The concept that social factors impact health can be found in the epidemiologist Rudolf Virchow’s writings from the 19th century, but I didn’t know any of this when I was a medical student studying in Chicago during the 1980’s.
During this time, massive, public housing projects such as Robert Taylor Homes, Stateway Gardens, and Cabrini-Green Homes warehoused thousands of poor, mostly minority, Chicagoans and were infamous for their high rates of community violence. Cabrini-Green Homes was located less than a mile away from Northwestern University Medical School, but it may as well have been in a different city. Access in and out was limited by dead end streets and limited public transportation which even included no service on some routes on Sundays. No grocery stores were located in the 70-acre housing development nor was there easy access to laundry facilities, safe playgrounds, or high-quality schools.
I volunteered in a health promotion and tutoring program founded by a group of Northwestern University medical students which served Cabrini-Green children. Spending time in Cabrini Green provided me the opportunity to begin to understand how the social and physical environment impacted the health of the projects’ residents although it took years for me to articulate this concept. My medical education utilized the biomedical model and without the access we have today with the internet to instantly connect to varied approaches, it took me years to learn the language related to the social determinants of health (SDH).
Fast forward 30 years. I now direct the portion of the Feinberg School of Medicine curriculum that oversees SDH teaching. My colleagues and I grapple with what to teach and how to teach this content. I think many physicians of my generation have similar experiences to what I reported above–with time we realize the limitations to enhance a patient’s overall health status by only focusing on what we can provide in the clinical setting. We have discovered through trial and error what works for our patients in our practice to promote their overall health, but surely there is a more efficient and effective method to teach students about this issue.
We recently undertook a modified Delphi study to survey an expert panel of educators, researchers, students, and community advocates about knowledge, skills and attitudes and logistics regarding SDH teaching. The following findings have been published in Academic Medicine.
- Knowledge: Panelists noted that was hard to choose one topic over another, but three of the highest ranked topics identified that impact health included racism, poverty, and the overall health care system and policy.
- Skills: The most important skills identified were for students to learn how to work effectively in teams with providers such as community health workers and how to screen patients for assets and needs.
- Attitudes: Panelists identified that students should appreciate that addressing the SDH is a strategy to promote health equity.
- Timing: Most panelists recommended that the SDH curriculum should be taught continuously over the entire training period and integrated into the overall curriculum.
- Delivery: The highest ranked methods for delivering teaching about the SDH in the curricula included longitudinal integration and experiential learning.
- Assessment: Panelists reported that assessment methods included patient feedback and health outcomes and measures of improved community health.
Medical education has evolved from the exclusive biomedical model of my training to be more holistic in its approach. The Liaison Committee on Medical Education now requires SDH teaching to be included in medical school curricula, however little guidance is provided on exactly what and how to teach. The recommendations from the experts in our study can be used to help inform curricular design to educate medical students about the SDH.
-Karen Sheehan, MD, MPH
Karen Sheehan is a Professor of Pediatrics and Preventive Medicine at Northwestern University, Feinberg School of Medicine.