What SDH, SDOH, & social determinants teach us about healthcare
Rebecca Slawter
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Posted Jul 26, 2024
What is health equity? Use SDH and social determinants of health (SDOH) to create positive patient outcomes in your private practice.
What SDH, SDOH, and social determinants can teach practices
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At a Glance
Social determinants of health (SDOH), such as where people live and work, account for 30–55% of health outcomes and impact patient quality of life.
Achieving health equity means ensuring everyone has a fair opportunity to attain their highest level of health, regardless of social determinants.
Independent healthcare providers can improve patient outcomes by implementing SDOH screenings and partnering with community organizations to address SDOH.
While most efforts to improve health outcomes in the United States focus on the medical healthcare system, other factors have an even bigger impact on overall health, quality of life, and health outcomes. These are called the social determinants of health (SDOH). The social determinants of health are defined as the conditions where people are born, live, learn, work, play, worship, and age that influence a wide range of health, functioning, and quality-of-life outcomes.
According to the World Health Organization (WHO), multiple studies suggest that SDOH accounts for 30–55% of health outcomes. It estimates that these outside health determinants impact population health outcomes more than contributions from the healthcare industry.
Does that mean independent healthcare providers have little hope in the fight for better health outcomes and social equity?
Not necessarily. However, healthcare providers should learn to recognize SDOH and craft care plans based on their impact on patient health.
Keep reading for a deep dive into the following questions:
What are the 5 social determinants of health?
How do SDOH impact health outcomes?
How can independent practices improve SDOH for patients?
What is health equity?
How can private practices pave the way for health equity?
What do social determinants of health impact?
SDOH contributes to health and quality-of-life disparities, mostly outside the healthcare sector’s current purview. These systemic factors impact health outside of individual habits and behaviors, like geographic location, income, education, access, and more.
An example of SDOH's impact is how food deserts in low-income neighborhoods contribute to poor health. People living in food deserts have little access to healthy food options. They’re less likely to have good nutrition habits and more likely to face health conditions like heart disease, diabetes, and obesity. Living in an area without easy access to affordable and healthy options can decrease quality of life and overall life expectancy.
However, assessing and addressing SDOH requires a thoughtful approach. Encouraging healthy eating, for example, requires more than information. Education on food and nutrition may need to start in early childhood with the help of educators and healthcare professionals, but access is just as important. Solving the disparity requires a concerted effort from multiple disciplines to close the gap.
What are the 5 social health determinants?
The US Department of Health and Human Services and the CDC cite 5 social health determinants in the country:
Economic stability: According to the Department of Health and Human Services, people with steady employment are less likely to live in poverty and more likely to be healthy.
Education access and quality: People with higher levels of education are more likely to be healthier and live longer.
Healthcare access and quality: People who can't access healthcare services, particularly outpatient services, quickly and conveniently may have poorer health.
Neighborhood and built environment: Health and safety risks, like high rates of violence, polluted air, and unsafe water, impact health and quality of life.
Social and community context: Meaningful relationships and positive interactions with family, friends, neighbors, and community members benefit health and well-being.
The World Health Organization includes a few more SDOH on its list:
Income and social protection
Working life conditions
Food insecurity
Early childhood development
Social inclusion and non-discrimination
Structural conflict
Health agencies worldwide agree that addressing SDOH is paramount for improving health outcomes and health inequities.
Let’s take a deeper look at each of the social determinants.
Social determinant #1: Economic stability
In the US, 1 in 10 people live in poverty, and many people can’t afford housing, healthcare, and healthy foods. A lack of access to healthcare alone can greatly impact health outcomes. It can keep people from getting prevention and screening services or mean that they ignore symptoms of serious diseases.
Job stability also plays a factor. Switching between jobs, gig work, or multiple part-time positions makes it difficult to maintain insurance, especially employer-sponsored insurance. Those who have steady employment are less likely to face poverty and more likely to be insured.
Programs focusing on career counseling, childcare, and vocational training can help improve economic stability and influence public health at a macro level. But there’s a lot you can do as an independent healthcare provider, too. At the practice level, being sensitive to patients’ realities may help ease some of the difficulties of economic stability concerns. Make administrative tasks as easy as possible for patients. You can also encourage adults to bring their children to appointments when possible to help ease childcare concerns.
