If there was ever any doubt as to whether social advocacy should be a formal part of medical training, 2020 dispelled it. Last March, we as faculty educators found ourselves abruptly part of what every other residency training program in the country was experiencing: supporting and teaching our resident physicians and medical students as our patients grappled with the sky falling. Our clinic’s interdisciplinary team found our patients facing housing, job and food crises, as well as lack of access to regular medical care or transportation. In fact, the COVID-19 pandemic has proven to elucidate long-existing health care disparities, particularly in minority communities.
The social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks. Acutely, it has been witnessed that long-standing social inequities, as defined by their SDOH, have put people from racial and ethnic minority groups at increased risk of severe illness and increased risk of dying from COVID-19.
Perhaps, though, this global pandemic has really been a sobering paradigm of the historic barriers that have always existed in our communities. The frequently cited 2003 Institute of Medicine report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," states that racial and ethnic disparities exist even when insurance status, income, age and severity of conditions are comparable. I also refer readers to a paper published in February in The New England Journal of Medicine that outlined the history of structural racism as applied to residential segregation, police violence and unequal health care, and in which the authors powerfully spoke on our role in dismantling structural racism, stating, “the medical and public health communities need to turn a lens on themselves, both as individuals and as institutions.”
The question of what health equity training looks like at different levels of medical training has been a topic of discussion for some time. The authors of a 2010 letter to the editor in Academic Medicine reflected on their own student-led multiyear curriculum at Boston University School of Medicine. They suggested that learning objectives in advocacy could focus on “formally identifying and distinguishing between the roles that physicians must, should and could perform within the spectrum of physician advocacy and developing a rigorous understanding of the social determinants of health.”
The authors of a perspective piece published in Academic Medicine in 2018 conferred that we are remiss in the current approach to teaching SDOH as “facts” as opposed to “conditions to be challenged and changed.” They perhaps captured the core of what our patients need us to understand most when they wrote, “Educators talk about poverty but not oppression, race but not racism, sex but not sexism, and homosexuality but not homophobia.”
It is likely that residency programs across the country and across specialties will be re-evaluating and sharing their curricula on health equity this year. As such, there are several tools that can be used for reference. In 2012 the Multnomah County Health Department in Oregon published a document titled “Equity and Empowerment Lens” that can be used by individuals and organizations. The Lens is a tool that asks us to question “people, place, process and power” and seeks to incorporate a diverse set of voices of all involved individuals (including community stakeholders) to identify barriers and opportunities leading to equity and racial justice. The document itself contains helpful concept papers for educators and learners alike, including a pictorial demonstrating what “upstream, midstream and downstream” actions may be necessary to eliminate the root causes of inequities. This tool could be introduced to resident physicians by asking them to evaluate their quality improvement projects through this “lens.”
There has also been a much-needed focus on examining our individual unconscious (implicit) biases as health care professionals, as well as implementing mitigation strategies to overcome implicit bias. Although many people believe that bias is often a conscious stereotyping and expressed directly, we know that self-awareness of implicit biases that are not overtly apparent to ourselves can be a powerful tool in the fight for health equity.
There exist several helpful toolkits to guide facilitator/learner discussions on racism and implicit bias. The Society for Teachers in Family Medicine’s 2017 Toolkit for Teaching about Racism in the Context of Persistent Health and Healthcare Disparities contains several group activity guides on exploring disparities, implicit bias and institutional change, as well as many helpful podcast, book and article references to facilitate further learning for educators. The AAFP’s Implicit Bias Training Facilitator Guide contains a framework to better understand the neuroscience of implicit bias and gives the facilitator guidance on how best to create a safe and inclusive learning environment, in addition to presenting a series of strategies to mitigate implicit bias in clinical practice. In 2019, a report in Family Medicine described an effective way of achieving health equity benchmarks in residency education: a comprehensive four-part diversity initiative that included recrafting the mission statement, creating a diversity task force with a focus on recruitment, a longitudinal curriculum creating a shared language, and ongoing evaluation of the processes.
Finally, there has been recognition of the importance of teaching our learners the skill of physician advocacy, as can be seen in the implementation this year of the Accreditation Council for Graduate Medical Education Family Medicine Milestones 2.0, which devotes one section to advocacy. This competency encourages educators to evaluate resident learners on the diverse spectrum of roles we now know is imperative for family physicians to fulfill in our goals toward health equity. It is heartening that the ACGME and family physician leaders nationally have recognized advocacy as its own skillset. This step will encourage faculty educators nationally to evaluate the unique curricular needs of each of our programs as we train family physicians to address the systemic inequities in the communities we serve.
There exists an overwhelming sense of urgency in pushing for the inclusion of health equity training for our learners. I challenge myself and all of my faculty colleagues nationally to truly assess the quality of education we provide in health equity.
There is truly no room or justification to graduate physicians into our communities without the skills to address social determinants of health in an interdisciplinary model, as well a sense of awareness of organizational roles in achieving health equity and racial justice.
Shoba Belegundu, M.D., is a fellow of the 2021 AAFP Health Equity Fellowship. She is an assistant program director in the Mount Carmel St. Ann’s Family Medicine Residency program in Columbus, Ohio. Her views are her own and do not represent those of the organizations with which she is affiliated.