Introduction
Social Determinants of Health (SDH)—such as housing, racism, education, access to nutrition, and language and literacy skills—have a major impact on people’s health, well-being, and quality of life.1 Inequities created by SDH have a large effect on patient outcomes, such that zip code has a stronger correlation to life expectancy than genetic code.2 In recognition of its significance, the Accreditation Council for Graduate Medical Education requires residency training programs to develop residents who can demonstrate awareness and responsiveness to SDH as part of competency in systems-based practice.
Much existing SDH content focuses on macroscopic inequities by comparing differences between countries and large populations; other curricula have leaned heavily on experiential activities with patients.3, 4 However, these curricula leave gaps in quantitatively understanding inequities in learners’ own communities and developing physician-specific skills to confidently approach a wide spectrum of patient challenges inherent to SDH.
We introduced a curriculum developed in the ambulatory setting for internal medicine residents. This curriculum teaches learners to understand the principles of Social Determinants of Health, identify the role of Social Determinants of Health in patient outcomes, and confidently address Social Determinants of Health in ambulatory practice.
Methods
This curriculum was presented to primary care-focused internal medicine residents through eight weekly one-hour sessions during outpatient clinical rotations. Sessions included brief didactics, paired-learner practice, interactive community assessment activities, and small group discussions. A senior resident facilitated each session with assistance of faculty. Week 1 began with a presentation that defined and illustrated the categories of SDH and the significance they play in patient outcomes. Learners reflected in group discussion on their own attitudes/experiences regarding these topics and how they influence patient care in their own clinics. Week 2 focused on financial stability. Visualized data highlighted the distribution of poverty in the clinic’s zip code and in the neighborhoods of the patients served by the clinic. Week 3 highlighted health literacy and numeracy with trainees predicting “reading level” for various patient instructions. They were given tips for adapting communication to match patient needs. Learners went on a virtual “neighborhood visit” in Week 4. Pairs of learners were given a list of details to explore a neighborhood in one of the three main zip codes where their clinic patients predominantly live. This included availability of transportation to clinic and necessary resources. Following this they shared their findings aloud and brainstormed as a group what physicians can do to reduce the health & wellness barriers discovered. Epidemiologic data on the impact of suboptimal housing and homelessness/housing insecurity and food insecurity were addressed in weeks 5 & 6. In weeks 7 and 8, ancillary staff members in social work, pharmacy, and nursing care coordination presented their work to the trainees. Then, learners participated in case-based discussions to identify relevant SDHs, altering care plans appropriately, and assigning applicable clinic-specific resources to optimize a patient’s quality of care.
A survey assessing knowledge, attitudes, and skill confidence related to SDH in the clinic was completed at the beginning and the end of the curriculum. Residents were asked to recall information from didactic session materials and rate their perceived skill at addressing SDH in the clinic using a 5-point Likert scale. Statistical analysis of the data included paired pretest and posttest differences of median. The Wilcoxon Signed Ranks Test and Exact test methods were utilized based upon inability to meet normality assumptions for parametric analysis in the context of small sample size.5 IRB approval was obtained.
Results
Eleven residents (PGY1-PGY3) participated in the curriculum. The distribution by training level: 4 PGY-1s, 4 PGY-2s, 3 PGY-3s. When assessing their understanding of the principles of SDH, residents reported higher familiarity of SDH on health outcomes (p = 0.047) and confidence in their ability to discuss evidence-based literature (p = 0.008). Assessment of specific environmental barriers improved significantly by the end of the curriculum (p = 0.004). Residents began to value routine screening of SDH in the clinic, though were unclear on the importance of aggregate data analysis on patient outcomes. Residents reported more confidence in their ability to manage SDH in the clinic (p = 0.004) and to coordinate care with ancillary services to overcome identified barriers (p = 0.008). There was no change in perceived ability to address language barriers in the clinic (p = 0.125). Confidence in adapting for low literacy patients and ability to use evidence-based literature improved but were not statistically significant.
Discussion
Understanding and actively managing SDH is an emerging need in medical education. This ambulatory curriculum integrates didactics, experiential activities, and reflective discussion to develop learners understanding and confidence in managing SDH as part of a team-based approach to care in the clinic. Curricular evaluation demonstrated that residents often bring existing SDH knowledge and positive attitudes toward collecting SDH information. However, this curriculum fills significant gaps in skills necessary to confidently manage SDH in the ambulatory clinical setting.
A unique aspect of this curriculum is that it was developed by a senior resident to enhance the ambulatory educational experience for other residents. Our clinic environment can be challenging given its location in an underserved area of the city; this exposes trainees to a wide variety of SDH factors which impact patient care. Through independent research and reflection of her own clinical experiences, this resident designed the curriculum to be particularly relevant to our clinic patient population and her peers’ needs. This curriculum utilized specific local resources for addressing health inequities in the resident clinic patient population. The discussions encouraged by this curriculum prompted reflection and brainstorming sessions on how to approach barriers to health equity in the future. While the richness of these discussions was not captured by the survey, the anecdotal feedback was overwhelmingly positive.
Generalizability is an area of weakness in this curricular design. However, the basic general outline can be followed and modified to meet the needs of communities and residency programs across the country. For instance, the Social Vulnerability Index for the area surrounding our clinic was obtained through an interactive map through the Agency of Toxic Substances and Disease Registry (https://svi.cdc.gov/map.html). Visualized data through Data USA (https://datausa.io) was also useful in summarizing trends in a variety of metrics such as distribution of poverty and property prices compared to income. Discussion and reflection are integral to the curriculum, and these can mirror the specific SDH factors that learners experience with their own clinic populations.
While our results are promising it is important to note that it has only been introduced to 11 residents. Even though the course was presented during a time blocked off from clinic responsibilities, not all of the participants were able to attend every lecture. Future directions include involving a larger cohort of residents. Additional study on how health outcomes are affected by the intervention of SDH education is still needed.
It is crucial for physicians in training to not only understand SDH but be empowered to address them. The structure and practical applications of this curriculum allowed for resident physicians to immediately apply the principles learned in their own clinical practice. Further investigation on optimal timing for SDH didactics in the clinic and the impact of SDH training on clinical outcomes remains to be determined.