Social health determinant #2: Education access and quality
People with higher levels of education tend to be healthier and live longer lives, according to Healthy People 2030.
Children from low-income families, those with disabilities, and those who face social discrimination, such as bullying, often struggle with math and reading. They are less likely to graduate from high school or attend college. This in turn affects their ability to secure safe, high-paying jobs. This cycle can lead to health issues like heart disease, diabetes, and depression.
Some children live in areas with underperforming schools. The stress of living in poverty can hinder brain development, making academic success more challenging. By implementing interventions that support children’s education, states can foster long-term health benefits and brighter futures.
As a healthcare practice, you can share information with patients and their caregivers about literacy programs in the community. Pediatricians and primary care providers who work with families can join programs. For instance, Reach Out and Read provides literacy education to parents and children and gifts developmentally appropriate books at every appointment.
Social determinant #3: Healthcare access and quality
Without quality healthcare, people (especially those without insurance) often avoid visiting doctors, leading to poorer health outcomes. Approximately 1 in 10 people in the US don’t have health insurance, often leading them to miss out on essential healthcare services.
Those without insurance, who are disproportionately more likely to be people of color, are less likely to have a primary care provider, and more likely to struggle to afford necessary services and medications. Increasing insurance coverage is crucial to ensuring more people receive vital healthcare services, including preventative care and treatment for chronic conditions.
People often miss recommended healthcare services, such as cancer screenings, because they don’t have a primary care provider. Or, they may live too far from healthcare providers who offer specific services.
While insurance is a tough hill to climb at the practice level, this is a great opportunity to connect with patients. Ask about their pain points for acquiring insurance or generally making and keeping appointments. Something as simple as helping people understand their employer-sponsored insurance options or filling out forms can make a difference. You may even suggest insurance companies that work well with your office.
The patients you’re least likely to see, and the ones with healthcare access struggles, are often one and the same. Try appointing an office champion, like an MA or RN, to improve screening completions and remind everyone about the importance of completing them.
“The patients you’re least likely to see, and the ones with healthcare access struggles, are often one and the same. ”
When transportation is an issue, something as little as knowing your closest bus stop can help when patients call asking for directions. Medicaid can also help pay for transportation, but patients might not be aware of this. You can also connect with larger medical offices when referring patients to specialists, as these offices likely have social workers on staff who can provide additional help.
Social health determinant #4: Neighborhood and built environment
Neighborhoods where people live significantly impact their health and well-being. Some people in the US reside in areas with high rates of violence, unsafe air or water, and other health and safety risks. These issues are more prevalent among racial and ethnic minoritized groups and people with low incomes. And some workers are exposed to harmful conditions like secondhand smoke and loud conditions.
Local, state, and federal interventions and policy changes can help mitigate these risks and promote better health. Changes can range from adding sidewalks, which creates opportunities for walking and biking, to building green spaces, which can do a lot to improve community health. As a healthcare provider in these communities, your voice carries a lot of weight. Join the conversation at the local level — your expertise can make all the difference.
Social determinant #5: Social and community context
People’s relationships and interactions with family, friends, co-workers, and community members significantly impact their health and well-being. Many individuals face uncontrollable challenges like unsafe neighborhoods, discrimination, and financial difficulties, which negatively affect their health and safety throughout their lifetimes.
Positive relationships at home, at work, and in the community can help mitigate these negative impacts. However, some people, such as children with incarcerated parents and adolescents who are bullied, often lack support. That's why interventions to provide social and community support are essential for improving health and well-being.
Remember, as providers, you’re part of these communities, too. Respectful, compassionate interactions with office staff can make a difference to someone's day, mood, and, ultimately, health outcomes, regardless of whether that person is a patient or not.
Further Reading
What are health outcomes?
A health outcome is the result of the health of an individual, a group of people, or a population that can be attributed to an intervention or interaction with the healthcare system.
Health outcomes include but aren’t limited to the following:
Mortality: The percentage of patients who die as a result of intervention.
Morbidity: Having a disease or the amount of a disease within a population.
Life expectancy: The average period a person may expect to live.
Healthcare expenditures: The total amount spent on healthcare and related activities.
Health status: A person’s overall physical, mental, and social well-being, as well as freedom from illness or injury.
Functional limitations: Restrictions or lack of abilities to perform an activity within the normal range.
