The Necessity of Social Medicine in Medical Education

Abstract

Research and clinical experience reliably and repeatedly demonstrate that the determinants of health are most accurately conceptualized as biosocial phenomena, in which health and disease emerge through the interaction between biology and the social environment. Increased appreciation of biosocial approaches have already driven change in premedical education and focused attention on population health in current U.S. health care reform. Medical education, however, places primary emphasis on biomedicine and often fails to emphasize and educate students and trainees about the social forces that shape disease and illness patterns. The authors of this Commentary argue that medical education requires a comprehensive transformation to incorporate rigorous biosocial training to ensure that all future health professionals are equipped with the knowledge and skills necessary to practice social medicine. Three distinct models for accomplishing such transformation are presented: SocMed’s monthlong, elective courses in Northern Uganda and Haiti; Harvard Medical School’s semester-long, required social medicine course; and the Lebanese American University’s curricular integration of social medicine throughout its entire four-year curriculum. Successful implementation of social medicine training requires the institutionalization of biosocial curricula; the utilization of innovative, engaging pedagogies; and the involvement of health professions students from broad demographic backgrounds and with all career interests. The achievement of such transformational and necessary change to medical education will prepare future health practitioners working in all settings to respond more proactively and comprehensively to the health needs of all populations.

In October 1897, renowned British physician Sir Patrick Manson¹ delivered a lecture to an incoming medical school class in which he argued for universal incorporation of specialized training in tropical medicine into medical education. Titled “The Necessity for Special Education in Tropical Medicine,” Manson’s oratory implored educators to make reforms to adequately prepare future practitioners for the global shifts transforming clinical practice by requiring biomedical knowledge and skills such as microscopy and blood film preparation to properly prepare practitioners to manage “diseases special to the tropics.”¹

In both Manson’s time and today, however, social processes drive the epidemiology, severity, and experience of disease more so than the latitude at which the disease is experienced. Qualitative and quantitative research provide strong evidence that health outcomes inequitably disperse across the axes of social class, gender, and race, both within and between countries.^2–4 In Manson’s time, colonial territorial expansion, increasingly globalized trade, and the promulgation of industrial capitalist practices to all corners of the world ultimately determined disease and illness patterns. Similarly today, socioeconomics, education, housing, employment, and one’s lived environment, all of which are forcibly shaped by societal and structural factors, determine 90% of health outcomes while only 10% are determined by biomedical health care.⁴ Thus, the determinants of health are best conceptualized as biosocial phenomena, in which health and disease emerge through the interaction between biology and the social environment. This understanding forms the basis of the discipline of social medicine.

Notably Asocial Medical Education in an Indelibly Social World

Despite such overwhelming evidence of the great import of biosocial forces in society and in the lives of our patients, medical education continues to favor pedagogy that heavily draws on the biomedical model alone. During the preclinical years, most schools do not teach social medicine; if courses are offered at all, they are usually relegated to elective time. During the clinical years in ambulatory and inpatient settings, typically the only reference to “social medicine” is the obligate “social history,” usually satisfied by three cursory questions—“Do you smoke? Do you drink? Do you use illicit drugs?”

Without explicit education about social context, clinicians may never learn to recognize and respond to the social factors that are at the root of patients’ risk for, response to, and experience with disease. Clinicians, lacking advocacy knowledge and skills, provide palliative care to patients dying of AIDS in rural areas of sub-Saharan Africa while remaining unengaged with advocacy opportunities to expand antiretroviral access. Here in the United States, diabetic patients present in clinics requesting as much medication as possible because they are about to lose health insurance, and all the provider knows to do is refill the prescription and offer a nervous “good luck.” Further, physicians tell obese patients from poor neighborhoods to change their lifestyles by exercising and eating healthy without recognizing the lack of affordable, safe exercise and eating options near these patients’ homes. Medical education, in its noble drive to educate the young clinician in the intricacies of human anatomy or the wonder of the biochemical processes that sustain life, has failed to link the interplay of important biological processes with the social space their hosts inhabit.

We believe that undergraduate and graduate medical education must thoughtfully and intentionally incorporate the social context into all aspects of biomedical education—that a biosocial model must become the foundation of all medical education. Preparatory standards for medical school entry have already been recalibrated to require knowledge of the biosocial.⁵ The U.S. Affordable Care Act of 2010 includes provisions that promote intensified engagement with the social spaces in which people live, work, study, and play as an essential element of improving population health.⁶ Now is the time for academic health centers to recognize their central role in serving as an anchor for continuous biosocial training that is first initiated in premedical education and refined in postgraduate training. Doing so effectively requires incorporation of a comprehensive biosocial curriculum that spans across the preclinical and clinical years of medical school as well as residency training in both domestic and global settings.

Models of Biosocial Education

Three examples, all of which we have been deeply involved with, provide worthy models for moving us forward in biosocial training.

An organization that promotes social medicine curricula

SocMed⁷ is a nonprofit organization that advocates for and implements social medicine curricula. It offers annual courses in northern Uganda and Haiti for health professionals interested in global health. The principles of praxis (the constant interplay between reflection and action), the personal (that who we are and where we come from matter deeply addressing health inequities), and partnership (community building amongst individuals with varied demographic backgrounds) inspire SocMed course content and experience. SocMed’s unique approach, built upon Freirean critical pedagogy,⁸ merges field visits, classroom-based presentations and discussions, group reflections, films, theater, patient clerking and presentations, and bedside teaching to create an innovative and interactive learning environment. Students participate as both learners and teachers to advance the entire class’s understanding of the biosocial interactions that influence illness presentation and social experience of disease. Classes are diverse, composed half of local students (from Uganda or Haiti) and half of students from elsewhere in the world. The course curriculum also places considerable importance on building partnerships and encouraging students to reflect upon their personal experiences with power, privilege, race, class, gender, and sexual orientation.

