Angela Y. Song|Edward L. Poythress|Claire Bocchini|Joseph S. Kass
Reorienting Orientation: Introducing the Social Determinants of Health to First-Year Medical Students
Baylor College of Medicine|Baylor College of Medicine|Baylor College of Medicine|Baylor College of Medicine
open accessseptember 18 2018reorienting orientation introducing social determinants health firstyear medical students angela song edward lee poythress md claire e bocchini md joseph kass md jd angela song medical student baylor college medicine email address email protected google scholar articles author edward lee poythress md assistant dean office student affairs baylor college medicine associate professor department internal medicine baylor college medicine google scholar articles author claire e bocchini md assistant professor department pediatrics baylor college medicine google scholar articles author joseph kass md jd associate dean office student affairs baylor college medicine professor department neurology baylor college medicine google scholar articles author httpsdoiorg1015766mep2374826510752 sectionsaboutpdf toolsdownload citations sharefacebooktwitteremail abstract introduction medical students rarely learn intersection socioeconomic environmental effects access health care maintenance health casebased discussion cohesively highlight social determinants health complement preclinical education modules foster future interest working vulnerable populations help students recognize barriers care identify strategies help patients methods social determinants health orientation program sdhop introduced students nonbiomedical factors contribute patients health key topics presented small discussion groups led faculty facilitators subjects addressed included access care immigrationlanguage barriers lesbian gay bisexual transgender health human trafficking raceethnicity womens health results sdhop initiative integrated formal curriculum successfully implemented first year institution pre postsurveys administered assess student satisfaction course well changes knowledge attitude regarding topics covered 186 sdhop participants 111 medical students responded surveys reported improvements knowledge comfort level topics specific related terms ninetyone percent rated overall quality sdhop individual modules good excellent discussion sdhop contributes medical education providing allinclusive model teaching students social determinants health results suggest presenting topics smallgroup discussion model improves medical student cultural competency comfort level patients diverse backgrounds educational objectives end activity learners able 1define discuss social determinants health specifically relate access care immigration language barriers lgbt health human trafficking race ethnicity womens health2identify social inequities examine shape health population delivery health care3demonstrate awareness personal bias social institutional structures lead poor health outcomes among marginalized groups4apply knowledge public health communicate effectively compassionately introduction students interface social determinants health every day receive minimal formal preclinical training identifying nonbiomedical factors contribute patients health evidencebased clinical decisionmaking includes factors social context patients life1 likelihood contextual errors patient care exacerbated lack training attention patients individual background environmental circumstances2 contextual errors one many reasons underserved patients receive poorer care poorer outcomes errors reduced appropriate guidance recognize social determinants health3 furthermore prior studies shown medical student attitude toward care underserved declines time4 interventions attempted mitigate effect later medical school optional opportunities selfselecting group interested students56 believe prioritizing integrating education social determinants health early medical school required course help prevent attitude change increase student investment effective compassionate communication optimize patient care future present curriculum teaching medical students social determinants health cases presented interactive modules emulate patient population new medical students serve future also individually used separate modules based community need social determinants health orientation program sdhop uniquely suited knowledge level new medical students designed applicable wide range contexts encounter training major governing bodies within medical education recently heightened emphasis social factors medical college admission test liaison committee medical education lcme graduate medical education standards lcme standards medical schools mandate education cultural competency understanding underserved populations within context health care disparities order become clinically proficient physician objective 767 many medical schools required curriculum social determinants health finding efficient effective method teach subjects cultural competency health care disparities challenging curriculum provides tool kit introduce fundamentals social disparities affect way patients interact health care system faculty supervision committee medical students conducted literature searches surveyed appropriate patient educational materials topics identified selected centers disease control prevention resources health disparities committee consulted faculty community members write case discussion materials