Well over 100 years have passed since Virchow1 wrote that “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Since that time, the world’s population has septupled, and billions of people are “trapped in the health conditions of” his era.2
That social status and wealth impact human health profoundly is incontrovertible.3 Poverty, illiteracy, discrimination, and disenfranchisement all have predictable negative consequences for health, and all are as real and potentially modifiable as the presence of diabetes or an inborn genetic mutation.4
Given the high prevalence, significant medical impact, and sociopolitical complexity of these and other nonmedical elements, providing medical students with training in how these factors influence human disease is vital.5 Further, many medical students in the 21st century want to work to decrease health disparities, and increasing numbers of medical graduates indicate they intend to work with people who are often underserved.6 This groundswell of medical student interest in remedying health disparities joins urgent calls for the integration of specific social justice competencies into medical school curricula7,8 and aligns with new considerations and the ranking of the quality of institutions’ “social mission.”9 Most promising, an august group of stakeholders from medical schools worldwide generated the Consensus for Social Accountability of Medical Schools document, which suggests ways medical education can better align with the health needs of all people, including populations who have historically been marginalized.10 This document and the social accountability movement from which it arose provide a tremendously helpful framework of principles to guide the allocation of health care resources including those for medical education.11,12
Despite these many signs of progress, we know of no published resources detailing the specific design of a nonelective medical social justice curriculum.13,14 To address this educational need, we report the design of a social justice curriculum at the Geisel School of Medicine at Dartmouth (hereafter, simply, Geisel).
Key steps in the process included developing educational goals and objectives, reviewing medical education literature and other institutions’ practices, creating a topic outline, and determining how to embed key concepts in both experiential learning and the core biomedical curriculum.
Merriam-Webster defines “social justice” as a state or doctrine of egalitarianism,15 which as applied to medicine, implies to us the equal provision of health care despite social obstacles. Although a medical school social justice curriculum is informed by public health concepts and practices, it concentrates on the awareness and skills physicians need in order to provide health care for patients who are marginalized and underserved. These patients are distinct from other populations and historically have suffered neglect unless they are the focus of specific attention. As discussed below, the phrase “social justice” may carry political connotations in popular culture,16 but our intent here is to describe the design of a curriculum that provides medical students with uncontroversial and politically neutral clinical skills.
Approach to the Design of a Social Justice Curriculum
In 2011, the senior associate dean for medical education at Geisel commissioned the Social Justice Vertical Integration Group (SJVIG) to design a new social justice curriculum. The multidisciplinary committee—comprising eight students (including A.C., T.G.M., P.C. and M.W.), four community preceptors, four medical school faculty (including T.L), and one dean as well as two nongovernmental organization representatives—employed the vertical integration approach to curriculum design.17 Over nine months, during monthly meetings augmented by interim research, the group addressed five goals:
- To define core competencies in social justice education;
- To identify key topics that a social justice curriculum should cover;
- To assess social justice curricula at other institutions;
- To catalog Geisel-affiliated community outreach sites at which teaching could be paired with hands-on work; and
- To provide examples of the integration of social justice teaching into the core (i.e., basic science) curriculum.
The final product was the result of approximately 150 hours of faculty work and 100 hours of student work and represents the negotiated consensus of all participants.
Defining core competencies in social justice
Many medical schools have oriented their curricula around a set of core competencies which trainees must master; a competency-based curriculum helps schools ensure that graduates have acquired the skills and knowledge appropriate to their training stage, ultimately reaching, stepwise, a goal that is “by definition lofty, vague, and far-reaching.”18
Geisel had already adopted the competency-based evaluation of its MD candidates prior to initiating the design of the social justice curriculum. The SJVIG, therefore, defined core competencies specific to social justice that related directly to institutional competencies as previously ratified by the faculty in 2010 (Table 1). The group designed these competencies and their associated learning objectives to bring all students, regardless of their baseline knowledge at the outset of medical school, to an academically rigorous understanding not only of how social factors can affect a patient’s health but also of the physician’s ethical and legal obligations to engage these factors.
