When a man arrived at a New Jersey emergency room complaining of pain from an enlarged prostate, the resident ordered a catheter insertion — standard treatment for the patient's condition — and discharged him with medical instructions until he could be followed up by a specialist.
Doctors early in their careers were doing everything right formally, but informally overlooking important aspects of their patients’ lives, which led to poor outcomes.
The patient had no health insurance. He was an illegal immigrant who spoke little English and may not have fully understood how to manage the catheter at home. A visit to a specialist who could have removed the catheter would have been expensive, and he could not afford it. He tried to return to work, but his employer said he could not work in his condition.
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So he removed the catheter himself, but it caused an infection and kidney damage. The patient returned to the hospital, where doctors said he needed surgery to permanently cure his enlarged prostate, but the surgery was never performed.
“Despite a lot of effort and investment from the social workers and all the doctors here, we just couldn't get him to have that surgery,” recalls Dr. Mary Grace Zetklick, director of internal medicine residency at Hackensack University Medical Center in New Jersey and associate professor at its affiliate, Hackensack Meridian School of Medicine, which opened in 2018. “That's because our system allows for emergency care but doesn't have mechanisms for non-emergency care that would prevent hospitalization. So he ended up going off of observation.”
Scenarios like this are common.
But Hackensack Meridian is part of a growing number of medical schools with the mission of training a new generation of physicians who can identify important nonmedical factors in patients' lives, incorporate them into treatment plans and ultimately promote equitable health care policies.
Medical school curricula do this by teaching medical students the importance of social determinants of health: the environmental conditions in which people are born, live, work, and age. According to the National Academy of Medicine, these factors influence 80 to 90 percent of health outcomes.
“Problem Solver”
The mission of New Jersey Medical University focuses on social accountability, which influenced the creation of the school's core curriculum and structure.
The driving force behind the curriculum is an intensive, long-term course called Human Dimensions: Beginning in the first semester, students are paired with a family within the school's service area with whom they will continually interact in clinical, community, and home settings throughout their time in medical school.
“Students become intimately familiar with the determinants of health because they see how all other factors impact the health and well-being of their families,” says Miriam Hoffman, PhD, co-founder and vice dean for academic affairs at Hackensack Meridian School of Medicine. “As a result, they become incredible problem-solvers.
“They're not afraid to look for problems. A lot of veteran doctors are afraid to ask these questions because they assume there's nothing they can do, but our students realize that there's actually a lot that can be done about the problem.”
With the support of the School of Medicine's innovative Community Programs Unit, students are trained to identify the goals and needs of the families they are paired with and help them access non-direct medical support, such as transportation, food and medical equipment.
Additionally, groups of eight medical students are paired with a faculty mentor to work with local governments to outline a structured community assessment that includes geospatial mapping, interviews with community leaders, and service-learning work to identify community-specific health challenges. This assessment feeds into a required community health project in which students collaborate with assigned community partners to address the identified challenges.
It's all part of an effort to prepare future physicians to consider non-medical factors that affect patients before they reach residency, where they'll be responsible for making important decisions about patient care.
“They're taught how to deal with BPH,” Dr. Zetklik says, “but they're not taught the complex social things that have to be put in place to manage it once they're gone. They don't know how to deal with it, and they don't even expect it.”
Dr. Tanner Kors graduated from Hackensack Meridian School of Medicine in 2022 and is currently doing a combined internal medicine and pediatrics residency at Indiana University School of Medicine. He said Hackensack Meridian's advocacy-focused curriculum prepared him for the job. Many of the patients he treats at his federally funded clinic in southwest Indianapolis are poor and food insecure.
“Instead of just looking at what's going on inside the patient or in the clinic where I'm seeing them, I've started to think in a much bigger picture,” he said. “I've started to think in a much bigger picture: They're here for 30 minutes, but what are they going to be dealing with the rest of the hours, days, months that they're not here?”
Hackensack Meridian, which graduated its first class of 18 physicians in 2021, had the luxury of building its mission-based curriculum from the ground up, but a paper published in the journal The Clinical Teacher earlier this year found that its social accountability-based mission and curriculum could be replicated at other medical schools.
