When I worked in Washington, DC, I would get off the Metro, go up the escalator, and walk quickly past the ragged men and women jiggling loose change in tin cans, avoiding their eyes on my way to my Senate Finance Committee office to work on programs to assist the needy. I was scarcely aware of the irony of passing them by. Eventually, the looks on the faces of these homeless people, the shabbiness of their clothing, and my growing familiarity with them softened my heart. One day, I picked out one of them—a ruddy, middle-aged, bearded man in a T-shirt and jeans—and dropped two quarters into his can. “Thanks,” he muttered, barely looking at me as I walked past. Another day I passed out donuts that I had intended to give to my Finance Committee staff colleagues. Soon I was a regular, saving my change every morning to be able to fill the various cans.
Later, when I returned to Albuquerque, I noticed men and women with similar plaintive looks, but instead of holding cans, they carried signs that they displayed at various intersections. Some of their faces seemed familiar, and I wondered whether I had treated them in the emergency department. The signs were of variable literacy and creativity. One said, “Vet, hungry,” and the man holding the sign nevertheless looked fit and was wearing a green army jacket. Another told a story: “Please help my wife and 3-year-old daughter. Car broke down.” A man held the sign and a weathered blond woman stood next to him. I wondered where the three-year-old might be. Another sign said simply, “Hungry.” A creative young man held a sign with the message, “Smile. Don’t look away. I’m a person too.” He waved and looked right in at me as I sat in a line of traffic to see if I was smiling. It was difficult not to smile, and I opened my window and offered him the change I kept in my glove compartment as a reward for changing my mood in a positive direction. Another couple held a sign: “Trying to get to California. Stranded with pregnant wife. Need help. Thanks.” As I contemplated their predicament, I rolled down my window and gave them a dollar. The sign that was, at the same time, the most eye-catching and the most poignant, was “Too ugly to prostitute. Need money for food.” The bearer of the sign was a young woman with scraggly hair and a pockmarked face. I gave her a dollar as I imagined the difficult choices she encountered every day.
The signs and the people holding them were daily reminders of the gulf that separated me, with my various privileges, from the vulnerable poor and homeless. In my role as a medical school teacher I wanted to encourage empathy for these same individuals when they came to the emergency department or the clinic; I even used the plight of these individuals to discuss the social determinants of health. But out on the street, I had a different reaction: cautious avoidance with occasional and superficial engagement.
I considered my contradictory responses when Tomas, one of the sign holders I had passed at an intersection the day before, visited me in the emergency department. (All Tomas’s identifiers have been changed.) He had gotten into a fight after using methamphetamine while staying at a homeless shelter. He had a small cut on his forehead that needed stitches, but the larger problem was that he had been expelled from the shelter. His chart said that he had end-stage liver disease and had been hospitalized several times for hepatic encephalopathy. The resident working with me phoned the director at the homeless shelter, who explained the shelter’s policy of refusing to take back anyone involved in a fight. I took the phone to explain the serious medical consequences of the policy for this patient; the policy could lead to Tomas’s death. The shelter director then delivered a lecture about the need for order and safety at the shelter. If he let Tomas back in, he would lose control and fights would become more frequent and dangerous. He explained that Tomas had made his choices and now had to live with the consequences. While I understood the director’s perspective, I also imagined that the constraints of living in a shelter with no privacy might be difficult for even the most even-tempered person. I also wondered if the decision not to readmit Tomas to the shelter could have had anything to do with his Hispanic ethnicity. After the resident and I examined Tomas, sutured his wound, and decided that there was nothing else to treat, we asked him where he was going to sleep.
“Under the bridge,” he said.
“But what about your lactulose and your encephalopathy? We could try and find you another shelter. We could call the social worker,” I said.
“No. I don’t want to go to another shelter. I don’t want the social worker. I’ll be okay. I have everything I need in my backpack. But I could use a sandwich.”
We noticed his sign against the wall of his cubicle as he prepared to leave. On one side it said, “Need Help. God Bless” On the other it said, “Need Food.” We got Tomas the sandwich.
We knew that Tomas would likely be back in hours or days in hepatic encephalopathy and would probably require many days of hospitalization and cost our health care system thousands of dollars, all of which might have been prevented with a bed in a shelter. The resident and I were frustrated at our inability to fix the system for Tomas. We talked about the need for a better social support system, housing for the homeless, or vouchers for a hotel room.
I was reminded of a public symposium I had attended last September, sponsored by the National Academy of Medicine, at which we discussed how addressing the social determinants of health should be a priority for the health system. The symposium, “Vital Directions for Health and Health Care: A National Conversation,” attempted to identify priorities in health for the incoming president and administration. In a lead paper discussed at the symposium, McGinnis et al1 note,
Harnessing society’s full potential for optimizing health outcomes across the lifespan requires reaching out well beyond the health care system, from the earliest days of childhood.
They identify a broad group of stakeholders and resources that could participate in health systems transformation. These include clinicians and health care organiza tions but also social services, public health, schools, law enforcement, families, and communities. The authors make clear that we must broaden our view beyond clinical care delivery, and I believe that the education of our students should reflect this broad perspective.