Identifying key topics in a social justice curriculum
The SJVIG identified specific topics that are important to address in any social justice curriculum (List 1). For the purposes of teaching and prioritization, the group divided these essential topics into three broad areas: scope of health disparities, reasons to study and address health disparities, and means of addressing health disparities. The SJVIG chose these broad areas to represent a logical, though often overlapping, sequence that would progressively focus on the pragmatic aspects of social justice work in tandem with students’ increasing familiarity with the basic causes of social injustice in medicine and their growing understanding of physicians’ ethical and legal obligations.
The social justice curriculum designed by the SJVIG includes a minimum of 55 hours of content divided into 30 hours of classroom work (didactic and small group) and at least 25 hours of experiential learning. The 30 classroom hours comprise 15 hours of new large- and small-group teaching and 15 hours of social justice topics integrated into closely related subjects already addressed in the formal medical school curriculum. The 25 hours of experiential learning are configured as a mandatory, longitudinal, mentored experience spread over four years and potentially encompassing myriad activities, including volunteerism, community outreach, and scholarly research relevant to social justice. This project is complemented by an elective intensive immersion experience undertaken during summer sessions by interested students.
Students interested in an intensified experience in social justice learning can participate in an elective track involving a longitudinal seminar and the completion of a scholarly thesis. For these students, participation in the summer immersion session is mandatory (List 1).
Assessing social justice curricula at other institutions
Numerous U.S. medical schools have incorporated aspects of social justice and health disparities into their curricula. To guide its deliberations, the SJVIG conducted a nonexhaustive convenience review of existing approaches to social justice curricula using published literature and online resources. Group members searched PubMed and Google for the key words social justice, medical school, curriculum, and selected key words from subtopics. Examples of innovative or compelling approaches to social justice teaching that helped inform the SJVIG’s approach included the multiyear scholarly concentrations in “Advocacy and Activism” and “Caring for Underserved Communities” at the Warren Alpert Medical School at Brown, the combination of elective and required work in “Social Medicine and Global Health” at Harvard Medical School, and the incorporation into the core curriculum of early community health practice immersion experiences at the University of New Mexico School of Medicine (Table 2).
Cataloguing community outreach sites at which teaching can be paired with hands-on work
To provide medical students with a learning context in which to better understand and address health disparities, the SJVIG catalogued established sites affiliated with Geisel at which students could obtain solid longitudinal mentorship through hands-on work. The group felt the real-world work within the local community would serve as a necessary adjunct to the didactic component of the social justice curriculum. These community sites were diverse: They included rural and urban community health clinics, issue-focused community outreach organizations (e.g., support groups for battered women or pregnant teens), community clinical practices known to cater to underserved populations, and international outreach sites (e.g., a pediatric HIV clinic in Dar es Salaam, Tanzania).
Integrating social justice teaching into the core curriculum
Early on the SJVIG recognized a major threat to its success: Unless well integrated with other core topics, social justice topics could be marginalized and undervalued in students’ minds. The group envisioned close collaboration with both basic science and clinical faculty as a necessary antidote to this potential obstacle.
To facilitate the integration of key social justice material into the core curriculum, the group devised examples of how social justice topics could be taught in an integrated fashion with existing basic science content (Table 3).
One means of integrating social justice topics into the core curriculum is embedding them into clinical or basic science lectures. For example, for many years at Geisel, a popular biochemist–endocrinologist has lectured on lipid metabolism in the context of starvation in the preclinical biochemistry course. Additional opportunities for highlighting social justice material in the core curriculum will be realized via collaborations with key champions of social justice material among the clinical and basic science faculty.
Key Concepts Identified During the Design of a Medical School Social Justice Curriculum
Assessing achievement in a medical school social justice curriculum Evaluating students.
Previous literature has enumerated well the difficulties of student evaluation in the realm of professionalism and social justice.19,20 Yet, the SJVIG felt that for students to invest in social justice topics, the content would have to be evaluated as rigorously as other important content. Standard written exams are an appropriate measure of student competency for some social justice concepts, such as familiarity with the social factors that impact disease epidemiology. However, competency at addressing social determinants of health disparities necessarily requires complementary and more innovative evaluation instruments, such as self-reflection pieces; presentations to peers, mentors, and community members; and actual work to redress social conditions adversely affecting health.