How much do social determinants impact health outcomes?
Health outcomes measure the overall success of clinical care. But even when measuring clinical care, health outcomes are meaningfully influenced by social determinants of health (SDOH). While there’s no consensus on how much they impact health, WHO reports that SDOH are responsible for 30–55% of overall health.
When social health determinants are addressed, patients typically:
Get better management of chronic conditions like diabetes through tailored treatment plans, nutrition plans, etc.
Have increased adherence to treatment protocols when social determinants are addressed, like ensuring transportation to appointments
Experience reduced frustration and improved communication with providers
Increase engagement and empowerment since they feel like they’re more in control of their outcomes
These benefits naturally lead to improved patient outcomes: lower mortality rates, decreased chronic conditions, and better overall quality of life.
What’s being done to address SDOH?
More initiatives are targeting SDOH, both inside and outside the healthcare systems. Some initiatives focus on integrating health considerations into non-health sectors. And others concentrate on enabling the healthcare system to address broader factors that influence health.
Addressing SDOH outside the healthcare sector
Efforts outside the healthcare sector focus on creating healthier environments and addressing SDOH through various policies and community initiatives, including:
Policies and practices that address early education in low-income communities, improved transportation, etc. You can see this in action in the North Carolina public education system. After the school system struggled to meet students’ educational needs, a third-party consultant (as ordered by the Supreme Court of North Carolina in Leandro v. the State of North Carolina) observed several low-income communities. Then, it created an action plan to mitigate student hunger, create a welcoming and positive environment, and attract more educators. Addressing SDOH, like education and hunger, could lead to better overall health outcomes.
“Health in all” policies consider health in all governmental decision-making processes, including city planning, education plans, and building permits. For example, California created a Health in All Policies Task Force in 2010, which works cross-agency to consider the health implications of state programs. Their goal is to identify strategies to improve the health of Californians while advancing existing goals around air and water quality, natural resources, affordable housing, infrastructure, public health, and climate change.
Place-based initiatives that target poor health outcomes in geographic areas, such as the Harlem Children’s Zone.
Inside the healthcare system
Within the healthcare system, initiatives focus on integrating social care into medical care and ensuring that providers address patients’ broader social needs. These include:
Multi-payer federal and state initiative collaboration to address SDOH.
Medicaid initiatives led by states or health plans, with 91% of Medicaid-managed care plans reporting activities to address SDOH.
Provider-level activities focused on identifying and addressing patients’ non-medical and social needs.
SDOH loom large, so tackling them from multiple angles makes sense if we, as a society, want to create a more equitable healthcare environment for everyone. Individual practices can also play an important role here.
What are the challenges of addressing SDOH for practices?
Addressing SDOH presents several challenges for independent healthcare practices. And in an already overburdened healthcare environment, these additional challenges can seem overwhelming. Understanding these barriers is essential for developing strategies to overcome them.
Socioeconomic factors
When addressing SDOH, healthcare practices must navigate a complex landscape of diverse patient needs, coordination of care, and patient engagement.
Diverse patient needs
Patients come from various backgrounds with different social needs, making it challenging to provide tailored interventions for everyone.
Limited time and resources in practices often hinder comprehensive assessments of patient’s social determinants.
Engaging patients in discussions about their social needs can be difficult, especially if staff are unaware of available resources or patients feel stigmatized.
Solution: Lean on standardized screening tools to quickly identify patients’ social needs. The Centers for Medicare and Medicaid Services has a comprehensive screening tool for health-related social needs that can help independent practices quickly identify immediate patient needs.
Coordination of care
Blending social care with medical care requires coordination across multiple sectors that may be outside of a care team’s purview, like housing, education, and transportation.
Practices may struggle to establish and maintain partnerships with community organizations and social services.
Solution: Reach out to local organizations and establish formal partnerships. Together, you can create shared care plans that include social services. You can also work with care coordinators to bridge the gap between medical and social services.
Reduce no-shows
Learn more about supporting patients to reduce no-shows and cancellations.
Legal constraints
Legal constraints present significant barriers to integrating social and medical care, complicating efforts for private practices to address SDOH.
Privacy laws, such as HIPAA, can complicate the sharing of patient information between healthcare providers and social service agencies.
Inconsistent state laws and regulations lead to varied approaches to address SDOH.
