Social determinants of health — the conditions in which people live, learn, work, play, and age that influence their health — have substantial, and sometimes determinative, impacts on individual well-being and on population health. It is estimated that traditional medical care accounts for only 10 to 20 percent of the modifiable contributors to health, while the remaining 80 to 90 percent are determined by an individual’s social and economic conditions, physical environment, and participation in healthy behaviors.1 Policymakers, providers, payors, and administrators have begun to recognize that extending the scope of medical care to include the treatment of social determinants of health through well-coordinated and patient-centered interventions is of critical importance.Reference Tyler2
Percent of Respondents Perceived Patient Need
Percent of Respondents Comfort Screening Patients
An innovative model that is used with increasing frequency, the medical-legal partnership (MLP), integrates the expertise of lawyers into the clinical healthcare setting to address social determinants of health.3 Embedding legal expertise into clinical care can help clinicians support patients in addressing social and legal issues that are affecting their health.4 MLPs are generally well- received by providers who gain the opportunity to practice in an interdisciplinary environment. A survey of approximately 450 MLPs nationwide found that 85 percent of physicians working with such services reported improved health outcomes for their patients.5 Sixty-four percent of physicians reported improved patient compliance with medical treatments.6 Thirty-eight percent of all clinicians working with MLP services reported an improved ability to practice “at the top of their license.”7
MLPs inherently require collaboration between health care organizations and legal services, which are generally established through formal agreements.Reference Girard, Perry and Kessler8 Many of these partnerships are based in academic settings, utilizing law schools or medical schools as one of the partners.9 Currently, 61 law schools and 39 medical schools participate in a MLP.10 With their emphasis on education, academic MLPs provide a unique opportunity to transform the professional identities of future health care providers and attorneys.11 Through interdisciplinary education and practical experience, students learn about the context and structural factors that impact patients’ and clients’ health — all knowledge that can aid them in their future careers.Reference Maalouf12
In this study, we sought to assess the knowledge of a group of neurology resident physicians of the extent to which social determinants of health can impact their patient population in an urban, socioeconomically disadvantaged setting. We also assessed the resident neurologists’ comfort with screening patients for social risk factors that could impact health.
Due to the learning and career development goals of academic MLPs, many are established in physician residency training programs.Reference Paul, Curran and Tyler13 Lawyers, through grand rounds, conferences, and policy-focused rotations, train residents on health-related legal issues and ways in which they can screen patients for the effects of social determinants of health.14 Residents thereby become more comfortable discussing social determinants of health with patients, more knowledgeable about available resources, and more likely to document the legal needs of their patients.Reference Klein, Kahn and Baker15 This version of MLP is most common in pediatrics and family medicine residency programs, while residents in other specialty and subspecialty programs are less likely to receive MLP training.16 The model is beginning to expand to other specialty programs as well.17
At the time of conducting this study, there is little literature that reports evidence on MLP outcomes in neurology, but studies show both that social determinants of health are a strong risk factor for the development of neurological diseases and worse health outcomes, and that MLPs could play a role in addressing those social risk factors.18 Low socioeconomic status and adverse environmental conditions can cause changes in neuroanatomy that are associated with greater odds of developing neuropathology, such as Alzheimer’s disease and other forms of dementia.19 Inflammatory neurological diseases, such as multiple sclerosis and traumatic injuries of the brain are also associated with low income.Reference Dobson20 Similarly, health insurance status is associated with the likelihood of recovery or persistent disability following these brain injuries.21 Insurance can influence the ability of patients to access post-acute medical care that is critical for their recovery, such as physical and occupational rehabilitation, cognitive therapy, and vocational training.Reference Shafi22 Helping to gain some form of health insurance is one example of the ways in which a MLP service could help patients who have a range of neurological conditions realize better clinical outcomes.
In this study, we sought to assess the knowledge of a group of neurology resident physicians of the extent to which social determinants of health can impact their patient population in an urban, socioeconomically disadvantaged setting. We also assessed the resident neurologists’ comfort with screening patients for social risk factors that could impact health.
Methods
We assessed the attitudes of neurology residents toward social determinants of health using a 30-question survey. The survey was distributed to all 40 neurology residents in the training program at the Hospital of the University of Pennsylvania as part of a departmental quality improvement initiative using Qualtrics survey software. The questions were adopted from the Accelerating Health Equity, Advancing through Discovery (AHEAD) initiative Medical Legal Partnership Learner Surveys published by the Association of American Medical Colleges.23 Only residents in their second, third, and fourth year of training were included, as first-year residents did not yet have enough experience to speak to the clinical population at the time the survey was distributed. Twenty-eight responses representing 70% of residents were received and analyzed through the Qualtrics analytical tools and Microsoft Excel.
Results
In the survey, residents were first asked to estimate on a 3-point Likert scale how many of their patients they believed were impacted by specific social and legal issues (response options: none or less than half; about half; most or more than half) including: an unstable family life, insufficient or unreliable income, issues with immigration status, lack of safe and affordable housing, difficulties accessing public benefits, inability to access transportation, and lack of access to nutritious foods.
The majority believed that at least half or more than half of their patients were impacted by a lack of access to health care (65% of respondents), unstable family life (60% of respondents), insufficient or unreliable income (70% of respondents), lack of access to transportation (55%), and lack of public education (65%). When asked if they thought their patients were faced with low or unstable incomes, 30% thought none or less than half of their patients faced this challenge, while 35% thought half of their patients had insufficient or unreliable income, and another 35% thought that between half and all of their patients dealt with this same issue. When asked if their patients dealt with lack of access to health care, 40% of respondents thought this issue affected between half and all of their patients, while 35% thought none or less than half of their patients were affected.
