Social Determinants of Health in Family Medicine Residency: A National Survey of Program Directors

Excellent clinical care includes serious consideration of each patient’s life experience and the impact of the patient’s psychological state and social surroundings on health care. Social and environmental factors account for more than 50% of all health outcomes, underscoring the need to address social determinants of health (SDH) to eliminate health disparities. ^{1, 2}

Considerations of family, neighborhood, community, and social factors are fundamental to the specialty of family medicine. ³ Education of family physicians requires a curriculum that supports early, robust continuity experience across a diverse spectrum of patient populations. ³ Additionally, training primary care physicians to screen for barriers to healthy living can shape counseling options and care plan discussions.

To achieve the quadruple aim of improving population health, improving the patient experience, improving care team wellness, and reducing health care costs, undergraduate medical education and graduate medical education curricula must integrate information about both the prevention and treatment of disease and the impact of the community of the patient on health care. ⁴ Recent studies have indicated that longitudinal patient care experiences in medical school, over the course of years rather than weeks, result in improved performance, greater learner satisfaction, and a strong sense of patient-centeredness in learners. ^{5, 6} Limited parallel work has been done in graduate medical education, with principal examples being the impact of single determinants on specific outcomes (eg, impact of food insecurity on nutrition outcomes). Additionally, data show that greater capacity to address SDH may be associated with lower rates of burnout. ⁷

Relevant knowledge and skills for training in family medicine residencies include awareness of social needs and their impact on health, development of approaches to identifying the presence of social needs among primary care patients, and operationalization of the connection between patients and the available resources that exist within the service landscape of the communities they serve. The challenge for programs is to prepare residents to function effectively while in their training setting as well as their future practice settings, which may have a different prevalence of social needs, screening tools, and available resources. Recent Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements emphasize the importance of SDH training: for example, section IV.B.1f states:

However, the extent to which these competencies are fully implemented is not clear. Barriers and facilitators to implementation have not been adequately studied. The purpose of this study is (1) to describe the scope of SDH screening and education in family medicine residency, (2) to identify residency program characteristics associated with robust SDH curricula, and (3) to identify barriers to addressing SDH in residency.

We conducted a cross-sectional survey of family medicine residency program directors (PDs). Survey items were included as one component of a larger national survey conducted by the 2020 Council of Academic Family Medicine Educational Research Alliance (CERA). For the purposes of this survey, social determinants of health were defined as the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.

The methodology of the CERA Program Director Survey has been described previously in detail. ⁹ The CERA steering committee evaluated questions for consistency with the overall subproject aim, readability, and existing evidence of reliability and validity. Pretesting was conducted with family medicine educators who were not part of the target population. Following pretesting, questions were modified for flow, timing, and readability. The project was approved by the American Academy of Family Physicians Institutional Review Board in September 2020. Data were collected from September 23 to October 16, 2020.

The sampling frame for the survey was all ACGME-accredited US family medicine residency program directors as identified by the Association of Family Medicine Residency Directors. Email invitations to participate were delivered with the survey using the online program SurveyMonkey (Momentive). Two follow-up emails, to encourage nonrespondents to participate, were sent weekly after the initial email invitation, and a third reminder was sent 2 days before the survey closed. There were 693 program directors at the time of the survey; one had no email address indicated. Twenty-eight previously opted out of SurveyMonkey surveys or their emails were undeliverable. Therefore, the survey was emailed to 664 individuals. The survey contained a qualifying question to remove programs that had not had three resident classes. Forty program directors indicated that they did not meet that criterion. Those responses were removed from the sample, reducing the potential sample size to 624.

We summarized all items using descriptive statistics, including frequencies and means. We examined differences between group-level findings using χ² tests and logistic regression. We conducted multivariate analyses to refine our understanding of univariate associations. We used ordinal logistic regression to identify program characteristics associated with PDs’ greater perception of resident SDH competency upon graduation from residency. Results were considered statistically significant at P<.05. Data were analyzed using R version 3.5 (R Foundation for Statistical Computing) and SPSS version 26 for Windows (IBM).

A total of 312 respondents completed the omnibus survey, and 279 went on to answer questions related to SDH curricula, for a response rate of 45%. Most respondents (60%, 166/279; Table 1) led community-based, university-affiliated residency programs. A plurality (46%, 128/279) had between 19 and 31 residents in their total complement. The composition of residents and faculty that identified as underrepresented minorities in medicine (URiM) is included in Table 1.

A majority of respondents (59.1%, 165/279) strongly agreed that screening for social needs should be a standard part of care, though a minority (41.1%, 115/280) used standardized screening tools to identify SDH in clinical settings with trainees (Table 2). Among those that used standardized screening tools, a majority (76.5%, 88/115) indicated that those tools were incorporated into the electronic health record as opposed to being a stand-alone or paper-based system. Thirteen percent (37/279) indicated that their residents were not formally trained in SDH, 45.5% (127/279) reported some formal training, and 41.2% (115/279) reported significant training (Table 2). Approximately 47% of respondents (129/277) reported that their residents graduated with “none” or “basic” competency in addressing SDH.