Navigating the legal landscape requires additional administrative effort and resources, diverting focus from patient care.
Solution: Develop clear protocols for working with outside organizations to prevent the accidental sharing of protected health information (PHI). Loop in legal and administrative support early on to help you establish these protocols. If you’re unhappy with your local laws regarding social and medical care integration, advocate for policy change in your local government.
Funding limitations
Securing adequate funding is a persistent challenge for practices looking to address SDOH concerns.
Programs targeting SDOH often lack adequate funding, making it difficult to implement and sustain these initiatives.
Practices may not receive sufficient financial incentives to address non-medical needs, reducing their motivation.
Solution: Identify outside funding sources to support your practice’s efforts at managing SDOH. Many federal and state-level programs, including waivers, grants, and Medicaid, are often underused.
There are also many nonprofit organizations that help with specific tasks. For example, Triage Cancer will mail out free health information to your patients and Stop HCC-HCV offers turn-key infrastructure for screenings. Identify a need in your practice and look for partners to help you achieve your community goals.
Physician burnout
With the pressure on private practices high and the labor pool getting critically low, SDOH concerns (and, in the case of Medicare and Medicaid providers, additional tracking and paperwork) can just add to the burden healthcare workers already face.
A 2023 Medical Economics report found that 92% of physicians have experienced burnout over the course of their careers.
So it’s nothing to scoff at. Looking beyond the immediate issue at hand to other factors of their patients’ lives could add to an already stressed-out workforce. But, there are potential benefits to using SDOH to care for patients that physicians should consider — including reduced burnout.
Benefits of addressing SDOH for physicians and private healthcare practices
Addressing SDOH is essential for improving overall health outcomes, but it also benefits physicians and private healthcare practices. By integrating it into their core strategies, practices can reduce stress and burnout among healthcare providers, as well as increase satisfaction through better patient outcomes and improved relationships.
“By addressing SDOH, physicians and private healthcare practices can both improve outcomes for their patients and also create a more efficient, satisfying, and supportive work environment. ”
Reduced stress and burnout
By incorporating social and community health workers into care teams, physicians can delegate non-medical tasks, allowing them to focus more on clinical care.
Employing technology for SDOH screening and targeted intervention recommendations can enhance administrative efficiency.
Increased satisfaction
Patients who receive support for their social needs tend to have better health outcomes, which can be fulfilling for physicians and improve job satisfaction.
Strengthening the patient-provider relationship enhances trust and cooperation, making the care process more rewarding for both parties.
By addressing SDOH, physicians and private healthcare practices can both improve outcomes for their patients and also create a more efficient, satisfying, and supportive work environment.
How can practices improve SDOH for patients?
While SDOH may seem overwhelming, independent healthcare practices don’t have to take on the entire system to help patients. Start with a screening process for SDOH.
Regularly assess patients for social determinants that impact their health, such as housing stability, food security, and access to transportation. The American Academy of Family Physicians (AAFP) has a list of screening resources, plus information on how to integrate it into your workflows.
10 strategies to address SDOH for patients
Addressing SDOH can run the gamut from low to high effort. You can start small with 1 or 2 of these strategies and increase as you go.
Partner with community organizations: Collaborate with local organizations to connect patients with essential resources, such as food banks, housing services, literacy programs, and job training programs.
Integrate social workers and community health workers: Include them in your care teams to address patients’ social needs and coordinate with community resources.
Offer transportation assistance: Provide transportation options to ensure patients can attend their medical appointments, reducing barriers to accessing care.
Provide health and education resources: Educate patients on healthy living practices, preventive care, and available social services to empower them to manage their health effectively.
Promote healthy lifestyle programs: Encourage participation in programs that promote physical activity, healthy eating, and mental well-being to improve overall health.
Increase access to affordable and nutritious food options: Ensure patients have access to healthy food through prescriptions and collaborate with local organizations to connect patients with nutritious food.
Develop a resource referral system: Create a system to refer patients to community resources and social services, ensuring they receive comprehensive support.
Use technology for patient support: Implement digital tools and platforms to screen for SDOH, provide telehealth services, and offer online resources for patients.
Provide financial counseling and assistance: Offer financial counseling to help patients manage healthcare costs and access financial assistance programs.
