How do we teach social determinants of health—and related skills, like cultural humility and structural competence—to health professions learners at the bedside? How do we make these critical facets of human health and well-being visible to learners inside hospital and clinical walls? And how do we know when we’ve succeeded?

I started reflecting on these questions in earnest several years ago. I was in clinic, seeing a young patient whose family had been quickly labeled “difficult.” His parents were young and poor. Neither had finished high school. Child protective services had been called more than once—often by one or the other parent. Sometimes they yelled at staff. Sometimes they yelled at each other. Sometimes they merely texted each other profanities across the length of the clinic room during the visit.

I developed a habit of taking a few calming breaths before each encounter, reminding myself that their prickly, aggressive approach to life had helped them, and their two children, survive thus far. It was not personal. Wasn’t about me. My job was to help them care for a medically complex child in a world that had dealt them few favors so far. When they refused—yet again—to allow early intervention into their home—my job was not to become frustrated or judgmental but to understand why and try to find a compromise that got their son the services he needed.

The difference on this particular day was that I had a medical student with me. As a pediatric specialist, having students and residents in my clinic is relatively infrequent and it can be hard to integrate them into the routine of our practice. I paused at the doorway of her workspace, thinking about what to say to her. I wanted her to be prepared for what would likely feel quite tense or even hostile. I didn’t want it to come across like the kinds of warnings I’d sometimes been given as a student or resident: as in, “Hey, if you can, stay out of that room tonight. That mom is craaaazy.” I realized, in that moment, that I needed to make my thinking—about how social and structural determinants of health mattered for this patient, and how it influenced my approach to his care—visible for my learner.

The more time I spent in pursuit of this goal, the more I became interested in how others did this. Sure, medicine and healthcare has a long way to go in terms of fully addressing the impact of SDOH in our practices. But I was surrounded by outstanding clinician-educators, whose work in SDOH was widely recognized. The med/peds-trained director of our refugee healthcare program. A child psychiatrist who worked closely with the Onondaga Nation. A national leader in geriatric medicine. Most of my time is spent with preclinical students, so many of my colleagues also had more experience than I did teaching students and trainees in clinical spaces. I wanted to learn from them.

In the spring of 2019, child psychiatrist Nayla Khoury and I began collaborating with Ann Botash, Upstate’s Senior Associate Dean for Faculty Development and Faculty Affairs, on a project taking my questions one step further. Our interprofessional team1 solicited nominations from students and faculty for clinicians who excelled in teaching SDOH at bedside, and then we sat them down for a series of interviews about what they do. We asked each interviewee to nominate someone else for participation. Concurrently, we invited students to participate in focus groups where they were asked similar questions about their experiences with this type of bedside teaching.

“…even though I don’t explicitly say humility is important, what I try to approach is to try to be open to lots of viewpoints, to try to be open to — even if we are talking about differential diagnoses, trying to make sure that the student as well as the resident has an equal voice on that, at least in the initial discussion. And then I try to be pretty explicit on when I messed up. So when someone had to be readmitted because [of something I did] … I try to make it a point in saying that I’m not the keeper of knowledge.” – VISIBLE Study Participant

We deliberately framed the questions to emphasize positive examples and identify potential best practices. It was important to us that we add something constructive to the conversation and that this not just be another study of the negative aspects of the hidden curriculum (a subject that has already been richly reported). Many of the interviewees struggled to put into words exactly what they do that so inspires their colleagues and students. My co-investigator, Lauren Germain, summed it up in a single phrase: “Just being a human being and seeing patients as human beings.” Eventually, these five best practices emerged from our early data2:

  1. Modeling for learners how to sensitively address SDOH during a clinical encounter.
  2. Debriefing with learners about what they observed, after the encounter.
  3. Reviewing the chart with learners to highlight important SDOH-related elements in the electronic medical record.
  4. Providing opportunities for hands-on experiences where health professions students and trainees can learn by doing.
  5. Adapting and applying existing frameworks for teaching SDOH to clinical training experiences.

“I think when you’re dealing with somebody from another culture you need to be open to be with that person with an open heart and remember your share of humanity.” – VISIBLE Study Participant

Recently, another student joined me for a morning in my pediatric hematology/oncology practice. My first patient was a young woman from Africa with a chief complaint of menorrhagia. An extensive work-up had not identified a bleeding disorder. She’d stopped taking the hormonal contraceptive pills prescribed by a gynecologist after a few days, when they didn’t immediately alleviate her symptoms. Her foster mother wondered if she simply wasn’t changing her pads often enough, resulting in blood soaking into her clothes and sheets. After taking the history through the interpreter, I decided to start back at the beginning: What did she know about menses, or about her anatomy and physiology? When she shook her head, I grabbed an iPad and we began pulling up colorful graphics and short videos. Through the interpreter, I ran through the kind of basic lesson I used to love providing to my peers as a college health educator. I talked about why hormonal contraception might help her and addressed concerns about infertility. I will probably never know with any certainty whether our visit was helpful to her: she doesn’t need to ever see me again.

I might have left my clinic that day wondering the same thing about my student: what had she learned? Instead, I took an extra five minutes to debrief with her and asked for her thoughts after the encounter. She replied, “It’s really helpful to see someone do a visit with an interpreter the way we’re taught—addressing questions to the patient, rather than the interpreter, making eye contact, speaking slowly and pausing frequently. I’ve heard it described but I’ve never actually seen it done that way before.

“If you learn medicine only from books, it’s like having the sail only without the boat.”  – VISIBLE Study Participant

Amy Caruso Brown, MD, MSc, MSCS, NCEAS Community of Practice Member

Dr. Caruso Brown is a tenured Associate Professor in the Center for Bioethics and Humanities and in the Department of Pediatrics, Division of Pediatric Hematology/Oncology at SUNY Upstate Medical University. At Upstate, she directs the Ethics and Professionalism thread in UME and designed and directs Patients to Populations, a required course in bioethics, population health and related disciplines for first-year medical students. Her research interests include evaluation and assessment in social determinants of health education; pediatric disagreements; and ethical issues related to social media in pediatrics.

1 The VISIBLE Study Team includes: Amy Caruso Brown, MD, MSc, MSCS, Associate Professor of Bioethics and Humanities and Pediatrics; Nayla Khoury, MD, MPH, Assistant Professor of Psychiatry; Ann Botash, MD, Professor of Pediatrics and Senior Associate Dean for Faculty Development and Faculty Affairs; Lauren Germain, PhD, Assistant Professor of Public Health and Preventive Medicine and Director of Evaluation, Assessment and Research; Rachel Fabi, PhD, Assistant Professor of Bioethics and Humanities; Simone Seward, MPH, Director of the Center for Civic Engagement; Caitlin Nye, BSN, RN, Nursing Residency Director; and Hannah Connolly, BA, fourth-year medical student.

2 Preliminary data from the study was presented by Simone Seward and Rachel Fabi at the Association for Prevention Teaching and Research annual meeting in the spring of 2020.

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