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Disparities, Health Inequities, and Vulnerable Populations: Will Academic Medicine Meet the Challenge?

Sklar, David, P., MD

doi: 10.1097/ACM.0000000000002010
From the Editor

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

Several years ago, I was caring for Thomas Chee (name changed), a Native American man, who had been transferred from another hospital after he was hit by a car while crossing the street. The part of New Mexico where the injury occurred is an area known to be a high-risk one for Native American pedestrians. Gallaher et al1 have suggested that the high death rate for Native American pedestrians in New Mexico is due to off-reservation drinking at night that leaves individuals with limited options to “hitch rides back to the reservation on unlit roads with intoxicated drivers” or causes some to attempt to wait until morning “at the mercy of winter in New Mexico, when nighttime temperatures often drop below minus 12 degrees Centigrade.” Gallaher et al noted that compared with other New Mexicans, “Native Americans were nearly eight times more likely to die in pedestrian motor vehicle crashes and 30 times more likely to die of hypothermia.”

As I admitted Mr. Chee to the trauma service for treatment of his skull fracture, spleen laceration, and pelvis injury, I reflected on the high number of patients from the same area whom I had cared for with similar problems. While the trauma care at our trauma service saved many of them, the costs were substantial, and many of the patients were left with permanent disabilities. I wondered if there was something we could do to prevent the injuries. I decided to approach the state traffic safety bureau to see whether we could find funding to investigate the cause of the problem. I received a small grant. With a team of residents and staff, we interviewed community members, families, elected officials, medical professionals, and law enforcement personnel. We looked at several years of data and maps of the locations of the crashes and found that the crashes mostly occurred on one stretch of dark highway where two bars were located on opposite sides of the road.

So what to do about it? No one had ever taught me how to approach a health problem like this during medical school or residency. I suggested that we attempt to close the bars, but the consensus from the rural community where the dark highway was located was that the lighting of the roadway near the bars should be improved, so that drivers would be able to see the pedestrians at night. The highway department found the money to install the lights. But questions were raised about who should pay the electric bill for the lighting. Was the problem primarily a Native American one, since Native Americans were most often injured? Or was this a problem for the entire community? Should the costs for the lighting be borne by the bar owners, the drinkers, health insurance companies, or the community? The costs for one injured pedestrian might reach hundreds of thousands of dollars, but there did not seem to be any way to connect the money saved in the health system through prevention of an injury to the money needed to pay for the lighting. There was money to pay for the air transport and the medical and surgical treatments of injured pedestrians, but none to address the social and behavioral factors that led to the injuries, such as alcohol abuse, poor roadway design and lighting, racial and ethnic mistrust, and disparities in living conditions. Fortunately, the money was eventually found: the city council members voted to pay for the electricity for the lights, and the pedestrian deaths greatly decreased in the lighted area.

I learned a lot of lessons from attempting to understand and prevent pedestrian injuries in that rural community—in particular, how funds are available for health care but not available to prevent the illnesses and injuries that require health care. My experience also made clearer the importance of research to elucidate the causes of population health problems and the most effective preventive interventions, the complex political forces that must be navigated when solving a health problem that requires public funds, and the lack of health professions education devoted to health inequities and disparities in health.

My impressions about health disparities were influenced by Woolf,2 who identified the contributions of individual behaviors and the physical and social environments that result in suboptimal health and health inequities. While he recognized that health care can help achieve health equity, the effects of care are often limited. He suggested that

health equity is achieved not only by treating illnesses but also by addressing the physical and social environments that shape health behavior and produce disease and by creating the opportunity for vulnerable populations to build social and economic resources.

There are several definitions that I have found useful in considering health equity. McGinnis et al3 stated that the social determinants of health include education, employment, income disparities, poverty, housing, crime, and social cohesion. They also noted that environmental conditions, such as toxins and pollutants, and behavioral choices, such as diet, substance abuse, and physical activity, contribute to health outcomes.

Braveman4 suggested that health disparities are

systematic, potentially avoidable differences in health—or in the major socially determined influences on health—between groups of people who have different relative positions in social hierarchies according to wealth, power or prestige.

She added that health equity is achievable and disparities are preventable as part of the leveling of social hierarches and power.

Whitehead and Dahlgren5 explain that health equity implies

that ideally everyone could attain their full health potential and that no one should be disadvantaged from achieving this potential because of their social position or other socially determined circumstance.

