AAEM/RSA President’s Message: Addressing the Social and Structural Determinants of Health in Medical School and Residency Education

Addressing the Social and Structural Determinants of Health in Medical School and Residency Education

Jennifer Rosenbaum, MD – Vice President, AAEM/RSA

In light of the ongoing COVID-19 pandemic and increased focus on social justice, physicians are more aware that patients’ social determinants effect their health. These times are also highlighting how the structural determinants, which include government process and economic and social policies, are efclinical courses. Even presently, the extent to which SDH are taught by medical schools varies. In 2019, when surveyed, medical schools were nearly split down the middle about whether the teaching of SDH was a low priority or a high priority.3 If the population’s health is to be improved, and if disparities in outcomes are to be reduced, medical schools and residencies must do a better job of incorporating the SDH into their

fecting their patients. As the safety net of the health care system, emergency physicians have the privilege of taking care of any patient that Medical School Curriculum walks through the door. We are often the frontline providers for under- Recently, many medical schools have developed creative ways to inteserved populations and we bear witness to the societal patterns of health grate public health into their coursework. During the preclinical years inequity. Despite our advanced training, health care disparities persist. some medical schools have developed seminars and didactics on culturSocial emergency medicine is an emerging branch of emergency medi- al competency, reformatted Objective Standardized Clinical Examinations cine that investigates the interplay of the social determinants of health (OSCEs) with cases highlighting the SDH, created a service-learning (SDH) and emergency medical care. As emergency medicine adapts to curriculum, or attempted to teach the SDH at the bedside through an meet the needs of our patients, it is essential that social and structural emergency medicine clerkship.4 Creating a curriculum that emphasizes determinants of health are incorporated into medical school and residen- SDH is important, but some of these interventions have been critiqued cy education. for being flawed. A positive experience requires a considerable investment of time and planning on the part of academic institutions and faculty. For example, if service learning is not well coordinated, it places burdens on community partners. Cultural competency education has been integral in drawing attention to health inequities, but it has also been criticized for being reductionist. It often involves teaching homogenized ideas of culture that may overstate cultural or racial differences and unintendedly reinforce stereotypes. Medical educators must continue to re-examine their SDH curriculum to make sure its intentions are being met. Medical education in the 20th century was largely influenced by the Flexner Report, which called upon American medical schools to enact higher admission and graduation standards.1 It established the biomedical model as the gold standard of medical training and challenged U.S. medical schools to become more academic. In response, medical schools redesigned their curricula to focus on training physicians to practice using the scientific method and engage in original research. The Flexner Report was integral in creating standards for academic rigor. However, it is also contributed to racial bias in medicine and is partially responsible for the disproportionally low AS THE SAFETY NET OF THE HEALTH CARE SYSTEM, EMERGENCY PHYSICIANS HAVE THE PRIVILEGE OF TAKING CARE OF ANY PATIENT THAT WALKS THROUGH THE DOOR.” number of diverse physicians in the workforce today.2 Most Black medi- Residency Curriculum cal schools in the early 20th century did not have the resources necessary to implement the standards that Flexner called for, and consequently were shut down. In the 100 years since the Flexner Report, the Beyond the Flexner Alliance (BFA) was created to address the disparities that still exist today. The BFA’s mission is to promote social mission in health professional’s education. Several residency programs have SDH “tracks” for interested EM physicians in training. These may allow residents to focus on scholarly projects and advanced professional development. However, to really narrow the gap between health care and the community, it is important that all residents have this type of formal education. Emergency medical educators are uniquely positioned to incorporate structural competencies into Despite great strides in public health throughout the 20th century, histori- residency education. Emerging frameworks of structural competency call cally public health courses took a backseat to core basic science and for physicians to recognize that health outcomes are shaped by complex, curriculum.

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IF THE POPULATION’S HEALTH IS TO BE IMPROVED, AND IF DISPARITIES IN OUTCOMES ARE TO BE REDUCED, MEDICAL SCHOOLS AND RESIDENCIES MUST DO A BETTER JOB OF INCORPORATING THE SDH INTO THEIR CURRICULUM.”

interrelated structural forces. One group of educators provided their framework for incorporating structural competencies into emergency residency education.5 They highlight that it is critical to develop community partners with organizations in your area. These might include free clinics, shelters, food banks, substance use disorder clinics, domestic violence resource centers, and many more. Some EM residencies introduce their residents to these organizations during their orientation period. Curriculum can also be routinely integrated into resident conference sessions and journal clubs by choosing topics, speakers, and articles centered on the voices of patients and community organizations.6,7

Beyond Residency

For residents who seek a career dedicated to understanding and intervening on the social origins of health and disease, there are now fellowships available in population health and social EM. For others not seeking a fellowship, there are plenty of ways to get involved. Making connections with community partners, learning from social workers, and taking time to ask patients about their SDH are easy tasks that can be done on your next shift. By doing these things, you might be setting an example for a newer learner. Medical education must also continue to diversify with initiatives led by persons that represent the communities they serve. By emphasizing diversity in medicine and the importance of the social determinants of health throughout a medical career, we will be graduating a cohort of clinically well-trained physicians who are better equipped to restore the health of underserved populations. 

References

1. Page D, Baranchuk A. The Flexner report: 100 years later. International

Journal of Medical Education. 2010;1:74-75. doi:10.5116/ijme.4cb4.85c8. 2. Hlavinka E. Racial Bias in Flexner Report Permeates Medical Education

Today. Medical News and Free CME Online. https://www.medpagetoday. com/publichealthpolicy/medicaleducation/87171. Published June 18, 2020. Accessed November 9, 2020. 3. Lewis JH, Lage OG, Grant BK, et al. [Full text] Addressing the Social

Determinants of Health in Undergraduate Medical: AMEP. Advances in Medical Education and Practice. https://www.dovepress.com/ addressing-the-social-determinants-of-health-in-undergraduate-medical-peer-reviewed-fulltext-article-AMEP. Published May 22, 2020. Accessed

November 5, 2020. 4. Moffett SE, Shahidi H, Sule H, Lamba S. Social Determinants of Health

Curriculum Integrated Into a Core Emergency Medicine Clerkship.

MedEdPORTAL. 2019;15(1). doi:10.15766/mep_2374-8265.10789. 5. Salhi BA, Tsai JW, Druck J, Ward‐Gaines J, White MH, Lopez BL. Toward

Structural Competency in Emergency Medical Education. AEM Education and Training. 2019;4(S1). doi:10.1002/aet2.10416. 6. Porter S. Residency Curriculum Hits Mark on Social Determinants. https:// www.aafp.org/news/education-professional-development/20190322sdohre sidency.html. Published March 22, 2019. Accessed November 5, 2020. 7. Axelson DJ, Stull MJ, Coates WC. Social Determinants of Health: A

Missing Link in Emergency Medicine Training. AEM Education and

Training. 2017;2(1):66-68. doi:10.1002/aet2.10056.

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