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Medical Schools Integrate Health Disparity Education Across Curriculum

AAMC Reporter June 2013

By Kim Krisberg, special to the Reporter

For fourth-year medical student Katie Raffel, learning about health disparities is not just an interesting side project on the road to becoming a physician. Studying disparities and the social factors that create them, she said, will make her a better doctor and lead to better health outcomes for her future patients.

The Health Care Disparities in America course is part of what drew Raffel to the University of Chicago Pritzker School of Medicine. The course, which began about eight years ago and now is required for all first-year medical students, involves classroom learning and development of a research, educational, or service project that addresses a disparity in the community. For Raffel, that disparity was obesity, a chronic disease that tends to affect black children in low-income families at higher rates than their white counterparts.

Along with fellow medical students, Raffel met with educators at Carter G. Woodson Middle School on Chicago's South Side to see whether obesity and healthful eating were indeed a problem. They found it was—educators said they had sixth-graders who already had been diagnosed with diabetes and hypertension. In partnership with the middle school, the medical students created Mission Nutrition, an interactive, after-school program to teach kids about nutrition and healthful food choices. Today, Mission Nutrition, which has grown from a six-week to a 14-week program, just wrapped up its fourth successful year.

“Working with Mission Nutrition, I certainly learned an immense amount about adolescent nutrition, but more important, I developed a better understanding of the obesity epidemic, the community resources available to address it, and the art of teaching kids about nutrition,” Raffel said. “The [health disparities] course was a powerful introduction to the social mission of medicine.”

At the time of its creation, Pritzker's course was one of only a few freestanding disparities courses within a medical school, said Monica Vela, M.D., who developed the course and serves as an associate professor and associate dean of multicultural affairs at Pritzker. Even today, many medical schools either integrate health disparities education across the curriculum or fit it into courses on the social determinants of health. Health disparities—defined by the Centers for Disease Control and Prevention as a “type of difference in health that is closely linked with social or economic disadvantage”—are usually inextricably linked to social determinants such as income, education, and geography.

Vela first developed the course as an elective for first-year medical students that would require them to start school a week early. She thought seven or eight students would respond. Instead, 70 percent of the incoming class signed up for the course. In that first year, the health disparities curriculum developed into a 40-hour intensive course that involved about 25 faculty. In addition, students traveled around the city to visit the public hospital, free clinics, and community centers.

Growing up in a Mexican-American community with immigrant parents who had little formal education, Vela said she experienced first-hand the barriers that lead to disparities.

“I wanted our students to recognize the importance of being advocates for all of society,” she said. “The feedback from students is that the hands-on experience is a crucial part of the course. Just sitting in a classroom won't bring this issue to life.”

According to a 2010 study in the Journal of General Internal Medicine that Vela co-authored, the health disparities course most likely contributed to an increase in underrepresented minority students choosing to attend Pritzker.

Real-life community experience often is a cornerstone of health disparities education within medical schools. At the University of Oklahoma School of Community Medicine in Tulsa—a city with a 14-year difference in life expectancy between residents in the north and south parts of the city—the topics of disparities and social determinants are integrated throughout the curriculum for both undergraduate medical students and residents, said Sheila Crow, Ph.D., assistant dean for curriculum and faculty affairs. Crow noted that with so much already on a medical student's plate, it can be difficult to add new course work.

“It is tough, which is why we address it by integrating it across the curriculum. This is a challenge for every medical school,” said Crow, who is also an associate professor of pediatrics.

To gain first-hand knowledge of disparities, students in Oklahoma’s community medicine track take part in a weeklong Summer Institute, which first began in 2008. During the institute, medical students, along with students from the colleges of social work, pharmacy, and nursing, learn about health and health care through the eyes of some of the city's most vulnerable residents, Crow said.

Among the activities, students visit with patients in their homes, visit social service agencies, participate in a poverty simulation, and brainstorm ideas to improve community health. Along the way, they get an intensive exposure to the social determinants that contribute to Tulsa's health disparity rates.