teaching students issues cases provided foundation medical students key topics encountering diverse patient population clinical training case designed student participation smallgroup setting promote thoughtful discussion among students different levels exposure subjects pedagogical methods utilized cases included asking students access publicly available medical information way patient might asking students fill intake forms perspective patient asking students work challenges patients might face following physicians recommendations methods formed committee students faculty baylor college medicine office student affairs organize execute sdhop group created required program firstyear medical students orientation discussion groups 1hour sessions led faculty facilitators small groups 10 students worked interactive learning exercises six core topics topics selected relevant critical early medical student training based office disease prevention health promotion healthy people 2020 topics objectives access care food insecurity immigrant refugee health lesbian gay bisexual transgender lgbt health human trafficking race ethnicity womens health8 firstyear medical students required participate sdhop first week orientation program designed introductory course social determinants health encourage students continue explore subjects future students required prior knowledge participants given pre postsurveys assess knowledge attitude toward subjects highlighted sdhop resources required sdhop minimal inexpensive included use meeting rooms smallgroup sessions printed student handouts discussion sessions however hard copies required faculty facilitators recruited clinicians expertise six topics covered discussion groups volunteered time support initiative list brief overview main topics addressed case references corresponding appendices included resource case 1 access care food insecurity environment students stepped shoes jones family navigated barriers accessing care used online references plan logistical aspects transportation clinic hours physician appointments understand challenges food insecurity preparing grocery list explore exercise options family topics addressed included access health care food insecurity transportation built environment materials included casespecific facilitator guide appendix student handout appendix b case 2 human trafficking students walked encounter trafficked patient alleged boyfriend choose adventure style case selected clinical course trafficked patient saw actions helped hindered medical care topics addressed included human trafficking translation services domestic abuse red flags screening tools materials included casespecific facilitator guide appendix c student handout appendix case 3 immigrant health language barriers students discussed challenges immigrants face navigating american health care system learned means uninsured emergency medical treatment active labor act emtala affects care population followed fictional case ms garcia inspired actual patient whose citizenship status revealed health care providers authorities outside medical care students reflected legal ethical aspects case also discussed language cultural barriers impact patient care topics addressed included emtala language barriers citizenship status materials included casespecific facilitator guide appendix e student handout appendix f supplementary information appendix g case 4 lgbt health students completed new clinic intake form perspective shawn trans man holly lesbian woman discussed initial form set stage patient interactions care team ways health care providers sensitive barriers care disproportionately affect lgbt patients topics addressed included lgbt terminology sexual health health risks lgbt populations materials included casespecific facilitator guide appendix h student handout appendix intake form appendix j supplementary information appendix k case 5 raceethnicity students participated privilege walk activity adapted peggy mcintoshs article white privilege unpacking invisible knapsack9 student given vignette describing patients many different racial socioeconomic backgrounds embody participating exercise topics addressed included implicit bias privilege walk diversity racial ethnic health disparities materials included casespecific facilitator guide appendix l student handout appendix case 6 womens health students attended clinic visits mrs smith asked help pain management discussed providers unconscious biases womens symptoms biases negatively influence care provided students also observed warning signs intimate partner violence clinical setting well topics disproportionately affecting women maternal mortality contraception reproductive health issues topics addressed included pain management domestic abuse parental leave maternal mortality contraception reproductive coercion sterilization materials included casespecific facilitator guide appendix n student handout appendix results curriculum required 186 students firstyear medical student class participated 2017 sdhop initiative survey responses collected 186 participants presdhop survey 111 186 participants postsdhop survey appendix p using electronic questionnaires via qualtrics surveys included responses questions 5point likert scale 1 knowledgeable comfortable 5 extremely knowledgeable extremely comfortable openended responses changes knowledge comfort students asked rate confidence level knowledge terms discussed sdhop