As a primary care residency program director, I’ve had the privilege of being able to reflect on all aspects of our curriculum and how they teach about the social and structural determinants of health (SSDOH). Since the uprising for racial justice catalyzed by George Floyd’s murder, I’ve been thinking more deeply about how with do this work in collaboration with the community our residency program serves.
My training program is in the Bronx, in the poorest congressional district in the nation. Teaching about social determinants of health isn’t just academic. The population is mostly immigrants and people of color. The community has been deeply impacted by the effects of systemic racism on everything from affordable housing, transportation, and air quality to incarceration and the opioid epidemic. The consequences of NOT effectively teaching about SDoH is having trainees mistake the health consequences of the interplay of these systems to disadvantage the communities for a fault on the part of individuals or groups of people, perpetuating negative stereotypes about people of color. Residents could also develop a sense of hopelessness if the training we provide is ineffective to address the root of health inequities experienced by our patients.
As part of this reflection, I conducted a qualitative study of 10 community-medical collaborations that include medical students and residents from various medical specialties. We conducted semi-structured interviews of physicians and their community partners (such as parent advocates supporting families involved with the Administration for Children’s Services aka ACS) who maintain these relationships, as well as trainees who participate in them.
We found that these community-medical collaborations provide rich opportunities for learning about SDoH, but in ways that expanded my conceptualization of the value of these relationships. First these collaborations provide direct experiences with people with deep expertise. It seemed obvious that trainees would learn from physician mentors and from patients. Less obvious to me was how much learning could occur across disciplines – health workers– who had developed deep and intimate knowledge of the issues their organizations focused on – from immigration to incarceration– sometimes through their own lived experience. Community partners often had an enhanced understanding of how to navigate systems to advocate for the population they served. By modeling how to navigate these interconnected systems, they teach our residents how to do it as well. For example, one community partner explained how a resident had expressed despair for an undocumented, uninsured immigrant in need of specialty GI care. She was able to help the resident and patient to set up an income-based sliding scale fee system and to apply for charity care to make the specialty care affordable and accessible.
We also found that service-focused collaborations help prepare trainees to better care for the communities served by the collaboration. In addition to providing HIV primary care or buprenorphine for returning citizens transitioning care back to the community from jail or prison, trainees’ experiences in these collaborations open their eyes to how social systems like justice involvement interact with health systems to create inequities in health outcomes. They also improve communication skills that support trusting relationships between patients and providers. Trainees learn to slow down, let patients take the lead on which issues to address first, be it hypertension or housing, and practice specific skills like harm reduction and trauma-informed care. By developing a sense of accomplishment, satisfaction, and agency in working with what otherwise might be labeled a ‘difficult patient population,’ trainees choose to continue to pursue opportunities to work with these populations and communities in their future careers.
These collaborations opened trainees’ eyes to how breaking down silos helped them to become more effective advocates for change.
Working with environmental activists who knew the legislative cycle and had established political contacts, trainees shared information about the adverse health effects of air pollution on childhood asthma rates with politicians, and were able to help secure funding from Biden’s transportation bill to address highway-related air pollution in the Bronx.
Finally, trainee involvement has a multiplier effect. Experience allows trainees to become teachers to their peers. One trainee worked with an organization focused on care for unaccompanied minors as a medical student. As a child psychiatry resident, he was not only able to create a strong relationship with a teen suffering from mental health sequelae related to the trauma of entering the US as an unaccompanied minor, but he was also able to help his peers develop a better understanding of the social and structural factors faced by this population and learn ways that they too could become advocates.
So, how do we as educators support this work? Kolb states that to gain genuine knowledge from an experience, the learner must have four abilities:
- The learner must be willing to be actively involved in the experience;
- The learner must be able to reflect on the experience;
- The learner must possess and use analytical skills to conceptualize the experience; and
- The learner must possess decision making and problem solving skills in order to use the new ideas gained from the experience.
Educators can support this process by providing a theoretical framework of social and structural determinants of health to help residents analyze and conceptualize the experience. They can also provide opportunities for reflection. Additionally, educators can also think about how to break down silos between medicine and other disciplines that are also working on these SDoH topics. To realize our fullest potential, we must help residents to recognize the wealth of knowledge maintained by community partners and to develop skills in communicating and collaborating with the community they serve.
-Erin Goss, MD, AAHIVS, Community of Practice Member
Dr. Goss is an Associate Professor in the Departments of Medicine and Family & Social Medicine at the Albert Einstein College of Medicine in Bronx, NY and a core faculty member for the Primary Care/Social Internal Medicine residency program at Montefiore Medical Center. She has developed, implemented, and assessed curricula focused on the care of marginalized populations, community engagement and health advocacy.
Twitter handle: @ErinGossMD