There is a profound irony at the heart of modern healthcare: physicians are required to ask patients about their social determinants of health (SDOH), yet institutions are often unwilling or unable to ask the same questions of their employees. Regulatory concerns, privacy considerations, and fear of liability/discrimination/harassment, create a culture in which employers avoid probing into workers’ personal circumstances. Yet we know all too well that the same social issues that shape patient health also shape workforce reliability, efficiency, and ultimately productivity. This creates a paradox. How can institutions mitigate social determinants of productivity if they are systematically blind to them? Ignoring these factors does not eliminate their impact; it merely shifts the burden onto employees which, in turn, affects the healthcare system’s performance when employees’ productivity is affected. If healthcare institutions are serious about optimizing performance, they must recognize that social determinants are not just patient variables — they are workforce variables. I like to call this social determinants of productivity.
The CDC defines five core domains of SDOH: economic stability, education, social and community context, health and healthcare access, and neighborhood and built environment. These factors are widely recognized as powerful predictors of patient outcomes — typically more influential than medical interventions themselves. They determine whether a patient can attend appointments, adhere to medications, or implement lifestyle changes.
Time and space won't allow me to go into how each of these social determinants affects productivity. Social and community context, though, is probably the most underappreciated determinant. A national survey of clinically inactive physicians was conducted to identify the factors driving early exit from the clinical physician workforce in the U.S. It found that women physicians left clinical practice earlier than men more often because of childcare and family caregiving pressures. These are classic social determinants tied to social roles, family structure, and institutional support systems. The findings imply that inadequate childcare access, inflexible scheduling, and unequal workplace expectations reduce physician retention and undoubtedly their productivity prior to their departure. A nurse who is a single parent must navigate school schedules, childcare gaps, and unexpected illnesses. A medical assistant caring for an aging parent may face sudden interruptions that require leaving work. These are not rare exceptions — they are common realities.
I've even witnessed directly the effects of unaddressed social determinants on productivity.
A physician fairly new to the community with a child in elementary school had to take significant time off work when their spouse sustained a fractured femur in a car accident. The spouse was hospitalized and rendered immobile while undergoing rehabilitation. The physician now had the responsibility of taking their child to and from school. The health system did not have a mechanism for the physician to work part-time (it was all or nothing), and offered no childcare or transportation support for the child. As a result, all of the patients assigned to that physician had their appointments canceled or rescheduled to their colleagues who were already overwhelmed by the volume of their own patients. Being new in the community, this physician’s family also did not have the social network that could have allowed them to continue working through their spouse’s recovery. The consequences of this physician being taken out of the workforce because of a health system’s inability to deal with a social determinant clearly affected the bottom line for both the health system and the physician — double losses.
A single mother working as a medical assistant was called by her child's school informing her that her child was sick and needed to be picked up. Having no reliable family to step in to help, she had to leave work abruptly to tend to her child, taking several days off work. This directly impacted patient throughput with tasks she normally handled directed to the already busy nurses.
A radiology technician missed a shift because his car would not start and he could not afford a taxi or rideshare service. The cost of a ride to pick him up and take him back home would have been easily offset by the revenue generated from the scheduled studies — all of which had to be canceled because of his absence.
Healthcare operates in a way that assumes the workforce is not human. While “lean management” may work for Toyota as a manufacturing company, it does not work well in hospitals or clinics where we see unpredictable patient acuity and complexity and unpredictable social determinants among healthcare staff. Lean management never addresses childcare burdens, housing/transportation insecurity, or gender/racial inequities within healthcare employment. Lean management assumes that people never get sick, never need to leave work to care for sick family members, never get into an accident, and never experience natural disasters.
To address this gap, healthcare organizations need to adapt from an operational mindset like lean management to a more holistic workforce strategy. This does not require invasive surveillance of employees’ personal lives (which is illegal), but it does require acknowledging that external factors influence workplace performance. One of the most effective interventions is on-site or subsidized childcare. Reliable childcare directly reduces absenteeism and stress for working parents, particularly in a field with rigid schedules. Similarly, flexible scheduling and shift-swapping systems can accommodate caregiving responsibilities without compromising coverage. The balance of respecting privacy while learning about unmet needs among employees may involve the use of anonymized surveys to assess workforce needs without violating privacy. By aggregating data on challenges such as childcare, transportation, and financial stress, organizations can design interventions while maintaining confidentiality.
Transportation support — such as transit stipends, parking subsidies (instead of making us pay for parking at our own institutions), or shuttle services — can address commute-related barriers. A cab or rideshare fund can help those employees who unexpectedly find themselves with a non-operable vehicle. Housing assistance programs, particularly in high-cost areas, can improve retention, reduce financial strain, and reduce the length of commutes.
Healthcare access for employees must also be prioritized. This includes protected time for medical appointments, robust mental health services, and wellness programs that go beyond superficial initiatives. Addressing burnout not only requires operational structural changes, such as appropriate staffing ratios, reduced administrative burden, and improved EHR usability, but also the investments in resources to address the same CDC-defined SDOH for their employees, but reframed as social determinants of productivity.
What about housing? It’s common knowledge that hospitals and clinics in high-cost cities have difficulty recruiting and retaining ancillary support staff, and even higher-paid physicians. Could there be a model like what company towns in the 19th century had where employees live on-site for low or no cost as part of their benefit package, while being able to come to work without worrying about spending hours in traffic living in more affordable but distant housing, or spending an unsustainable portion of their pay on housing to live closer?
Investing in the SDOP of healthcare workers is not a charitable endeavor; it is a strategic imperative. The return on investment includes improved retention, reduced absenteeism, enhanced morale, and ultimately better patient outcomes. In a system increasingly focused on value-based care, these gains are directly aligned with financial and clinical goals.
A good institutional example is the Cleveland Clinic, which frames employee support as essential to patient care. Their “Caring for Caregivers” infrastructure includes confidential counseling, support for childcare and eldercare issues, financial counseling, occupational health services, mental health resources, and wellness programming. They acknowledge that problems such as marital stress, caregiving burdens, substance use, and financial strain affect workplace performance and patient care. Their model goes beyond the traditional Employee Assistance Program model of merely reacting to crises. Instead, Cleveland Clinic treats workforce stability as an operational priority tied to retention, safety, quality, and productivity.
The concept of social determinants has transformed how we understand patient health, but its application remains incomplete. Physicians and healthcare employees are not immune to the same forces that affect their patients. Economic instability, caregiving responsibilities, health challenges, and environmental factors all shape their ability to perform.
The irony that healthcare institutions mandate SDOH screening for patients while avoiding similar inquiry into their workforce highlights a fundamental disconnect. If organizations are unwilling to acknowledge these determinants, they cannot effectively address them. To build a resilient and productive healthcare system, institutions must extend the SDOH framework inward. Institutions do not even need to “illegally” ask about an employee’s social determinants. We already know what they are. Recognizing and mitigating social determinants of productivity is not only a logical business strategy — it is essential for a sustainable healthcare system.