The most reported barrier to addressing SDH in residency was lack of clinical resources to address SDH (eg, social workers, legal advocates), followed by lack of community resources (Table 3). Respondents’ agreement that screening for social needs should be a standard part of care was associated with PDs’ greater perception of resident SDH competency (OR=5.88, P=.01). Percentage of URiM faculty was not associated with perceived SDH competency (OR=1.10, P=.17). Similarly, the percentage of URiM residents was not associated with perceived SDH competency (OR=1.04, P=.57). Availability of SDH tools was associated with greater independent-level perceived SDH competency (OR=5.24, P<.01). Team collaboration for SDH response (referring patients to individuals, such as social workers or community health workers who can link the patient with appropriate resources) was associated with PDs’ greater perception of independent-level resident competency (OR=2.11, P=.03).

The immense impact of SDH on health outcomes has been described for decades. Social barriers leave patients vulnerable, and many physicians feel inadequately prepared to identify or meaningfully address these issues. ⁵ With this in mind, our findings are not surprising: Viewing SDH as a priority, providing significant training, and having tools available to address SDH were associated with PDs’ increased perception of resident SDH competency. As with any clinical topic, teaching learners to value the impact of SDH on the patients they serve is imperative.

Our survey showed that having available referral resources to address SDH was associated with PDs’ increased perception of resident SDH competency. This finding begs the question of whether having a team-based approach to SDH increases learner skills or merely results in overestimation of competency. Team-based care is increasingly being implemented to distribute the immense work of helping patients with complex biopsychosocial needs.¹⁰ Learning when and how to refer to social workers or community health workers is a necessary skill, but perhaps insufficient. This approach can be expanded into a discussion of the overall goals for SDH education in graduate medical education. Does the provider need to develop the skill set required to personally help patients overcome SDH barriers? Or should the emphasis remain on identification and effectively using an interprofessional, team-based approach? Most likely, given the variations among both the barriers themselves and the available resources from community to community, a combination of skills should be fostered during training.

In this study, we identified lack of resident knowledge or training as a barrier to addressing SDH. The ACGME common program requirements ⁸ now include training on identifying and addressing SDH for all residency programs. As with any learner skill, expertise is not expected at the onset of training. Just as residents progress in their knowledge of disease processes and treatment interventions, identifying and addressing SDH with patients within the context of their communities is a vital skill that needs to be nurtured. Instilling SDH as a longitudinal thread throughout training allows learners to continually assess and build on their knowledge and skills. We identified lack of faculty expertise as another program-level barrier. Published SDH curricula are widely available, including didactic teaching, community-based training, and clinical experiences that have been successfully implemented in graduate medical education.⁵ A variety of approaches may allow for increased repetition and further reinforcement of SDH as an institutional priority.

Barriers related to screening and lack of clinical or community resources have been identified and cited as common roadblocks to addressing social determinants of health. With several tools already developed and disseminated,^{11, 12} providers are increasingly using tools to identify and address SDH in clinical practice. Screening for SDH has been shown to increase both identification of barriers and referral to available resources, ¹³ though best practices for how to incorporate screening into the clinical encounter have not yet been determined. ¹⁴ Though most providers understand the impact of SDH on the lives and health of their patients, routine screening is still not standard practice. Physicians routinely cite both time constraints and lack of necessary skills or resources to address SDH as barriers for screening implementation.¹⁵ Though screening may add time, knowing the far-reaching impact SDH can have on health outcomes, that time is undoubtedly well spent.

Routine screening without adequate resources to act on the results may lead to unintended negative outcomes, in addition to ethical issues.¹⁶ However, tools are available for addressing SDH barriers once they have been identified. Geographic information system (GIS) programs allow care teams to identify community-based resources and referral sites for a range of SDH domains. GIS offers the potential to overcome both the perceived lack of clinical and community resources. As with screening, further study to determine the best use of these promising technologies is underway.

Our study had several limitations. First, our response rate was 45%, and we do not have information on nonresponders. To meet criteria for inclusion in CERA’s omnibus survey, we were limited in the number of questions we could ask. Therefore, our findings may not capture other important aspects of SDH curricula. Responses are self-reported by the program director and could be subject to social desirability bias. Program director-reported competency may be less accurate than resident-reported competency. Future studies designed to measure resident perception and outcomes may complement our study of program directors’ perception of competency. These limitations notwithstanding, we feel this study can aid program directors and faculty in advancing SDH curricula.

In our survey of program directors of family medicine residency programs, nearly all agreed that screening for social needs should be a standard part of care. This vision, however, is not yet realized. Factors associated with PDs’ greater perception of resident SDH competency were team-collaboration for addressing SDH, availability of SDH tools, and program director buy-in (respondent agreement that social needs should be a standard part of care). To better train the next generation of physicians to identify and meaningfully address social needs, additional research is needed, including mixed-methods approaches incorporating qualitative assessments to define best practices and patient-centered outcomes related to identifying and responding to SDH.

Preliminary findings were presented at the 2021 North American Primary Care Research Group (NAPCRG) Annual Meeting, held virtually due to COVID-19, as well as Beyond Flexner 2022 in Phoenix, AZ.