Should We Be Screening for Poverty as a Risk Factor?

The Untouched Vital Sign in Clinical Medicine
Introduction: The Missing Risk Factor in Our Clinical Checklists

When a patient walks into your clinic, what do you typically screen for?

Smoking? ✅
Alcohol use? ✅
Family history? ✅
BMI? ✅
Poverty? ❌

We regularly ask about cholesterol but often overlook whether the patient can afford the heart-healthy food needed to lower it. We inquire about medication adherence but don’t always ask whether they had to choose between insulin and rent.

Yet poverty may be one of the strongest and most persistent social determinants of health, influencing everything from life expectancy to disease recurrence. Which leads to a powerful question:

Should poverty be screened for like any other medical risk factor?

1. Poverty as a Clinical Determinant, Not Just a Social One

Physicians are trained to diagnose disease through biomarkers, scans, and ICD codes. But experience teaches us that poverty reshapes disease itself.

Patients living in poverty are more likely to:

• Postpone or avoid care due to cost
  
  
• Suffer from chronic conditions at higher rates
  
  
• Lack access to healthy food and clean environments
  
  
• Live in hazardous or overcrowded housing
  
  
• Miss appointments due to unreliable transportation

A landmark 2022 study in The Lancet Public Health identified poverty as “the single largest modifiable risk factor for all-cause mortality” in many demographic groups.

This isn’t just a socioeconomic background detail—it’s a clinically significant force.

2. Why Don’t We Screen for It Already?

Many physicians recognize the devastating effects of poverty on health, yet poverty rarely appears in routine assessments. Why not?

• It’s not part of standardized vital signs
  
  
• Few of us received formal training in identifying social determinants
  
  
• Discussing money can be uncomfortable or feel inappropriate
  
  
• There’s often a sense of helplessness: “Even if I know, what can I do?”

But these barriers are not unbreakable. And often, physicians already see the signs of poverty—they just don’t have a structured way to respond.

3. What Does Screening for Poverty Actually Look Like?

It doesn’t need to be complex or time-consuming.

The American Academy of Pediatrics recommends a remarkably simple screening question:

“Do you ever have difficulty making ends meet at the end of the month?”

A single yes-or-no query that opens the door to understanding material hardship.

Other questions that can be integrated into intake forms or verbal history include:

• Are you worried about your housing situation?
  
  
• Have you skipped meals or medications due to cost?
  
  
• Do you have consistent transportation to your appointments?

These can be asked universally, quickly, and with dignity—just like questions about substance use or mental health.

4. Does Screening Help? The Evidence Says Yes

When poverty screening is implemented effectively, the impact is measurable:

• Clinician awareness of patients’ real-life barriers increases
  
  
• Referrals to supportive services such as food banks or housing programs improve
  
  
• Patients report feeling more understood and less stigmatized
  
  
• In some systems, health outcomes have improved, particularly in pediatrics and prenatal care

Examples include:

• Kaiser Permanente implemented a social risk screening tool in over 100,000 patients, which led to enhanced resource allocation and improved care access.
  
  
• In Canada, physicians have begun using “poverty prescription pads” to connect patients directly to income support resources.

Screening without follow-through is ineffective—but with referrals and system support, it becomes transformative.

5. Poverty and Diagnostic Overshadowing

There is a danger in recognizing poverty—but only seeing poverty.

• A patient in tattered clothes presenting with chest pain might be dismissed as “anxious.”
  
  
• A single mother missing follow-up could be labeled non-compliant—without asking why.
  
  
• Homeless individuals might not receive full diagnostic workups, based on unconscious assumptions.

Screening must not become stereotyping. The goal is compassionate, equitable care—not shortcuts based on socioeconomic profiling.

6. What About Already Overburdened Doctors?

The concern is valid:

“I’m a doctor, not a social worker.”

And yet, we screen for:

• Depression, then refer to mental health
  
  
• Obesity, then refer to dietitians
  
  
• Substance use, then refer to addiction counselors

Likewise, we can screen for poverty and refer to trained social care teams. This doesn’t mean adding more responsibility—it means using a wider lens to understand clinical problems.

What healthcare systems need are:

• Integrated care coordinators
  
  
• Social workers embedded in clinical teams
  
  
• Resource directories within EMRs
  
  
• Stronger community partnerships

But awareness is the necessary first step.

7. How Poverty Impacts Clinical Outcomes (With Real-World Examples)

These are not hypotheticals. They happen every day.

• A hypertensive man skips meds due to co-pay → hemorrhagic stroke
  
  
• A diabetic woman cuts insulin to buy groceries → admitted in DKA
  
  
• A child with asthma lives in a mold-infested apartment → multiple ER visits
  
  
• A pregnant patient postpones care due to lack of transport → preterm delivery

Every time we treat symptoms without addressing poverty as a root cause, we risk medical recidivism. The same patients return, with worsening conditions and dwindling trust.

8. Ethical Considerations: Is It Our Role?

Some may argue that poverty is a political issue—not a medical one. But that same argument could apply to:

• Domestic violence
  
  
• Substance use
  
  
• Mental health disorders

All of these are influenced by social context and yet recognized as appropriate domains for clinical inquiry.

Avoiding poverty screening in the name of neutrality is, in effect, a form of neglect.

9. What If Patients Feel Embarrassed?

It’s a common worry—but not well-supported by evidence.

When handled respectfully and universally, patients don’t feel targeted—they feel seen.

In fact, studies show that:

• Patients appreciate being asked about financial stressors
  
  
• They feel less judged when questions are routine rather than selective
  
  
• Being asked opens up opportunities to receive help they didn’t know existed

Framing matters. Universal screening ensures no one is profiled, and everyone is supported.

10. Final Thoughts: The Sixth Vital Sign?

We’ve long relied on five standard vital signs: heart rate, respiratory rate, blood pressure, temperature, and pain. But what if we added a sixth—poverty?

Not to reduce it to a checkbox, but to ensure it’s never overlooked.

We are not social engineers. But we are eyewitnesses to the toll economic hardship takes on health. We see the hypertension that never resolves, the wounds that never heal, the depression that worsens with financial strain.

Screening is not about fixing poverty. It’s about identifying those most at risk and using the tools at our disposal to help them navigate the healthcare system more safely and more equitably.

Because sometimes the most effective intervention isn’t a medication—it’s a food voucher, a bus pass, or simply an understanding conversation.

Conclusion: Poverty Belongs in the Clinical Conversation

Poverty is not just a backdrop. It is a clinically relevant, ethically urgent, and scientifically supported risk factor that belongs in our patient assessments.

We ask about smoking, sexual behavior, and substance use—why not poverty?

We track cholesterol and HbA1c—why not material hardship?

As the landscape of modern medicine evolves, we must include social context as part of our diagnostic framework. And that begins with asking the right questions.

So next time you take a patient history, consider asking:

“Do you ever have trouble making ends meet at the end of the month?”

It might not change their income. But it could change their care.

And in many cases, that’s the first real step toward healing.