While these definitions are aspirational, disparities in health related to income are real and demand attention. Chetty et al6 have shown that higher income was associated with greater longevity in the United States between 2001 and 2014. There was a 14.6-year difference between the life expectancy of the richest 1% compared with the poorest 1%. Equitable allocation of health resources could narrow this gap, allowing more people to reach their potential and enjoy a full life.

In the rest of this editorial, I will discuss what I believe to be the challenges and opportunities for academic health centers (AHCs) to address health disparities, to contribute to health equity, and to meet the needs of vulnerable populations. In particular, I will give examples of how AHCs could help achieve health equity by educating a workforce that would be interested in meeting the needs of vulnerable populations and equipping them with the skills and attitudes to address health equity problems. I will also discuss the need to continue the conversation about health equity begun in this editorial, and will outline the steps that Academic Medicine intends to take to highlight this important topic.

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What AHCs Could Do

Train a health equity workforce

As the educators of the future workforce, AHCs have enormous influence on selecting who will provide health services, where they will work, and what values they will carry with them. Will they care for the poor and homeless, racial and ethnic minorities, mentally ill? Will they live and work in rural areas where shortages of physicians reduce access to needed care? Will they learn the languages and the cultures of their patients? In this issue of Academic Medicine, Parlier et al7 provide a theoretical model to explain the factors that contribute to the development of rural physician identity and the successful recruitment and retention of rural physicians. They discuss the possible influences that medical training may have in nurturing the intention to practice in a rural area such as medical school rural tracks and rural residency rotations. Garcia et al,8 also in this issue, report their investigation of the intention to practice with underserved populations among medical school graduates who responded to the AAMC Medical School Graduation Questionnaire from 2010 to 2012. They found that whether choosing a primary care or specialty care career, underrepresented minority students had a greater likelihood of an intention to practice with underserved populations than did other students. Both Parlier et al and Garcia et al note the importance of selection criteria that include a background consistent with caring for underserved or rural populations.

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Develop health equity attitudes

Medical education can also influence students to develop attitudes and skills that could help address disparities and inequities in health and health care. Exposure to underserved populations through clinical experiences can help students to understand the unique needs of underserved populations and reduce the students’ initial biases. In this issue, Hinrichs et al9 describe, through the comments from focus groups of patients who were transgender or gender nonconforming, the negative experiences of such patients in obtaining sensitive clinical care. One informant noted:

I visited a doctor at one point that almost ran out of the room when he got a sense I was different somehow. He could not leave the examination room fast enough.

While the focus group participants were supportive of incorporating transgender education along with their care, they also raised concerns. For example:

My doctor’s always training someone, and that’s really cool, and I’m excited for the new providers to get the knowledge, but sometimes I just don’t want 50 people in the room when I’m trying to talk about this really difficult thing.

Also in this issue, Bedoya et al10 describe a different type of vulnerable patient, one with multiple chronic medical, social, and mental health conditions. Such patients often receive high volumes of care that is fragmented because of the numerous specialists involved in their care, as well as their recurrent utilization of emergency departments. Bedoya et al then discuss a project in which an interprofessional team of medical, nursing, pharmacy, and social work students visited complex patients at home, accompanied them to appointments, and visited them if readmitted to the hospital. This project was part of a national collaborative with a number of goals, including teaching students to participate in intensive case management of complex patients and increasing students’ awareness of the role of social determinants of health and their ability as future clinicians to have an impact on those determinants. Students described “developing a deeper appreciation of the lives of complex patients and how interprofessional teams can address unmet health and social needs.”

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Create a social determinants curriculum

Medical schools and residency programs can, and sometimes are, finding ways to teach students about the social determinants of health and their relation to issues of health equity. For example, in this issue Greer et al11 describe a curriculum built upon visits by interprofessional students to households in underserved areas that occur longitudinally throughout medical school, where students identify social determinants that could adversely affect the health of the household, and attempt to remedy the social determinants using community resources. Students integrate classroom material on population health with their household experiences to help achieve competencies they are expected to master prior to their graduation. To reinforce its commitment to the curriculum, the medical school has a social accountability competency domain that includes having an understanding and incorporation of the social determinants of health into patient care and applying “knowledge of health advocacy, systems, and policy to identify strategies for reducing health disparities and promoting individual and population health.”

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Deepening the Conversation

While the introduction of social determinants into the health professions curricula could be a step toward recognition of health disparities, Sharma et al12 in this issue question the current educational approach to social determinants of health as content to be learned rather than as “conditions to be challenged and changed.” While they acknowledge the important contributions of social determinants in causing health inequities, they raise concerns about discussing the problems without a commitment to change. Ideally, “students would be expected to work toward developing skills and tools to address health inequities that are rooted in injustices rather than just acquiring abstract knowledge.”

