Social Determinants of Health - Taking a Social History

Social Determinants of Health in Cancer Care

This episode was originally released January 21, 2021

In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Dr. Jacquelyne Gaddy (University of North Carolina Chapel Hill) moderates a discussion with Dr. Reginald Tucker-Seeley (University of Southern California) and Dr. Katie Reeder-Hayes (University of North Carolina Chapel Hill) on how to take a social history, with a focus on cultural humility and addressing implicit bias. Read more about this topic in Dr. Gaddy’s recent ASCO Connection article.

TRANSCRIPT

PRESENTER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

JACQUELYNE GADDY: Welcome to episode three of the ASCO Social Determinants of Health Series. My name is Dr. Jacquelyne Gaddy, and I'm a fellow in the Division of Hematology and Oncology at the University of North Carolina at Chapel Hill. Today, I am joined by Dr. Reginald Tucker-Seeley, Assistant Professor of Gerontology at the University of Southern California, and Dr. Katherine Reeder-Hayes, Associate Professor of Oncology and a Health Services Researcher at UNC Chapel Hill.

This series is a part of a new initiative proposed by ASCO president, Dr. Lori Pierce, focused on increasing oncologist's understanding of social determinants of health, its impact on patients and modifiable risk factors for cancer inspired by Dr. Pierce's presidential theme of equity, every day, every patient, everywhere. In this episode, we will look at how to take a social history with a focus on cultural humility and addressing implicit bias. Dr. Reeder-Hayes, I think I will start by asking, why do you think the social history and the taking of it is so meaningful and impactful?

KATHERINE REEDER-HAYES: So to me, as a provider, it has always felt that the social history really is serving a dual purpose. One of those purposes is simply the development of rapport and relationship, learning about your patient as a person, learning about maybe points that the two of you have in common or that you may be able to connect about, just as we would in social conversation with any other human being. But the other purpose is to identify social factors that may impact the journey that your patient is starting out on, assuming that you're meeting a new patient. We know that social determinants of health have a huge impact on a patient's ability to stick with their treatment plan, their ability to navigate their way through the health care system, and have direct impacts actually on their physical health. So those are all reasons why the social history really may be as important as any other part of a new patient history and physical exam.

JACQUELYNE GADDY: I want to Pose this next question to both you, Dr. Reeder-Hayes, and Dr. Tucker-Seeley. What are key questions that you guys believe should be asked of your patient when completing the social history? Or Dr. Tucker-Seeley, just for you, like, what are just meaningful things that you should be able to walk away knowing about your patient?

REGINALD TUCKER-SEELEY: Well, I think it's important to understand that, as Dr. Reeder-Hayes mentioned, the things that impact how a patient navigates health care and their ability to adhere to treatment, those things may be happening outside of the doctor's office. So getting an understanding of your patient's life outside of that 10 to 20 minutes that you see them is really important.

So for example, I'm working with some colleagues-- and I'll be talking about this throughout the conversation today-- with some colleagues at the Los Angeles Department of Health Care Services, and we've decided to focus on three key areas. One is housing insecurity, food insecurity, and transportation needs. And so those are three key factors that have been shown to impact how folks are navigating health care, and also, to impact their ability to adhere to treatment.

KATHERINE REEDER-HAYES: So I would add to that the kinds of approaches that Dr. Tucker-Seeley is talking about and the kinds that are pretty natural to folks who work in a public health situation are not the same-- [AUDIO OUT] we were taught in medical school, right? So we were taught to ask about risk factors. It's really an epidemiology-based understanding of what the social history is for.

What have you been doing? Have you been smoking? Have you been drinking a lot of alcohol, doing illicit drugs, sitting around being sedentary instead of exercising, and how did that lead to the health state that you're in now? That's how we were taught as physicians to obtain a social history.

Now, some of these things are still relevant. I'm not saying that they're not relevant. But you can imagine, if this is the first interaction you have with your provider, first of all, it might be kind of off-putting to be intimate about your health habits as the very first encounter with the person, especially when it's the only focus. So you need to move to a more complex model. As Dr. Tucker-Seeley was saying, that focuses on actionable items.