In a 2011 report, Bradley et al2 demonstrated the contributions of social services to overall health outcomes. In an international comparison of 30 countries, they showed that the ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy, and fewer potential life years lost, after adjusting for the level of health expenditures and gross domestic product. The United States had high health care spending but low social services spending compared with other countries. The authors’ message was that by spending more on social services, spending on health care services could be lowered.
In the current issue of Academic Medicine, we present a cluster of articles3–7 that explore the importance of understanding how social structures and “structural competency” influence health and how to integrate training and care delivery systems to better meet the needs of patients like Tomas, whose medical issues could be better addressed with more adequate social and psychological support. In an Invited Commentary that provides an overview of the other articles in the cluster, Hansen and Metzel3 explain that
structural refers to clinical interventions above the level of the individual patient and in collaboration with community organizations, non-health-sector institutions, and policy makers. Structural competency thus draws on the social science, medical humanities, and public health scholarship illustrating the systemic, institutional determinants of health inequalities and therefore indicating that health disparities require institution-level intervention for remediation.
They observe that each of the articles demonstrates how medical education can improve health equity and justice, and conclude,
Ultimately it is only by preparing clinical trainees to partner with entities outside the clinic that we can empower them to influence the social determinants of their patients’ health and reduce health inequalities.
In another Invited Commentary, Geiger8 provides historical context and some suggestions for furthering structural competency. He describes the challenges of teaching about the social determinants of health to students who are more interested in acquiring basic medical sciences knowledge and clinical skills, and describes his approach of providing population health data and direct experience to encourage students to engage in communities and to understand disparities and social determinants. He raises important questions:
We need to ask if teaching social determinants of health and their political determinants is an epidemiological exercise, or if it is a call for political action.… Do clinicians have responsibility not only for individual patients but also for the health status of communities from which those patients come…?
He cautions that
efforts to assist individual patients and more effectively manage their interactions with the health care system, as in the case studies described in this special collection, are worthy and useful, but they are not structural and they do not confront root causes.
To achieve structural change, he suggests,
requires the participation of and collaborations with other local, state, and federal agencies that deal with housing, transportation, education, urban planning and development, environmental regulation, and health care. It also requires sustained efforts at public education and ultimately the active participation of legislative bodies and other political entities.
This leads us back to the patient Tomas that I described earlier. His problems of liver failure, homelessness, violence, and substance abuse were both medical and social. We attempted to knit together resources to temporarily help Tomas as one needy individual, and ultimately we failed because of the combination of his individual decisions and the constraints of the social support system. Unfortunately, under the bridges, at various intersections, and even back in Washington, just outside the U.S. Capitol building, there are many more men and women like Tomas who are one misstep from a medical crisis.
When we encounter the homeless, like Tomas, or persons of races or ethnicities different from our own, how do we confront the fears and negative attitudes that we may feel? Through our conscious or unconscious attitudes about race, class, ethnicity, and other stigmatizing characteristics, we may contribute to the persistence of disparities in health care. Holm et al9 in this issue describe an exercise that they used to raise awareness of social privilege and to initiate conversations about the effects of social privilege upon disparities related to the social determinants of health.
Wear et al10 and Acosta and Ackerman-Barger,11 also in this issue, address the unique challenges of talking about race and racism. Wear et al introduced a curriculum that includes literature, film, clinical, and community experiences that are meant to explore historical power relationships, white privilege, and structural competency. Acosta and Ackerman-Barger describe the need for faculty development to facilitate conversations about race and racism in the health professions.
What is clear from these articles is the need to have difficult conversations about race, power, class, and social structures with our students, facilitated by trained faculty who are prepared for the deeply personal emotions that such conversations can elicit. Kumagai et al12 explore the challenges of discussing difficult topics in medicine and assert that while these topics may create discomfort, the experiencing of discomfort may be a necessary part of personal and professional ethical development. They note that faculty and students need to be aware of the challenges and opportunities that discussing difficult topics presents and attempt to create safe supportive spaces for conversations without avoiding those topics. It is likely that difficult topics will arise with our students in the aftermath of the past election, and our ability to discuss them respectfully and compassionately will be more important than ever.
What I gleaned from reviewing these important articles is that structural competency begins with education that will broaden our perspective and include the difficult topics of power, race, and privilege. But as Geiger suggests, learning about social determinants and structural problems is not enough. Learning must be linked to experience and a commitment to the kinds of action to achieve structural change that he advocates. And while the action needed for individual patients like Tomas is difficult enough, transformative action affecting the social determinants of health requires a broader and more sustained commitment to health equity. We hope these articles can help us begin or, in some cases, continue a dialogue with all our health professions and hospitals as well as with our patients and communities. We hope such dialogue leads to better solutions for patients like Tomas and gives us the courage to not look away when we see the people holding their signs asking us to notice them, to care—and to act.
David P. Sklar, MD