Offer training: Invest in training healthcare staff to recognize and address SDOH, such as workshops with real-life scenarios, to improve their ability to support patients effectively.
How can private practices use Medicaid to address social determinants?
Private practices have several opportunities to use Medicaid to address SDOH and improve patient outcomes. Participating in models like ACO Realizing Equity Access and Community Health (ACO REACH) provides tools and financial support to form accountable care organizations that offer coordinated care in underserved communities. Medicare will also pay separately for SDOH risk assessments, which identify unmet social needs that may affect the diagnosis and treatment of medical problems as of January 1, 2024.
Medicaid also offers several options in different states, including waivers for innovative approaches, homes for integrated care for chronic conditions, and managed care contracts that require screening for and addressing social needs.
Private practices can enhance coordination using Medicaid funding, forming partnerships with community organizations, or investing in training for providers and staff to identify and address SDOH. By participating in specific programs and accessing available resources, practices can integrate social care into their medical services.
What are some SDOH examples?
To really tackle SDOH, it’s helpful to have a picture of what they look like in practice. Here are some real-life examples of SDOH.
Safe housing, transportation, and neighborhoods
Living in safe, stable housing and having reliable transportation and secure neighborhoods significantly influence overall health and well-being.
For example, a family living in a low-income neighborhood with high crime rates may experience chronic stress and anxiety, which could lead to higher rates of hypertension and other stress-related conditions. Meanwhile, the lack of reliable transportation can prevent them from accessing healthcare services regularly to diagnose and treat the problems.
Racism, discrimination, and violence
Experiences of racism, discrimination, and violence can lead to chronic stress and trauma, adversely affecting both physical and mental health.
A person experiencing racial discrimination in the workplace may suffer from chronic stress and depression. The ongoing stress can lead to serious health issues, such as cardiovascular disease and mental health disorders.
Education, job opportunities, and income
Access to quality education, job opportunities, and sufficient income levels are foundational for achieving good health, as they provide the means to afford healthcare and a healthy lifestyle.
A person without a high school diploma may have limited job opportunities and lower income, restricting their ability to afford health insurance, nutritious food, and preventative healthcare. This could ultimately result in poorer overall health and lower life expectancy.
Limited access to nutritious foods and physical activity opportunities
The availability of healthy food options and opportunities for physical activity are essential for preventing chronic diseases and promoting overall health.
Residents of a food desert, where fresh produce and nutritious food options are scarce, may rely on fast food. This can lead to higher rates of obesity and diabetes. Similarly, the absence of safe parks or recreational facilities can limit physical activity.
Polluted air and water
Exposure to polluted air and water can cause a range of health issues, including respiratory and cardiovascular diseases, making it a significant environmental determinant of health.
Communities living near industrial areas may be exposed to higher levels of air and water pollution. For instance, Flint, Michigan, faced a severe water crisis with lead-contaminated water, leading to widespread health problems.
What is health equity?
The CDC defines health equity as “the state in which everyone has a fair and just opportunity to attain their highest level of health.”
In other words, health equity is when all people, regardless of race, gender, sexual orientation, socioeconomic status, location, or social determinants, reach the highest level of health. Achieving health equity requires removing obstacles to health, such as poverty and discrimination, and their consequences.
Social health determinants are often the root cause of health inequity and can directly impact the healthcare system’s ability to achieve equity. Population-level factors, such as physical, social, and policy environments, often have a greater impact on health outcomes than individual-level factors, while practices fall somewhere in the middle. Inequities typically stem from a failure to address these broader SDOH.
Health equality and health equity: What is the difference?
In healthcare, both equality and equity play key roles in ensuring fair treatment and outcomes. Equality provides everyone with the same resources, regardless of their gender, race, orientation, or other factors.
Equity, on the other hand, recognizes that people have different needs and circumstances and adjusts resources to achieve similar health outcomes for all. Understanding and balancing these concepts is crucial to creating a truly inclusive healthcare system.
What is health equity vs. equality in healthcare
AccessCoverageFinancingEqualityAll patients have access to the same number of clinic visits per year.All patients receive the same insurance plan with identical benefits.Everyone pays the same premium for their healthcare coverage.EquityPatients with chronic conditions and complex health needs have access to more frequent clinic visits and specialized care.Insurance plans are customized based on individual health needs, providing additional benefits and services for those with greater health challenges.Premiums are adjusted based on income and healthcare needs, ensuring those who need more care or have lower incomes receive adequate support without financial strain.