When was the last time we were taught in medical school to ask about how our patient got to the appointment and how reliable their transportation is, and it's highly actionable. And it's also an approach to the social history that's really multilateral. The physician probably can't make the best come on time to pick up the patient for his appointment. There might be a social worker who can get the patient a Lyft coupon or help the patient find public transit or get a volunteer to give them a ride. There are lots of things that a social worker on the team might be able to make that actionable information.

And then, finally, I think the models that we need to move to for social history need to be much more patient-led and patient-centered, so open-ended questions. Tell me something about yourself outside the hospital. What's been your biggest challenge since you got this diagnosis? Let the patient tell us which parts of their social Story. Are most important or most challenging rather than assuming that we have a checklist that's going to hit the right pieces of information if we just go down the checklist.

REGINALD TUCKER-SEELEY: I think Dr. Reeder-Hayes is highlighting that the difference in training from those of us who come from a more public health background-- I trained in public health, specifically, social epidemiology and health and social policy, and we've been talking about the social determinants for a very long time. And so I think making sure that, in addition to having physicians at the table, having social work at the table, having someone from social epidemiology or medical sociology at the table to help the team come up with the best set of questions that are most relevant for that particular practice environment.

KATHERINE REEDER-HAYES: Absolutely. And the last thing I would say is that we are in the era of the electronic health record. Not everything about it is great for patients. But one thing we can do is we can build social history over time.

So if the chart tells you the patient's smoking history you can go deeper in a small amount of time. You can say, hey, Mr. Jones, I saw it mentioned in your chart that at some point, you were a smoker. Have there been some times you tried to quit smoking? That shows respect for the patient, respect for time, and the fact that they maybe already answered this question many times, and it also allows you to get to a point in the social history that's more actionable than just repeating the same questions over and over again.

JACQUELYNE GADDY: Dr. Tucker-Seeley, you mentioned something earlier that I wanted to ask, and I know, Dr. Reeder-Hayes, you'll be able to add to this also. Who do you believe is the best person on the care team to ask these questions? Who should be initiating this conversation?

REGINALD TUCKER-SEELEY: That's a very good question. And I think we often see this in the financial hardship and cancer space where patients want to talk about cost, but physicians may not necessarily want to talk about cost because you aren't aware of what everything is going to cost, so trying to think about what is the best framework or model for thinking through this process. In the project that I mentioned earlier, we developed this framework and it's called Screen, Navigate, Connect, Address, Evaluate.

And so it takes you through the entire process. So not just thinking about am I checking something off of a list that I'm required to do, but also thinking about, how do I help the patient navigate through the process? How do I then connect the patient to the social service that will eventually address that social need? And then investigating whether or not that need was actually addressed, and then an evaluation component that then determines, did addressing this particular need actually impact outcomes or help facilitate the navigation of health care?

It can be a challenge to figure out who on the team should be asking these questions. And I think with this particular framework, you can decide who's going to be responsible for screening. Who's going to be responsible for navigation? Who's going to be responsible for connecting? And thinking within the scopes of practice of the members of the care team, who's best suited for those particular roles?

KATHERINE REEDER-HAYES: That is a great thought. And I think it connects to what I would call the need for professional humility as physicians to realize that-- we have been taught that we have to do it all, but we're not necessarily very good at doing it all. When we walk into the room with the patient, we're faced with a lot of different competing priorities, including the care of their cancer.

I think we can learn something here from the patient-reported outcomes field where what many years of painstaking research have eventually really strongly shown is that doctors and patients in a room together with the doctor trying to figure out what the patient's are in a short space of time, maybe not in real-time as the symptoms are happening, is a way to get accurate information about reported outcomes. You put in a system, patients are able to report this remotely, where they're able to report it in a systematic way, and where there are those screening and navigation components where team members are responsible for responding to those symptoms, making sure they're taking care of, not only does that patient experience get better, but survival gets better.

Cancer survival actually improves when we use the whole team, systematic, and we do screening, navigation, response, evaluation. I think there were some patient-reported outcomes for physical symptoms. It's likely to work in terms of the social components of their illness as well.

REGINALD TUCKER-SEELEY: And two, I want to make sure to point out we know that system change is hard. Doing something new is going to be a challenge. So there was a recent report by the National Academy of Medicine, a consensus study focused on integrating social care into health care delivery. And they introduced a framework as well that really focuses on the awareness within the organization of the importance of social needs, adjusting the clinical workflow to the integration of these new social factors. So I think that report can be quite helpful for any department or organization that's looking to attempt to integrate social care into their current clinical workflows.

