Family physicians are acutely aware of the forces and systems that shape their patients' lives. In many parts of the United States, a family physician is the only health care professional for miles around. In those instances, the local "family doc" isn't just a physician; depending on the circumstance, that person also serves as a counselor, teacher, coach, role model and friend.
But it's not just immersion in the community that makes family physicians such valuable members of the towns and cities in which they practice. It's also the knowledge and training FPs receive in the social determinants of health (SDOH) that makes them leaders in treating patients with compassion and respect.
The AAFP is a strong proponent of addressing SDOH. With regard to educating physicians, the AAFP's policy on SDOH is clear:
"The AAFP supports the assertion that physicians need to know how to identify and address social determinants of health in order to be successful in promoting good health outcomes for individuals and populations. In preparing students for practice, medical schools must foster core competency in this patient-centric concept. Physicians in training must develop awareness of the potential obstacles patients confront when following treatment plans. Without this core competency, physicians and patients alike will be impeded by suboptimal outcomes."
- A review of residency program curricula has found wide variations in the ways in which primary care residents in the United States learn about social determinants of health (SDOH).
- In many programs, SDOH training was mandatory, but in several other programs such training was elective.
- The study authors called on accrediting agencies to be more direct in requiring that physicians receive SDOH training, and encouraged medical specialty societies to develop standard practices on the content, implementation and evaluation of SDOH curricula.
Less clear is how residency programs actually incorporate SDOH into their training. While the Accreditation Council for Graduate Medical Education requires family medicine residents to receiving training(www.acgme.org) on the effects of the community, the environment and similar factors on patient health, the requirements for residents in other primary care specialties, such as pediatrics and internal medicine, are not as well defined.
Not surprisingly, as the authors of a new study(www.ncbi.nlm.nih.gov) published in the January issue of Academic Medicine have pointed out, there are considerable differences in the way programs throughout the United States teach primary care residents about SDOH. These differences made it hard to determine which programs did the best job of educating residents and medical students, but they also served as examples for other programs that want to include SDOH in the curriculum or to enhance current SDOH training.
In reviews of 43 articles on SDOH curricula in U.S. primary care residency programs published between January 2007 and January 2017, the authors found considerable variations in curricula development, implementation and evaluation.
Sixteen articles reported on how SDOH curricula were developed. Of these, two reported development based on literature reviews, two used input from expert faculty, two used input from resident focus groups, four used existing frameworks to develop a curriculum and six used multidisciplinary teams.
Of the residency programs studied, 20 provided training on SDOH via one-time sessions or short programs lasting less than six months; typically this training was integrated into existing one-month rotations. Fifteen programs offered longitudinal training lasting six months or longer; in one of these programs, residents participated in an urban health track implemented over several years. The length of SDOH training was not discussed in the papers on the remaining eight programs.
One notable finding was that SDOH training often was not mandatory. Only 17 programs reported that SDOH training was required, while 15 programs reported that training was elective. The other 11 programs did not specify whether SDOH training was mandatory.
The way in which residents learned about SDOH varied considerably. In 32 programs, the SDOH curricula used didactics to deliver content, while 22 programs used experiential community-based learning. Most curricula (38 programs) used a combination of these and other methods to deliver content. In most programs, these methods ranged from small-group discussions to individual research projects, but two programs relied exclusively on online modules to educate residents.
The type of content covered also varied considerably. Thirty-two programs taught SDOH from a broad perspective and reviewed multiple topics, such as food insecurity and barriers to care. In the other 11 programs, SDOH curricula focused on specific determinants, such as health literacy, poverty or domestic violence.
Programs also varied as to when residents received SDOH training. In most programs, some type of training occurred during all three postgraduate years, but SDOH training occurred only during postgraduate year one in eight programs and during postgraduate year two in four programs.
In terms of evaluating the curricula, 27 articles reported on outcomes. Of those, seven programs evaluated postintervention outcomes only; 12 used a single-arm pre/post study design; six used nonrandomized designs with control groups; and two used randomized controlled designs. Self-reported knowledge or attitudes toward SDOH was the most common method of assessing outcomes, followed by satisfaction surveys or questionnaires.
The authors found both challenges and encouraging signs in their review. For example, because the SDOH curricula varied so wildly in terms of content, implementation and evaluation, it was virtually impossible for the authors to compare them and determine which curricula were most effective in educating residents.
On the other hand, the variations also showed that there were many ways of educating residents on the same topic. The authors provided highlights from six studies throughout the review, and suggested that those studies could serve as guides for other residency programs that wanted to implement or augment SDOH training.
The authors emphasized the importance of SDOH training as critical to resolving health disparities. They called on accrediting agencies to be more direct in requiring that physicians receive SDOH training. They also encouraged specialty societies and organizations -- particularly those representing family medicine, internal medicine and pediatrics -- to develop standard practices on the content, delivery and evaluation of SDOH curricula and to select standard outcomes assessments. Doing so would help researchers better understand how a program's curriculum shapes a learner's behavior, and ensure that residents of family medicine and other specialties receive the best possible training.
Academy Expert's Take on Study Results
Danielle Jones, M.P.H., manager of the AAFP's Center for Diversity and Health Equity (CDHE), told AAFP News that she agreed with the study authors' conclusions regarding family medicine residency programs. She thought the specialty should take steps to ensure there is a set of core competencies for SDOH not just in residency programs, but across the landscape of medical education.
Jones was encouraged about the findings, saying they show family medicine "is actively engaging in the development of new and innovative strategies aimed at preparing the next generation of its workforce to effectively deliver care in the context of complex social risk factors."
While some programs used distinct ways of teaching SDOH, Jones approached the differences pragmatically.
"The variation described in this study should be viewed from the perspective that like politics, addressing SDOH requires localized approaches that are developed in collaboration with community partners," she said, adding that in some programs, longitudinal components that gave residents hands-on experience with SDOH in the field may deliver the best outcomes.
For family medicine residency directors who want to update their program curricula or improve the SDOH training they currently provide, Jones offered the following tips.
"Start with the outcome in mind, whether it's changing the attitudes and behaviors of residents and students or improving population health outcomes," she said. "Then develop a shared goal within your organization for what you want to achieve, followed up with professional development for faculty."
Jones noted that the AAFP's Program Directors Workshop/Residency Program Solutions Residency Education Symposium is an excellent opportunity for attendees to learn best practices and tips from other family medicine educators about how to get started. The 2019 symposium will be held in Kansas City, Mo., April 5-9.
Jones also dropped the news that later this year, the CDHE will roll out a new resource called the Health Equity Curricular Toolkit. The toolkit will provide educators with guidance on the most effective ways to have important discussions about SDOH, with the aim of improving equitable outcomes within communities at both local and national levels. "The toolkit will be accessible to all people engaged in trying to improve primary care and health outcomes for all, but especially for those participating in traditional curricula in which these topics are not currently prioritized," Jones said.
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