Resuscitating the Social History

A physician is obligated to consider more than a diseased organ, more even than the whole man—he must view the man in his world. —Harvey Cushing

Taking a thorough history is often the very first clinical skill we master in medical school and polish throughout our careers. However, although the “medical” aspects of this skill are refined over time, a detailed social history is frequently overlooked in the routine clinical setting. An article from Byhoff and Gottlieb emphasized that a thorough social screening includes many aspects of a patient’s life, providing a path for preventive health measure advocacy, in addition to praising patients for current healthy practices that may prevent disease (1). Despite this, we often take a physician-centered approach and complete social history as another box to check—ask about tobacco, alcohol, and substance use—and move on (2). Evidence suggests that a patient-centered approach inquiring about diet, exercise, occupation, education, sleep, birthplace, travel, and so on improves patient satisfaction and strengthens the therapeutic alliance (3).

During my clerkship rotation, an asymptomatic man presented to the clinic for the establishment of care. He was eventually diagnosed with hereditary hemochromatosis and referred to the hematology clinic, where I met him. Understandably, he was anxious about the uncertainty of the diagnosis and the experience of becoming a “patient.” We discussed his medical and family history in detail, but he remained reluctant to stay at our clinic and receive additional care. After all, he was and remains asymptomatic. Was he even a patient? Once I initiated a discussion about his social history, his demeanor changed dramatically. He lit up and was thrilled to elaborate on his education, career, hobbies, and achievements. Our discussion of his social history illuminated one of his true passions—diet. Remarkably, he had been a vegetarian for most of his life and a strict vegan for the past few years. His typical diet included a uniquely structured, time-restricted meal intake on weekdays. On weekends, he consumed only water but no food. For this patient, taking a thorough social history, based on a foundation of trust and respect, allowed me to recognize and quantify how his diet affected his illness. Notably, it empowered the patient in the context of the therapeutic physician–patient relationship. My patient initially hesitated to begin and commit to phlebotomy treatments, despite his level of iron overload necessitating some intervention. Through reviewing the literature, my attending physician and I learned how extremely low-iron diets may help reduce phlebotomy requirements (4). Shared decision making, while respecting patient autonomy in the context of my patient’s lifestyle, allowed him to proceed with less frequent phlebotomy sessions while still achieving an appropriate therapeutic response.

Overall, the decreased frequency of required laboratory testing and treatments reduced this new burden for my patient. This clinical standard of care would have been unachievable if I had failed to explore his social history in greater detail. Overuse of laboratory tests and overtreatment are pervasive throughout our medical system and place unreasonable costs and challenges on both patients and the health care system (5). A 2020 review by Speer and colleagues estimated overuse to be the single most wasteful U.S. medical care spending, with a median waste of $451 billion; the next most wasteful spending was missed prevention opportunities at $310 billion (6).

Dietary history provided an opportunity to leverage this approach against overuse of requisite medical interventions. Although taking a thorough social history is not a universal solution, my patient’s experience further underscores the importance of the comprehensive history taking all physicians should embrace as a routine part of their practice. I hope others can incorporate a thorough social history into their practice to improve the physician–patient relationship, effectively counsel on preventive health measures, allocate resources, and, overall, provide higher-value care for patients.

References 

1. Byhoff E, Gottlieb LM. When there is value in asking: an argument for social risk screening in clinical practice [Editorial]. Ann Intern Med. 2022;175:1181-1182. [PMID: 35696689] doi:10.7326/M22-0147
2. Bickley LS, Szilagyi PG, Hoffman RM, et al. Bates’ Guide to Physical Examination and History Taking. 13th ed. Wolters Kluwer; 2021.
3. Mohd Salim NA, Roslan NS, Hod R, et al. Exploring critical components of physician-patient communication: a qualitative study of lay and professional perspectives. Healthcare (Basel). 2023;11. [PMID: 36673530] doi:10.3390/healthcare11020162
4. Kowdley KV, Brown KE, Ahn J, et al. ACG clinical guideline: hereditary hemochromatosis. Am J Gastroenterol. 2019;114:1202-1218. [PMID: 31335359] doi:10.14309/ajg.0000000000000315
5. Korenstein D, Chimonas S, Barrow B, et al. Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments. JAMA Intern Med. 2018;178:1401-1407. [PMID: 30105371] doi:10.1001/jamainternmed.2018.3573
6. Speer M, McCullough JM, Fielding JE, et al. Excess medical care spending: the categories, magnitude, and opportunity costs of wasteful spending in the United States. Am J Public Health. 2020;110:1743-1748. [PMID: 33058700] doi:10.2105/AJPH.2020.305865