The 21st century demands physicians know more than biomedicine to be effective and exceptional practitioners. Social determinants of health include individual behavior, environmental exposure, social circumstances, plus a patient’s medical care. Factors such as education, work environment, living conditions, access to health care services, lifestyle factors, and general socio-economic, cultural and environmental conditions all contribute to health, wellness and disease. Systems issues, including health care finance and the ongoing reform of health care delivery and reimbursement, have a substantial impact on how and if patients access health care services. Physicians must understand how these factors influence their patients, at both the individual and population levels, and be prepared to apply relevant knowledge to provide the best care possible.
By having a foundation in the concepts and knowledge of social medicine, new physicians will be equipped to understand their patients in the context of their lives and be ready to deliver excellent evidence-based patient-centered care.
UPSOM has integrated social medicine as an important theme explored through classroom and experiential learning throughout the curriculum. The following examples illustrate how social medicine is addressed in the UPSOM curriculum.
Introduction to Being a Physician
This week-long course is the first curricular experience in medical school. A key course is an introduction to health and social disparities and communities. Students are introduced to a diverse array of factors that influence health and disease, from access to care to violence, through case discussions, presentations and readings.
For students, a highlight of the course are the sessions where students hear directly from patients and families about how they manage and are affected by their medical conditions, such as HIV, sickle cell disease, cystic fibrosis and diabetes. Basic human emotions and concerns – fear, confidentiality, frustration, grief, courage and resilience – are unavoidably and appropriately prominent in these memorable patient interactions.
Ethics, Law and Professionalism
In their first semester, medical students participate in panel discussions, lectures, and simulated cases to explore issues of: ethical treatment of patients, end of life care, consent and self-determination, religious considerations, assisted reproduction, health care finance, medical errors, and liability/malpractice.
Students develop and refine their communication skills during the introductory (Fall of year 1) and Advanced (Spring of year 2) Medical Interviewing courses. Highly skilled standardized patients provide a supportive environment for students to practice their skills before they encounter real patients. They are challenged by patient cases that are progressively more complex in regards to content and patient communication styles. These richly-developed cases are one important vehicle for student learning about the social context of a patient’s current condition. The cases introduced include domestic abuse, substance abuse, psychological and behavioral issues, disabilities, environmental and military considerations. Students build upon their classroom learning as they speak with real patients in their patient care courses throughout all four years of the curriculum.
A unique feature of standardized patient case instruction at UPSOM is a specialized bank of patient social histories that form the foundation of each standardized patient’s “story”. Each patient case is a highly detailed account of a patient’s social history, based on an in-depth interview with an individual. These rich and comprehensive histories are used as high-fidelity sources as UPSOM faculty develop standardized patient cases for student instruction. The library of available cases is as diverse as Pittsburgh itself, incorporating a broad representation of occupations and life situations.
First and second years medical students spend time in clinical sites learning how real-world medicine is actually practiced, as part of this longitudinal course.
Every student spends one-third of their clinical sessions in a service learning setting, such as a free clinic or a drug/alcohol treatment program. Small group instruction supplements the direct clinical experiences, allowing students to have in-depth discussions about these issues with their preceptors.
Another focus of this course is learning about the “medical home,” how care is accessed, delivered, paid for, and the community resources available, especially for the underinsured. Other topics include prevention in practical terms, and the profound impact of low health literacy. Students have the opportunity to write about social medicine in their required essay at the conclusion of the course.
Advanced Physical Examination
During this longitudinal course, students in years 1 and 2 develop their hands-on skills with real patients. Despite the course title (“Physical Examination”), students invest a major portion of their effort on developing effective communication skills as they learn about the medical – and social – components of their patients’ histories. Students have course segments in a range of locations which provide them with exposure to the diverse spectrum of patients who seek care at UPMC facilities (including Children’s Hospital of Pittsburgh) and the VA hospital.
This first year course integrates a broad spectrum of subjects that converge as influences on behavioral health. Directly addressing social determinants is a session, "Social Determinants and Behavioral Health." Topics such as obesity and smoking teach motivational interviewing as a method to help patients achieve behavioral change that will promote health. Sessions on stress, pain, dying, grief, adherence, and integrative medicine expose students to additional dimensions of the human experience that have substantial influence on health and wellness.
This second year course sets the foundation for health systems education. The course addresses how physicians think broadly about improving the health of a population, not just an individual patient. Focusing on social determinants of health and a patient safety, students examine: quality improvements, global and public health, health care finance and reform.
