The social determinants of health are defined by the World Health Organization as “the conditions in which people are born, grow, live, work and age” and are shaped by the distribution of money, power, and resources.1 The social determinants of health are also responsible for most inequities in health.2 Structural factors, such as the physical and social environment and health behaviors, account for 80% of health outcomes, whereas only 20% of outcomes are thought to be due to health care.3 Vanderbilt and colleagues4 write, “Social medicine is the umbrella that encompasses health disparities, cultural competency, diversity, service, and population health.” Given the importance of the social determinants of health in the health outcomes of a population, the inclusion of social medicine or the “biosocial perspective”5 in health sciences education is of the utmost importance.
Leaders in medical education call for the incorporation of social medicine into the curriculum as a key intervention to address the health needs of our population and to promote health equity.5,6 Despite this, within medical education, the social determinants of health remain on the fringe. When they are addressed, it is typically through elective or introductory courses without a shared vocabulary, standardized core curriculum, or integration into clinical practice.5,6 The need to demarginalize structural competency (i.e., clinical practitioners’ ability to intervene on social and institutional determinants of health)7 and shift the biosocial perspective into the core of medical education is clear: Factors that account for 80% of health outcomes cannot be addressed only in an elective course that most learners do not take.
Sixteen years have passed since the publication of the Institute of Medicine’s sentinel report on health disparities, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” which raised awareness of how differing socioeconomic conditions and differing treatment based on race or ethnicity contribute to health disparities.8 This work ignited a new emphasis on health disparities, yet they still persist. The time for this change in health sciences education, therefore, is long overdue. The solution seems simple—we should stop talking about the need for a biosocial approach to patient care and start teaching it universally, moving from social medicine electives to modeling the biosocial approach during all patient interactions. This is a far leap, however, from the current situation in most academic medical centers.
To bring social medicine and structural competence to center stage, we must recognize and address the challenges that have hindered this metamorphosis to date. In this Invited Commentary, we discuss practical barriers to the incorporation of the social medicine perspective. Our observations are informed by both our reading of the literature and by our experience in creating a structural competency curriculum for emergency medicine trainees at our own institutions. Finally, we suggest a framework of a shared vocabulary, a standardized core curriculum, and the creation of clinical metrics to overcome these barriers.
Speaking With a Shared Vocabulary
The first barrier to general acceptance of a biosocial perspective in medical education is the lack of a shared vocabulary. The names for social medicine concepts vary between groups and disciplines and may be totally unfamiliar to a clinician. When we began to talk about “social emergency medicine” in our institutions, our colleagues were sometimes surprised by the term and asked if it was related to social media. Those who work with anthropologists may be comfortable with the term “structural vulnerability”—an individual’s or a population group’s condition of being at risk for negative health outcomes through their interface with socioeconomic, political, and cultural/normative hierarchies—whereas groups of clinicians may do similar work under a different label.
Clinicians, sociologists, anthropologists, and social workers must find a shared lexicon. Some use the term “upstream” to refer to structural factors that impact health, and refer to those health professionals who incorporate a full structural vulnerability assessment as “upstreamists.”9 Structural competence is a less familiar term to clinicians, but connections can be made to make the term more familiar. Metzl and Hansen10 incorporate the “upstream/downstream” terminology into their definition of structural competence, defining it as the ability to discern how clinical information such as symptoms and diagnoses also represents “the downstream implications of a number of upstream decisions.” Others use terms such as social mission, social medicine, and health equity promotion. Table 1 presents a brief guide to core terminology of social medicine using some of our preferred definitions from the literature.
When a common terminology to describe the biosocial perspective is taught to clinical trainees, it provides a vocabulary to express the unmet needs confronted in their patient encounters. This was a key finding in Neff and colleagues’11 study of family practice residents—residents stated that a shared vocabulary lowered the barrier to having conversations with colleagues and teachers about structural vulnerability. Shared vocabulary is key to organizing efforts to promote the biosocial perspective in medical education.
