Social Determinants of Health Gaining Prominence

Fragmented, essentializing, simplistic. That’s how students at Perelman School of Medicine at the University of Pennsylvania, Philadelphia, described their required course on cultural competence. Lectures and discussions about cultural groups and communication issues weren’t providing them with the skills they needed to navigate doctor-patient relationships.

Their criticism was a wake-up call that Horace Delisser, MD, associate dean for diversity and inclusion at the school, took to heart. He enlisted medical students to help reinvent the curriculum. The result, Introduction to Medicine and Society, launched in 2013 and described in an article published in 2017 (Acad Med. 2017;92[3]:335-43), emphasizes self-awareness and reflection about one’s own biases and the adoption of a less hierarchical and more respectful “other-oriented” approach to the patient relationship.

The course examines social determinants of health (SDHs) – the influences of society, government, culture, and health systems. Students analyze how health and health outcomes are affected by a patient’s income, education, and living and working conditions, as well as access to healthy food, safe water, and transportation.

The Perelman School of Medicine is just one of the many medical schools across the country that is revising training, both didactic and experiential, to teach students about SDHs. A host of policy makers, advisory groups, and organized medicine groups have called in recent years for educational efforts to boost all physicians’ working knowledge of health inequities and SDHs.

Dr. Delisser, associate professor of medicine who also practices as a pulmonologist at the Harron Lung Center in the Perelman Center for Advanced Medicine, said SDHs play into daily care.

Consider the patient who is chronically late for appointments. “It may not be an issue of the patient being disinterested in their health care, but maybe the public transportation system is unreliable, or maybe the patient has to take two buses and a subway to get there. I need [this knowledge] to inform my care and to engage my patient. I need to know, ‘what does it take for you to get here?’ That factors into how I [make the care plan],” said Dr. Delisser.

Malika Fair, MD, MPH, who teaches a longitudinal professional development class at George Washington University, Washington, and is senior director of health equity partnerships and programs at the American Association of Medical Colleges, provided the example of how her medical students intervened during their rotation in the emergency department on behalf of a newly-diagnosed patient with diabetes who had been unable to fill a prescribed medication. After determining where the patient lived, the students ensured that she had transportation and was able to get the needed medication at a local grocery store. They asked about her barriers to healthy eating, researched local grocery stores, and made practical recommendations that the patient was amenable to implementing. They identified a clinic closer to the patient’s home, and worked with her on making an appointment at a time when she could take off from work.

“Because of their training, these students were able to identify and address social risks in their first month on the ward,” said Dr. Fair, who also practices emergency medicine. They had learned about how to ask about food access and how safe it was for the patient to walk and exercise in her neighborhood.

At Perelman, most students work in student-led community clinics, and some fourth-year students participate in an elective rotation as apprentices to community health workers, learning to address SDHs and develop the cultural humility that they learned about in the classroom. The rotation was similarly created in 2013 and is described in a 2018 article (J Health Care Poor Underserved. 2018;29[2]:581-90).“Being a good physician involves being technically competent as well as what I call relationally competent,” Dr. Delisser said. “And [this involves] being aware that my relationship with a patient doesn’t exist in a vacuum … that there’s a bigger, broader social and structural context that I need to know and understand. I [then need] to use that to inform how I mediate and empower that relationship.”

Aletha Maybank, MD, who became the American Medical Association’s first chief equity officer earlier this year, explained that “the medical profession had a very strong social context at one point in time,” but this was dampened by the Flexner Report of 1910.

The report revolutionized medical education by increasing its rigor, but “it was really focused on clinical and basic science and took out the social context, the context of what medicine is about,” said Dr. Maybank, a pediatrician with a board certification in preventive medicine/public health. “[Now] we’re asking, how do we revolutionize medical education again at this point in time, recognizing the confluence of information and data that we now have available to us about inequities and disparities … and the sense of urgency from students.”

Students driving practice change

Students nationally are “the most important” drivers of the increasing focus on SDHs in medical education, according to Dr. Fair. “They are demanding experiences to learn about the entire patient. We know that only 20% of a patient’s health is dependent on their health care. Our students are demanding education about the other 80%.”

More and more, communities are identifying needs and “students will then come up with initiatives to meet those needs,” Dr. Fair said.

