Health inequities have become even more magnified during the COVID-19 pandemic, placing greater importance on educating medical students to meet the complex and unique needs of diverse patient populations. Future physicians must evaluate patients’ concerns and problems with a frame built around social determinants of health (SDOH). Graduating students entering all specialties must learn to apply cultural and structural humility to individuals as well as systems level patient safety and quality improvement principles. Such complex domains should be incorporated continuously through all four years of medical education, allowing for appropriate growth throughout the curriculum with spaced repetition and ever advancing concepts. The University of Kentucky College of Medicine (UKCOM) introduced two curricular threads in 2021: The Health Equity and Advocacy Thread (HEAT) and the Health System Science Thread (HSST).

As an overview, UKCOM has four campuses in distinct geographic areas and in two time zones. The average class size is approximately 200 students across all campuses. In the first two pre-clinical years, students learn through system-based courses complimented by longitudinal classes emphasizing clinical and doctoring skills. Third-year students complete eight clinical clerkships and a longitudinal class, which integrates and assesses concepts between clerkships. Fourth-year students pursue required acting internships, electives, and finish with a capstone course, an intern year preparation bootcamp.

Each thread cohesively builds vital skills as students navigate through the curriculum. As a guide, the UKCOM core competencies or program-learning objectives were revised to emphasize the value and importance of the HEAT and HSST. The updated language emphasizes SDOH as well as the skills to effectively navigate and improve health systems. For example, each student is expected to “identify and address one’s own cultural norms, attitudes, and biases that affect one’s interactions among people in diverse health care settings and teams” as well as to “demonstrate willingness to learn from patients and other individuals of diverse backgrounds, including their lived experiences and historical contexts.”¹ These updated core competencies have helped spark collaboration between the thread leaders and course directors. Session objectives are deliberately linked to specific course and thread objectives, which are mapped to these core competencies. Content is delivered by thread directors, course directors, and invited faculty.

The HEAT focuses on how SDOH contribute to certain populations being disproportionally affected by the burden of illness. This includes race, ethnicity, sex, sexual identity, disability, age, weight, geographic location, socioeconomic status or stigmatized health conditions like addiction and other psychiatric diseases. The framework of the thread emphasizes structural and cultural humility. Students learn to understand the SDOH, examine root causes, and engage in discussions to use this knowledge for patient advocacy.

In the first year, students are introduced to the concepts of health equity and cultural humility. They identify race as a social construct in contrast to skin color as a polygenetic trait. They participate in panel discussions in flipped classroom settings to discuss health inequities experienced by patients. Students complete a group project focused on health inequities in Kentucky and propose possible routes for advocacy. In the second year, students participate in panels with physicians, patients, and other healthcare providers that focus on different SDOH: they learn about the experience of transgender patients within the healthcare system, about patients with alcohol use disorder and liver disease needing a liver transplant, and how access to health care affects oral health.

In the third year, the clerkships discuss SDOH in a clinical context, and some have required clinical experiences, including observing treatment plan adjustments based on SDOH. In the Entrustment in Clinical Medicine course, topics that cross clerkships are taught, including a workshop on microaggressions. At the end of fourth year in the Transitions to Residency capstone course, students learn about treating pain adequately in patients with opioid use disorder and participate in a workshop on inclusive leadership as rising interns. Throughout the four years, students are assessed with a mixture of reflective writings, multiple choice questions and presentations of group projects.

Faculty are encouraged to use a didactic inclusive learning checklist to assess all content and assessments for biases, and to ensure the use of inclusive, non-stigmatizing language. The goal is to empower faculty members to teach and engage students on these challenging topics. An evaluation question was added to all course and clerkship evaluations to determine if students feel like the instructors addressed SDOH adequately. This data is used by the UKCOM Curriculum Committee to give feedback to individual courses. Additionally, students complete an anonymous annual survey to document their progress and give feedback on HEAT related curriculum changes. A student advisory council with students from all years and campuses serves to advise the thread leaders on evolving student needs.

The HSST consists of patient safety, quality improvement, healthcare value, population health, clinical informatics, and evidenced based medicine. The success of proper health systems science implementation is predicated on appropriate culture. The HSST establishes this culture and systems-thinking early in the first year and reiterates the culture throughout subsequent years. The backbone of the HSST curriculum is quality improvement (QI) and patient safety. Over the four years, students learn to assess patient safety events using root cause analysis tools, including the fishbone diagram and 5-why’s technique. They then learn to utilize QI methodology to design appropriately aligned projects. This is achieved through didactics, group sessions, and workshops with multiple touch points each year across courses. The HSST streamlines material related to public health to build appropriately throughout the curriculum. The two threads overlap as SDOH often present as patient safety issues. Physician advocacy is broad and often includes QI at local institutions.

Implementing the threads has posed several challenges. When introducing new, important concepts, we quickly discovered that we could not solely focus on our first-year students as current upper classes also needed to be included; this required repetition of initial key concepts across years to establish a foundation to build upon in subsequent years. With four diverse campuses, we had to overcome challenges of different opportunities at each campus. In some cases, compromises were needed to ensure all students, regardless of location, could get comparable exposure to vital content. While course directors are consistently supportive of the threads, they also face their own challenges of limited course time, requiring creative solutions to add content without replacing other necessary content. Often this has meant building on principals already being taught, adding a perspective from a different angle.

Grading and competency assessments pose another challenge: interpersonal skills like cultural humility can be difficult to assess and require more in-depth evaluation than a multiple-choice question can offer. In addition, care needs to be taken to ensure these topics are handled with appropriate cultural humility by faculty presenting material and facilitating discussions. Faculty development is required to ensure faculty can provide a safe space and conducive learning environment for challenging conversations around topics like systemic racism.

Though the curricular threads are new, they already have a huge impact. Future goals are to build more joint didactics that unite the thread to supply students with tools to be effective patient advocates. Though all the United States struggle with the impact of SDOH, Kentucky has challenges with high rates of obesity, poverty, opioid use disorders and overdoses, and with many counties having poor access to medical care.^2-5 Training physicians to understand the importance of SDOH as part of the treatment plan ensures quality of care for all patient populations. The new threads at UKCOM strive to train compassionate physicians who practice cultural and structural humility.