Screening for poverty should be included in the medical curriculum

Poverty is a significant public health concern affecting 10-15% of individuals living in Canada and the United States. Recommendations to eliminate poverty have focused on areas of income, housing, food security, and early childhood development. Calls for government action and provision of resources to healthcare professionals have been issued. Notably, educating medical trainees to address poverty has been absent from the discussion.

Low socioeconomic status (SES) is a risk factor for a multitude of medical conditions including cardiovascular disease, respiratory disease, cancer, and mental illness. In medical training, learners are educated on SES and poverty as significant predictors of health, but there is little evidence to suggest that students are adequately trained to meet the unique health needs of people living in poverty. The virtual absence of education around screening and interventions to address poverty is puzzling, when contrasted with countless hours of medical training devoted to managing other common risk factors for disease such as hypertension. What we do know from the sparse medical education literature on the topic is disappointing: medical students have less favourable attitudes towards people who are poor and are less willing to provide care for vulnerable populations by their fourth year of medical school. Clearly, there is much room for improvement in educating trainees to address poverty.

Screening and interventions for poverty should be included in the medical curriculum. Medical trainees could be introduced to clinical resources aimed at addressing poverty and the recently developed, single-question screening test (“Do you ever have difficulty making ends meet at the end of the month?”), which has shown to be reliable in identifying patients who are living below the poverty line. Questions around housing, neighbourhood, food security, employment, income, and health insurance coverage could be integrated into the traditional clinical exam, providing learners with crucial information for patient care. Trainees also need to be taught how to incorporate SES into clinical decisions about screening and treatment options, especially when patients have suboptimal health insurance coverage.

Medical training is an opportune time to positively influence learners’ attitudes towards vulnerable patients. Medical trainees can be encouraged to reflect on potential biases when caring for patients who are poor. Making unwarranted assumptions or treating persons based on stereotypes could lead to cognitive errors in medical decision making and have devastating consequences. Fostering empathy for patients and families living in poverty should be a cross-cutting theme of a curriculum focused on alleviating poverty.

Educating students on interventions to address poverty could happen at the individual and community level. Trainees could be educated about housing, social assistance, or government benefits programs. Educating learners around referrals to allied health professionals (e.g. social workers) and community organizations (e.g. disease-specific advocacy organizations, free income tax clinics) would be an important step to ensuring patients are well-supported. Discussion could also revolve around barriers for vulnerable populations in accessing healthcare, public health implications, and significant cost-savings for the healthcare system in addressing poverty.

Medical schools could also offer clinical electives and service-learning opportunities that are centered on caring for vulnerable populations. Some examples include the local-global health elective at Dalhousie Medical School, inner city health elective at the University of Toronto, and student-led SWITCH clinic in Saskatchewan, Canada.

One other promising avenue for change is advocacy training for medical students and residents. Health advocacy is recognized as a professional responsibility, but advocacy training is arguably minimal throughout medical education. Teaching trainees to advocate for people who are poor could include didactic and skills-based sessions on communicating with government officials and effectively engaging with the media. Education around partnerships with institutional and community organizations as well as advocating for policies that will address the needs of people living in poverty will ultimately lead to better health for our society as a whole.

With recent attention to poverty in the healthcare field, there is no better time to incorporate poverty alleviation into the medical curriculum. In the midst of a rapidly aging population and climbing healthcare costs, training the next generation of physicians to tackle poverty is an urgent priority for ensuring patient and community well-being.

Matthew J. To is a medical student.  Colin Van Zoost is an internal medicine physician and assistant professor of medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

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