Clinical problem solving and social determinants of health: a descriptive study using unannounced standardized patients to directly observe how resident physicians respond to social determinants of health
Authors: Wilhite Jeffrey A. , Hardowar Khemraj , Fisher Harriet , Porter Barbara , Wallach Andrew B. , Altshuler Lisa , Hanley Kathleen , Zabar Sondra R. , Gillespie Colleen C. 
Published: August 2020

Abstract

Objectives
While the need to address patients’ social determinants of health (SDoH) is widely recognized, less is known about physicians’ actual clinical problem-solving when it comes to SDoH. Do physicians include SDoH in their assessment strategy? Are SDoH incorporated into their diagnostic thinking and if so, do they document as part of their clinical reasoning? And do physicians directly address SDoH in their “solution” (treatment plan)?

Methods
We used Unannounced Standardized Patients (USPs) to assess internal medicine residents’ clinical problem solving in response to a patient with asthma exacerbation and concern that her moldy apartment is contributing to symptoms – a case designed to represent a clear and direct link between a social determinant and patient health. Residents’ clinical practices were assessed through a post-visit checklist and systematic chart review. Patterns of clinical problem solving were identified and then explored, in depth, through review of USP comments and history of present illness (HPI) and treatment plan documentation.

Results
Residents fell into three groups when it came to clinical problem-solving around a housing trigger for asthma: those who failed to ask about housing and therefore did not uncover mold as a potential trigger (neglectors – 21%; 14/68); those who asked about housing in negative ways that prevented disclosure and response (negative elicitors – 24%, 16/68); and those who elicited and explored the mold issue (full elicitors – 56%; 28/68). Of the full elicitors 53% took no further action, 26% only documented the mold; and 21% provided resources/referral. In-depth review of USP comments/explanations and residents’ notes (HPI, treatment plan) revealed possible influences on clinical problem solving. Failure to ask about housing was associated with both contextual factors (rushed visit) and interpersonal skills (not fully engaging with patient) and with possible differences in attention (“known” vs. unknown/new triggers, usual symptoms vs. changes, not attending to relocation, etc.,). Use of close-ended questions often made it difficult for the patient to share mold concerns. Negative responses to sharing of housing information led to missing mold entirely or to the patient not realizing that the physician agreed with her concerns about mold. Residents who fully elicited the mold situation but did not take action seemed to either lack knowledge or feel that action on SDoH was outside their realm of responsibility. Those that took direct action to help the patient address mold appeared to be motivated by an enhanced sense of urgency.

Conclusions
Findings provide unique insight into residents’ problem solving processes including external influences (e.g., time, distractions), the role of core communication and interpersonal skills (eliciting information, creating opportunities for patients to voice concerns, sharing clinical thinking with patients), how traditional cognitive biases operate in practice (premature closure, tunneling, and ascertainment bias), and the ways in which beliefs about expectancies and scope of practice may color clinical problem-solving strategies for addressing SDoH.