Social Medicine Thread

Overview

Social inequities are major contributors of poor health.  Social medicine aims to elucidate the root causes and pathways of how social forces and disparities affect health outcomes.  Moreover, social medicine embraces social justice principles and evidence-based strategies and remedies to improve the health of patients and communities impacted by adverse social and structural factors. Structural determinants refer to social and economic policies, the root causes of inequities affecting the distribution of resources necessary for health. They impact the social determinants of health, including education, employment, housing, immigration, environment, and access to healthcare.  At UPSOM, social medicine is a major thread deliberately and systematically integrated into the Three Rivers Curriculum. 

Our social medicine curriculum is built around the structural competency framework proposed by Metzl and Hansen.  Structural competency is defined as the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures.  By having a foundation in the concepts and knowledge of social medicine, future physicians will be equipped to understand their patients in the context of their lives and to identify and address the social and structural factors impacting their health. 


Implementation

UPSOM has integrated social medicine as a core theme explored through classroom and experiential learning throughout the curriculum.  The Antiracist and Health Equity Solutions (AHES) and the Community Alliance Program (CAP) are two flagship courses, but social medicine concepts are also embedded in Keystone Fundamentals and Organ Systems as well as clerkships through structural analysis—clinical reasoning that takes into consideration contextual factors and social determinants of health.  The following examples illustrate how social medicine is addressed in the UPSOM curriculum:

Orientation – Neighborhood Visits

Organized by Social Medicine Fellows, incoming medical students will have the opportunities to visit community-based organizations in several neighborhoods around Pittsburgh including Homewood, Hill District, Hazelwood, South Hills, Braddock and McKeesport.  Students learn from community members about the neighborhood’s history, resources, assets, and healthcare challenges. 

Introduction to Being a Physician

This week-long course is the first curricular experience in medical school. Students are introduced to an 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.

Community Alliance Program (CAP)

CAP was developed as part of the 3RC to provide community engagement and learning about the social and structural determinants of health.  The community as classroom model places groups of students with community-based organizations and nonprofits to work on service and advocacy projects mentored by community experts outside the walls of hospitals, clinics, and academia.

Longitudinal Alliance Program

Students get to know their LAP patients in clinical and non-clinical settings to understand their perspectives on health and healthcare.  Through this longitudinal experience, students learn about social factors that influence the health of their patients as well as the complexity of navigating the healthcare system. 

Patient, Physician, and Society

Beginning in the first month of medical school, Wednesday morning workshop sessions are dedicated to the Patient, Physician, and Society course, which includes three content areas:  Ethics, Population Health, and Antiracist and Health Equity Solutions (AHES). The ethics content includes case-based discussions of ethical principles applying to patient care, including informed consent and autonomy, as well as discussions of responding to medical errors, physician impairment, and larger social issues such as the legal status of reproductive health care in the United States.

Population Health addresses how physicians think broadly about improving the health of a population, not just an individual patient. Students examine patient safety, quality improvement, health inequities, global and public health, gun violence, and health care finance and reform. 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.

AHES critically examines the impact of racism on health outcomes, as well as teaches students to utilize their skills and influence to mitigate the effects of structural racism in medicine. An interdisciplinary team of content experts engage students in small group discussions on the impacts of racism in education, health outcomes, intersectionality, criminal justice system, and other institutions and political economic systems that reinforce inequities.  

Patient Centered Care

Highly skilled standardized patients provide a supportive environment for students to practice their communication and exam skills in an educational, simulated classroom setting. 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 introduce topics such as gender identity, domestic violence, substance use disorders, fat bias, disabilities, coping with serious illness, and environmental considerations. Students build upon their classroom learning as they interact with real patients in their patient care courses throughout all four years of the curriculum. 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.

Clinical Clerkships

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.

In Neurology, students spend one-half day with the discharge planner and nurse caring for their patients to learn about discharge planning, medication reconciliation, insurance coverage, home safety evaluation, transportation needs, and caregiving support for patient with complex neurological conditions. 

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 within interprofessional teams. 

During the Adult Inpatient Medicine Clerkship, students work with social workers and case managers on discharge planning for patients, 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.

Electives

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 individuals with complex health and social needs.  Students rotate through the Birmingham Free Clinic, Enhanced Care Program, substance disorder clinic, Second Avenue Commons and street medicine rounds.
  • 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.

Streams

Students have the longitudinal para-curricular opportunity to explore and focus on care for disadvantaged communities in the Advocate/Activist Stream to build additional skills to bring about systems change as well as regional and/or national policy change to address health inequities.  Similar opportunities exist in the Innovator and Leader Stream category.  A medical humanity stream could help students reflect and become more aware of issues related to social justice and health equity and equip them with the extra-clinical language and tools to become future leaders and change agents. 

Flex Week Activities

During flex weeks, a variety of social medicine theme Professional Enrichment Courses or experiences are offered such as Refugee Health, Pittsburgh Reads, Taking Better Care of Patients with Disabilities, Addiction and Hope, Environmental Impact of Healthcare, Global Health, Introduction to Palliative Care, Quality Improvement, Narrative Medicine, Protecting the Health of the Public, Medical Advocacy Writing, Rural Medicine Experience. 

Service and Volunteering

Many first-year students connect with under-resourced populations through experiences such as the PALS Program, which pairs individual students with pregnant teenagers, and through service learning at various free and community-based 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 Street Medicine at Pitt that brings medical care to those experiencing homelessness in Pittsburgh. These experiences reach beyond the core curriculum to enrich students’ understanding of patients’ context of health and disease and promote the spirit of service and selflessness that is fundamental to the medical profession. Many students also take advantage of Pittsburgh Schweitzer Fellows Program and Bridging the Gaps Internship to learn and serve community organizations over a year or summer period, respectively.

Research and Scholarly pursuits

All UPSOM students complete a Longitudinal Research Project that is conducted throughout the four years of the curriculum.  Students have the option of focusing their research project in any area of biomedical science, and many opt to undertake projects in community health, population medicine and public health.  Students connect with mentors within the School of Medicine and beyond, including neighboring universities, the School of Public Health, and community organizations. 

Since 2021, first-year medical students completing a Dean’s Summer Research Project (DSRP) were offered the opportunity to complete an optional Social Determinant of Health (SDH) Enrichment Program. Completed in parallel with a DSRP research project, this program facilitates community engagement with dedicated faculty and community mentors. By making the importance of SDH more concrete for students who are actively engaged in medical research, the SDH Enrichment helps students begin to consider how medical research can contribute to the goal of creating a more equitable society.  In addition, students are also encouraged to present their health-disparities scholarship and community engagement in the Health Disparities and Social Justice Poster Competition.