Chicago Health is committed to publishing a diversity of opinions. The opinions expressed in this op-ed article are the author’s own.
Many nonmedical issues affect our health — such as the conditions in which people grow up, work, live, and age, as well as the systems that shape these conditions. Together, these social determinants of health play a great role in our overall health. They can even affect people’s recovery from orthopedic surgery.
But while we can address many symptoms impacting physical health, it’s more difficult to address the underlying social determinants of health.
The challenge is much like this story that Chicago-based social reformer Saul Alinsky popularized: A child is drowning in a fast-flowing stream. You spring into action to pull the child to safety. Soon after, however, you see another child, followed by another. As fast as you pull children out of the water, more keep appearing. A group of people gather to accomplish this task. One day, a member of the group heads upstream. Shouting after the person for help, you demand to know what they’re doing. “I’m going to find out who is throwing these children in the water!” comes the reply.
The moral of the story? More lives can be saved, more energy better spent, if we identify and address the root problem. And therein lies our work in tackling the factors that negatively impact our nation’s collective health.
As a longtime orthopedic surgeon in Chicago, I’m particularly interested in how these issues affect patients requiring orthopedic assessment and treatment. The remarkable advances in technology and medical knowledge have greatly advanced our ability to care for our patients; however, in cases where the results are not ideal, or when complications occur, the root analysis of the problem often leads back to a deficit in the social determinants of health.
The need for diversity and representation
When addressing social determinants of health, we must think critically about the issues surrounding health disparities in terms of race. A 2020 study, published in the journal Arthritis Care and Research, looked at racial differences in pain and function after knee arthroplasty, or knee replacement. Though the study did not find significant differences in most adjusted outcomes, it noted that Black patients underutilize knee replacements, in part due to a lack of trust in the healthcare system. Clinicians may contribute to that underuse because of their implicit or explicit bias.
A lack of diversity in the medical profession contributes to a care deficit. Nationally, about 13% of Americans identify as Black, but only 5% of physicians are Black. In orthopedics, this gap widens with a mere 2% of orthopedic surgeons identifying as Black.
This lack of representation may stymie open dialogue between patients and their healthcare providers, in effect throwing up a roadblock to them receiving the best possible care. Therefore, a first and urgent step is diversifying the medical profession as a whole.
The Chicago scene
A University of Chicago study, published in 2020 in JAMA Network Open, analyzed census data to examine how social determinants of health affected neighborhoods in Chicago compared with those across America. The study went beyond commonly tracked social determinants of health — education, minority status, and poverty — and looked at variables ranging from English-language proficiency to transportation access to high rent burdens.
The team found that more than 60% of premature mortality in Chicago was associated with the 15 social determinants of health they explored — even after accounting for violent crime and regional differences.
One way health systems can address this is through geographic data science, where we examine social determinants of health by ZIP code or neighborhood. This may help us more easily identify patients who require additional preoperative screening and support. Although this isn’t an exact science, it is an early attempt to use large data sets to identify at-risk populations so we can leverage upstream measures to reduce complications and failed treatment.
Although many physicians recognize the link between social determinants of health and patient outcomes, it’s hard for any one physician to make meaningful change on their own. Too often, they’re trying to institute an incomplete and downstream treatment plan. Therefore, clinical leadership needs to understand health disparities and leverage their authority to shape team culture and values in hopes of driving nationwide change.
It’s true that patients can play a vital role in strengthening their surgical outcomes through weight management, smoking cessation, managing their diabetes, and establishing a healthy diet.
As doctors, however, we must take a closer look at each individual patient’s circumstances and acknowledge the reality of obstacles they may be facing: Does this patient have access to healthy food? Do they have access to nature and green spaces? Do they have access to rehabilitation and physical therapy services? Finally, we can look at offering further support — usually in the form of patient counseling or referrals.
As I try to make a positive impact on the social determinants of health within my own Chicago practice, I find that open, honest, and compassionate communication with all patients is key.
I also continue these conversations outside of my office with other medical professionals in hopes of diversifying the medical field and strengthening our commitment to improving the health and care of our communities overall.
The question is: Will you be a part of the conversation?