Residency Curriculum Hits Mark on Social Determinants

Researchers Aim for Culturally Proficient Residents

March 22, 2019 04:05 pm Sheri Porter

Health disparities and underserved populations are terms that pop up often in discussions about shortcomings in today's health care system and the best way to serve patients. Some U.S. residency programs already have introduced innovative concepts into postgraduate medical education to address these challenges.

[Illustration showing elements of a health clinic]

New research shines a spotlight on one of those programs.

An article(journals.stfm.org) in the January issue of Family Medicine details results of family medicine residents' immersion in a longitudinal experiential curriculum at a federally qualified health center (FQHC) located in an underserved community.

Researchers set out to test the efficacy of the residency curriculum as a strategy for eliminating health disparities in an urban underserved population. Over the course of five years -- from July 2011 to June 2016 -- a total of 22 residents participated in the research as part of their training at the St. Louis Family Medicine Residency in St. Louis, Mo.

Story Highlights
  • Researchers at a St. Louis family medicine residency program assessed outcomes after implementation of a longitudinal experiential curriculum in 2011.
  • Family medicine residents saw patients in a federally qualified health center (FQHC) located in an underserved urban community.
  • After assessing five years of training outcomes, researchers found the longitudinal immersive curriculum increased the level of residents' passion, knowledge, skills and familiarity with resources when caring for patients in underserved areas.  

In an interview with AAFP News, lead author and family physician Christine Jacobs, M.D., explained that the residency involves a partnership between an FQHC, a hospital and Saint Louis University (SLU).

Jacobs currently serves as chair of the SLU Department of Family and Community Medicine and was the founding program director of the residency program. She created the longitudinal underserved community curriculum that launched with the residency in 2011.

The curricular project was funded in part by a five-year grant from the Health Resources and Services Administration (HRSA). "Even after the funding ending, we've continued the curriculum to this day, and it's very successful," said Jacobs.

The research team discovered that a longitudinal curriculum that is both immersive and experiential "can give residents the passion, knowledge, skills and familiarity with resources that will enable them to embrace urban underserved medicine," she said.

Jacob's message to colleagues is this: "In order to help residents experience joy and mastery in urban underserved care, continuity practice must be augmented by curriculum that takes residents out of daily practice and into the world of their patients."

This type of curriculum "gives them skills and tools to address social determinants of health and close contact with mentors who thrive in the community health setting," she added.

Study Methods, Key Findings

During those five years, all program residents attended monthly one-hour, community-focused seminars, led by guest speakers from the community or local agencies, during which topics such as health disparities, behavioral health, violence and health policy were discussed.

Second-year residents attended monthly daylong workshops that included

  • conversations with patients,
  • visits to community organizations,
  • introduction to resources,
  • hands-on clinical workshops,
  • fieldwork,
  • short didactic sessions and
  • awareness-raising exercises.

And all residents practiced in a culturally diverse FQHC where 15 percent of patients spoke a language other than English and 55 percent fell below the federal poverty level.

Researchers used written tests, focus groups and resident surveys to assess knowledge gained, as well as residents' confidence levels and attitudes.

Among the key findings were

  • a 31 percent increase in resident knowledge after PGY-2 daylong workshops,
  • a 28.8 percent increase in average resident knowledge after seminars,
  • a 50.9 percent increase in resident self-ratings of "good " or "extremely aware" regarding obstacles faced by groups of color seeking health care, and
  • an 80.9 percent increase in resident self-ratings of "good" or "extremely knowledgeable" regarding ways cultural factors may influence nursing care.

Also, "the proportion of residents indicating 'totally confident' or 'confident' in incorporating culturally relevant information into a treatment plan significantly increased from 30 percent to 81.8 percent," wrote the authors.

In written feedback, residents repeatedly expressed development of a "greater understanding of the challenges and barriers faced by underserved patients" and "increased knowledge of community resources," said researchers.

They pointed out that their study was limited by small cohort size within a single residency program but noted that the experiential workshop format and diversity of seminar topics were generalizable to other specialties and practice settings.

Residents' Reflections

Jacobs shared portions of some focus groups transcripts in which residents spoke of their out-of-clinic experiences with patients in food kitchens, on street corners and in workshops.

One resident described sitting at a table "breaking bread" and talking with homeless people as "one of the most humbling experiences."

Family medicine residents also found themselves pounding the pavement with social workers in search of patients who needed certain immunizations. Most were homeless, and many had mental health needs.

One resident recalled, "We went out looking for these people to follow up … that was a pretty eye-opening experience, too. We were going to parks and street corners and saying, 'Hey, do you know …?'"

And an international workshop brought residents in contact with a Somalian refugee couple who described what their home life was like before war in their country left them first in a refugee camp and then in the United States. They described living in a country where they didn't speak the language or have friends.

The encounter left one resident more cognizant of the importance of patients' stories and the insights they bring to the exam room. "I might dread when this person comes in because they have a lot going on, but there's a reason they have a lot going on," this resident said during the focus group.

In written feedback after various workshops on topics that included addiction and homelessness, disabilities and implicit bias, and neighborhood safety nets, authors said residents indicated how the workshop experiences would positively affect the way they would practice medicine in the future.

"Better understanding of afflictions prevalent in homeless and addicted populations," wrote one.

"It will help (me) to not make assumptions. To ask open-ended questions," said another.

"Better knowledge of community resources and situations our patients come from," noted a third.

Additional Author Insight

Training residents in an FQHC is a big and important step, but it's not enough, said Jacobs. "We really need to give them lots of tools and support to make them successful at becoming physicians who are comfortable and excited about taking care of urban underserved patients."

One of the challenges, added Jacobs, is navigating both the science and the art of medicine. For instance, diagnosing a patient's high blood pressure and treating it with evidence-based blood pressure medications invokes the scientific component.

But helping a patient embroiled in a domestic violence situation involves much more art than science. "It's the art of being present with the patient and thinking carefully about how to help that person move forward in the context of the situation," she said.

The kind of longitudinal experiential curriculum that was created for residents in the St. Louis program "prepares residents to ask the hard questions they need to ask in that kind of environment," said Jacobs.

Residents training in the more traditional settings may not have the same set of tools and, therefore, "are not going to ask the questions or open that door because they don't feel well equipped to deal with the answer," she added.

That's unfortunate, said Jacobs. "There are many social determinants -- including violence, addiction and depression -- that do not respect socioeconomic class."

The solution?

"We need to continue to implement diverse curricular models in a multitude of settings, and to examine the outcomes of those curricular," said Jacobs.

What's up next for this cutting-edge residency program? "We created another curriculum, and we're now in another five-year HRSA cycle to train our residents in integrated behavioral health," said Jacobs.

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