orientation terms included access care food insecurity gender identity healthy diet homelessness human trafficking intimate partner violence mass incarceration medical literacy reproductive health sexual orientation terms significant change increased confidence level wilcoxon signed rank test performed prism 7 p 0001 students asked rate knowledge comfort level discussing topics covered sdhop patients orientation topics covered curriculum displayed significant change increased knowledge comfort level time points wilcoxon signed rank test performed prism 7 p 0001 student participant satisfaction ninetyone percent students reported overall quality sdhop good excellent individual smallgroup discussion topic covered rated good excellent 9096 students see table details openended responses section sdhop indicated overall student satisfaction highlighted specific strengths new curriculum table student satisfaction social determinants health orientation programtable student satisfaction social determinants health orientation program general many students spoke sessions opened eyes things even consider introduction human side medicine students reflected crucial us aware certain social issues physicians inevitably encounter frame understanding medicine social determinants reported topics discussed relatively foreign prior sdhop definitely equipped able talk determinants much less talk patients social determinants health feel lot comfortable talking topics students enjoyed group sessions allowed us grapple tough reallife scenarios well recognize personal biases many students liked faculty facilitators actual daytoday practice experience leading sessions felt reallife examples made sessions authentic informative passionate also appreciated cases required exercises engaging demonstrated patient might participants supported early introduction topics orientation curriculum inspired delve deeper issues discussed students stated exposure topics made realize wanted seek learning opportunities clinics would feel comfortable discussing topics patients others wanted extra vigilant aware future hoped focus topics later curricula also prioritized creating safe learning space new students students commented smallgroup sessions fostered open environment learning without judgement students didnt feel uncomfortable asking questions might usually able ask liked hearing different points view feeling challenged consider beliefs people group really disagreed faculty facilitators spoke enlightened encouraged hearty discussion engagement participants feeling fortunate enough provide safe space discussion combination using fictional vignettes reallife patients media stories seemed bring home students dealing biology cases real people discussion sdhop successfully implemented first year baylor college medicine part required firstyear medical student curriculum overall student feedback positive many participants expressing desire continue learning subjects community outreach opportunities student physician organizations elective courses offered institution data collected surveys saw distinct improvement three primary domains measuredstudent comfort level discussing topics student knowledge topics student familiarity particular terminology associated social determinants health resource designed adapted institutions interested initiating program social determinants health although curriculum planned firstyear medical students content appropriate health professional students levels majority content presented cases applicable patient circumstances nationwide information specific city houston texas statistics presented evidence challenges many metropolitan areas face nationwide reflect generalizability fundamental themes addressed tool kit adapt cases cities recommend following suggestions case access care food insecurity environment uses google maps find local community clinics houston area compare transportation options clinic hours information food deserts across united states found united states department agricultures interactive food access research atlas10 statistics urban pollution major cities united states found united states department transportations air quality index11 case e immigrant refugee health references number uninsured individuals texas amended regionally specific data information locations located united states census bureaus report health insurance coverage1213 institutions reluctant make space education social determinants health especially given difficulty securing mandatory curricular time however approaching challenge preformed curriculum specific time stamps logistical outline helps demonstrate feasibility new programming institution able allocate time orientation activities small discussion groups however since case stands alone also spread six individual hourlong sessions throughout school year another challenge recruiting faculty facilitators recommend reaching least 3 months advance optimize scheduling faculty facilitators expect spend least 23 hours preparing small discussion groups using included facilitator guides sdhop presents opportunity community engagement approached cooperatively way students learn communities give back future institution students also participated site visit program exposed many local nonprofits presented opportunities volunteer locations future recommend implementing similar program foster longitudinal student interest communities social disparities minor adjustments