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Doctor's Little Secret

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Doctors do their best to cure what ails you, and to engage in preventive medicine, too. But Dr. Baldeep Singh says the truth is that the biggest obstacles between you and good health may be largely beyond his control.

Recently I saw a patient in my clinic with multiple medical problems - diabetes, hypertension and heart disease. As we were finishing up, she commented on how important our visits were to her overall health. I smiled and thanked her for her thoughtful remarks. One of the joys of primary care is helping patients manage their health over years, often through many challenging medical moments.

But we doctors have a little secret. When it comes to overall outcomes, the actual medical health care a patient receives only accounts for 10 to 20% of health outcomes. That is not to say that medical care is not important; it is. But when we look at data on the health outcomes of Americans, genetic and social determinants of health are even more important. These include personal behaviors, like smoking, genetic factors like a family history of early heart disease, and the social and physical factors, like pollution and crime. Smoking, obesity and exercise may be key behavioral predictors, but surprisingly so is income. In a recent article in a major medical journal, the difference in life expectancy between men in the top 1% of income earners and the bottom was an astonishing 14 years. The overall contribution of medical care to health outcomes in this study was modest.

As a physician, data like these are very humbling. When we take a history in the office, we don't often ask about social determinants like income. We cannot write prescriptions for affordable housing, a safer environment, or a living wage. But while many health care professionals are involved in activism to improve social determinants and tax policy, many of us, myself included, should be doing more.

Advocacy for a better and healthier standard of living is not only about what happens between doctor and patient, it's also about improving the overall health of our nation.


With a Perspective, I'm Dr. Baldeep Singh.

Dr. Baldeep Singh is an internist at Stanford Hospital.

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