In the health insurance workshop, students quickly recognize the importance of understanding the components and coverage of a plan and the importance of being able to help patients navigate the complexities of payment for medical care.
Quality and medical error are studied as students work through a root-cause analysis that reveals the complexities of care delivery and opportunities for improvement. Population-scale considerations are addressed in sessions on improving the health of patient populations and global health.
Many of the core clerkships include specific elements that bring social medicine considerations to the forefront. The following are representative examples of current activities within the clerkships.
The Family Medicine clerkship includes workshops on the “medical home,” with exercises and activities that help students learn how to provide care in our current system.
During the Psychiatry Clerkship, a workshop session on motivational interviewing prepares students to address substance abuse in their patients using the Screening, Brief Intervention and Referral to Treatment (SBIRT) model.
During the Adult Inpatient Medicine Clerkship, students participate in quality conferences, complete self-learning modules on medical errors, and conduct a review of a patient’s hospital bill.
During the Obstetrics and Gynecology Clerkship, students work with standardized patients to develop their skills in speaking with patients about certain sensitive topics. This specialized communication skill training aims to enhance connections with patients in ways that will promote patient sharing of important but highly personal information. OB/GYN students complete a writing assignment detailing their reflections on speaking with a person from a different cultural background than their own.
Practicing Medicine - What Awaits You?
This fourth year program provides students with an opportunity to examine how the clinical practice environment and patients connect with the health care system.
Structures of health care delivery in American Medicine are changing rapidly; they are continually influenced by the outcome of regulatory, policy, state/federal executive and judicial rulings about the Affordable Care Act. Despite these uncertainties health care delivery is and in the future will likely be driven by the objectives of the“Triple Aim”:
- Better health and health care outcomes (quality/safety/prevention) consistent with evidence based medicine and population based health concerns;
- Improved delivery of health care related to patient access and satisfaction;
- Cost control (reduction or stabilization of health care costs).
These developments are affecting the everyday practice of medicine at the residency level and beyond. The Practicing Medicine program addresses the implications of these changes, new patient care dilemmas for residents, and evolving requirements for medical practice and intervention.
Numerous one-month elective opportunities are available for third- and fourth-year students interested in learning more about social medicine. These examples illustrate the range of options:
- Health Care for the Underserved: Taught by the Department of Medicine, this elective emphasizes systems of care related to homeless individuals. Beyond direct care activities, access to and cost of care is a major focus, along with quality improvement.
- Operation Safety Net: Students join the Operation Safety Net team in hands-on care delivery in the streets of Pittsburgh and at their clinical site.
- Medical Leadership, Management, and Administration: Lead by Family Medicine faculty, students explore utilization management, cost-benefit assessment, health care economics, medical staff administration, physician incentives and practice trends.
- Quality and Patient Safety: Emergency Medicine faculty have created a unique experience utilizing online modules from the Institute for Healthcare Improvement, with asynchronous class discussion and specialty-specific learning for students. Each student completes a root-cause analysis on a particular quality issue with improvement plans. Nearly every senior student chooses to enroll in this award-winning elective.
Areas of Concentration
Several AOCs provide students with well-structured support as they dive deeper into a specific domain relevant to social medicine. These include the AOCs in Global and Public Health, Women’s Health, Integrative Medicine, and Humanities, Ethics and Palliative Care. Each Area of Concentration (AOC) is a longitudinal four-year experience which includes a scholarly project in this area, faculty mentorship, reflective writing, and elective courses.
Through a diverse menu of mini-electives, students in years 1 and 2 have opportunities to explore topics with social medicine considerations. These include Adoption and Foster Care, Advanced Pediatric Interviewing, Global Health, Intimate Partner Violence, Mind Body Seminar, Motivation Proclamation (motivational interviewing), Public Health, and Refugee Health Care.
Service and Volunteering
Many first year students connect with underserved populations through experiences such as the PALS Program, which pairs individual students with pregnant teenagers, and through service learning at the English speaking or Spanish speaking health clinics in our community. Students commonly volunteer in programs such as the SALUD Clinic, the Guerilla Eye Service that brings sophisticated ophthalmology services to underserved regions in Southwest Pennsylvania, and Operation Safety Net that brings medical care to the homeless of Pittsburgh. These experiences reach beyond the core curriculum to enrich students’ understanding of patients’ context of health and disease in a social context, and promote the spirit of service and selflessness that is fundamental to the medical profession.