Establishing a Core Curriculum
Undergraduate and graduate trainees have varying levels of familiarity with the biosocial perspective. Some may feel overwhelmed by the increased awareness of the magnitude of the influence of structural factors on health; however, this may be countered by teaching them concrete steps for intervening on unaddressed social needs.11 Others may have a substantial background in social determinants and may be more knowledgeable than the faculty. Faculty may be uncomfortable with teaching the social determinants of health, and understandably so—for many, the biosocial perspective was not addressed during training, and thus they lack concrete examples of how to incorporate the biosocial perspective into bedside teaching and didactic curricula.
Knowledge and comfort level in the biosocial perspective vary widely amongst faculty members, departments, and schools. This was true even among faculty in our department’s division of health equity, the Section of International and Domestic Health Equity and Leadership of the University of California, Los Angeles (IDHEAL UCLA), a group dedicated to social mission. When we began to pilot test case modules12 promoting structural competency for emergency medicine residents and students, we learned how difficult it is to teach about a social determinant outside of our areas of expertise. If a faculty member is an expert in immigration as a social determinant, for example, they may feel ill-equipped to teach about gender identity. We challenged ourselves to teach the modules with which we were most uncomfortable, and doing so required ample preparation. We are now writing a faculty guide to these modules to lower the barrier to using our curriculum for other clinical faculty within and outside of emergency medicine and at other institutions. These modules are a first step in teaching structural competence in the clinical setting as we move toward an integrated curriculum.
Our experiences highlight the need to create a standardized curriculum that integrates structural competencies: The scope of the curriculum and what constitutes the basic knowledge and facility that we expect our students and residents to attain are not currently defined. To address this challenge, we put forth a proposed framework for core content and skills to guide curricular development (Figure 1). Within the crowded medical school curriculum, this framework would not add a new block or chapter. Instead, it can be used to tie together the many disparate existing pieces in medical education and become a core facet of each substantive area. This framework can be integrated into each existing block as a component of didactics, small groups, and other activities, similar to how the social history is not taken in isolation on select patients but is a core component of each patient encounter. Using this framework, we, as faculty, can learn alongside our trainees, from our patients, from other members of the health care team, and from our community as we build our own skills and experience. This approach enhances existing curricula and improves the efficacy of delivered care instead of replacing or shortchanging other core competencies.
Constructing a Continuum of Care, From Classroom to Bedside
Sharma and colleagues13 argue that isolated trainings in the social determinants may lead trainees to believe that these are a static list of contributors to health that must be memorized. They call for a major transformation in medical education to foster an active commitment to social justice.13 In our experience, a contributor to this static view of the social determinants of health in education is the lack of connection between classroom content and models in clinical training. A solid course in social determinants during medical school will remain static if no application of the material follows during residency.
Several tools are available for application in the clinical setting that deserve mention. First, in 2014 Metzl and Hansen10 introduced a five-point model of structural competency for training clinicians. The model includes five core competencies: (1) recognizing the structures that shape clinical interactions, (2) developing an extraclinical language of structure, (3) rearticulating “cultural” formulations in structural terms, (4) observing and imagining structural interventions, and (5) developing structural humility. Second, Bourgois and colleagues14 put forth a structural vulnerability assessment tool that can be used in any patient encounter to assess the impact of structural forces on the patient’s life and health. Finally, Kleinman and Benson’s15 ethnographic approach uses a series of questions to guide a clinician’s understanding of the patient’s perspective on his or her illness.
The Residency Program in Social Medicine of Montefiore Medical Center in New York is at the forefront as a complete biosocial training model for graduate medical education. Founded in 1970, the mission of the program is specific to the integration of social medicine, training physicians to practice in community health centers and underserved areas.16 Residents are exposed to curricula and clinical innovations with the common theme of promoting health and social justice. Because this is a residency in social medicine, however, applicants self-select into the program because of existing interest.