Evaluating a project’s value to the community.
The appropriate primary goal of any medical school curriculum is the education of its students; thus, concordantly, the medical school social justice curriculum should focus on medical students’ competency with concepts and skills related to social justice. Further, from an ethical standpoint, just as medical student provision of direct patient care should improve the health of individual patients, the experiential component of the social justice curriculum should also benefit the communities that students aim to serve (or, at the very least, student projects should not further compromise the health of these already vulnerable populations). The complicated and evolving assessment of the impact of socially accountable medical education is beyond the scope of this article but addressed elsewhere11,21,22 and exemplified by the Stanford public health curriculum (which explicitly addresses the impact of student projects on community, health policy, and hospital and clinic systems).23 Ideally, durable alignment of the medical school social justice curriculum with community needs will engender long-term student interventions that continue from one class to the next and that allow both short-term and long-term evaluations. Notably, such evaluations can be structured to teach students how to assess the impact of health interventions; as such, these sorts of evaluations would align with the health care delivery science portion of the Geisel curriculum. Such evaluations must have a flexible format specific to each community outreach site. One common approach might be a formal yearly evaluation of each site’s outreach goals, infrastructure to address those goals, future plans for expansion, and impact of student work on specific achievable indices of success in each of those domains.
Introducing the concept of social justice Using discussion of “social justice” as a teaching tool.
The phrase “social justice” has different connotations for different people. Activities to address social injustice may range from opening and running a clinical practice for marginalized populations to participating in nonclinical advocacy for health-related social issues. Student and physician opinions regarding the proper role of the medical professional in these activities vary greatly.
Rather than attempting to enforce uniform adherence to a single rigid definition, we propose incorporating active discussion of what social justice may entail into an early portion of the curriculum. Discussion should cover what “social justice” means to different people, the evidence linking social factors to health disparities, and the ways students with different values and interests can effectively address social determinants of health. Not only should such lively discussion (even debate) promote student engagement with and understanding of the physician’s varying role in social justice advocacy, but also, we believe, such a flexible, meta-cognitive activity will ameliorate backlash against social justice topics. For example, we believe that the recent vigorous discussion in Academic Medicine regarding whether physicians have a professional obligation to engage in political advocacy24 is itself likely to promote student and physician engagement in social justice work while a more directive, simplistic mandate might not.
Addressing the educational needs of students with a range of declared interest in and familiarity with social justice work.
In designing the curriculum, the SJVIG faced the challenge of how to bring social justice awareness into the medical school curriculum in a way that not only exposes all medical students to the importance and power of social justice in medicine but also nurtures the existing enthusiasm for social justice that many medical students bring with them. The group hoped to include sufficient flexibility in their recommendations to accommodate individual students’ differing needs. Beyond imbuing the core curriculum with flexibility, the SJVIG also outlined possibilities for, as mentioned, a specialized elective intensive track in social justice such that interested students could dedicate additional time to developing their skills through extended experiential learning and a longitudinal seminar.
The Importance of Experiential Learning to a Social Justice Curriculum
Although the SJVIG valued the epidemiological and other conceptual underpinnings of the medical school social justice curriculum, the group identified experiential learning as the keystone of the curriculum. Learning about social justice, and thus professionalism,25,26 via direct, hands-on experiences in the community allows for training in “critical consciousness.” Critical consciousness occurs when learners recognize and think critically about the practical social context of what they have discovered through reflective dialogue with their instructor.27 In the context of a medical school social justice curriculum, critical consciousness involves critical self-reflection on assumptions, biases, and values prior to principled action in a cross-cultural context—a practice requiring dialog that others have advocated as a way of minimizing clumsy cross-cultural interventions.20
The classroom and experiential segments of the curriculum are designed to complement each other: Students are expected to bring real-life examples from their projects into the classroom and, likewise, to introduce scholarly concepts in the experiential setting. Longitudinal projects are also intended to result in periodic reports to the medical school community in the form of yearly student-led exhibitions and symposia, which provide opportunities for reflection on professional formation, peer mentorship, and service project leadership transitions.
