Identifying social determinants of health is critical to the patient interview


After a semester of medical school, I returned home to the Antelope Valley in California, an area CNN coined, “health care’s nowhere land” because of low health insurance rates and limited provider networks that force residents to travel far for care. I wanted to help my family and neighbors by using the physical exam skills I learned during my first few months as a medical student, but that turned out to be more complicated than I expected.

As I thought about the best way to help those with troubles integrating into our costly and complex health care system, the health fairs my undergraduate colleagues and I devised for low-income populations came to mind.

During one of these health fairs, vendors from local health organizations helped screen residents of East Los Angeles for high blood sugar and elevated blood pressure. Of all the attendees who visited, one memorably struck me. Her name was Marcela (not her real name), a middle-aged Spanish-speaking woman who hadn’t planned on attending our event until she was coaxed to come in by her two daughters so they could play at our booth for kids. Naturally, volunteers at the abutting table kindly persuaded Marcela to have her blood pressure checked.

Once Marcela had been sitting quietly for five minutes, she was asked to relax her arm and uncross her legs as we wrapped the blood pressure cuff around her arm. “Inflate, inflate, inflate, decompress,” I said silently, walking myself through the process as the volunteer executed the diagnostic. Marcella’s blood pressure was high, but not so high that she immediately required medicine. She didn’t have a primary care provider to see for follow-up, so we urged her to consume less salt, eat more fruits and vegetables, and exercise around her neighborhood or in a gym.

It was approximately a year later when I realized how we had let Marcela down.

There’s little question that lifestyle modifications can help stave off the complications of high blood pressure. This “silent killer,” a sobriquet we learn of as first-year medical students, is responsible for nearly 7.5 million deaths per year worldwide, most of them from heart attacks and strokes. High blood pressure itself does not have any symptoms, which is partially why we screen — the seemingly random test that Marcella sat for is important.

When I returned to the Antelope Valley, I realized that neither of my parents knew their blood pressure. In their 23 years as U.S. residents, neither had seen a primary care physician. Not because they don’t believe in medicine, but because of cost, time-constraints, language barriers, access, and more.

My father often works endless hours at low-paying jobs to make ends meet. He comes home, eats a late dinner, and repeats the cycle. My mother cleans homes part time, cares for her granddaughter, and often serves at a restaurant. Beyond not having health insurance, they and many others alike, do not have the resources to change their lifestyles.

Analyzing their livelihoods and daily routines made me think twice about the advice we had given Marcela. What I had learned about treating high blood pressure in medical school — the litany of lifestyle modifications — felt overly simplistic as I realized their situation in the Antelope Valley.

Their limited leisure time, financial barriers, and inability to see a provider dampened my enthusiasm to take their blood pressures. I feared the psychological repercussions they could face from an ominously elevated blood pressure they felt no control over.

After two weeks of struggling with the decision of taking their blood pressures, I asked my niece and mother if I could measure their blood pressure. Their readings were normal. Later that night, I approached my father and similarly asked if I could do the same for him. “Inflate, inflate, inflate, decompress,” I voiced in my head. Mildly elevated blood pressure, but in no immediate danger.

My father’s busy work schedule and meager finances stopped me from earnestly suggesting an exercise regimen and diet makeover. The tortillas with beans and sour cream for breakfast and the satiating rice and meat for lunch and dinner were inexpensive, filling, and customary.

What I did suggest was that my father repair an old bicycle in our garage and use it for his commute to work instead of driving. A combination of affordability, efficiency, and better health — plus, perhaps, his pride in my becoming a doctor — nudged him to eventually fix the bicycle and spend an extra ten minutes riding it to work.

Following our conversation, we finished packing my bags, exchanged overdue smiles, and headed to the airport.

Even though medications, healthier foods, and exercise regimens were impractical for my parents to consider, understanding their limitations helped me find an area for change. Having an actionable plan to address a slightly elevated blood pressure influenced me to screen. Had I not remembered the run-down bicycle in our garage, my blood pressure cuff would have remained in its bag, supplanted by a conversation to help discern his barriers to care.

Health care providers need to understand their patients before formulating treatment strategies. As medical students, we are taught to inquire about our patients’ families, jobs, religion, finances, and even gun and driving safety. What Marcela and my father taught me adds an element that strengthens the patient interview: it is vital to get a sense of a person’s ability to take action and whether or not they require extra resources to do so. This holistic interview approach should be used in all health care settings, including health fairs. Sometimes, an intervention as simple as a bicycle can allay barriers to care and improve a loved one’s health.

David Velasquez is a medical student.

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