To date, 125 students have completed SocMed courses. Pre- versus postcourse self-assessment has demonstrated that SocMed’s curriculum significantly improves students’ knowledge of the social determinants of health and ability to practice biosocial medicine in over 20 different assessed metrics. Further, participants subsequently integrate the principles of social medicine into future clinical, curricular, and political work. One former student, now completing his internal medicine residency, recently cared for a Nepali patient misdiagnosed as mentally ill and institutionalized against her will. With a biosocial approach, our student correctly recognized an underlying nutritional deficiency and then used his awareness of cultural beliefs about mental illness to successfully transition the patient back home to her family. Another alumnus is working to design a social medicine curriculum for community health workers in Uganda. SocMed offers a blueprint for the successful development of intensive, one-month electives that train students in social medicine.

A required first-year social medicine course

Since 2008, Harvard Medical School has required a course on social medicine for all first-year medical students. Lectures and a core body of social medicine literature expose students just entering the field of medicine to the biosocial perspective that is indispensable for engaging meaningfully with patients’ experience of illness and disease patterns at the community level. Each week a team of tutors, with broad social medicine experience in domestic and international settings, guide small-group, case-based discussions in an attempt to help students design biosocially informed interventions. Topics covered in recent years have included global health responses to the 2010 earthquake in Haiti, the management of HIV/AIDS in resource-poor settings of Boston, and the past and present history of racism in U.S. medicine. Such a course provides a model of a discrete, semester-long course that can be successfully integrated into required medical studies.

A four-year curriculum that fully integrates social medicine

Finally, in the most expansive model of biosocial training, the recently founded school of medicine at the Lebanese American University (LAU SOM) integrates social medicine into all aspects of its four-year curriculum in an effort to create socially oriented physicians. Social medicine is 1 of 12 basic and clinical science disciplines that are taught and assessed simultaneously in an integrated and problem-based curriculum at LAU SOM. In preclinical course work, social medicine is taught biweekly in system-based modules. For example, dialogue on individual and social responsibility for smoking is fostered during the pulmonary module, and a critical analysis of the social determinants of diarrhea is covered in the gastroenterology module. In the clinical years, social medicine remains central through a longitudinal primary care clerkship in a refugee camp, a continuity clerkship focused on following a patient or family for two years, and bimonthly social medicine rounds during inpatient clerkships. The LAU SOM model socializes students to understand social medicine as equally integral to their physician formation as other traditional topics.

Anticipating the outcomes of biosocial education

Given the relative infancy of these training models, we have limited systematic outcome data. However, we are clear that the primary outcome of interest for all social medicine education involves fostering health professionals who capably practice social medicine in whatever specialty or career path they choose. As demonstrated by Figure 1, developing practitioners of social medicine requires reflective knowledge acquisition that merges training in the “bio” (which includes basic science, epidemiology, and clinical knowledge) with training in the “social” (which includes economics, culture, history, politics, and social structure). Such training prepares practitioners to effectively practice social medicine, which involves working to improve health through building community partnerships, utilizing narrative medicine in patient care, participating in social movements, practicing community-based participatory action research, engaging in critical pedagogy, and collaborating in other activities to cultivate and respond to an understanding of the social determinants of health. As we evaluate our efforts, we anticipate that our educational models will demonstrate acquisition of skills, knowledge, and dispositions consistent with a biosocial framework and that participation in such training will bend the arc of career paths toward the practice of social medicine.

Figure 1: Elements of biosocial training. Fostering practitioners of social medicine first requires reflective knowledge acquisition of the biosocial in order to develop the ability to effectively act through praxis, the personal, and partnership.

Moving Toward Necessary Change in Medical Education

From the models described above, a number of shared principles can be gleaned to guide successful implementation of biosocial medical education. First, teaching on the social, economic, cultural, and behavioral determinants of health must be seamlessly integrated into the basic science, epidemiological, pathophysiologic, and clinical topics already in place. Biosocial training cannot be accomplished by relying on electives or applying haphazard curricular strategies. Effective biosocial education requires building institutional support by (1) highlighting credible research that demonstrates the import of the social determinants of health; (2) networking with curriculum committees; and (3) developing a community of individuals, departments, and organizations that appreciate a broader approach to health. Social medicine teaching requires the use of diverse pedagogies, rigorous self-reflection, and an integral emphasis on building partnerships to achieve a sound biosocial approach. Finally, aspiring health professionals from all backgrounds and in all settings—regardless of country, social class, race/ethnicity, gender, or future specialty—benefit from biosocial training. Biosocial education, in fact, is most successful when health professionals representing widely varied backgrounds jointly engage in the study of social medicine.

At a time of renewed calls for medical education reform, we resurrect Manson’s mantra for necessary change. In concert with others, Manson went on to build a robust field of tropical medicine, now codified in professional associations, training programs, and academic degrees, and Manson’s Tropical Diseases is now in its 23rd edition. Medical education now needs comprehensive incorporation of social medicine.^9–11 In a world where both social and biological forces determine health outcomes for rich and poor populations alike, the implementation of comprehensive biosocial curricula offers a tremendous opportunity to prepare health professionals to engage those realities. Only then can we honestly and effectively respond to disease and illness and truly move toward the promotion of health and well-being in all settings.

Acknowledgments: The authors wish to thank communities throughout the world that have taught us the central importance of the social in the delivery of health care.