JACQUELYNE GADDY: Dr. Tucker-Seeley and Dr. Reeder-Hayes, something that both of you just mentioned makes me think about when we're in medical school, we're taught this format. You do this, you go from A, you get to Z. You don't make any detours. If you get to a different stop before you were supposed to, that's the wrong thing.

So Dr. Reeder-Hayes, at what point in the history do you think it's important to start taking the social history? Do you do it when you first meet the patient? Do you do it at the end? Where do you think that should be structured?

KATHERINE REEDER-HAYES: So I think where we tend to put it is where it has come in the traditional format of an office visit notes or a history and physical, which is kind of down towards the bottom of when you're talking to the patient maybe right before you get to the physical exam, so you're distracted. You've already asked them about 85 things. And I would really challenge folks to think about putting social history up front and changing that standard flow.

I think there are a lot of advantages to putting social history up front. The big one is that it follows the conversational norms that we have outside of medicine. So if you walk into a bank to talk about getting a loan or you're getting to know a new neighbor, you're not going to start with the business. You're going to start by getting to know the person a little bit. And so that may feel more natural in the interaction.

And it also has an opportunity-- if we view the patient as a whole person and we give them a chance to share something that they think is meaningful or interesting about themselves, that they can just open up. I had a fellow come in last week in my clinic-- we were seeing a male breast cancer patient, and sometimes, these patients feel really awkward in our clinic. This is a clinic that's not particularly built for men. All the other patients in the waiting room are usually women. Things just sometimes don't feel culturally welcoming to them.

And he said, well-- he just told me about his encounter with the patient before I even met the patient and he said, he was kind of stiff and he wasn't saying much and his wife was doing much of the talking, but then I just switched gears and I ask him what brought him to the area, and he said, a grandchild had been born and they moved here for that, and I asked him about his granddaughter and his face lit up. He showed me pictures on his phone, and that changed the whole character of our encounter with the patient because he was able to share that. So that's one practical thing.

Also, there may just be barriers to care that will come out in the social history that are going to-- at first, I started to say derail the conversation, but not derail it. Really take it in the direction that's necessary to get anything else done with the patient's care, whether that's that they're actually having overwhelming worry about how they're going to do this care that's making them so anxious that they really can't even absorb complex medical information. I recently saw a patient who it turned out her financial worries about how she was even going to pay for the care she had already gotten and her diagnostic workup were so large that most of the options I was going to offer she didn't see options for her. And so if we had spent five minutes talking about them without my being aware that we needed to incorporate cost and financial help into the conversation we would have wasted all our time. So I think there are ways that even if using the social history up front isn't what we were taught, it may, in the end, make the visit more effective and time better spent for both the patient and the physician.

JACQUELYNE GADDY: In that same topic, what are other things that I would say mainly focused towards trainings, what can they do to become more comfortable when interacting with patients on this particular level?

REGINALD TUCKER-SEELEY: I think it's going to be important for moments of personal introspection because I think this can be very challenging given how you describe medical training is for physicians to get comfortable talking about these issues. So first, recognizing, what are some places where we're not comfortable?

So my personal research program focus is on financial hardship and cancer, and I know that one of the things that we as a country don't like to talk about are finances. And that's like-- I used to start talks with, if I asked everyone in the audience what your annual salary is, who's going to tell me what that is? No one's going to talk about it. So realizing what are the areas that you are personally not comfortable, sort of getting to the heart of how can I become more comfortable, or at least comfortable enough to be having these kinds of conversations with patients. I think also thinking about this needs to take a systems perspective, so thinking about where in the clinical workflow do I feel most comfortable having this conversation, but also, thinking about where in the clinical workflow do the patients feel most comfortable having this conversation, and trying to figure out sort of where is the happy medium for where these kinds of conversations need to happen as patients are navigating cancer care.

JACQUELYNE GADDY: What are potential challenges that one may experience when taking a detailed social history? And this is a twofold question. With that same part of the question, how can one address specifically cultural humility and implicit bias?