Medical students at Florida International University Herbert Wertheim College of Medicine also participate in experiential as well as classroom learning when it comes to the topic of health disparities. In addition to specific courses that focus on social determinants and disparities, medical students are required to take part in a service learning program that begins in the latter part of their first year and continues throughout their four-year education, said David Brown, M.D., assistant professor and chief of the Division of Family Medicine in the Department of Humanities, Health, and Society.

In the program, known as the Green Family Foundation NeighborhoodHELP™ (Health Education Learning Program), medical students are assigned to a household in a medically underserved community. They contact the household monthly and visit quarterly, conducting health assessments, providing health education, helping residents navigate the health care system, and much more. Throughout the service learning experience, medical students work alongside law, social work, and nursing students. “They learn how to work as a team,” Brown said.

“A lot of students who come in are very mission-focused, and this gives them something to grab a hold of, while for other students we really have to challenge their assumptions,” he said. “To me, social determinants and health disparities are so cross-cutting that there really is a role for everybody.”

Brown noted that organizations such as the AAMC and the Accreditation Council for Graduate Medical Education already have recommended that the social sciences play a larger role in medical education.

“The reason we have disparities is not that we don't have good clinics and good doctors, but there is a disconnect between the health care system and community health,” said Kola Okuyemi, M.D., M.P.H.

Okuyemi directs the Program in Health Disparities Research within the University of Minnesota Medical School, where all students are exposed to health disparities education and must participate in a service learning project. At Minnesota, Okuyemi and his colleagues take a longitudinal approach to health disparities education, spreading it over two years and integrating it into the curriculum. That way, no matter the rotation medical students end up doing, they will be able to put their health disparities knowledge into action, Okuyemi noted.

“They will know that treating patients is about more than just medicine,” he said.

At the University of Massachusetts Medical School, all medical students are required to take the Determinants of Health course, which exposes them to the topic of health disparities, said Suzanne Cashman, Sc.D., M.S., a professor within the Department of Family Medicine and Community Health. During the course, students not only learn the basics, but also are encouraged to reflect on how their own biases and perceptions may influence patient care and perpetuate disparities. In their second year, students take part in a Population Health Clerkship, a two-week immersion course in which they see first-hand the social barriers that lead to disparities.

“It's not enough to patch people up if we know we're sending them out to surroundings that are making them sick again,” Cashman said.

For Emily Chen, a rising fourth-year medical student at the University of Massachusetts, the social determinant and disparity course work had such an impact she decided that she—as well as her fellow students—needed even more.

As she attended classes, she noticed missed opportunities to mention disparities and began keeping a list. Eventually, she went to Cashman with the idea to review the medical school curriculum and identify places where mentioning determinants and disparities would be a natural fit. She and fellow medical students also thought it could be an innovative way to improve diversity at the medical school.

In her second year of medical school, Chen received a grant from the school's curriculum committee to create a rubric to systematically review course lectures and create supplemental slides that lecturers could use in class.

“We're very isolated when we learn about pathology and physiology, and we forget that all of this is happening on the background of the real world,” Chen said. “If we don't learn it in that context, then we won't be able to practice it in that context. It helps me focus on what's really important in medicine, which is to serve my patients.”

Chen’s project is ongoing. As of late spring 2013, students had reviewed about 50 lectures, she said. In the future, Chen and her project colleagues plan to evaluate whether students are benefiting from increased exposure to social determinant and disparity education.

Health disparities curricula are the “future of medicine,” according to Oklahoma’s Crow. “We're trying to change the health of the nation one community at a time,” she said.

June 2013 Home

three health care providers with a patient

Florida International University Herbert Wertheim College of Medicine students and an outreach worker meet with a patient as part of the Green Family Foundation NeighborhoodHELP™. Photo: Florida International University Herbert Wertheim College of Medicine

faculty and students

Faculty and students at an outreach program as part of the Green Family Foundation NeighborhoodHELP™. Photo: Florida International University Herbert Wertheim College of Medicine