Recently a former medical college official cautioned that the American College of Physicians “stepped out of its lane” by placing gun control in the purview of medical education. Stanley Goldfarb, formerly the associate dean of curriculum at the University of Pennsylvania’s Perelman School of Medicine, argued in the Wall Street Journal that teaching social justice issues and population health comes “at the expense of rigorous training in medical science” at a time when subspecialists are in short supply. But many physicians, ourselves included, think social issues should be at the heart of medical education.
Formal medical school typically takes four years, followed by several years of residency and often a fellowship, and during that short time students have a myriad of competing requirements. They must learn complex biological and chemical pathways that explain disease and health. They must be educated on how to read the scientific literature and apply it to their patients. They must master many therapies and know how to adapt them to patients’ varied disease states. On top of all this, they must learn to communicate effectively and compassionately with patients and colleagues.
Being a good doctor also demands that we understand the reasons behind poor health. Our mission is not simply to diagnose, manage and treat. Physicians should act to prevent the root causes of illness and improve well-being. The Centers for Disease Control and Prevention defines social determinants of health as “conditions in the places where people live, learn, work, and play” that affect their health outcomes and has as one of its Healthy People 2020 goals to “create social and physical environments that promote good health for all.” This goal serves our patients who are at risk for bad outcomes because they lack access to transportation or medications—or simply because of where they live.
Worldwide, life expectancy and health are directly linked with national spending on public health programs. The U.S., despite spending more on the treatment of individuals, ranks lower in life expectancy than nations that have similar overall health expenses but choose to direct funds to population-level interventions. Our own experiences underlie our perspective that teaching this is important. Practicing in Chicago, where people living only miles apart have different life expectancies—where black mothers disproportionately experience poor obstetrical outcomes and premature births as compared with their white counterparts, where residents name stress, drug abuse and depression as the greatest health threats to local children—we see the impact of social determinants of health on our patients. For individual patients, research tells us that high levels of toxic stress and adverse experiences create epigenetic changes that raise the risk of problems such as heart disease [see “The Health-Wealth Gap,” by Robert M. Sapolsky, Scientific American; November 2018].
We work daily to understand the best ways to teach medical students about social determinants of health. We offer classes on health equity and advocacy designed to place medicine in its larger social context. We lead bioethics curricula that guide students in making ethical decisions while incorporating principles of social justice, public health and population health. And we work with groups such as the National Collaborative for Education to Address the Social Determinants of Health, where the goal is to find and share best practices. It is through this kind of medical education and holistic understanding of systems that physicians begin to think about the total set of circumstances that brought the patient in front of us. As doctors, scientists and community members, what we want most is to prevent it from happening again.
Physicians are trained to tackle problems at their root. System-and structural-level social issues are also drivers of poor health, and it is our duty to address them. Rather than veering out of this lane, we should find ways to engage students here without sacrificing education in other areas. Medical training must evolve to produce doctors who are able to treat the individual but also understand the larger influencers of health—of which gun violence is most emphatically one. As medical professors, we would fail our students—and our patients—if we expected any less.