PEARLS+: Putting the Social Determinants of Health into Practice

By: William Ventres, MD, MA, clinical attending, Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine; Jay D. Kravitz, MD, MPH, assistant professor (retired), Department of Public Health and Preventive Medicine, Oregon Health & Science University; and Shafik Dharamsi, PhD, dean, College of Health Sciences, University of Texas at El Paso

Understanding the social determinants of health, including their upstream causes and downstream health outcomes, is a difficult task. Contemplating the complexity of these issues can often feel overwhelming, leaving medical students, residents, and clinician–educators feeling frustrated and helpless. Feelings of frustration commonly arise out a sense of indignation in response to observing injustice and inequity. Feelings of helplessness come from a perceived lack of power relative to the influence of culturally ingrained societal forces.

Many ask themselves, can we really alter health outcomes when such forces are seemingly so big?

For some, the answer is to study and practice within the confines of strict biomedical boundaries rather than to approach that same study and practice from a broader perspective, inclusive of such topics such as culture, class, politics, and environment. For many, it is to situate themselves in settings that limit uncertainty, settings that are mostly distant from the effects of adverse social determinants, which are unduly experienced and keenly felt by people living at the margins of society. For still others, it is to ignore the topic of the social determinants altogether and stick to the basics: the practice of medicine is about diagnosing and treating disease. Period.

Of note, and as a direct challenge to accepting these answers out of hand, the American Medical Association’s Declaration of Professional Responsibility calls on all physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”1 In accordance with the spirit of this Declaration, we hope to shed some light on the relationship between upstream causes and downstream health outcomes.

We invite readers to use PEARLS+ as described in a recent AM Last Page toward the following ends:

  • As an introductory guide to orient learners to the connections between societal forces, social determinants, and measures of health and illness, prior to delving into details offered by other informational sources;
  • As a reminder that, as in all things complex, there are opportunities for involvement, opportunities that speak both to personal interest and mutual engagement; and
  • As a touchstone to help us recall our duty to be socially responsible in our work as physicians, regardless of position, discipline, or location of practice.

How societal forces influence the social determinants and how those determinants in turn shape health outcomes are big issues. Being big, they demand physician attention and physician action. It is vital for physicians to acknowledge the huge influence that social forces and social determinants have so that collectively—in collaboration with other health care professionals—they can direct their clinical, teaching, research, and advocacy activities toward improving health outcomes among those most at risk.

We believe the PEARLS+ acronym, in its simplicity, distills to a manageable size the links between societal forces, social determinants, and health outcomes. We hope it will also encourage physicians in training, education, and practice to step up and attend to some of the truly “big issues” of our time. We urge you to consider how you might learn, teach, and practice “big medicine” in response.


  1. American Medical Association. Declaration of Professional Responsibility. In: Council on Ethical and Judicial Affairs. Code of Medical Ethics–Current Opinions, 2000-2001 Edition. Chicago, IL: American Medical Association; 2000: 144-145.

Related Posts


  1. Dr Benjamin A Bensadon
    December 16, 2017 at 3:39 PM

    All too often in medicine the psychological is mislabeled social. The more accurate category “psychosocial” determinants of health (e.g., aging, mood, family, distrust, shame, bias, self-efficacy, empowerment, fear) allows for clinical management of the psychological impact of social realities (non adherence, substance misuse). Need for standard behavioral medicine has been indicated and articulated (but not delivered) for decades. Unprecedented life expectancy and cultural diversity suggest this need will continue and likely intensify. Whether we are willing to respond by integrating behavioral and medical experts in both training and care remains to be seen.

  2. Robert C. Like, MD, MS
    December 18, 2017 at 12:19 PM

    Addressing the social determinants of health (SDOH) in clinical practice is increasingly being recognized as an important task for physicians and other health and human service professionals as members of interprofessional teams. Ventres et al’s, PEARLS+ acronym provides a very helpful summary and distillation of key SDOH dimensions that relate to the multiple upstream and downstream factors influencing health outcomes at the macro, meso, and micro systems levels.(1)

    We have similarly found that practicing clinicians and health professions learners can benefit from having easy to remember frameworks that can facilitate their obtaining an expanded social history during patient care encounters (2, 3). Patients often have to navigate a complex and frustrating “labyrinth of social and environmental challenges” in accessing health and behavioral health care and relevant community support services. Developing mutual trust and a respectful therapeutic alliance during clinical encounters is a critical first step for addressing these challenges.

    The following practical interviewing mnemonic, THEESEUS, can be employed in primary, secondary, tertiary, and quaternary care settings in eliciting and documenting SDOH information:

    THEESEUS – A Mnemonic for Addressing the Social Determinants of Health
    T: Transportation (e.g., auto, bus, taxi)
    H: Housing (e.g., home owner, renter, living arrangements, housing stock)
    E: Eating (e.g., typical diet/nutrition, adequacy of food supplies, meals on wheels, food deserts)
    E: Education (e.g., educational attainment, literacy, numeracy, health literacy)
    S: Safety (e.g., interpersonal, physical, community, environmental)
    E: Economics (e.g., current and long-term financial assets, budget for food, clothing, medications)
    U: Utilities (e.g., electricity, gas, water, heating, phone, internet, other)
    S: Social Supports (e.g., family, friends, work, religious, recreational, community)

    Developed by:
    Robert C. Like, MD, MS Department of Family Medicine and Community Health
    Rutgers Robert Wood Johnson Medical School © 2017

    In educating our current and future health professions workforce, there is a need to develop and disseminate appropriate case vignettes and role play simulations for use in various medical specialty fields and care contexts (e.g., hospital wards, intensive care units, emergency departments, ambulatory care settings, home visits) so that practitioners are equipped with the knowledge and skills needed to elicit the SDOH as part of life-long learning and ongoing clinical practice. Structural competency (4) will be especially important in improving care and service delivery to populations with complex needs,(5) addressing and preventing syndemics (“interacting epidemics”) (6), and as part of the Centers for Medicare & Medicaid Services Accountable Health Communities Model and other SDOH initiatives.(7)

    Integrating Upstream and Downstream Medicine needs to become Mainstream in order to address the Triple and Quadruple Aims!(8)

    1) HealthBegins, Accessed on December 18, 2017.
    2) Behforouz HL, Drain PK, Rhatigan JJ. Becoming a Physician: Rethinking the Social History. New England Journal of Medicine 2014; 371(14):1277-1279.
    3) Green AR, Betancourt JR, Carrillo JE. Integrating Social Factors Into Cross-Cultural Medical Education. Academic Medicine 2002; 77(3):193-197.
    4) Structural Competency, Accessed on December 18, 2017.
    5) Caitlin T-H, Schulman M. Brief: Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations, Center for Health Care Strategies/Robert Wood Johnson Foundation, October 2017., Accessed on December 18, 2017.
    6) The Lancet. Editorial: Syndemics: Health in Context. 2017; 389(10072):881. DOI:, Accessed on December 18, 2017.
    7) Billioux A, Verlander K, Anthrony S, Alley D. Discussion Paper: Standardized Screening for Health-Related Needs in Clinical Settings. The Accountable Health Communities Screening Tool. National Academy of Medicine, May 30, 2017., Accessed on December 18, 2017.
    8) Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine 2014; 12(6):573-576.

%d bloggers like this: