Family Medicine and Social Determinants

We would like to respond to the commentary by Drs Hollander-Rodriguez and DeVoe on the role of family medicine in addressing population health.1 We agree there is a need for the health care system to address population health and its social determinants. We disagree, however, on their proposal to add skills to our already overstretched residency training programs. The skills the authors proposed included

…community engagement, patient empowerment, community organizing, collaboration and team work, relationship leadership, informatics, data analysis and creative problem solving and the skills for conducting community assessments and for identifying adverse social determinants of health in our patient populations.

This list includes skills that most family physicians will never use. It is true that they are all important skills that are needed to effectively address population health, but there are other professionals with much more extensive training in these areas, who can better apply them in agencies that address population health issues. We should not try to make all family physicians population health experts. Recognition of and respect for the various competencies of other professionals, and collaboration with them is preferable to trying to take over their roles.

The vast majority of family physicians provide care on a daily basis to individual patients. What should we be training them to do to maximally serve a constructive role in addressing population health? We should emphasize the basic aspects of population health that are included in family medicine curricula and the patient-specific clinical skills that contribute to the population’s health. We would organize these competencies as:

1. Collaboration with population health agencies
   • Communicating with local and state health departments and other agencies that assess and address population health
   • Accurately reporting reportable diseases and conditions and unusual disease clusters
   • Accurately recording vital statistics (on which a large part of community health assessments are based)
   • Referring patients to community resources that can help address an individual’s adverse social determinates of health
2. Clinical prevention competencies
   • Fully implementing evidence-based clinical prevention guidelines (screening, immunization, counseling, and chemoprophylaxis)
   • Effectively counseling patients to achieve lifestyle changes
   • Providing guideline-based medical care of sexually transmitted diseases, tuberculosis, and other diseases important to the public’s health
3. Cost-effective stewardship
   • Developing and implementing a quality improvement plan
   • Interpreting and critiquing medical literature (basic epidemiology and statistics)
   • Providing evidence-based medical care for highly prevalent chronic diseases
   • Avoiding unnecessary and costly testing, ineffective treatments, and excessive use of antibiotics

Until we can assure that most family physicians are performing this list competently and consistently we should not be adding competencies for which we can, at best, only partially train our residents. Those family physicians who want to take a more active role within the system, population, and community levels and in our political systems would be well served to obtain many of the skills listed by the authors by way of additional training, including certificate or degree programs.