When people think about becoming a doctor, they often imagine diagnosing disease and prescribing treatment. Biology matters — but very early in clinical practice, it becomes clear that biology alone does not explain who becomes unwell, how illness progresses, or why outcomes differ so markedly between patients.
This is where social determinants of health become essential to clinical reasoning.
Social determinants are the conditions in which people are born, grow, live, work, and age. They shape exposure to risk, access to care, capacity to recover, and the choices people realistically have available to them. Importantly, they influence health long before a patient enters a clinic — and continue to shape outcomes long after a prescription is written.
Did you know you can use AI tools to turn your notes into short podcasts?
This can be a useful way to revisit key concepts while driving, walking, or at the gym, and can help reinforce ideas by hearing them explained in a conversational, narrative format.
Social Determinants – Phase 1 podcast (15 minutes)
Health follows a social gradient — not a simple divide
Health is not distributed randomly. Across countries and within countries, health follows a social gradient: as social advantage decreases, the risk of illness, disability, and premature death increases.
This gradient is not just about “the poorest versus everyone else”. At every step down the socioeconomic ladder, health outcomes worsen. Someone in the middle of society is generally less healthy than someone at the top, and more healthy than someone at the bottom.
Clinically, this matters because it explains why:
- chronic disease is more common in some communities
- risk factors cluster together
- preventable illness persists despite available treatments
These patterns are systematic and predictable, not accidental.
In medical practice, social determinants rarely appear as a separate problem. They show up as patterns:
- Missed appointments or delayed presentation
- Difficulty following treatment plans
- Repeated presentations with preventable complications
- Health advice that is technically correct but practically unachievable
Inequality vs inequity: a crucial distinction
Not all differences in health are the same.
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Inequality refers to measurable differences (for example, differences in life expectancy between regions or populations).
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Inequity refers to differences that are avoidable, unfair, and unjust.
This distinction matters in medicine because inequities are not inevitable. They reflect social, economic, and political decisions that shape access to education, housing, employment, healthcare, and safety.
When doctors encounter repeated patterns of preventable illness, poor access, or delayed care, they are often seeing the downstream effects of inequity, even if it isn’t labelled as such in the medical record.
Wealthier countries tend to have better overall health outcomes than poorer countries. However, research consistently shows that how wealth is distributed within a country has a major impact on population health.
Countries with greater income and social inequality often have:
- Lower life expectancy
- Higher rates of chronic disease
- Worse mental health outcomes
- Greater health gaps between social groups
In contrast, countries with stronger social safety nets and lower inequality tend to achieve better health outcomes across the whole population — not just for those at the top.
Within countries and between countries
The same principles apply at different scales.
Between countries, life expectancy and disease burden vary dramatically depending on wealth, infrastructure, stability, and access to healthcare.
Within countries like Australia, similar gradients exist:
- between urban and rural communities
- between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians
- across income, education, and housing security
- across disability, migration status, and incarceration history
These differences are not explained by biology alone. They reflect structural conditions that shape opportunity and risk.
Social determinants are often misunderstood as being “about disadvantaged groups”.
In reality, the social gradient means that everyone’s health is shaped by social position — not just those at the extremes.
This is why social determinants matter across all areas of medicine, not only in public or community health.
Intersectionality: patients don’t experience determinants one at a time
For example:
- financial insecurity may intersect with housing instability
- disability may intersect with reduced access to transport or employment
- cultural marginalisation may intersect with reduced trust in healthcare systems
Clinically, this means that a patient’s challenges are rarely explained by a single factor. Appreciating intersectionality helps doctors avoid simplistic explanations and one-size-fits-all solutions.
Why “lifestyle choice” is an oversimplification
Health behaviours are often framed as individual choices: diet, exercise, smoking, alcohol. While behaviour matters, choice is constrained by context.
Access to safe housing, affordable food, education, transport, healthcare, and supportive social networks shapes what is realistically possible. Two patients may receive the same advice — but their capacity to act on it may differ profoundly. Two people may make very different “choices” — but those choices are constrained or enabled by circumstances that sit well beyond individual control.
Understanding this doesn’t remove personal responsibility. It adds context, realism, and compassion to clinical care.
In clinical practice, this matters because it affects:
- what advice is feasible
- what treatments are accessible
- what follow-up is realistic
- and what outcomes are achievable
Understanding this doesn’t remove personal responsibility — but it adds context, compassion, and realism to clinical decision-making.
From population patterns to individual patients
Social determinants are often taught using population data — life expectancy curves, gradients, and statistics. In clinical medicine, those patterns appear as individual patients in front of you.
Understanding the broader picture helps you ask better questions:
- What barriers might this patient be facing?
- What assumptions am I making?
- What matters most to this person right now?
- How can care be adapted to their reality?
These are clinical reasoning skills, not abstract theory.
Social determinants are often taught using population statistics and graphs.
In clinical medicine, those same patterns appear as individual patients — each with a unique history, context, and set of constraints.
Good clinical reasoning involves recognising when a population pattern may be influencing an individual presentation.
What this means for you as a medical student (and future doctor)
- to recognise when social factors are influencing health
- to avoid moral judgement or assumptions about compliance
- to tailor care to a patient’s context
- to work with multidisciplinary teams
- and to advocate appropriately within health systems
A patient’s presentation rarely reflects biology alone — it reflects lived experience layered on top of biology.
A 52-year-old man presents to general practice with poorly controlled hypertension and type 2 diabetes. His medications have been escalated several times over the past few years, but his HbA1c and blood pressure remain above target.
He works casually in manual labour, has no paid sick leave, and travels long distances for work. He often misses follow-up appointments and has difficulty attending pathology tests during business hours.
He reports trying to follow dietary advice but relies on inexpensive, non-perishable foods. He has limited access to safe spaces for regular exercise and is caring for an elderly parent at home.
On review, there is no evidence of medication intolerance or non-adherence.
Reflection questions
- Which social determinants are shaping this patient’s health outcomes?
- How might inequity (rather than individual choice) be contributing to disease progression?
- What assumptions might a clinician be tempted to make?
- How could care be adapted to better fit this patient’s circumstances?
From Day 1, medicine is not just about what happens inside the body — it’s also about the world people live in.
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