The survey then asked whether residents were comfortable screening their patients for each social concern, and if not comfortable, to provide the reason. It also asked whether they would feel more comfortable screening patients if they knew legal services were available and whether legal services could benefit their patients’ health or access to care.
Despite believing that their patients were experiencing issues with various legal and social issues, more than half of respondents did not feel comfortable screening for social determinants of health. Resident physicians were most comfortable screening for health care-associated issues such as lack of access to healthcare (65% comfortable) and health insurance (60% comfortable). Fifty-five percent felt comfortable screening for family life instability, such as domestic violence and custody issues, while 45% did not. With other issues, the majority of resident physicians were uncomfortable: lack of childcare (60% uncomfortable), insufficient or unreliable income (80% uncomfortable), immigration issues (65% uncomfortable), lack of access to public benefits (75% uncomfortable), and lack of access to quality public education (80% uncomfortable).
When respondents were asked why they felt uncomfortable discussing these topics, four major themes emerged: (1) insufficient length of clinical visits, (2) lack of training, (3) discomfort with having conversations, and (4) not knowing what resources to refer patients to if they learn of a potential need. However, 91% felt they would be more comfortable asking patients about social determinants of health if they knew legal services were readily available. All respondents believed that access to free legal services would benefit their patients’ health, or at least patients’ access to health care.
Seven respondents shared reasons why they believed MLPs would be beneficial to their clinical practice and their patients. In the words of one:
I have multiple patients that would benefit from access to free/affordable legal counsel to aid with disability, transportation needs, and housing disputes. I often feel like I am incompletely addressing their healthcare needs as these gaps have a huge impact on their quality of life. I notice that my patients who are more apt at navigating the legal, government, and health care systems have enjoyed greater resources and have shown greater benefit from medical care. I think that medical-legal partnerships are particularly important in neurology, where many of the patients need additional resources or accommodations in addition to the care I can provide but may not know how to nor have the resources to access them on their own.
Others explained reasons that the presence of legal support would make them feel more comfortable screening their patients for health-impacting legal issues — there was clear support for the interdisciplinary education that an academic MLP can provide. As one stated:
I would definitely feel more comfortable bringing up issues if I know I had the support of such a partnership. I am honestly ignorant as to some of these issues and do wonder how much a medical-legal partnership can help address something like access to food or education.
The remainder of the open-ended responses also stated that an MLP would benefit their patients.
Results of a survey of resident physicians in a neurology training program reflect disparate impressions among them of the social determinants of health facing their patients. The majority did not feel comfortable screening their patients for basic social contributors to health outcomes, and they identified barriers to having these conversations during patient office visits. Academic MLPs serve an important role in training young physicians to evaluate social factors that may impact their patients’ health. The findings of this study suggest that there may be value in extending academic MLP training into specialty areas beyond primary care.
Discussion
Last year alone, more than 400 hospitalized patients living in West Philadelphia required a neurological evaluation during their hospitalization but were unable to access follow-up care after being discharged due to lack of insurance coverage. Of the 4,270 patients who were seen by a neurologist in an outpatient setting and recommended for follow-up care in 2022, only 2,728 were treated. While it is unclear as to why each of these patients did not return for follow-up care, only 133 patients, representing 3.1 percent of the total, declined a necessary follow-up appointment when contacted. One possible explanation is that these patients faced additional barriers that interfered with their ability to get the medical care they required. These data support the need to extend academic MLPs into specialty areas to fully realize the value legal services can have for patients. However, such a MLP can only succeed if physicians are adequately prepared to recognize and address social determinants of health.
Despite caring for similar patients within one clinic and with similar demographics, estimations of patient need by the study respondents varied widely. When asked if they thought their patients were faced with low or unstable incomes 30% thought none or less than half of their patients faced this challenge, while 35% thought half of their patients had insufficient or unreliable income, and another 35% thought that between half and all of their patients dealt with this same issue. When asked if their patients dealt with lack of access to health care, 40% of respondents thought this issue affected between half and all their patients, while 35% thought none or less than half of their patients were affected. The even distribution of responses suggests respondents are not consistently recognizing the social and legal needs of their patients. The results would be more homogonous if physician residents were properly identifying their patients’ needs.
The survey results suggest that one potential reason respondents fail to identify their patients’ needs is that they are uncomfortable screening for social and legal issues. Resident physicians were most comfortable screening for healthcare-associated issues such as lack of access to healthcare (65% comfortable) and health insurance (60% comfortable). This is likely because these issues can be screened for naturally during a clinical assessment. Patients’ insurance status and history of appointments within the health care system are available in their medical chart and therefore easily accessible by the resident physicians. Respondents reported feeling more uncomfortable screening for issues that are further removed from the traditional clinical setting such as insufficient or unreliable income (80% uncomfortable), immigration issues (65% uncomfortable), and lack of access to public benefits (75% uncomfortable).
The findings were used by one of the investigators who is a law student to develop a training presentation for the neurology residents who received the survey. Topics addressed in the presentation included the basics of social determinants of health and the ways in which social and legal problems could negatively impact their patients’ health. Because only 40 percent of respondents reported being familiar with MLPs prior to the survey, the training included an overview of how a MLP can be used as a tool to address their patient’s needs. The interdisciplinary academic session proved to be beneficial and well-received by the physician residents. Administering a similar survey after the training session would positively contribute to evaluating the success of the academic MLP.
Conclusion
Results of a survey of resident physicians in a neurology training program reflect disparate impressions among them of the social determinants of health facing their patients. The majority did not feel comfortable screening their patients for basic social contributors to health outcomes, and they identified barriers to having these conversations during patient office visits. Academic MLPs serve an important role in training young physicians to evaluate social factors that may impact their patients’ health. The findings of this study suggest that there may be value in extending academic MLP training into specialty areas beyond primary care.