smallgroup discussion cases based student facilitator feedback included recent versions cases also modified remove content geographically specific houston area several additional improvements implemented institution subsequent years suggested recommend subjects covered program revisited several times mandatory courses learning activities throughout medical school repetition emphasize topics students allow reflect experiences throughout different stages training limited patient exposure preclinical curriculum extensive patient interaction clinical years institution connecting sdhop longitudinally required curricular activities next step study limited data set 1 year pilot program data also restricted assessing selfreported student knowledge comfort level topics covered modules unable track longitudinal changes metrics predict whether significant effect student behavior clinical setting future continuing assess student facilitator satisfaction sdhop programs success improving knowledge attitude social determinants health formal pre postsurvey assessments used initially also incorporating formal methods evaluation 55word short reflection assignment references1 haynes rb devereaux pj guyatt gh clinical expertise era evidencebased medicine patient choice bmj evid based med 2002723638 httpsdoiorg101136ebm7236google scholar2 weiner sj schwartz weaver f et al contextual errors failures individualizing patient care multicenter study ann intern med 201015326975 httpsdoiorg10732600034819153220100720000002medline google scholar3 institute medicine care without coverage little late washington dc national academies press 2002google scholar4 crandall sjs volk rj cacy longitudinal investigation medical student attitudes toward medically indigent teach learn med 199794254260 httpsdoiorg101207s15328015tlm09042medline google scholar5 huang wy malinow curriculum evaluation results thirdyear medical student longitudinal pathway underserved care teach learn med 2010222123130 httpsdoiorg10108010401331003656611medline google scholar6 drake c keeport chapman chakraborti c social contexts medicine patientcentered curriculum empowering medical students provide contextualized care mededportal 20171310541 httpsdoiorg1015766mep2374826510541medline google scholar7 liaison committee medical education functions structure medical school standards accreditation medical education programs leading md degree washington dc liaison committee medical education 2016google scholar8 social determinants health healthy people website httpswwwhealthypeoplegov2020topicsobjectivestopicsocialdeterminantsofhealthgoogle scholar9 mcintosh p white privilege unpacking invisible knapsack notes facilitators national seed project website httpsnationalseedprojectorgwhiteprivilegeunpackingtheinvisibleknapsack accessed march 1 2018google scholar10 food access research atlas united states department agriculture economic research service website httpswwwersusdagovdataproductsfoodaccessresearchatlasaspxuudarftasgq updated may 18 2017google scholar11 air pollution trends selected metropolitan statistical areas united states department transportation bureau transportation statistics website httpswwwbtsgovcontentairpollutiontrendsselectedmetropolitanstatisticalareasgoogle scholar12 barnett jc berchick er health insurance coverage united states 2016 washington dc us government printing office 2017 current population reports p60260google scholar13 uninsured rate congressional district 2016 united states census bureau website httpswwwcensusgovcontentdamcensuslibraryvisualizations2017demop60260mapuninsuredratebycd2016pdfgoogle scholar sign latest publications mededportal add email appendicesreferencesrelateddetailsappendices access care food insecurity environment facilitator guidedocx access care food insecurity environment student handoutdocx human trafficking facilitator guidedocx human trafficking student handoutdocx immigrant health language barriers facilitator guidedocx immigrant health language barriers student handoutdocx immigrant health language barriers supplementary informationdocx lgbt health facilitator guidedocx lgbt health student handoutdocx lgbt health intake formpdf lgbt health supplementary informationdocx race ethnicity facilitator guidedocx race ethnicity student handoutdocx womens health facilitator guidedocx womens health student handoutdocx surveysdocx appendices peer reviewed integral parts original publication download citationsong ay poythress el bocchini ce kass js reorienting orientation introducing social determinants health firstyear medical students mededportal 20181410752 httpsdoiorg1015766mep2374826510752 copyright permissionscopyright 2018 song et al openaccess publication distributed terms creative commons attributionnoncommercialshare alike licensekeywordsaccess carecommunication barriersraceethnicitylanguage barrierswomens healthfood supplysocial determinants healthfood insecuritysocial disparitiescultural competencylgbt healthhuman traffickingacknowledgmentsbaylor college medicine committee social determinants health medical students hannah rebeccah abrams joniqua ceasar arina chesnokova caitlin comfort shelley fang margaret l hart rebecca long hetrick christabel jaiyeola anjali kumar disha kumar meera namireddy rebecca raven karen resnick jesal shahdisclosures none report fundingsupport none report informed consent identifiable persons resource granted permission ethical approval reported applicable pdf downloadloading