Should Family Medicine and Family Physicians Be Responsible for Addressing Population Health and the Social Drivers of Health?

• Family Medicine
• FMLC 2025
• Health Equity
• Physician’s Role
• Population Health
• Social Determinants of Health

The family physician’s commitment to whole-person, family-centered, and community-centered care, and their unique insights into the social factors that affect their patients, provides them an important role in addressing SDH. Utilizing validated screening instruments and community vital signs in the electronic health record (EHR) can facilitate appropriate referrals and address social drivers earlier. Team-based models can support the family physician’s work in this area, which also requires payment reform. Family physicians are central partners but not the sole leaders in these efforts to address SDH.

Alternatively, concerns were raised that conflating clinical responsibility with broader societal obligation lacks strong evidence of meaningful benefit, places additional strain on already limited visit time, diverts attention from numerous existing demands within office-based care, and may further contribute to physician burnout. Structural issues require structural solutions. Perhaps the family physician’s primary role in addressing SDH should be advocacy upstream rather than taking direct accountability downstream for changing SDH outcomes.

The central tension lies not in whether SDH matter, but in defining the appropriate scope of responsibility for family physicians within clinical practice.

To improve population health, attention to the social drivers of health is essential. The World Health Organization (WHO) estimates that non-medical factors account for up to 70% of avoidable deaths.¹ As healthcare systems have moved beyond traditional models of care, family physicians have become increasingly recognized as important contributors to SDH efforts.

Family physicians maintain continuity in their patient relationships, demonstrate a broad scope of clinical expertise, and employ a community-oriented approach to care, uniquely positioning them within the healthcare system to address SDH. A family physician’s commitment to whole-person, family-centered, and community-centered care is an important factor in this role. Evidence has shown that access to primary care improves health outcomes, reduces costs, and promotes equity.² Continuity and trust, long hallmarks of the family physician–patient relationship, offer insights into social factors that influence well-being and facilitate early detection of SDH, such as housing instability, food insecurity, or transportation barriers, before they escalate.

Routine office visits create opportunities for screening and shared decision-making. National initiatives such as the American Academy of Family Physicians’ EveryONE Project³ and the PRAPARE tool⁴ provide validated screening instruments and workflows tailored to primary care practices. Integration of “community vital signs”—such as local crime rates, transportation access, and grocery availability—into electronic health records can facilitate referrals to community services and raise awareness of factors that may affect treatment adherence and health outcomes.⁵

Team-based care models further strengthen the role of family physicians in addressing SDH. Practices incorporating social workers, care coordinators, or community health workers demonstrate greater capacity to respond to social needs, with improved follow-up and more consistent referral patterns.⁶ Federally Qualified Health Centers and other integrated care systems show a two- to three-fold greater ability to address social needs than smaller or independently owned practices.⁷ Despite these strengths, family physicians cannot effectively address SDH independently.

Time constraints remain a significant challenge. A typical primary care visit must address preventive care, chronic disease management, acute concerns, and documentation requirements. Adding comprehensive SDH assessment and care coordination can quickly overwhelm available time. Electronic health records increasingly include SDH documentation fields. In practice, many such fields remain incomplete, reflecting time limitations within the current 20-minute visit structure, which is already focused on multiple diagnoses, treatments, and preventive services for which physicians are held accountable.

Every choice carries opportunity cost. Time devoted to social drivers may reduce time available for unscripted patient interaction and relationship building, shared decision-making, and preventive counseling—core competencies of family medicine. These pressures also contribute to burnout; more than 80% of family physicians report that SDH challenges increase emotional strain and workload.⁷

Resources and staffing vary across practice settings. Burdening resource-limited practices may also widen disparities. Small, independently owned clinics often lack access to social care teams, integrated behavioral health, or data analytics platforms required for SDH work.⁷ Payment structures also present barriers. Traditional fee-for-service models rarely reimburse social care coordination, multidisciplinary team meetings, or partnerships with community-based organizations. Without payment reform aligned with value-based care, sustaining preventive, population-level activities remains difficult.⁸ Although many family medicine and internal medicine residency programs include SDH training, fewer than one-third of residents report feeling competent in identifying patients’ social challenges and only 10% report high competence in addressing patients’ social needs in practice.⁹

Garg et al¹⁰ noted that “screening for any condition in isolation without the capacity to ensure referral and linkage to appropriate treatment is ineffective and, arguably, unethical.” Similarly, the US Preventive Services Task Force (USPSTF) has recommended screening when systems for diagnosis, treatment, and follow-up are available.¹¹ Evidence directly linking SDH interventions in clinical settings to improved health outcomes remains limited.¹² Silverstein¹³ observed that most research on social determinants has been observational and that few interventional studies have examined health outcomes or costs, limiting the strength of evidence for health system–based interventions. For example, the March 2025 USPSTF final recommendation on screening for food insecurity issued an “I” statement, concluding that current evidence is insufficient to assess the balance of benefits and harms in primary care settings.¹⁴

Higher physician engagement in addressing health-related social needs has been associated with increased burnout risk.¹⁵ Patients may already experience reduced relationship-based, patient-centered care in increasingly transactional and time-pressured ambulatory delivery systems. Clinical education settings illustrate these pressures; residents may focus on task completion at the expense of relational continuity. Efforts may be best directed toward strengthening relational trust and areas within direct professional influence.

Steven Covey’s framework¹⁶ of circles of control, influence, and concern provides one lens for examining professional responsibility. The Circle of Control includes factors directly managed by clinicians (Figure 1).

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Figure 1. Medical College of Wisconsin population-based model of patient-centered care* with Steven Covey’s conceptual circles of influence.^†

^*Meurer LN, Young SA, Meurer JR, Johnson SL, Gilbert IA, Diehr S. Urban and community health pathway planning council: preparing socially responsive physicians through community-engaged learning. Am J Prev Med. 2011. https://www.ajpmonline.org/article/S0749-3797(11)00366-7/pdf

^†Covey SR. The Seven Habits of Highly Effective People. Simon & Schuster; 1989.

The Circle of Influence encompasses areas where clinicians can exert meaningful input without full authority. The Circle of Concern includes broader societal issues with limited direct control. Patient-centered care lies within the Circle of Control; local health systems and community engagement may fall within the Circle of Influence; broader societal drivers of health fall largely within the Circle of Concern. Responsibility may be most appropriately concentrated within areas of control and influence.

Structural challenges require structural solutions, and medicalizing upstream societal failures misplaces appropriate responsibility to the downstream family physician. Advocacy—working with policymakers, community organizations, and health systems—is an important part of the physician’s professional role in addressing SDH. At the same time, expecting individual clinicians to assume primary responsibility for systemic social inequities within the confines of a clinical encounter may not be realistic. Poverty, racism, and housing instability are upstream problems that require policy-level solutions. Treating them mainly as clinical responsibilities risks shifting accountability without resolving underlying causes.

Family physicians should remain informed about social drivers of health, attentive to how they affect patients, and responsive within the limits of their practice settings. They are well positioned to recognize social barriers, adjust treatment plans accordingly, and participate in team-based approaches when appropriate infrastructure is available. Sustainable progress in addressing SDH will require coordinated efforts among health systems, public policy leaders, and community organizations. Aligning expectations with available resources helps maintain clarity of professional responsibility, reduces burnout risk, and protects the relationship-based core of family medicine.

• Received for publication December 8, 2025.
• Accepted for publication April 8, 2026.