Many other medical schools, including Boston University, the University of Chicago and the University of California, San Diego, have also focused on health equity and advocacy, which have become increasingly popular over the past decade.
Increased focus on advocacy
Between 2013 and 2020, the number of medical school courses covering policy and advocacy jumped from 696 to nearly 1,200, according to the Association of American Medical Colleges Curriculum Inventory.
Kosse believes that within the next 10 to 20 years, most medical schools will offer curricula similar to Hackensack's advocacy-centered approach, which could help provide more comprehensive care to patients as the country struggles with a physician shortage, as well as inform health policy.
“The school's approach also helps develop people who are willing to make a difference outside of the clinic,” says Kosse, who recently visited Congress to advocate for increased funding for primary care providers, a high-demand specialty among health care initiatives. “If I had gone to a different school, I'm not sure I would have had the same passion for advocacy.”
Yet most medical schools don't offer training for doctors to become advocates as part of their curriculum. While most medical schools offer at least one advocacy course, the majority are electives and vary widely in scope and content, according to a 2021 study published in the journal Academic Medicine.
The Liaison Committee on Medical Education (LCME), which accredits US medical schools, requires curricula to teach social determinants of health but does not specify the format, content, or measurable outcomes. The LCME standards also do not include required advocacy or health policy training, according to a study published in the journal General Internal Medicine earlier this year.
The Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programs, supports a general approach to advocacy, but research has found that “published advocacy curricula in surgical specialties are scarce.”
Advocacy instruction is more common in training in primary care-oriented specialties, but varies by program. It is especially common in pediatric training, which is required by the ACGME to include specific training in advocacy skills. Thirty-seven percent of family medicine trainings require advocacy instruction. Only three percent of psychiatry trainings offer advocacy training, and about 54 percent of internal medicine trainings do not offer advocacy training.
Of 276 programs surveyed, 72 percent cited a lack of faculty expertise in advocacy, the most commonly reported barrier to implementing advocacy curriculum among internal medicine residents, the survey said.
“Indispensable”
Dr. Kelly McGarry, a co-author of the study and director of Brown University's internal medicine program, which has been incorporating advocacy into its curriculum since 2012, said she might have avoided a career in health care advocacy if she had to learn how to teach it herself.
“Curricular innovations related to advocacy aren’t going to happen if everyone around you feels the same way,” she said, recalling that the advocacy portion of Brown’s curriculum was initially initiated by a group of residents before she took over in recent years.
“This is not a skill that was learned over 10 years ago, and most of the faculty were only trained over 10 years ago,” McGarry said, hypothesizing that the rise of social media and other information technologies over the past 15 years has demonstrated the impact of health disparities to a broader audience, creating momentum for training physicians to advocate for large-scale change.
“We need more junior faculty,” she said, to encourage more medical schools to incorporate advocacy into their core curriculum. “They came into the picture at a different time. Advocacy in the physician role is now expected to be a big part of what we do.”
That led the University of California, San Diego, School of Medicine, which opened in the 1960s, to conduct a long course on health equity last year.
In the late 2010s, before the pandemic and protests related to the killing of George Floyd sparked a national conversation about long-standing health disparities, a group of medical students lobbied university officials to include more health equity and advocacy content in the curriculum.
One of those students was Dr. Betty Asmerom, now a resident in the UCSD combined internal medicine and pediatrics program, who grew up in East Oakland, California, and watched her mother, from Eritrea in North Africa, receive substandard medical care for a life-threatening health condition.
These experiences motivated Asmerom to go to medical school, but he was frustrated by the concept of “race-based algorithms” that many medical schools still teach, which reinforce the idea that racial differences are inherently biological. Critics argue that these algorithms are a relic of America's history of racism and can lead to inequitable treatment because doctors overlook the social determinants that influence patients' conditions.
“There's so much more that contributes to human health than the immediate medical need,” Bettyal says. “That's the power of this kind of curriculum. Part of it is challenging future physicians to think more critically and ultimately getting people to do more advocacy.”
