Today I am thinking about the patients who have visited me during my past few clinics. They have different backgrounds, personalities, and health states, something I love about academic general internal medicine. Yet they all have something in common. Social determinants play a critical role in their physical and mental health. Mr. Gonzalez*, a patient from Mexico, speaks some English, so he was reluctant to ask my nurse and medical students for a phone interpreter, who proved essential for our information gathering and counseling about his diabetes. Ms. Pierre, an artist, is in litigation with contractor who put shoddy siding on her home. The walls are rotting, the stress is making her eat, and she’s gaining weight that’s putting pressure on her knees, painful with osteoarthritis. Ms. Thayer, who has numerous medical problems, hasn’t made an appointment for a sleep study to diagnose her sleep apnea. Her sister’s violent death from intimate partner abuse less than a year ago weighs her down, making it hard for her to follow through on her own health care needs.
These three patients, and many others like them, demonstrate the importance of preparing the next generation of health care providers—nurses, PAs, physical therapists, physicians, and more– to attend to the social determinants of their patients. Not only must providers inquire about and understand the impact of the forces of discrimination, environment, policy, economics, and more, they must begin to address them at individual and systemic levels. The Liaison Committee on Medical Education’s 2018-19 accreditation standards include, in standard 7.2, that the faculty of a medical school must ensure that the curriculum prepares students to “recognize the potential health-related impact on patients of behavioral and socioeconomic factors.” 1 The World Health Organization and the National Academies of Sciences, Engineering, and Medicine have issued reports which emphasize the importance of educating health care providers about social determinants of health.2,3
These recommendations may be daunting to medical educators, who are not often specialists in social medicine. Program and course directors are responsible for ensuring trainees master a vast clinical field, with medical knowledge multiplying continuously and changing rapidly. Health education programs often face budgetary constraints, and the educators responsible for delivering curricula are pulled by clinical and research productivity requirements. One solution to this problem could lie in the creation of common digital resources for medical schools. Le and Prober recently proposed a “shared curricular ecosystem” of digital materials for use by all medical schools, underpinned by common standards.4 They suggested that schools could pick and choose the resources that worked for them, eschewing a “one size fits all” approach. MedEdPORTAL is a well-known, now open access, repository aiming to address this need. It contains thousands of peer-reviewed curricula on wide-ranging topics from basic science to professional development.
Social determinants curricula are growing, so there is ample opportunity to borrow what’s working, rather than re-inventing the wheel. The National Collaborative for Education to Address the Social Determinants of Health (NCEAS) has culled curricula from across the web—those in MedEdPORTAL, the Society of Teachers of Family Medicine, and other well-known and less well-known resources. We are soliciting curricula from our community of practice and from authors publishing scholarly articles in education as well. This is our education collection. We invite you to investigate it. Our team reviews every resource to ensure it is high-quality, updated, substantially addresses one or more social determinants topics, and is ready to use right off the page. We annotate the resource with our assessment of its strengths and areas for improvement, and we index it with searchable terms including learner discipline and level, as well as specific topics within the social determinants field. As of December, we have reviewed 65 resources and posted the 44 we think our network will find most helpful, and more are on the way.
What should you look for in a curriculum? The 2016 Medical Teacher article “Twelve tips for teaching social determinants of health in medicine” gives guidance.5 Look for activities that incorporate active learning, such as the Stanford Unconscious Bias CME module, a one-hour, interactive online experience to help providers learn to recognize biases and undertake strategies to mitigate them. Look for experiential learning, such as the home visitation curriculum out of Children’s National Medical Center in Washington DC, which was well received by residents. And look for curricula that incorporate reflection, such as the Society of Teachers of Family Medicine’s curriculum, “Breaking Barriers,” which asks first year medical students to think about the impact of social determinants of health on their own personal health.
Peruse our education collection, try out a resource, and contact us to tell us about your experience using it. We can learn much from discussing facilitators and challenges to implementation. If you have a great curriculum, please submit it to us at contact@sdoheducation.org. If we post it, we will share with you the analytics from our website including downloads and comments.
Medicine is changing fast, but the fight for health equity is a slow process. The importance of social determinants won’t decline any time soon. The goal of our education collection is to help our trainees gain the self-efficacy to approach patients like mine with confidence and competence.
-Heather Heiman, MD, NCEAS Education Collection Lead
Heather Heiman is an Associate Professor of Medicine and Medical Education and the Medical Director of the Clinical Education Center at Northwestern University, Feinberg School of Medicine.
*Names have been changed to protect the identity of patients.
References:
- Liaison Committee on Medical Education. Functions and Structure o a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree. http://lcme.org/publications/ Accessed December 16, 2018.
- Marmot M, Friel S, Bell R, Houweling TA, Taylor S, Commission on Social Determinats of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet. 2008;372:1661-1669.
- Institute of Medicine, Board on Global Health, Committee on Education Health Professionsals to address the Social Determinants of Health. A framework for educating health professionals to address the social determinants of health: National Academies Press; 2016. https://www.nap.edu/read/21923/chapter/1#ii. Accessed December 17, 2018
- Le TT, Prober CG. Proposal for a SharedMedical School Curricular Ecosystem. Acad Med. 2018;93(8):1125-1128
- Iveris L. Martinez, Isis Artze-Vega, Alan L. Wells, Jorge Camilo Mora & Marin Gillis(2015) Twelve tips for teaching social determinants of health in medicine, Medical Teacher, 37:7, 647-652.