Socially Complex Patients: More Resources Help Docs, Too

Nicola M. Parry, DVM

March 15, 2019

Medical systems that have the capacity to meet patients' social and financial needs improve not only patient outcomes but also physician job satisfaction, according to two recent studies.

"There is an expanded interest, these days, in integrating social issues — the so-called social determinants of health [SDoH] — into clinical care," Ranit Mishori, MD, MHS, FAAFP, Georgetown University Medical Center, Washington, DC, told Medscape Medical News.

There is even a push, she added, "to urge physicians, mostly in primary care, to actively screen for social and financial factors that affect health."

SDoH are the nonmedical factors, which include socioeconomic status, education, and healthcare access, that influence a person's overall health.

Studies have shown that addressing SDoH in the context of healthcare can positively affect patients' health and reduce healthcare use and costs.

What is less well characterized is how managing socially complex patients affects clinicians.

To address that question, Matthew S. Pantell, MD, from the University of California, San Francisco, and colleagues analyzed data from 890 US primary care physicians (PCPs) who responded to the 2015 Commonwealth International Health Policy Survey.

Physicians who worked in clinics that had greater capacity to manage the social needs of patients were more likely to feel satisfied with their job (adjusted odds ratio [aOR], 3.23; 95% confidence interval [CI], 1.47 – 7.09) and with how much time they spent with patients (aOR, 2.86; 95% CI, 1.37 – 6.00), the researchers report in the January/February edition of Annals of Family Medicine. PCPs in these clinics were also more likely to think that the quality of medical care has recently improved (aOR, 1.72; 95% CI, 1.19 – 2.49).

In addition, PCPs who found it easy to coordinate care for their patients were more satisfied with their job (aOR, 2.75; 95% CI, 1.33 – 5.67), personal income (aOR, 2.28; 95% CI, 1.22 – 4.26), and with how much time they spent with patients (aOR, 3.39; 95% CI, 1.63 – 7.06). They were also more likely to think that the quality of medical care for patients has recently improved (aOR, 1.66; 95% CI, 1.20 – 2.30).

However, neither ease of care coordination or capacity to address SDoH was associated with PCP-reported stress level. That was not the case in the second study.

In that study, published online January 8 in the Journal of General Internal Medicine, Jonathan Z. Weiner, MD, MPH, from Kaiser Permanente Northern California, Oakland, and colleagues surveyed 135 PCPs in the Kaiser system to investigate the association between PCP self-reported stress and the factors that define their most complex patients.

According to their findings, most PCPs (80%) reported their care of complex patients to be either moderately (47%) or extremely stressful (32%). In addition, PCPs who reported the greatest stress were more likely to identify patients' social or financial problems as major management challenges (aOR, 4.43; CI, 1.24 – 15.28), rather than medical or behavioral problems. These PCPs were also more likely to report having greater difficulty with care coordination (aOR, 2.20; CI, 1.01 – 4.79).

"Our results suggest that the existing systems of care delivery for socially complex patients contribute to extreme PCP stress, and that improving care coordination may be protective," Weiner and colleagues write.

In an interview with Medscape Medical News, Pantell noted that the two studies are somewhat complementary, though somewhat different.

"Weiner and colleagues showed that primary care physicians are stressed about working with complex patients that presumably have socioeconomic or financial issues, and our paper suggested that if clinic capacity to address patients with social needs is adequate, PCPs are more likely to be satisfied with their jobs," Pentell said.

Mishori, who was not involved in either study, said these two articles offer very important data and conclusions that add to the existing evidence base in this area. "There is little doubt about the impact of social complexities on patients' health, and there is certainly an urgent need to address them," she said. "And, as these two studies have shown, these factors can also contribute to extreme PCP stress and play a role in burnout and retention."

The findings reported by Weiner and colleagues are not surprising, Mishori said. She noted that despite a rising educational focus on clinician-centered interventions to address patients' complex social needs, most physicians remain inadequately trained for this role and are not in a position to create lasting change.

In addition, Mishori emphasized that PCPs should not be expected to address patients' complex social needs without some training, without awareness of existing resources, and more importantly, without having a system in place to help them navigate this (often unfamiliar) terrain.

"The sustainability of this is questionable, at best, without enhanced office capacity," she said. "As the Pantell study shows, practice capacity to address sociofinancial issues is critical and directly related to physician job satisfaction and 'the perception that patient medical care has recently improved.' "

Taken together, the articles suggest that providing more resources to assist patients with social and financial needs may lead to benefits that extend beyond the patient to the provider, Pantell said.

However, because both studies were cross-sectional, he highlighted the need for prospective studies to examine "whether providing more resources to help clinical practices assist patients with social and financial needs can improve provider job satisfaction. Until that happens, our results are only suggestive, and not conclusive."

If primary care is to address SDoH effectively, a coordinated approach based on research, capacity-building, and planning is required, Mishori agreed. "This must include the participation of primary care staff, researchers, patients, public health experts, urban planners, and policy makers."

In addition, she argued that it is not (and should not be) enough to address these issues only in the primary care office, because doing so would do little to ameliorate the overall problems — inequities, structural discrimination, and lack of opportunities for segments of the population. "Solving these issues requires broader interventions on the policy and political levels," she said.

"These two studies are a step in the right direction," Mishori concluded.

The study by Pantell and colleagues was supported by the Robert Wood Johnson Foundation. The study by Weiner and colleagues was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and by Kaiser Permanente of Northern California. All authors have reported no relevant financial relationships. Mishori has received a Mapping the Landscape grant from the Arnold P. Gold Foundation.

Ann Fam Med. 2019;1:42-45. Abstract

J Gen Intern Med. Published online January 8, 2019. Abstract

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