Training Future Doctors to Be Health Equity Advocates

A man walks into a New Jersey emergency room in pain from an enlarged prostate. A resident physician orders a catheter, standard procedure for the patient’s condition, and discharges him with medical instructions until he can follow-up with a specialist.

While the early career doctor officially did everything right, the doctor unofficially overlooked important aspects of the patient’s life that led to an adverse outcome.

The patient didn’t have health insurance. He was an undocumented immigrant, didn’t speak much English, and may not have had a clear understanding of how to manage a catheter at home. A visit to the specialist who could remove it cost money he didn’t have. When he attempted to return to his job, his employer said he couldn’t work in his condition.

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So he ripped out the catheter himself, causing an infection and kidney damage. The patient returned to the hospital, and doctors said he’d need surgery to permanently resolve his enlarged prostate, but it never happened.

“Despite enormous work and investment by our social worker and all the doctors here, we could not get him that surgery,” recalled Dr. Marygrace Zetkulic, internal medicine residency director at Hackensack University Medical Center in New Jersey and associate professor at the affiliated Hackensack Meridian School of Medicine, which launched in 2018. “This is because our system allows for emergency care but has no mechanism for nonemergency care that would prevent a hospitalization. Eventually he was lost to follow up.”

Scenarios like this are all too common.

But Hackensack Meridian is part of a growing number of medical schools on a mission to train a new generation of doctors to identify pertinent nonmedical factors in patients’ lives in order to address them in their treatment plans, and ultimately to advocate for equitable health policies.

The medical school’s curriculum does this by exposing medical students to the gravity of social determinants of health, the conditions in the environments where people are born, live, work and age. Those factors impact 80 to 90 percent of health outcomes, according to the National Academy of Medicine.

‘Problem-Solvers’

The New Jersey medical school’s mission focuses on social accountability, and informed the creation of the school’s core curriculum and structure.

An immersive longitudinal course called Human Dimension drives the curriculum. Starting in their first semester, students are paired with a family in the school’s service area, and consistently interact with them in clinical, community and home settings throughout their time at the medical school.

“The determinants of health come to life for these students because they see how all of these other factors are impacting the health and well-being of their family,” said Dr. Miriam Hoffman, vice dean for academic affairs who co-founded the Hackensack Meridian School of Medicine. “One of the outcomes of this is that students are incredible problem-solvers.

“They’re not afraid to look for problems, which we find in many seasoned doctors who are afraid to ask these questions because they think there’s nothing they can do about it. Our students realize there’s actually a lot they can do about it.”

With the help of the medical school’s novel community programs unit, students are trained to identify the goals and needs of the families with whom they’re paired and help them in accessing support beyond direct medical care, such as transportation, food or medical equipment.

Additionally, a group of eight medical students is paired with a faculty mentor and matched with a local municipality to outline a systematic community assessment which involves geospatial mapping, meeting with community leaders and service-learning work to determine the community’s specific health challenges. That assessment informs a required community health project, in which students work with their assigned community partners to address identified challenges.

It’s all part of an effort to prepare future doctors to consider the nonmedical factors at play with a patient well before they become medical residents charged with making important decisions about patients’ care.

“We get taught how to manage an enlarged prostate,” Dr. Zetkulic said. “But the complex social things that have to be in place to manage that after they leave, you don’t get taught. You don’t know how to manage it, and you don’t even anticipate it.”

Dr. Tanner Corse graduated from Hackensack Meridian’s medical school in 2022 and is now in a combined internal medicine and pediatrics residency at Indiana University School of Medicine. He said Hackensack Meridian’s advocacy-focused curriculum prepared him for the position. Many of the patients he treats at a federally funded clinic on the southwest side of Indianapolis are poor and live in food deserts.

“It made me look outside of what is going on only within the person’s body and the clinic where I’m seeing them,” he said. “It made me think much bigger. They’re here for 30 minutes, but what are they going to deal with in the other hours, days and months they aren’t at the clinic?”

Although Hackensack Meridian, which graduated its first class of 18 doctors in 2021, had the luxury of building its mission-driven curriculum from scratch, a paper published earlier this year in The Clinical Teacher, shows that its social accountability-driven mission and curriculum is replicable at other medical schools.

