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Friday Feb 14, 2020

Advocacy, Social Determinants Must Be Part of Physician Training

''If medicine is to fulfill her great task then she must enter the political and social life.''
-- Dr. Rudolf Virchow

[piggy bank and change]

It was my first time seeing Mr. Smith in our office. I briefly read through his chart and saw that he had seen several physicians during the last year with concern for continued weight loss. Labs had been ordered, tests run, images reviewed without concerning findings. No one had concluded why he was persistently losing weight.

I conducted my typical new patient questioning, collecting a thorough history as I had been trained to do in medical school. Then I asked questions that I wasn't taught in medical school but have learned during the course of my training that I must include, questions that screen for social determinants of health.  

I start with these:

  • Have you ever eaten less than you felt you should because of lack of money or food?
  • If I were to give you information to read, would you be able to do so on your own? In what language?

From just these two questions I found out that my new patient ate half a package of ramen daily, sometimes every other day, because he couldn't afford more nutritious food. He also could not find out where he could get assistance because he is unable to read.

We talked about hardships he has endured throughout his life, from not being able to complete his education to recently being laid off from his job and the difficulty of finding a new one. We completed a few extra tests to ensure we didn't miss a medical diagnosis, but my patient ultimately did not have a specific medical disease causing him to lose weight. He had, however, faced a lifetime of systemic racism and social inequity that ultimately left him unable to be healthy.

During my medical school training, there was a brief mention of social determinants of health. We did not have dedicated curriculum and we were not taught to screen for societal issues. The American Medical Student Association and AAFP started my education on how societal issues and health policy ultimately affect the health of the public. From these "introductory courses," so to speak, I was inspired to pursue my Master of Public Health degree concurrent with my Doctorate of Osteopathic Medicine.

By being involved in these organizations and obtaining this additional graduate degree, my perspective of how medicine should be practiced and what additional skillsets a physician needs to learn changed. It became increasingly important to me that the next step of my training would include education in population health. So, I sought out a residency program where there was a focus on public health as it relates to physical health and well-being, and where I was given the opportunity to participate in activism on behalf of and alongside the patients I was seeing in office.

Had I not been a part of these medical organizations or trained at a residency program that teaches residents how systems of oppression and social factors of disease impact the lives of patients, I may have been yet another doctor who overlooked the actual cause of this patient's weight loss.

It is crucial that medical education integrate curricula around activism, advocacy and public health if we wish to truly train physicians to be able to take care of communities.

In 1910, Abraham Flexner published "Medical Education in the United States and Canada," now more affectionately called the Flexner Report.(archive.carnegiefoundation.org) This report challenged U.S. medical schools to re-evaluate their curricula and become more academic to remove the "weaker and superfluous" institutions.

While the Flexner Report was appropriate for its time, ensuring that physicians were training in rigorous environments, utilizing the scientific method, participating in original research and learning by doing, we have come to a point in health care where we must look beyond what "traditional academic medicine" has been providing for the past century. In medical school, we still learn the Krebs cycle, become well versed in anatomy and physiology, learn the mechanisms of action of the many medications that we will prescribe or that our patients will possibly be on. Medical training is still rigorous, but we are now at a point in health care history where the U.S. life expectancy has decreased in three out of the past four years.(www.nytimes.com) Patients have a multitude of complex, chronic diseases, substance use disorder and deaths due to overdose are not uncommon, infant and maternal mortality rates continue to increase -- disproportionately affecting black women and infants -- and we can't go a week without hearing a news story about deaths due to gun violence.

How can we turn away from the fact that there is still bias in medicine that leads to underdiagnosing and undertreating specific populations? Or that many of our patients cannot make it to their primary care appointments because they cannot arrange or afford childcare? Perhaps they spent their last $7 for the week on food instead of bus fare to your office to receive care they also could not afford. And there are those who continue to be identified by the wrong pronouns, leading them to feel unsafe in the clinic and less likely to seek preventive care.

Social health and health policy have always played a role in determining who gets sick, who gets care, if and where that care is received, and how. By understanding this, we can then understand the social drivers of health and illness, which will ultimately aid in diagnosing and restoring health. By understanding this, we can affect the delivery and outcomes of health care and can effectively affect social health and health policy.

These issues include unemployment, housing instability, food access, systemic racism, sexism, LGBTQ justice, reproductive justice, immigration reform, climate change and violence. These issues directly affect our patients' overall health, the very thing we have trained and studied for years to help them improve and maintain. Understanding this, it is crucial that medical education continues to make changes and address activism and advocacy as standard components of the curriculum. If we fail to train physicians to identify and address these issues, then we fail to train physicians to care for patients completely.

Advocacy can take many forms, as illustrated by the report "The Physician Advocate: Advancing Policies That Support Health Equity"(835 KB PDF) from the AAFP's The EveryONE Project. The Academy offers members resources that go beyond party politics to focus exclusively on advocacy that supports family medicine so family physicians are most effective for their patients and communities, including assistance with grassroots advocacy and tools that make it easy to be heard by members of Congress and state legislatures. Physicians also can be heard by conducting research, publishing article and giving talks.

Family physicians need to be at the forefront of this work because we are the front line for our patients in our role of providing and coordinating care. We care for patients who face social injustices daily and we see how social issues can quite literally kill our patients. Prescriptions, labs and procedures mean nothing to our patients if we do not address the social determinants of health underlying their health issues. Our patients will never be healthy if basic human needs -- housing, health care, food and safety -- are not met.

We recognize now, more than ever in medical history, that human health is inextricably linked to the conditions in which we live, learn, work, and play. If the field of medicine is to serve the evolving needs of our patients and communities, it is of the utmost importance that we address social accountability of medical training and encourage integration of advocacy into medical education.

Kelly Thibert, D.O., M.P.H., is the resident member of the AAFP Board of Directors.

Posted at 04:05PM Feb 14, 2020 by Kelly Thibert, D.O., M.P.H.

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