In Reply to Barwise and Liebow : Academic Medicine

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In Reply to Barwise and Liebow

Sharma, Malika MD, MEd; Pinto, Andrew D. MD, MSc; Kumagai, Arno K. MD

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doi: 10.1097/ACM.0000000000003125
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We thank Drs. Barwise and Liebow for their response to our Perspective. We agree that medical students are not wholly responsible for changing how the social determinants of health (SDOH) are taught. This is primarily an institutional responsibility—medical schools, academic health science centers, and hospital leadership must ensure that future physicians learn that medicine includes upstream action on SDOH at individual, practice, and community levels.1

The authors note that most students “will become clinicians—not public policy experts or social scientists.” Although ostensibly true, this fails to recognize that physician voices are incredibly influential in public policy discussions. Clinicians are limited at best and ineffectual at worst when they are unequipped to screen for and address the impact of SDOH on their patients’ lives. We are not arguing that faculty must inculcate all medical students into a particular worldview. We are, however, arguing that they should prompt students to question why and how issues, such as racism and poverty, result in deleterious health effects and consider how these conditions can be changed.

Drs. Barwise and Liebow state that it is unrealistic to expect medical school curricula to change to incorporate our proposals. We argue that approaches in medical education have changed dramatically in the past and can do so again. Decades ago, the notion of teaching humanism through storytelling and poetry in medical schools would have likely seemed impossible, and yet it is now routinely done in medical schools globally.2,3

Lastly, the authors state that “inequality will not concern everyone equally.” We find this problematic and respectfully propose that it should. We are tasked with caring for all members of society, and especially the most marginalized for whom health and well-being are particularly at risk. Physicians are uniquely poised to bear witness to the downstream effects of social disparities. They are trusted members of society who are often in positions of leadership and authority. This trust is eroded when we trade in band-aids without calling for upstream solutions.

Malika Sharma, MD, MEd
Medical director, Casey House and HIV Physician, Maple Leaf Medical Clinic Toronto, Ontario, Canada; [email protected]
Andrew D. Pinto, MD, MSc
Assistant professor, Department of Family and Community Medicine, Faculty of Medicine and Dalla Lana School of Public Health, University of Toronto, and clinician–scientist, MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada.
Arno K. Kumagai, MD
Professor and vice-chair of education, Department of Medicine, University of Toronto, and F.M. Hill Chair for Humanism Education, Women’s College Hospital, Toronto, Ontario, Canada.


1. Hsieh D. Achieving the quadruple aim: Treating patients as people by screening for and addressing the social determinants of health. Ann Emerg Med. 2019;74(5S):S19–S24.
2. Charon R. To see the suffering. Acad Med. 2017;92:1668–1670.
3. Pentecost M, Gerber B, Wainwright M, Cousins T. Critical orientations for humanising health sciences education in South Africa. Med Humanit. 2018;44:221–229.
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