Why and How Civic Health Should Be Incorporated Into Medical Education

Abstract

Civic health refers to the ability of a community to organize and collectively address problems that affect the well-being of its members through democratic participation. Civic health should be an integral part of the medical school curriculum because improving a community’s civic health shifts the distribution of power toward patients, better enabling them to address social determinants of health that are affecting their well-being. This article details how to effectively integrate civic health curriculum into already-existing medical education frameworks, outlines how these interventions will improve both patient care and the student experience, and addresses barriers that might restrict the implementation. Civic health can be integrated into the didactic curriculum in the form of lunchtime guest lectures, panels with community organizations, and small-group discussions; it can be integrated into experiential curriculum by distributing QR codes to aid in voter registration, organizing voter registration drives, and participating in nonpartisan canvassing. This civic health content can be integrated into existing social justice curricula without massive investment or structural change. Medical students are capable and effective messengers of civic health and can affect change at all levels of training. Notably, because civic health is directly actionable, it can be a source of motivation rather than burnout for medical students. As students develop into medical professionals, the training in civic health improves their understanding of social determinants of health and enables them to play an important role in promoting civic engagement and empowering patients with the democratic tools necessary to enact social change.

The policy decisions within the government that influence our health and drive health inequities typically play out insidiously through unequal access to resources, such as healthy foods, clean water and air, affordable housing, and public transportation. The COVID-19 crisis made the impact of these decisions much more visible as public leaders and institutions have controlled the distribution of tests, personal protective equipment, and now vaccines.

Elected officials are expected to respond to their constituencies, but the living and working conditions, as well as economic and social structures and opportunities, that shape health—often referred to as social determinants of health (SDOH) ¹—have disenfranchised many people, particularly people of color, people living in poverty, and young people (~18–30 years of age). ² Thus, the priorities and needs of these communities are underrepresented in the political system.

The extent to which these and other communities are able to effectively access democratic recourse, drawing attention and resources to the problems they face, is called “civic health.” ³ Typically, civic health is achieved through civic engagement, including voting, volunteering, and participation in local social groups, such as Rotary club and parent–teacher association (PTA), that ultimately serve to strengthen communities. Civic health falls under the umbrella of SDOH and encompasses both political power and social cohesion as structures and opportunities. Communities that gain power and grow more cohesive are better able to shape SDOH, particularly those related to the conditions in which they live and work. Civic health has been positively associated with physical health, as well as with more generous social welfare policies. ^4–7 Thus, efforts to increase civic engagement through voter registration and mobilization may be important to improving health.

Health care settings have historically been underused as spaces for civic engagement, but the COVID-19 pandemic shifted this perspective. With the usual voter registration sites restricted during the 2020 election, health professionals across the nation mobilized with civic innovations to ensure patients could safely partake in the democratic process. ^8,9 Organizations like Vot-ER ¹⁰ and Patient Voting ¹¹ worked with more than 80 academic institutions and countless healthcare systems across the country to assist tens of thousands of hospitalized patients register to vote and cast emergency absentee ballots. ⁹

Medical students played a key role in health care-based voter registration and census advocacy, and in doing so, they became part of a broader movement in medical education to reframe how we teach the SDOH and consequent health inequities. ¹² In a 2018 article, Sharma et al challenged medical schools to change how they teach SDOH from “facts to be known” to “conditions to be challenged and changed.” ¹³ In the current system, we are taught to inquire about our patients’ housing status and access to quality food but are given limited tools to address these concerns. Promoting civic engagement among our patients, particularly among those underrepresented in the electoral process, is an actionable way to empower patients to engage in the democratic process. Empowering patients to vote and voice their concerns to their local and national representatives helps to build a government that is responsive to their needs and creates more equitable health policies.

While some argue that civic health advocacy is outside the purview of the medical profession, ¹⁴ these efforts are not dissimilar to other physician activist movements such as White Coats for Black Lives and American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) that have gained popular support. ^15–18 A 2021 report by the Lancet Commission on Public Policy and Health in the Trump Era ¹⁹ called for reinforcing voting rights to reinvigorate U.S. democracy and improve public health. The call came as a growing body of evidence linked voter disenfranchisement with a range of negative health outcomes and health inequities among individuals, communities, and regions. ^20,21 A scoping review summarized evidence associating voting abstinence with poorer self-rated health as well as with a range of health conditions, including heart disease, disability, and mental health disorders; discrimination and lack of social capital have been cited as possible mechanisms behind these associations. ²⁰ Indeed, the moral imperative for civic health advocacy has already been recognized by medical students across the country doing nonpartisan voter engagement work through extracurricular organizations. ^22–24

While these organizations have done important work normalizing the concept of civic health, a formal civic health curriculum would allow institutions to learn from each other as they develop instructional tools, strategies, and competencies as part of other justice-driven educational developments. ²⁵ Formal curricula would allow governing bodies to develop universal approaches for robust assessment of student performance and program effectiveness. Furthermore, such curricula would ensure that institutions train students to broach voting and other forms of civic engagement in a consistent, inclusive, and nonpartisan way. In incorporating formal civic health curricula, health professions schools will help prepare the next generation of providers to take meaningful action, fight against health inequity, and empower patients to advocate for themselves and their communities. ²⁶

Proposed Curricular Changes

We propose both actions for immediate direct implementation into medical school curricula and actions that may contribute to more long-term widely integrated change in curricula. Curricular actions can be organized into those that are didactic and those that are experiential; Figure 1 provides examples of both types of actions and the amount of effort needed to implement them. We envision a curriculum driven by 3 core competencies:

Figure 1: Examples of ways to implement civic health into the medical school curriculum. Implementing civic health does not require major restructuring of curriculum and can be incorporated into social justice curriculum that has already been created.