Also in this issue, Alberti et al13 describe another type of conversation about health equity associated with the annual meeting of the Association of American Medical Colleges that occurred in Baltimore after the death of Freddie Gray and subsequent rioting. Annual meeting participants viewed videotapes of community residents giving their views about how clinicians, medical students, and scientists could better work with the communities to address injustice, minimize inequity, and improve health for all. A common theme from the interviews was the need for scientists and clinicians to go out into the community, listen to local residents, learn about their lives, and incorporate that knowledge into their practice.

Both Sharma et al and Alberti et al raise important questions about the most effective way to address health inequities, and suggest opportunities for further dialogue. Because the issues of health inequities, disparities, and vulnerable populations are so important and the approaches so divergent, we at Academic Medicine have decided to continue the discussions illustrated in this issue with our New Conversations journal feature. In a recent blog,14 I have described in more detail the types of submissions we encourage. While I recognize that in this issue of the journal, the articles focus on health professions education, there are also important perspectives related to research, care delivery reform, finance, and health policy, all of which have a role in addressing health inequities and can be fostered by AHCs. We look forward to submissions on these topics, and the topic of health professions education, and their connections to achieving health equity.

I began this editorial with a story about how I learned about social determinants and health disparities through my quest to understand a cluster of pedestrian injuries among Native Americans in New Mexico. While I needed data, community guidance, and funding to implement a solution, what I believe was most important was for all of us who worked on the problem to have the will to persevere and not accept the status quo. I believe that this is what Sharma et al are getting at, and I also believe it underlies the process described by Alberti et al. We in academic medicine need this same will to bridge the various philosophical differences about the moral and economic arguments for health equity and to find common ground about why health equity is essential for everyone. Health professions education, which brings various health professionals, families, and the community together, could be where we find that common ground. Academic Medicine is committed to providing a forum for exchange of ideas on this important topic, which could help us all find the will to make health equity our priority.

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References

1. Gallaher MM, Fleming DW, Berger LR, Sewell CM. Pedestrian and hypothermia deaths among Native Americans in New Mexico. Between bar and home. JAMA. 1992;267:1345–1348.
2. Woolf SH. Progress in achieving health equity requires attention to root causes. Health Aff (Millwood). 2017;36:984–991.
3. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2002;21:78–93.
4. Braveman P. Health disparities and health equity: Concepts and measurement. Annu Rev Public Health. 2006;27:167–194.
5. Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in health: Leveling up part 1. 2006. Copenhagen, Denmark: World Health Organization, Regional Office for Europe; http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf. Accessed August 9, 2017.
6. Chetty R, Stepner M, Abraham S, et al. The association between income and life expectancy in the United States, 2001–2014. JAMA. 2016;315:1750–1766.
7. Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The road to rural primary care: A narrative review of factors that help develop, recruit, and retain rural primary care physicians. Acad Med. 2018;93:130–140.
8. Garcia AN, Kuo T, Arangua L, Pérez-Stable EJ. Factors associated with medical school graduates’ intention to work with underserved populations: Policy implications for advancing workforce diversity. Acad Med. 2018;93:82–89.
9. Hinrichs A, Link C, Seaquist L, Ehlinger P, Aldrin S, Pratt R. Transgender and gender nonconforming patient experiences at a family medicine clinic. Acad Med. 2018;93:76–81.
10. Bedoya P, Neuhausen K, Dow A, Brooks EM, Mautner D, Etz RS. Student hotspotting: Teaching the interprofessional care of complex patients. Acad Med. 2018;93:56–59.
11. Greer PJ Jr, Brown DR, Brewster LG, et al. Socially accountable medical education: An innovative approach at Florida International University Herbert Wertheim College of Medicine. Acad Med. 2018;93:60–65.
12. Sharma M, Pinto AD, Kumagai AK. Teaching the social determinants of health: A path to equity or a road to nowhere? Acad Med. 2018;93:25–30.
13. Alberti PM, Sutton KM, Cooper LA, Lane WG, Stephens S, Gourdine MA. Communities, social justice, and academic health centers. Acad Med. 2018;93:20–24.
14. Sklar D. New conversations: Justice, disparities, and meeting the needs of our most vulnerable populations. AM Rounds. www.academicmedicineblog.org/new-conversations-justice-disparities-and-meeting-the-needs-of-our-most-vulnerable-populations/. Published July 24, 2017. Accessed November 1, 2017.
© 2018 by the Association of American Medical Colleges