SCOPE OF SERVICE:
HEALING BEYOND THE BODY
What is the physician's job description? Where does taking care of someone start and stop when it comes to social determinants of health and all that “health”—in its near-infinite complexity—involves? What is the internal experience of creating “boundaries” to one's medical practice, of navigating which social maladies may fall outside
the feasible scope of service?
Defined forty years ago by academic medical leader Donald Seldin, MD as a “very narrow discipline” focused on “application of the theoretical knowledge incorporated in medical science to individual patients,” medicine in the United States has since evolved to encompass the promotion of “health” more broadly defined (1). Today, medicine applies a more intentionally collective and interdisciplinary—rather than individual and strictly biological—leading paradigm. Wellness and prevention are emphasized as much as symptomatic treatment of developed disease. Trainees are taught to recognize the breadth of extra-biological inputs into patients' behavior, lifestyle risk factors and wellbeing (1,2). Social determinants of health (SDOH) across economic, educational, environmental and sociopolitical arenas (e.g., food and housing insecurity, education access) are accepted as key contributors to health and disease at both patient and population levels (3).
In this sense, SDOH can reasonably be placed under the umbrella of modern medical practice (4). It follows, then, that medical providers may feel responsible for far more than the immediate treatment of “the patient in front of [them]" (5). Indeed, from an SDOH perspective, physician responsibility can be considered almost infinite—as infinite as the biopsychosocial inputs into the physical and mental health of individual patients and the communities in which they live, work and grow. From advocacy efforts led by renowned organization Physicians for Social Responsibility, to tax preparation support offered to patients through groundbreaking program StreetCred, the potential scope of physicians’ work appears at once impossibly vast and necessarily ambitious (6,7). Accordingly, some providers have posed questions probing the ideal versus feasible bounds of physicians’ “social responsibility" (8). Such questions imply internal struggles around wanting, wishing to consistently address SDOH—to help patients holistically and optimally—yet facing constraints of time, energy and individual ability to create change within a larger bureaucratic-legal system (1,8-9).
A 70-year-old patient is admitted to the hospital for pneumonia. The medical team quickly discovers that he struggles with food insecurity on a regular basis. They provide him with a grocery store gift card and information about local food services prior to discharge. Later that year, a physician on the team initiates an advocacy project to address food insecurity in the elderly across the county.
A patient struggling with an eating disorder is hospitalized for acute medical stabilization. When preparing for this patient’s discharge, the medical team recommends intensive residential treatment. Upon further investigation, none of the nearby/feasible residential centers accept this patient’s insurance. In the end, the patient is discharged to an outpatient-based treatment program considered “less ideal” for her level of illness.
Institute of Medicine (US) Division of Health Sciences Policy. Medical Education and Societal Needs: A Planning Report for the Health Professions. Washington (DC): National Academies Press (US); 1983. Chapter 6, Infusion of New Fields into Medical Education. https://www.ncbi.nlm.nih.gov/books/NBK217685/
Stefan L and Gordon D. “The Role of the Doctor and the Competencies Expected from the Doctor of the Future.” Routledge International Handbook of Medical Education. Routledge; 2015.
Rosenberg J. Social Determinants of Health Are Important, but Who Is Responsible for Addressing Them? American Journal of Managed Care. June 18, 2018.
Thomasson, C. Physicians’ Social Responsibility. Virtual Mentor, AMA Journal of Ethics. 2014;16(9):753-757.
Shah N. Physicians’ Role in Protecting Patients’ Financial Well-Being. Virtual Mentor, AMA Journal of Ethics. 2013;15(2):162-166.
Physicians for Social Responsibility. https://www.psr.org/
StreetCred. Boston Medical Center. https://www.bmc.org/streetcred
Rubin D. How much should physicians be responsible for addressing social risks to their patients? The Philadelphia Inquirer. July 1, 2019.
Heath S. Are Providers Responsible for the Social Determinants of Health? Patient Engagement HIT. May 10, 2018.