1. Students will develop an understanding of the complex connections between civic health and individual/population health.
2. Students will develop the skills to create a safe and trusting environment in which to discuss nonpartisan civic engagement with patients.
3. Students will seek out opportunities to incorporate civic engagement into patient interactions and their own lives.

Didactic curriculum

We propose that longitudinal civic health education should be integrated into preclinical and clinical didactic curricula. Most medical schools already have courses addressing SDOH, ²⁷ and many schools are presently developing antioppressive education materials focused on structural inequities and empowering students to advocate for patients both inside and outside of the medical visit. ²⁸ These courses and educational materials provide avenues through which civic health can be incorporated into the curriculum. Ultimately, the goal of such civic health instruction is to teach student–physicians about the importance of building, nurturing, and reinforcing patients’ agency, as well as of advocating for their patients. The Association of American Medical Colleges (AAMC) has numerous resources to facilitate curriculum development around health equity and SDOH. ²⁹ Programs can use these already-existing frameworks to incorporate civic health into medical school curricula.

Furthermore, faculty and students can also design civic engagement electives for course credit. While electives do not ensure uniform education within a class, they allow for a more comprehensive approach to complex topics. Such sessions could give students a deeper understanding of electoral processes and facilitate exploration of modalities of civic engagement beyond voter registration (e.g., helping patients complete the census, contact their local and national representatives, participate in local groups like the PTA). Additionally, curricula should include the history of voter suppression in the United States and how these barriers to voting persist today. These programs can engage local nonpartisan organizations and organizers to champion service-learning and bring civic health education directly into the community.

To be effective, the didactic curriculum should include (1) inquiry and self-discovery, (2) self-reflection, and (3) interactive small-group discussions. ^30–33 Inquiry can be implemented by students researching and then presenting on different connections they find between civic engagement and health, as well as how current policy decisions affect both individual and population health. Self-reflection can be implemented by asking students to reflect on their own experiences with civic engagement or their experiences discussing the topic with patients. Small-group discussions can be focused on how students can implement their increased understanding of civic health in clinical settings—with an emphasis on techniques that create a safe, respectful, nonpartisan environment when discussing civic engagement.

Experiential curriculum

There are many opportunities for experiential learning within the space of civic health. These opportunities include organizing nonpartisan canvassing, building coalitions with other advocacy or identity-based groups, and leading state legislative days where students contact their representatives to advocate for policies that improve population health.

However, the most direct and effective way to incorporate civic health into patient care is by offering voter registration opportunities in the social history portion of patient interviews. After students collect information about a patient’s health-related behaviors, housing status, and food access, they can segue naturally to questions around patient civic engagement. During these conversations, medical students can incorporate their knowledge from the civic health didactic curriculum to refer patients to resources such as voter registration, emergency in-hospital ballots, and nonpartisan voter information guides. Get-out-the-vote initiatives, like Vot-ER, offer samples of badge-backers, flyers, and websites to equip students and providers with the resources needed to carry out these tasks. These initiatives helped more than 46,000 community members to vote in the 2020 national election. ³⁴ Similar models can easily be adapted to match the needs of the patient population in different health center settings. For example, materials can be tailored to be more accessible for limited-English proficiency patients at a large county hospital or integrated with the already expansive social needs programs at the Veterans Affairs health system. By standardizing civic health questions in the social history, we can normalize health care spaces as places where patients can safely inquire about civic engagement opportunities, and we can build an additional layer of patient empowerment into our work.

Addressing Counterarguments

With any novel innovation in medical education comes reasonable questions and disagreements. Table 1 lists several of the main concerns regarding integrating civic health into medical education curriculum and offers solutions and counterarguments for overcoming them.

Table 1: Solutions and Counterarguments to Perceived Barriers to Implementing Civic Health Into Medical Education Curriculum

Implementation and Conclusions

The links between civic actions, such as voting access, and health are clear. ²⁰ Thus, inquiring about patient civic health should be just as central to the patient encounter as prescribing a new medication, screening for substance use disorders, or gaining a comprehensive surgical history. The effects of COVID-19 on traditional voter registration sites and the emergence of nonpartisan mobilization efforts in health care settings have highlighted the unique role that health professionals can play in improving population health via information sharing and empowerment of their most marginalized patients.

Medical education is a space where novel ideas for health innovation can take root and eventually become more broadly integrated into comprehensive health care. By including civic health in medical school curricula and, by extension, normalizing discussions about civic health in medical visits, we can empower patients to advocate for their health through civic engagement. This movement is already well underway across health systems, as was evident in hospital administrations embracing internal voter registration events, ³⁵ professional organizations mobilizing members to use new technologies that help patients vote-by-mail ballot, ³⁶ and tens of thousands of physicians and health professions students helping to empower their patients to vote in the 2020 elections. By embracing the link between civic health and patient well-being, health professionals can better recognize the SDOH of their patients. Health providers are trusted messengers in their communities. By leveraging this privilege and addressing civic health in both the classroom and the clinic, we can empower our patients and our communities.

Acknowledgments:

The authors would like to acknowledge the entire Vot-ER research team, including Madeline Grade, MD, as well as Heather Whelan, MD, Beth Griffiths, MD, and Martha Cain, for thoughtful discussions, feedback on the manuscript, and contributions to the figure.