gets shut-tled to different referrals/services, for patient and system when they end up in the hospital because of an inability to address the social determinants causing poor health).”
Aliza’s words remind me that though I think I am an open-minded, innovative thinker when it comes to care models, like many doctors, I still gravitate towards a “medical model” for addressing health: one in which the physician is the team lead and/or the medical system the lead partner. These models are predicated on the physician-patient dyad as the “center” of the work and other members of the team support them. Aliza’s question was an important call-out for me since doctors and medicine are but one of many drivers of health and resources for our patients. If we truly want the best for them, then there may be times when we may need to step back and let others lead. This takes a lot of humility.
Stepping back and allowing others lead in the drive for health is true at the individual level. There are many times across the life course that someone’s social drivers outweigh his medical drivers. For example, in the window of interconceptional care as a pathway to reducing maternal mortality, the highest need may be for a social work expertise, not medical. The “dyad” to support could be the patient, and a social worker rather than the patient, and a physician.
This non-medical led model will also be valuable if we really want to develop upstream, preventive models that drive well-being and not just health. Take an outcome like third-grade reading level that is highly correlated with reducing inequity. Achieving an outcome like that requires a mix of policies that are outside of the direct control of medicine, like broad availability of parental leave, access to affordable early childhood education, the availability of a living wage, of safe housing, health food and quality, affordable schools. Of course, there are also clinical drivers necessary to ensuring that children reach a third-grade reading level, including meeting the vaccination schedule and assessment of vision and hearing. But in this important social health outcome, medicine is a helpmeet, and should not be the lead.
We are just beginning this exciting and important journey of addressing health beyond the traditional tools in the healthcare sphere. Medicine and physicians have very important work to play as part of the broad fabric to support our patients and communities. As we build this work, we should recognize that we do not always need to be
at the center of the work building a system in which the team members and partners are spokes on our hub. Medicine needs to accept that in the case of addressing the social determinants of health, we may need to be the spoke in a partner’s hub, which is the goal of building a model that best meets the needs of our patients as people. This will require a significant shift in our world view and I am thankful to the provocative question that has caused me to mull this. This new humility will be necessary if we are to help our patients and communities achieve their physical, emotional, and social goals.