Social Determinants of Health are the fourth dimension of the American Academy of Physician Assistants Health Disparities Work Group’s effort to promote a more comprehensive approach to solving the health inequity puzzle.

The 4D framework focuses on (1) access to care, (2) systems quality, (3) provider attitudes and cultural competency, and (4) social determinants of health. This approach is an attempt to integrate all four components in closing gaps in care, and in understanding why racial and other disparities continue to persist.

Social determinants of health describe the array of complex forces that shape and influence the public’s health, often out of clinician sight. These include poverty, income inequality, lack of access to affordable and nutritious food, lack of educational and employment opportunities, violence and racism.

Evidence has mounted over the years that social determinants clearly impact the health of Americans. Richard Wilkinson, Michael Marmot and many other social science researchers have created a body of evidence that indicates fairness and equality determine the health of our communities. Wilkinson’s highly readable book Mind the Gap makes the argument in the most direct way: inequality kills.

When thinking about health disparities, it’s clear that even when the first three aspects of the 4D framework for health equality are in place – access, quality and cultural competency — the playing field will still remain uneven if patients are ravaged by social forces.

The AAPA’s 2012 Toronto Health Disparities Work Group’s “Making it Personal: Eliminating Health Disparities One Patient at a Time” CME activity describes the scenario best. Imagine a state-of-the art clinic with the most modern equipment, the finest providers trained at the best institutions, in a setting where all patients have free and full access to care. Also imagine this clinic’s providers have been through extensive cultural competency training and provide the most culturally sensitive care.

Now imagine this clinic being placed in two geographic areas. Area one is an affluent community, where crime is low, employment is high, food is plentiful and education is quality. Area two is a neighborhood characterized by violence, poverty, poor education and limited nutritional outlets. Most clinicians would agree that there would be very different levels of health in these two settings.

Perhaps one of the biggest challenges of increasing awareness about social determinants of health is solving the conundrum of whose job is it? When asked, many clinicians note that they don’t think it’s their responsibility to change the world and say addressing social factors falls outside of their scope of practice. After all, we are trained to practice medicine, not politics.

When we examine this idea closer though, we realize that it really runs counter the notion that PAs and NPs exist to improve the health of the public. If we find that we have as much or more of an effect on the health of our patients outside the exam room, can we afford the luxury of saying, “That’s not my job?”

What if traditional notions about how medicine works are wrong, and evidence shows that social forces impact health as much as, or more than all of our diagnostic acumen combined?

The most effective tools for addressing health disparities may in fact take place outside the examination room. Future efforts to reverse health disparities may be well served taking a 4D approach to healthcare with particular emphasis on recognizing social determinants of health.

Jim Anderson, MPAS, PA-C, ATC, is chair of the American Academy of Physician Assistants Health Disparities Work Group, founder of Physician Assistants for Health Equity and faculty of the Department of Anesthesia and Pain Medicine at the University of Washington School of Medicine in Seattle.