Others interviewed for this story predicted this trend will only intensify, since not-for-profit hospitals are required under the Affordable Care Act regulations to assess community health needs every few years and to intervene accordingly.

Education on health care systems is also advancing. Penn State University, for instance, utilized a million-dollar grant from the AMA’s Accelerating Change in Medical Education initiative to design and implement a 4-year curriculum on the health system sciences that started in 2014. The curriculum includes an immersive experience in patient navigation.

“Students were taught to be patient navigators, and they were assigned within the clinical context to work on issues like, why are [patients] having trouble getting their medications?” said Susan E. Skochelak, MD, MPH, who leads the 6-year-old Accelerating Change initiative as vice president for medical education at the AMA.

From the start, she noted, students at Penn State are encouraged to question inequities, social and structural barriers to health, and faults in the health care system. “The message given at their white coat ceremony is ‘Welcome to medicine. Now that you’re here, you’re a member of the health care team, and we want you to speak up if you think there are things that need to be addressed. We want you to tell us when the system is working and not working,’ ” said Dr Skochelak, who previously served as the senior associate dean for academic affairs at the University of Wisconsin School of Medicine and Public Health, where she had been a tenured professor of family medicine.

Tomorrow’s physician partners

Approximately 80% of medical school graduates who participated in the AAMC’s 2018 survey of graduates said they had received significant training on health disparities—up from 71% in 2014.

“There’s a huge amount [of innovation] happening, but on the flip side, there’s not really a set of accepted tools and practices, and certainly no robust evaluation [of the training],” said Philip M. Alberti, PhD, senior director for health equity research and policy at the American Association of Medical Colleges. A recently published review (J Gen Intern Med. 2019;34[5]:720-30) shows growing interest in the teaching of SDHs in undergraduate medical education but variable content, strategies, and instructional practices.

Dr. Philip Health care systems and practicing physicians are still very much feeling their way with SDHs. Screening tools are being developed and tested, and academic medical centers are trying to determine their roles in addressing issues such as transportation and housing – and what funding and structural levers can be pulled to fulfill these roles. “As we learn more about [these issues], it will become clearer what the right baseline set of competencies might be for all physicians,” Dr. Alberti noted.

In the meantime, some basic expectations for medical education are taking root officially. The National Board of Medical Examiners, with whom the AMA has partnered in its Accelerating Change initiative, has included questions in the United States Medical Licensing Examination on population health and SDHs, and plans to add more exam content on these topics and on health systems science, said Dr. Skochelak.

And through its site visit program (the Clinical Learning Environment Review program), the Accreditation Council for Graduate Medical Education has “made it pretty clear that there’s an expectation that residents and fellows are learning about the health system’s approach to identifying and addressing health care disparities – and that they’re given opportunities to develop quality improvement initiatives that target those disparities,” Dr. Alberti said.

In hopes of achieving consistency across medical specialties and in national accreditation and board certifications exams, the American Association of Medical Colleges is developing its first set of competencies in quality improvement and patient safety, with health equity being one of these competencies’ domains .

The competencies are tiered for medical school graduates, residency graduates, and faculty physicians who are 3-5 years post residency. At this point in time, said Dr. Alberti, the consensus among medical educators has been that physicians “need to be able to understand and consider [social, economic, and structural] contexts when they’re seeing patients, when they’re developing care plans, when they’re talking with caregivers, and when they’re looking at their own quality data.”

Elisabeth Poorman, MD, MPH, an internist at UW Medicine in Kent, Washington, said she worries that the passion of medical students for SDHs will too often be crushed, especially during residency and with immersion in the productivity-focused health care system. Studies show a drop in mental wellness and empathy and a rise in cynicism as training advances, said Dr. Poorman, who also writes about health care and issues of equity and serves on the editorial advisory board of Internal Medicine News.

With similar concerns, the AMA has recently launched a “Reimagining Residency” initiative that aims to improve transitions from medical school to residency and the wellness of residents and faculty, and expand educational content relating to SDHs.

Dr. Fair is optimistic that new physicians’ knowledge of SDHs will permeate medical practices.

“Physicians who are out practicing are going to be working with our graduates, and they’re going to be asking in [job] interviews, do you have flexible hours for patients? What community partnerships do you have? Are there other professionals on staff to help us address social determinants of health? What data [relating to SDHs] are you collecting?” she said.