Social determinants of health (SDH) have been defined by the World Health Organization as “the conditions in which people are born, grow, live, work and age … shaped by the distribution of money, power and resources at global, national and local levels” and are the major drivers of health and disparate health outcomes across communities and populations.1 Therefore, an understanding of the causes and impact of SDH is critical for physicians to provide effective clinical care and to improve public health. In addition, failure to consider SDH creates systemic inefficiencies and ineffectiveness that may increase the cost of health care.2 Finally, the tenets of medical professionalism require that physicians commit to addressing SDH, in part, through managing complexity, providing wise stewardship of resources, and promoting health equity.
As a consequence of the importance of SDH and physicians’ role in addressing them, medical societies increasingly highlight their work in advocacy and the promotion of social justice.3 Policy and clinical leaders have called on medical schools to place their social mission at the forefront of institutional priorities4 and urged educators to develop curricula that are accountable to community needs and that more comprehensively address health inequities.5
We assert that competency in recognizing and mitigating SDH should become a vital component of graduate medical education (GME) in all specialties. Our experience at Boston Medical Center, the largest safety-net institution in New England, has demonstrated that care for patients from all social strata, and particularly patients from vulnerable populations, is not possible without a deep commitment to the recognition and mitigation of SDH. We believe that competency in this aspect of clinical care is essential to improving the health of our patients. We also believe that an important obligation of medical educators is to help our trainees find meaning and mastery in medicine. Trainees derive a strong sense of self-efficacy and satisfaction when they have the skills to effectively address the health needs of their patients and to engage more productively with their communities. Therefore, competency in SDH is also essential to equipping trainees with the full range of knowledge, skills, and attitudes necessary to meet the future needs of their patients. To fully accomplish both of these goals, medical education will require a multidimensional approach that includes traditional didactic instruction, community-based learning opportunities, and, critically, regular role modeling throughout the continuum of medical education. In this Invited Commentary, we offer an educational framework and strategies designed to help GME trainees in all specialties recognize and mitigate SDH.
Education and SDH
Medical educators have provided examples of thoughtful curricular initiatives in health disparities, advocacy training, and community-based medicine.6 And yet, despite a growing understanding of the importance of SDH, inclusion of this material into standard training curricula remains sporadic, and when it is included, it is often considered optional (e.g., service–learning programs and elective course work emphasizing public policy pertaining to social justice). Although the most effective approaches to educating trainees about SDH are uncertain, useful lessons may be derived from existing related curricula that address cultural sensitivity, end-of-life discussions, and the need to expand and emphasize key components of the social history.7,8
Beyond individual program-based curricula, the various health systems that host GME programs have shown inconsistent commitments to addressing SDH and have had incomplete connections to relevant community-based resources. Therefore, in addition to curricular content, experiential learning—through modeling by faculty and the institutional clinical learning environment—will need to more regularly and effectively address SDH. Lastly, with few exceptions, residency review committees have yet to identify critical components of SDH for integration into the six core competencies; this will be necessary to ensure ongoing programmatic commitment to including this material in curricula.
Key Principles for Curricular Implementation
A few key principles for implementing curricula on SDH will be useful to consider. First, SDH curricula must be universalized and integrated into broader educational programming. Universalization suggests that there are aspects of training related to SDH that are pertinent to all areas of clinical practice and serves to combat the notion that SDH are elective or only to be covered by trainees participating in tracks or pathways dedicated to health equity, advocacy, or the amelioration of health disparities. The needs of trainees will vary across specialties, but a core set of knowledge and skills needed to effectively recognize and mitigate SDH will be important for all GME trainees.
Second, curricula on SDH need to be integrated seamlessly into clinical education in standard conferences, morning reports, and other educational encounters across all clinical training sites. The incorporation of SDH in the formal and informal curriculum will increase educational impact by building integrative skills in trainees and, importantly, will explicitly affirm the values of the training program.
Third, programs should create opportunities to stimulate trainee introspection about their own stories and cultures and how they influence their thinking about SDH. This may take the form of small-group discussions, reflective writing, and/or community conversations around challenging subjects such as race and class. For trainees and aspiring physicians, having a keen awareness of personal power and privilege in comparison with others is a powerful clinical tool.
Fourth, specific competencies in identification and mitigation of SDH will need to be defined. The communication skills needed to elicit SDH from patients and their families are distinct from those needed to successfully address or mobilize resources to mitigate SDH. Consequently, trainees will need to identify social, legal, and financial services along with other clinical professionals who can help to effectively address patients’ SDH—a skill that would fit well under the systems-based practice competency. Further SDH competencies might include the recognition of implicit and explicit biases, advocacy skills, development of a basic awareness of health care financing and payment structures, and the communication skills needed to unravel the socioeconomic barriers to effective clinical care. Lessons pertinent to this principle can be derived from pediatric educators who have developed a series of competencies and associated milestones related to community health and advocacy skills.9 Then, as SDH competencies are defined and accepted, programs and regulatory organizations can develop evaluation tools to assess for relevant resident growth and development as well as program success. As examples, objective structured clinical examinations might assess trainee communication skills in recognizing SDH; licensing examinations could include questions regarding health and social policy; metrics around self-efficacy might be developed; and program evaluations might inquire about opportunities for trainees to work with interprofessional teams and community organizations.