Beyond carefully structuring the experiential portion of the medical school social justice curriculum, ensuring that outreach activities are sufficiently educational is important. O’Toole and colleagues28 showed that mandatory service with the homeless in undergraduate and graduate medical training can lead to more favorable student attitudes toward working with the homeless and increase reported likelihood of working with underserved patients in the future. To maintain these benefits over time, it will be critically important for students and faculty to provide input on what is and is not an adequate experiential learning environment. Establishing systems to link new medical students with existing projects and defining expectations for project sustainability will be required. New projects will be created to replace successful projects that mature and end as well as projects that are failing.
Supporting the Medical School Social Justice Curriculum
The strategic implementation of aligned experiential and didactic components of a medical school social justice curriculum requires a significant administrative support infrastructure. The structure will need to be able to assign students to community outreach sites, track outcomes at individual sites, and facilitate the resultant evaluation process. Additional functions will include the creation and maintenance of a database of current and past project sites, a mechanism for pairing students with project sites and mentors, an application and evaluation system for new sites, a process for working through issues and grievances related to project placement, and a system for evaluating a site’s effectiveness at reinforcing the core competencies (and thus preparing the student for graduation).
To facilitate this and other related work, Geisel formed a new Center for Health Equity in 2012. The purpose of the center is to ensure, via oversight and the formation of community liaisons, the enduring quality of community outreach projects, for the benefit of both the communities Geisel serves and the students learning in those contexts.
Phases of implementation of the social justice curriculum
After activating stakeholders and building consensus on the content and structure of a social justice curriculum at Geisel, the school now turns its attention to curriculum implementation. To facilitate a smooth implementation, elements of the curriculum will be rolled out in phases. Phase 1, which began in July 2012, includes the identification of existing lectures and clinical opportunities that address the social justice competencies defined in the curriculum redesign (Table 1). Phases 2 and 3 began in July of 2013 and will run in parallel. The former involves the development of new classes and learning sessions that will cover key topics such as ethics and the science of health care delivery. Faculty, students, and community members will work on developing these new classes in skill-building sessions and workshops. Phase 3 entails the formalization of the optional focused social justice track for students who wish for a more in-depth learning experience.
This three-phase process will occur in the context of an overall curriculum redesign at Geisel, occurring from 2012 to 2015. The curriculum redesign has provided novel opportunities for the expansion and integration of social justice material into the core curriculum. Importantly, the success of a medical school social justice curriculum is directly affected by the institutional commitment to the egalitarian provision of health care to all; that is, optimal results arise from simultaneous reform of both the curriculum and its institutional context.29
Summary and Future Directions
Social issues, such as poverty, illiteracy, and discrimination, deeply affect human health.3,4 The core medical school curriculum therefore should include training that enables students to recognize and redress adverse medically relevant social factors. To design a medical school social justice curriculum that will provide this training, the SJVIG at Geisel identified core competencies with linked objectives. The group also identified key topics that will facilitate student achievement of these competencies and objectives. After reviewing other medical schools’ diverse approaches to social justice teaching, the SJVIG examined ways by which both the classroom and the experiential components of the social justice curriculum can be integrated with other important basic science and clinical curricular components. Multifaceted written and verbal student evaluation will be a critical component of the medical school social justice curriculum, as will adequate infrastructure support and ongoing assessment of the impact of students’ hands-on work on the communities they serve.
After implementing the new social justice curriculum at Geisel, critical next steps will be to assess student and faculty satisfaction with the curriculum and to conduct pre- and postintervention surveys to measure indicators of student idealism. Another vital step will be to delineate rigorously the impact of the new curriculum on students’ competency in recognizing and ameliorating social injustice as well as on the likelihood of graduate work with underserved populations. These assessments will allow Geisel to test the hypothesis that this new social justice curriculum will have a protective effect on student wellness, empathy, and intention to work with underserved populations.
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