Letters to the Editor
In Reply to Walaszek and Reardon:
In light of the recent debate around the Affordable Care Act, the authors’ reminder that medical specialties must partner more effectively with primary care providers, and their corresponding call for training residents in advocacy as necessary to translate evidence-based practice into changes that will improve the mental health system, could not have come at a more crucial time. We know that the prevalence of illness follows a social gradient.1 So, why do specialists continue to focus primarily on clinical interventions, only to then send patients back to the conditions that made them sick?
In our ongoing study of social accountability in medicine and the physician’s role as health advocate, we find that some residency program directors, representing a range of specialties, are struggling to balance the lure of genomic medicine (despite the accumulating evidence of its limitations) with the fundamentals of population medicine—a crucial issue for the future of medical education.2 We observe that many residents in different specialties are seeking good role models to emulate, as well as opportunities to collaborate on health advocacy initiatives with trainees from other medical specialties, particularly from primary care. Trainees point out that if health advocacy and partnerships with primary care providers are going to be taken seriously, trainees need to experience these in medical training and witness them in medical practice.
Yet, this proposition continues to appear daunting in light of a predominantly siloed, clinical, and subspecialty-oriented medical training structure, without a reasonable effort to integrate the “incontrovertibly social nature of disease.”3 While institutions outside of the core medical system call for a more sensitive, compassionate, and community-responsive physician, the existing medical environment rewards the opposite. The current system does not enable specialists to practice in an intraprofessional manner, nor does it emphasize particular attention to the multiple determinants of health outcomes. Training residents for advocacy and to collaborate more decisively with primary care providers will require medical schools to establish principles of social accountability, drawing on an explicit, three-tier engagement: (1) identifying current and prospective societal priorities, (2) adapting medical training to equitably meet the priorities, and (3) verifying that anticipated effects have benefited society.4
Shafik Dharamsi, MSc, PhD
Associate professor, Department of Family Practice, and faculty lead of social accountability and community engagement, Faculty of Medicine, University of British Columbia, Vancouver, Canada; email@example.com.
Robert Wollard, MD
Professor, Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
1. Fisher M, Baum F. The social determinants of mental health: Implications for research and health promotion. Aust N Z J Psychiatry. 2010;44:1057–1063
2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923–1958
3. Jones DS, Podolsky SH, Greene JA. The burden of disease and the changing task of medicine. N Engl J Med. 2012;366:2333–2338
4. Woollard B, Boelen C. Seeking impact of medical schools on health: Meeting the challenges of social accountability. Med Educ. 2012;46:21–27