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.