Education Columns

Patrick Masseo, MA; Jose Tiburcio, MD; Doug Reich, MD; Arafat Omidiran, MHA

Background
Medical schools and training must pivot from producing doctors who venerate medicine, toward producing care providers who appreciate and address the influences of environment and community on a patient’s health. Medical care has historically focused on addressing patients’ acute, ambulatory, and chronic conditions. However, it is often socioeconomic factors and lack of basic resources that cause or inflame health issues.

High health care spending in the United States is undermined by the nation’s low investments in social services. The disproportionate investment of public and private funding negatively impacts health outcomes.¹ The University of Wisconsin developed a population health model for the Robert Wood Johnson Foundation that asserts clinical care contributes only 20% to overall health outcomes. According to the model, 40% of factors that influence health are related to social and economic conditions.² Measuring health status across socioeconomic groups provides additional evidence of a relation between socioeconomic factors and health. Social demographic patterns that manifest in health disparities data strongly suggest that modifiable socioeconomic conditions such as access to income, wealth, education, and neighborhood play a key role.³ However, the US government has failed to collect longitudinal health data across economic groupings.

Intervention/Curriculum Overview
Bronx-Lebanon Hospital Center is located in Bronx Community District 3, geographically within the South Bronx. The community has a high disease burden, with rates of adult asthma and diabetes-related avoidable hospitalizations three times the New York City average. Bronx Community District 3’s life expectancy of 75.3 years is 5 years below the NYC average and 10 years less than Manhattan’s Community District 1.⁴ Despite these statistics, patients’ socioeconomic circumstances are often ignored or unaddressed by physicians.

Family medicine residents at Bronx-Lebanon Hospital Center are introduced to these nonmedical influences through a series of community medicine lectures. Beginning with an overview and the importance of the biopsychosocial model, lectures discuss inequity, bias, and prejudice, as well as systemic disparities among geographic areas and populations.

The 4-week rotation consists of six 90-minute lectures complemented with community experience. Lectures focus on four key areas:

• Housing and homelessness
• Inequity
• Nutritious food access
• Youth engagement and community building

Community activities include a park clean-up, community bike ride, homeless shelter visit, film screening and discussion, as well as conversations with community leaders (eg, tenant association leaders and former gang leaders).

Impact
The rotation’s effect is measured through pre/post surveys. After lectures were completed, 95% of residents agreed that it was important to screen patients for their social resource needs. There was a 100% increase in the number of residents who agreed that “they understood the distinction between implicit and explicit bias” after completing the curriculum. Additionally, all residents agreed they were cognizant of biases or prejudices after completing the curriculum, compared to 67% of residents initially.

Conclusion
Residents were able to engage in meaningful and reflective conversations with their peers and patient communities about the larger context in which medical care is delivered. Most importantly, residents were able to participate in the community they serve and gain an appreciation for the circumstances their patients’ lives. Physicians, and the process that produces health care providers, must immerse in the community, acknowledge socioeconomic barriers, and recognize the responsibility of the physician to address these conditions to effectively improve patient health.

References

1. County Health Rankings University of Wisconsin Population Health Institute. http://www.countyhealthrankings.org/. Accessed October 5, 2017.
2. Robert Wood Johnson Foundation. RWJF Commission to Build a Healthier America, 2009. https://www.rwjf.org/en/how-we-work/grants-explorer/featured-programs/rwjf-commission-to-build-a-healthier-america.html. Accessed October 5, 2017.
3. Gnadinger T. Health policy brief: the relative contribution of multiple determinants to health outcomes. Health Affairs [blog]. August 21, 2014. http://healthaffairs.org/blog/2014/08/22/health-policy-brief-the-relative-contribution-of-multiple-determinants-to-health-outcomes/. Accessed October 5, 2017.
4. Measure of America. DATA2GO.NYC. http://data2go.nyc. Accessed October 5, 2017.