A number of other medical schools, including those housed at Boston University, the University of Chicago and the University of California, San Diego, also focus on health equity and advocacy, which has become increasingly popular over the past decade.

Advocacy Focus on the Rise

Between 2013 and 2020, the number of medical school courses covering policy or advocacy jumped from 696 to nearly 1,200, according to the American Association of Medical Colleges’ curriculum inventory.

Corse believes most medical schools will offer a curriculum similar to Hackensack’s advocacy-centered approach in the next 10 to 20 years. Not only will that help deliver more comprehensive care to patients as the nation grapples with a physician shortage, it could also inform health policy.

“The approach of the school helps develop people with an inclination to make change outside of the clinic, too,” said Corse, who recently traveled to Capitol Hill to advocate for more funding for primary care providers—a specialty in high-demand—among other health care initiatives. “If I had gone to another school, I don’t know if I would have that same passion for advocacy.”

But training doctors to also be advocates isn’t currently baked into the curriculum at most medical schools. While most offer at least one advocacy course, the majority are elective and vary widely in scope and content, according to a 2021 paper published in the journal Academic Medicine.

The Liaison Committee on Medical Education (LCME), which accredits U.S. medical schools, includes a curriculum mandate for teaching about the social determinants of health, but doesn’t specify format, content or measurable achievement goals. The LCME’s standards also exclude required advocacy or health policy training, according to a study published in the Journal of General Internal Medicine earlier this year.

The Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programs, endorses a general commitment to advocacy, but “published advocacy curricula in surgical specialties are sparse,” according to the study.

Advocacy instruction is more common in training for primary care-oriented specialties, and it varies by program. It’s especially prevalent in pediatrics residencies, which are required by the ACGME to include specific training on advocacy skills; Advocacy instruction is mandatory in 37 percent of family medicine residencies. Only 3 percent of psychiatric residencies provide any advocacy training, and about 54 percent of internal medicine residencies offer no advocacy training.

Seventy-two percent of the 276 programs surveyed cited a lack of faculty expertise in advocacy, which the study said was the most reported barrier to implementing an advocacy curriculum among internal medicine residencies.

‘Part and Parcel’

Dr. Kelly McGarry, one of the paper’s co-authors and director of Brown University’s internal medicine program, which has included advocacy in its curriculum since 2012, said she may have shied away from medical advocacy work if she had to learn about teaching it on her own.

“If everyone else around me feels that way, then no curricular innovation related to advocacy is going to get off the ground,” she said, recalling that the advocacy piece of Brown’s curriculum was first launched by a group of residents before she took it over in recent years.

“This is not a skill people learned a decade or more ago, and most faculty were trained more than a decade ago” McGarry said, hypothesizing that the rise of social media and other information technology over the past 15 years has illustrated the consequences of health disparities to a wide audience and built momentum for training doctors to advocate for large-scale change.

“We need more junior faculty,” to push more medical schools to integrate advocacy work into their core curricula, she said. “They have come along at a different time, where … advocacy in the role of the physician is now expected to be largely part and parcel of what we do.”

That’s how the UC San Diego School of Medicine, which first opened in the 1960s, came to implement a longitudinal course on healthy equity this past academic year.

In the late 2010s—before the pandemic and protests related to the murder of George Floyd sparked national conversations about long-standing health disparities—a group of medical students pushed the school’s administration to infuse more health equity and advocacy content into its curriculum.

Dr. Betial Asmerom, now a resident physician at UCSD’s combined internal medicine and pediatrics program, was one of those students. She grew up in East Oakland, California watching her mother, who is originally from Eritrea in North Africa, receive substandard medical care for a life-threatening health condition.

Those experiences eventually motivated Asmerom to pursue medical school, but she was frustrated by a concept many medical schools still teach known as race-based algorithms, which reinforces the idea that different races have inherent biological differences. Critics have argued such algorithms are relics of America’s racist history and can cause doctors to overlook the social determinants influencing a patient’s condition, resulting in inequitable care.

“There’s so much more that contributes to someone’s health than the immediate health care needs in front of them,” Betial said. “That’s the power of these types of curriculums. Part of it is that we challenge future physicians to think more critically and ultimately get people more involved in advocacy.”