Our next goal should be to expose all clinical learners to the biosocial perspective, regardless of prior interest or discipline. Neff and colleagues11 describe the development, evaluation, and implementation of a structural competency curriculum for family medicine residents and report a positive impact on physician–patient relationships. Noting the lack of available curricula for instructing residents and students in structural vulnerability, we created a set of comprehensive teaching modules that faculty can use at the bedside or during small-group instruction to ensure that all learners can recognize and address basic unmet social needs. These modules are open access and available for download.12 Experiential learning can also contextualize structural competency for learners through, for example, simulated patient experiences related to structural vulnerability or poverty, and programs that have trainees screen for structural vulnerabilities and refer patients to social services while also visiting these community resources themselves. The poverty simulation described by Hsieh and Coates17 and the “Hot Spotters Student Program” described by Harpin and colleagues18 are successful examples.
Although clinical curricula are already packed with content, the biosocial perspective can also be incorporated into existing curricula by adept faculty. For example, when discussing how to determine a patient’s insulin needs, the instructor might add a discussion of insulin cost and how the need to refrigerate insulin impacts a diabetic person who is homeless or marginally housed. Finally, the simplest and potentially most influential approach to experiential learning is for faculty to point out the impact of the social determinants in each case learners encounter in their usual clinical setting.
These examples represent initial innovations that bring structural competence to the bedside; however, large-scale adoption of these concepts has not yet occurred. As more universities and medical schools develop programs in health systems science and population health to train health care providers to address population health needs,19 structural competence is a natural fit within the health systems science foci of quality improvement and outcomes measurement. These new programs represent a potential home for structural competence within academic medicine.
Creating Clinical Measures and Metrics That Value Outcomes, Not Process
Another issue we must confront is the lack of explicit emphasis on social interventions in the clinical environment. We practice in an era when we are compelled to achieve measurable goals (patients per hour, relative value units, billing levels, door-to-disposition times, etc.) with few metrics incentivizing physicians’ attention to structural vulnerability. The lack of messaging from administrators regarding social interventions may be perceived as a lack of importance by those in training. Furthermore, in the current environment, clinician–educators model a practice that emphasizes these metrics and may relegate structural competency to the background. Additionally, despite the ability to list certain unmet social needs, such as homelessness, as a diagnosis or a comorbidity, these “social” diagnoses do not increase the level of complexity of care for billing and compensation purposes, which further hinders uptake of intervention.
The changing landscape of health care delivery, with an emphasis on accountable care organizations and the shift of risk and cost to the provider, presents an opportunity for emphasizing structural competence. This new framework values quality and outcomes, not quantity and process. Given that addressing structural vulnerability improves health outcomes and is thus part of quality care, measures and metrics incentivizing structural competence should be adopted. For example, administrators could track and provide feedback to clinicians on the percentage of limited-English-proficiency patients offered an interpreter, or how many homeless patients were offered a referral to social work, instead of simply measuring door-to-provider time or number of patients seen in a day. Adopting this mindset and creating a set of metrics emphasizing structural competence allows clinicians to address the seemingly insurmountable challenges of poverty and health outcomes through manageable steps in their daily practice.
Prioritizing Social Medicine and Structural Competence in Training Programs
How can we measure our progress toward advancing a social medicine agenda within clinical training programs? Mullan and colleagues20 propose a useful metric by which medical schools can be ranked by their dedication to social mission. Not surprisingly, on implementation of this scoring system, the rankings by social mission differed greatly from more traditional rankings of research funding and subjective assessment of reputation.20 This ranking system could and should be modified to apply to graduate medical education as well. Further, standardized testing drives the curriculum. Board examinations should include questions that incorporate the social determinants of health to be sure that the place of structural competency in residency curricula is solidified.
The transition to a core curriculum that emphasizes social medicine and structural competencies is overdue. To advance this agenda, proponents of social medicine must agree on a common vocabulary and the scope of expected knowledge and proficiency that should be required of all clinical trainees. Universities and teaching institutions should support faculty in establishing a necessary baseline and investigate creative ways of measuring impact. With common lexicon, curricula, and goals, we can surmount the barriers and mold a clinical workforce of the future that is structurally competent and confident as a mechanism to promote health for all.
The authors thank all the members of the Section of International and Domestic Health Equity and Leadership of the University of California, Los Angeles for their continued contributions to the development of the structural vulnerability curricula mentioned in this essay.
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