Health equity and insurance
Insurance rates are impacted by a variety of social determinants of health, with the most prominent factors being income and race. According to KFF, 25.6 million nonelderly people were uninsured in 2022. Most uninsured are adults, in working low-income families, and are people of color.
Uninsured people visit their doctors less frequently, don’t get regular checkups, and leave health concerns unaddressed, leading to worse health outcomes. Nearly half (47.4%) reported not seeing a doctor or healthcare professional in the past 12 months, compared with 16.6% with private insurance and 14% with public coverage.
Many of the uninsured in 2022 cited not having a regular place to visit when they’re sick or need medical advice (43.1%). But cost plays a role, too. Over 1 in 5 (22%) said they went without needed care because of cost, compared to 4.7% of adults with private coverage and 7.4% with public coverage.
Health equity and private practice
Achieving health equity requires concerted efforts from individuals within private practices to address SDOH and ensure positive patient outcomes. By understanding and applying key frameworks, healthcare providers can create more inclusive and supportive environments for their patients.
Collaboration and team-based care
Integrating social workers, community health workers, and care coordinators into care teams allows for comprehensive support that addresses both medical and social needs. This team-based approach ensures that patients receive the resources and assistance they need to improve their overall health.
Screening and referral systems
Implementing routine screenings for SDOH helps identify patients’ social needs early on. By developing a robust referral system, practices can connect patients with community resources, such as housing assistance, food programs, and transportation services.
Patient engagement and communication
Building strong relationships with patients through communicating and addressing their social needs reduces frustration and improves satisfaction. Engaged and empowered patients are more likely to adhere to treatment plans, be more proactive about their care, leave better reviews, get less sick, and experience better health outcomes overall.
By coming together and focusing on these strategies, private practices can ensure that all patients have the opportunity to reach their highest level of health.
Paving the road to health equity and implementing SDOH
Addressing social determinants of health is critical for achieving health equity and improving patient outcomes. By recognizing the significant impact of factors such as economic stability, education, healthcare access, neighborhood environments, and social contexts, practices can develop comprehensive strategies to address them.
Independent healthcare providers have a unique opportunity to integrate SDOH into their practices. These efforts both improve patient outcomes and contribute to the overall health of the community.
By embracing a holistic approach that addresses both medical and social needs, private practices can reduce health disparities, enhance patient satisfaction, and create a more supportive and efficient healthcare environment. The collective effort of healthcare providers will pave the way for a healthier and more equitable future for all.
What matters most? Quality patient care. Empower your practice to seamlessly balance patient and staff needs with Tebra’s intuitive platform. Book a demo today.
Checklist
Essential steps for independent practices to promote health equity
Start with these steps to address social determinants of health and help patients achieve better outcomes.
Screen for social needs: Implement tools to identify patients’ social determinants of health (SDOH).
Create a referral system: Develop a database and protocol for referring patients to community resources.
Partner with food organizations: Collaborate with local food banks and nutrition programs to improve access to healthy foods.
Offer transportation help: Provide solutions for patients to attend appointments.
Form community partnerships: Collaborate with local organizations for comprehensive patient support.
Promote healthy lifestyles: Encourage participation in wellness programs and activities.
Provide health education: Educate patients on preventative care and healthy living.
Integrate social workers: Add social workers to care teams to address non-medical needs.
By incorporating these strategies into your practice, you’ll create a more equitable healthcare environment and significantly enhance the well-being of your patients.
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Rebecca Slawter, freelance healthcare writer
Rebecca Slawter is a seasoned freelance content and copywriter focusing on healthcare and B2B SaaS. Rebecca has first-hand knowledge of the importance of connections between patients and their providers — connections that are easier to build in independent practices. Her passion for writing about healthcare is rooted in wanting to spotlight healthcare professionals and their tireless efforts, and to do what she can to improve the industry as a whole.
Reviewed by
Lauren Wheeler, BCPA, MD
Dr. Lauren Wheeler, MD, BCPA, is a former family medicine physician who currently works as an independent healthcare advocate as well as a medical editor and writer. You can get in touch with her about anything writing or advocacy at her website www.lostcoastadvocacy.com.