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Over 3 years, global health threats and national headlines have spurred medical schools to better address social and community-based determinants of health. What comes next?
Shanta Zimmer, MD, was a resident completing internship hours at a primary care clinic at Grady Memorial Hospital in downtown Atlanta. During an appointment with an elderly woman, Zimmer recommended she take up daily walks through her neighborhood as part of an exercise routine.
The patient’s reply was quick, and resonant 25 years later: “Do you want me to get shot?”
Zimmer was able to reach a creative solution. The patient would drive to her local mall, where her grandson worked and could keep an eye on her, and she would take her walks there. But the greater takeaway stayed with Zimmer through her residency, recurring throughout her career in different iterations of physician-patient collaboration, and eventually manifesting as a core component of her current job as senior associate dean of medical education at University of Colorado Anschutz Medical Campus: physicians must learn to treat the individual patient, not the disease, as they live in their communities.
“Of course you’ve got to learn the medicine,” Zimmer said to HCPLive. “But we are all starting to understand that it doesn’t matter if you know the medicine if you don’t know how to help people achieve their health goals.”
Put lightly, it has been a turbulent half-decade for the medical education system. Though the Association of American Medical Colleges (AAMC) recently reported an approximate 30% increase in annual applicants and a 16% increase in annual graduates since 2013 – 14,1 many current patients experienced disruption and alteration to their curriculum and schedule due to the COVID-19 pandemic. With the pandemic additionally came growing public scrutiny over medical and pharmaceutical science, and a pronounced role of public health education for physicians.
And throughout currents of other crises and emerging threats to population-level health, alteration to the general US education system has loomed like a storm cloud. The United States Supreme Court’s ruling to end affirmative action mandates in college admissions threatens to potentially mitigate decades’ worth of efforts to improve representation in health care.
In a statement opposing the decision, the AAMC acknowledged “the undeniable benefits of diversity for improving the health of people everywhere.”2
“The AAMC and its member institutions are committed to providing the most effective medical education and patient care, as well as advancing scientific discovery to improve lives in our communities,” the statement read. “We will work together to adapt following today’s court decision without compromising these goals. The health of everyone depends on it.”
In short, the process toward becoming a physician has new obstacles—and the responsibilities for those who do achieve it are increasing in variety and significance. But while health care continues to complicate, medical schools are adapting in a way that embraces Zimmer’s story from residency. For the sake of patient-tailored care, the education system is prioritizing lessons on communication and connection that a textbook may not contain.
“How students talk to patients come through how we talk to them about patients as well,” Zimmer said. “We teach them to learn things about their patient that are not just their medical diseases…the disease is part of their context, but it’s not who they are.”
The concept of narrative medicine as a study is straightforwardly described in the name: optimal clinical intervention is informed by context—the patient’s story. So is how Donna D. Elliott, MD, EdD, vice dean for medical education and chair of the department of medical education at Keck School of Medicine of USC, describes her institution’s relatively new Master of Science in Narrative Medicine degree.3
Just the second such degree offered in the nation at the time of its launch, Keck’s program embraces core concepts in English literature analysis and criticism just as it does the practical work of health care. Students are expected to develop skills that let them “meet patients where they are” in their practice, Elliott explained to HCPLive. Coupled with a full, early semester of education around communication and patient history skills in the doctor of medicine (MD) program, the Los Angeles-based students rehearse the role of a physician before they ever take it on.
“You’re taught a skill, you practice it both with standardized patients in our clinical skills center, as well as with actors and actresses portraying cases,” Elliott said. “And then with actual patients in the hospital, you get assessed on that particular skill.”
It may sound particularly unique for a medical school, but major curricula changes have become standard in the US of late. Duke University School of Medicine’s MD program now features the Patient FIRST (Foundations Immersion, Research, Service, Transformation) program that prioritizes the social contexts of medicine and holistic methods of care, launched in 2021.4
The University of Chicago Pritzker School of Medicine announced in April the launch of the Pritzker Phoenix curriculum—focused on “empowering students to serve as patient advocates and enhance small-group learning and community engagement—starting in Fall 2023.5
Harvard Medical School recently announced plans to add climate change-related health care lessons into its curriculum.6 The Albert Einstein College of Medicine plans to shorten the time until new students interact with patients by 6 months beginning in 2025.7 Even Zimmer’s institution at Anschutz launched its CUSTOM Trek Curriculum in 2021 with an emphasis on health equity.
This trend of widespread curriculum changes is relatively uncommon among US medical schools. Data from a survey of 147 medical schools, conducted just 5 years ago, showed only one-third (34.7%) of schools were planning a curriculum change to be implemented in the near future at that time. Another 15.7% stated no changes were in the work.8
It’s been in the pandemic era that shifts to societal norms and cultural strife have driven medical schools to adopt more curriculum focused on the context of individual patient care. Interestingly, Zimmer and Elliott both cited the same 2020 incident as their institutions’ catalyzing event for embracing social determinants of health: the murder of George Floyd and its corresponding nationwide protests.