Lastly, ensuring that faculty preceptors have the skills they need to teach the principles outlined above will require robust faculty development programming. Recognizing that didactic teaching regarding SDH will be insufficient, respected clinical mentors will need to demonstrate by example how to impact SDH. Therefore, faculty will need ongoing education in eliciting and addressing SDH in the course of their regular clinical work. However, it cannot be assumed that clinical faculty will accept the idea of operationalizing work to address SDH in their clinical practice, as they may see this as added work burden. Important opportunities also exist to learn from one another; many of our colleagues with long-standing commitments to caring for vulnerable populations have developed effective approaches to integrate medical and social needs into clinical care.
Examples of Curricular Approaches to SDH
As we consider some key components of GME, we need to recognize that training is heavily influenced by both the formal or stated curriculum of a given training program as well as the hidden curriculum.10 Because formal education in GME often begins with orientation, at Boston Medical Center, we include an interactive session on recognizing the role of SDH in common clinical presentations during our formal GME orientation for all entering residents and fellows. The session encourages entering trainees to immediately consider the role that education, income, housing, access to transportation, and so forth, can play in determining health and health outcomes. It also challenges trainees to avoid making assumptions about their patients’ lives. In addition to the important content covered during the session, the timing emphasizes our institutional commitment to mitigating SDH and conveys the expectation that addressing SDH is expected of all trainees.
GME training programs have an opportunity to work collaboratively to create core curricula on SDH that expand on the material covered during orientation. Programs may codevelop didactic training about central themes pertinent to all medical specialties such as the SDH themselves, the impact they can have on health, relevant health economics, health policy, and the role of various allied health professionals and social, financial, and legal services in addressing SDH.
Subsequent exposure to SDH will vary across clinical departments depending on their scope of practice. Experiential learning is an important element in the educational approach. As an example, simulation exercises are useful in teaching communication skills for eliciting SDH. We believe trainees would benefit from simulations explicitly designed with people representative of the populations they serve who will provide nuance about the intersection of social needs and clinical care planning. Such exercises would allow trainees to appreciate the risks for unintended outcomes that are linked with a lack of shared decision making that takes social needs, such as medication affordability, food insecurity, or neighborhood safety, into account.
Although examples of community-based and service–learning opportunities have been described11,12 for a variety of trainee levels, fewer examples exist in GME. At Boston Medical Center, residents from several departments participate in structured neighborhood walking tours where they see “in action” several nearby social service sites—such as homeless shelters, needle exchanges, a food pantry, and community advocacy organizations—to which they often refer patients. Another opportunity for experiential learning is advocacy training,13 in which trainees acquire tools for persuasive communication with policy makers and community leaders.
Beyond formal educational elements, institutional resources—such as social workers, community health workers, navigators, care coordinators, and nurses—have a vital role in broadening trainees’ skills in SDH. Training programs need to clearly define the roles and responsibilities of all members of the health care team in identifying and addressing SDH. This might include basic introductions to allied health workers as well as direct training experiences in interprofessional activities. More advanced work could include direct incorporation of trainees into health system efforts to address SDH. As a local example, faculty working with trainees at Boston Medical Center have developed a screening and referral system for SDH.14 This collective work demonstrates how institutions can operationalize efforts to address SDH and allow residents to incorporate systems-based learning skills into their own clinical practice.
Finally, the hidden curriculum plays a major role in trainees’ perception of SDH. For example, faculty require support and resources to adequately address SDH in their own clinical practice; if these resources are absent, the impact of the formal curriculum in helping trainees understand how to operationalize impact on SDH will be greatly limited. Addressing commonly encountered forms of bias and microaggressions in training is critical because disparaging or discriminatory language used toward patients or populations is often internalized by our residents and fellows. Further, ensuring that SDH are not subject to curricular segregation is important. When trainees learn that employment status meaningfully impacts patient morbidity, but rarely witness mentors asking about employment during clinical history taking, the lesson’s impact is diminished. Lastly, some institutional practices, such as steering patients with less remunerative health insurance to “resident clinics” or creating “teaching” versus “private” services that may separate patients along socioeconomic lines, might inadvertently endorse ignoring SDH or even promote health inequity. If we are to truly model a commitment to diminishing health inequities, these types of practices need to be challenged.
In conclusion, SDH have a profound impact on the health and well-being of our patients. Accordingly, clinicians and health systems have a shared responsibility to address SDH. To enable physicians to meet this responsibility, education and training in the recognition and mitigation of SDH should occur across the continuum of medical education, especially in GME. Recognizing that our community must continuously learn how to incorporate this material into GME training programs, we posit that training in SDH must be expanded and comprehensively integrated into clinical education. Faculty development and institutional engagement will be crucial to effective implementation. Competencies in the recognition and mitigation of SDH will need to be crisply defined by national accrediting agencies to aid programs in identifying and assessing residents’ and fellows’ abilities in these areas. Providing our trainees with the skills and knowledge needed to mobilize broader and more effective care for their patients will enhance their personal sense of competency and self-efficacy. Moreover, and, most important, this will ensure the development of a future workforce ready to more comprehensively address society’s most pressing health needs. We offer a call to action to the medical education community to work collaboratively toward this goal.
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