Training doctors to think outside the box
As a student about to begin medical school, I am fascinated by the art of healing. So far, my premedical coursework has focused on the sciences. But the more I learn about medications, the more I contemplate the lives taken by overdoses. The more familiar I become with malaria, the more intrigued I am by racial disparities in health. The more I read about HIV, the more moved I am by how a patient’s home, school, job, and neighborhood shape his or her health outcome. In other words, the more deeply I get into the biomedical sciences, the more I realize the importance of the social sciences—a part of medical education that is often lacking.
Less than half (42.9 percent) of graduating medical students in 2015 agreed that they had a fundamental understanding of social science issues like ethics and humanism, and only about two in five (39.7 percent) agree that they are adequately prepared to care for patients from different backgrounds.
Despite our current golden age of medical education, medical schools have not succeeded in creating a physician workforce that can fully meet the needs of our changing society. As a result, the Institute of Medicine has called for transforming medical curricula so that students better understand the social, political, and economic factors that influence the health of people and communities.
A good start is to advance the roles of cognitive science, behavioral psychology, and social sciences. Physicians who understand behavioral economics, for example, could better coach patients in making healthier choices. Doctors who understand food insecurity can anticipate why some patients may struggle to manage their diabetes. We need an integrated curriculum that incorporates concepts and case studies from social and behavioral sciences. All students should partake in field experiences, community-service learning projects, and clinic volunteerism—components of medical education that are not always used by students.
Medical school rankings should reflect more than high MCAT scores
The notion that physicians should be trained in the social determinants of health dates back to ancient times, when Hippocrates’s On Airs, Waters, and Places pointed out factors outside of biology that affect health. In 1974, the Lalonde Report became the first modern government report to emphasize that health care was not sufficient to improve the health of the population. Today, we know that a person’s living conditions, working environment, education level, and resources influence his or her health. In fact, close to 50 percent of the top 10 leading causes of death in the United States are attributable to social factors.
Six years after the Affordable Care Act’s prevention mandate, which aims to improve public health by increasing access to clinical screenings and immunizations, health outcomes have remained stagnant or, in some cases, declined. The default action for physicians is to treat their patients; that is what doctors are trained to do. But to prevent patients from becoming sick in the first place and to fully understand how to recover health requires an understanding of broad social factors—and not all medical schools focus on these critical insights.
In part, this reflects how the field has historically conceptualized a first-rate medical education. For example, in their widely read medical school rankings, US News & World Report considers the school’s reputation, student selectivity factors like high MCAT scores, and level of research funding. But other factors may be equally or more important to the communities where medicine is most needed.
Fitzhugh Mullan and colleagues have proposed a different ranking system they call the social mission score. It considers other measures, such as the percentages of graduates who are underrepresented minorities, who enter primary care fields, and who practice in underserved areas of the country—factors, they argue, that are important for the public’s health. Based on these criteria, about one-third of the schools ranked among the top 20 by US News & World Report fall in the bottom 20, according to the social mission score.
Over 82,000 students are enrolled in 171 US medical schools. They might be well prepared to dissect the human body or explain the latest technological advancement, but much more is needed from medical education—like critical thinking about social and cultural issues—to ensure healthy communities. With a greater understanding of the social determinants of health, doctors may decide to pursue different paths within medicine, such as more primary care–focused specialties, or advocate for changes in how our health system is organized and financed. They will also be better positioned to partner with nonmedical service providers to optimize the value of the health services they are delivering.
John Askew, Sr., left, a patient/actor, gives feedback to third-year Georgetown medical student Gregory Shumer after a training session in an exam room on the Georgetown Medical School campus in Washington, Friday, March 16, 2012. Photo by Kevin Wolf/AP