“Physicians more and more started to say, ‘These disparities that exist in health care in our country are our responsibility, and we should jump into the fray here’,” Zimmer said. “And when you back that up to the medical education end of it, you ask, ‘What does it look like to become a physician today? How are we going to address some of these problems, and how do we prepare students to be able to talk about it?’”
Elliott explained that medical school decision makers, including the AAMC Council of Deans, had been actively seeking redesigns to curricula that better addressed social determinants of health and efforts to educate students on health inequity when events of public, cultural and racial strife became headline events in 2020. Seminal moments like Floyd’s murder generated “intense focus” on the curricula changes, however.
“I think it really has had an exponential rise, I think, in the attention to issues of equity, injustice and social determinants since 2020,” Elliott said. “And now, coupled with our political environment, there’s schools in certain states that are really struggling to accomplish the goals they set in terms of curricula.”
Elliott sees the Supreme Court’s ruling against affirmative action counterintuitive not only to the medical school industry’s effort to promote representation in health care, but to the well-evidenced data showing a diverse health care workforce equates to improved patient outcomes. She maintained faith that she and her peers will be able to develop methodologies that foster medical student body diversity going forward—but the frustration remains in how this could set back the earliest stages to patient-centered curricula.
Much of that frustration stems from the fact that the ones predominately informing curricula changes are its newest students.
The modern medical student applicant is likely living the job before they learn it. As recently as 2015, 1 in 5 medical students grew up in a household where at least 1 parent was a physician.9 Zimmer said many students accepted into Anschutz have a history of volunteering in their community as well. But many more than in previous decades are entering with diverse backgrounds—be it racially or ethnically, geographically, culturally, sexually, socioeconomically, or otherwise.
“Medical students remind us to pay attention to these things—to think about immigrant communities, or maybe they have parents who don’t speak English and have played the role interpreter since they were a kid,” Zimmer said. “They really remind us how to be more inclusive.”
Zimmer described current students as the “senior physicians” of the rhetorical curricula-building staff: driving key decisions, providing constructive feedback, and speaking out on gaps of coverage and needs for improvement. She created a literal comment box for students to anonymously give feedback on the curricula; everything from notes on daily lectures to suggestions for full course modules are submitted.
One example of feedback from a student was on a request to expand on research from a lecture stating that a higher rate of Black women die from breast cancer than White women. “What students are saying to us is, ‘Let’s not say this is some kind of biological essentialism—let’s back up and talk about what are the reasons that contributed to this difference’,” Zimmer explained.
The feedback Elliott has observed at Keck and beyond is a bit more challenging, particularly on matters of embedded stereotypes in medicine. “This generation of learners has thrown down the proverbial gauntlet and said, ‘Do better. Do what’s right, and do better things’ that we’ve accepted for generations that just hadn’t crossed our mind,” she said.
Much of this evolving dynamic has required teaching faculty and curriculum planners to concede there are gaps in their own knowledge where students may want to expand theirs. Zimmer likened it to physician-patient interactions, wherein it may go against the instinct of an experienced clinician to concede they don’t have an answer—but it may be the necessary answer to foster trust.
“I’ve never had somebody say, ‘How come you don’t know what you’re talking about?’ when I say things like that,” Zimmer said. “They just appreciate me taking the time (to figure it out).”
Zimmer recalls a poem penned by Beatriz M. Rodriguez, MD, in 2000 titled “Trouble.” Describing the value of medical students, Rodriguez begins by stating:
“The trouble with med students is
They are young
Not young like spring time
But young like morning
Full of possibility
Full of questions you have stopped asking.”10
The steps medical schools are taking to prioritize health equity and personalized care feel like a natural response to recent developments in the US, but the sentiment to progress medicine is historically embedded in each new generation of students. Though educators like Elliott and Zimmer the latest calls to modernize care sincerely, they have control in only a portion of the physician development ladder: pre-med, internships, and residency must also meet the call if sincere change is to be had.
Elliott believes the foundation being laid in medical school is paying off in real-world practice. She referenced the post-graduation Accreditation Council for Graduate Medical Education (ACGME) programs that have been developed and reinforce methods of equitable care and community-based health. Regarding residencies, much depends on where physicians match.
“Are you at a very private fluent community, or a hospital or academic medical center?” Elliott said. “Are you in a rural community hospital, or inner-city public hospital? I think depending on your practice setting it’s going to look very different, how much reinforcement you get during your residency training.”
Zimmer is optimistic that residencies have adopted more of the same sentiments as medical school, citing her own experiences with rounds focused on humanism in medicine or designated times for reflection on her work. What’s critical is that residents find opportunity to apply modern lessons on care in their practice—a challenging task during a stressful period of their young career.
“In the busy times of residency, I think it’s easy to forget some of that stuff,” Zimmer said. “Making space in the residency curriculum to reflect and to process some of the challenges that they’re going through, I think it’s helpful.”
Times change quickly, and medicine is tasked with the never-ending job of keeping up with what’s being learned. Zimmer mentioned she and her peers now need to address artificial intelligence programs like ChatGPT in their curricula, based on the bounds of progress the technology has made this year alone and what it could mean for the future of health care.
That is not to say the rush to address community- and social-based health is complete—nor has it been forgotten. Perhaps, optimistically, it’s simply becoming a fixture in medical schools.