REGINALD TUCKER-SEELEY: So I think I've shared with both of you briefly about how I approach navigating health care as an African-American gay man. So I trained at Harvard. So I have master's and doctoral degrees there. So it's part of the sort of you're there, you're going to get multiple Harvard T-shirts, Harvard sweatshirts and everything, and sweatshirts and tee shirts for your family.

But I am conscious of when I enter a health care facility, how I'm going to be perceived. And so I will make sure I'm wearing a Harvard sweatshirt or a Harvard T-shirt, and I'll make sure that I tell the physician what I do for work. And I realize that that changes the conversation.

It changes how the physician talks to me. I think it makes the physician view me more as a partner in the interaction as opposed to several preconceived notions that she or he may have about how I'm going to approach care and how I'm going to navigate care. And so I think from the physician perspective, sort of figuring out what can you do so that those of us that have to navigate care are not trying to adorn ourselves with the symbols that will garner respect from you so that you will treat us with respect as a patient.

KATHERINE REEDER-HAYES: And I think I would just mirror that story by saying that when we walk into the room as a provider, there are a lot of things that patients are going to assume about us on our appearance, perhaps what we're wearing and how we interact, whether we stand or sit, eye contact we make, and those things are not only informed by what's happening in the present moment, but also, by this person's previous experience, positive or negative. What were there experiences with other people in white coats been? Do they see a white coat as a message that I took effort to make sure that I wasn't bringing germs from my home to them and that the things I was wearing were clean to take care of them, or do they see it as a symbol that I'm trying to make myself an authority in the conversation with them?

So it could mean either of those things, and neither of those things is necessarily completely right or wrong. But I need to be conscious of all those possibilities. And those listening skills are really important, both the listening to the verbal cues, and also to the non-verbal cues.

Is a patient looking down on the floor? Are they avoiding eye contact with me? Are there some cues here that something about our interaction in that room is making them uncomfortable or not feeling like they can share?

I think a simple rule of thumb for trainees is ask more questions-- [AUDIO OUT] more statements. If you're asking questions, assuming that you're asking them in a polite and respectful way, you're going to continue to elicit information. You don't elicit a lot more information by making declarative statements.

And it may be that your declarative statements need to wait a little bit until you've asked enough questions to really understand where the patient is coming from. Patients will usually tell you the extent to which they might feel comfortable discussing something if you ask, how deep they want to go on that, or how much information they want to receive about a certain topic, or whether they're open to help on a certain topic, whether it be smoking cessation, or help with financial barriers or transportation barriers. I think if you ask, most patients are willing to tell you, and they're also going to communicate to you how much they want to share and how much, at this time, they're still going to hold back. So we just work on our communication skills, not only the talking ones, but the listening ones.

JACQUELYNE GADDY: I think this topic is so important. I know we're getting close to time for our viewers, but one last question. I want to know, how do you think that you can correct inaccurate and/or damaging information so that other care providers can access this?

KATHERINE REEDER-HAYES: So I think that's a challenge of the electronic health record. To the extent that systems and organizations can work to make the social history structured, I think that enables us to go back and fix structured information that may then be shared into or pulled into others notes. If others have documented unstructured information in their notes that is clearly not our information to correct, that can be really problematic.

I think if it's truly an egregious error or an error that might impact significantly on the patient's care, for instance, their spouse has recently died and the person has documented that their spouse is living, something like that, they've documented that the patient is a smoker and needs to stop, and in fact, the patient is a non-smoker and they're just going to continue to be asked about that. You can contact your colleague and say, hey, usually, these notes are editable for a long time. Do you mind going back and correcting that? That's inaccurate. We may not be able to correct every small inaccuracy, but we can make our own documentation appealing enough that maybe others will borrow from our accurate information and not from the previous inaccurate information.

JACQUELYNE GADDY: As we come close to time, Dr. Reeder-Hayes and Dr. Tucker-Seeley, I want to thank both of you for spending time and educating all of those in our viewers, and I want to thank you for joining us for this episode of the ASCO Social Determinants of Health Series. To keep up with the latest episodes, please click Subscribe. Let us know what you think about the series by leaving a review or by emailing us at [e-mail].

PRESENTER: Thank you for listening to this week's episode of the ASCO e-learning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive E-learning Center at elearning.asco.org.