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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  • Doug

    I think some of this is great stuff, and other parts of it would be more futile and unhelpful. The end result is medical attention to, and use of, a patient’s SES and the impact of their SES on the care you intend to provide. As a medical student, I’ve received plenty on the didactic side about the effects of poverty in medicine, both in mandatory and non-mandatory lectures. Ask anyone – we don’t suffer from lack of lectures. More on that side as a requirement of schools would be not only infeasible, but also, I believe, uneventful.

    Poverty and its effects on patient means to obtain care, the problems wrapped up in their insurance coverage and ability to seek care, the negative feedback loop that creates in their likelihood to seek care again especially through “slower” routes (specialist scheduling, non-PCMH PCP scheduling) as opposed to “faster” and less efficient routes (the ED).

    I’m a fourth year medical student. I tackle these issues in the political forum on the local, state, and national level. I get involved in organizations that garner political movement and action behind these types of issues. When I’m in the exam room, I make sure when I talk about assessments and plans we reach the plan together – a plan’s no good without its action.

    My point is a lot of the electives and information on poverty in med ed already exist. And new box-checking “Must ask this question” type scenarios would likely fail to produce the result wanted, like so many before this one. But through talking with the patient, and not talking to them, you’ll get the information you need without obviously appearing like you’re clicking another box on the EMR. And in my limited experience in the clinical world – patients are thankful for this collaboration. And when I see them back in the clinic, the plans were followed more often than not. It just takes – like so many things in this world – some mindfulness and effort.

  • ninguem

    All medical training, undergraduate, postgraduate, and continuing medical education, must be upended and changed to reflect the importance of My Pet Cause.

    • Dr. Drake Ramoray

      I was curious as to which of the three years of medical education in the shortened curriculum would accomodate all these pet causes. My vote is first year, while they are bright eyed, bushy tailed, and much more susceptible to stuff like this.

    • Matthew J. To

      I’m not sure how this is relevant, but if there’s something you would like to discuss about the post, feel free to do so.

    • guest

      Also, it looks really great on my residency applications, and it endears me to attendings who might write me recommendation letters, to create blog posts for social media talking about yet another perceived deficiency in our healthcare system and how a new initiative/guideline/website/regulation/etc. will be helpful.

      I sit on the Executive Committee of the state medical association and our lobbyist recently informed us of a proposed bill to make it illegal for a radiologist to not inform a patient that she has fibrous breast tissue. Introduced by a OB fellow, who should have, but didn’t, go through her hospital’s advocacy department first. What I often wonder about is this: do the trainees who propose such legislation/initiatives/etc actually plan to practice medicine in this climate they are creating? Or do they think they will be going directly into jobs as “policymakers?”

      • Matthew J. To

        I would certainly hope that people who suggest changes would practice in the climates they propose and are not suggesting new changes just because they want to add one more thing and make others’ lives difficult. Some trainees may want to focus more on the policy side while others will being providing patient care. We definitely need both.

        • guest

          However, in the brave new world of medicine, the paradigm is that doctors who don’t practice (and have never really practiced) are coming up with an ever-increasing and overwhelming array of initiatives and mandates to impose on those of us who are still out there actually taking care of patients.

          I disagree that we need more trainees who want to “focus on the policy side.” The only people who should be focusing on the policy side are people who have spent significant amounts of time practicing and (ideally) are still in some form of practice, so that they are in a position to understand the realities of clinical practice, and how significantly it can be impaired by excessive micro-management.

          • Matthew J. To

            Thanks for sharing your perspective. I think there are very few trainees that actually go directly into policy-making. To my understanding, the vast majority will be either providing patient care or doing a mix of patient care and advocacy/policy-related work. We are just highlighting that trainees need to be equipped with both skill sets. I can see how micro-management is a significant concern. The intention of including a curriculum devoted to poverty alleviation is to help students become aware and address important health-related concerns that are typically overlooked in the traditional medical curriculum. In a recent report, Canadians identified poverty as the most significant concern affecting their health (http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/HCT/What-makes-us-sick_en.pdf) so we believe this is important to address from the context of medical education. The “how” is actually quite flexible and we propose a broad number of strategies that students and schools can adapt.

          • guest

            I understand what you’re saying, and I completely agree on the public health implications associated with poverty, which are very significant. However, as someone who teaches on the medical student and the resident level, I can tell you that in medical education, like in clinical work, the level of regulation and volume of curricular requirements has reached such a critical mass that we spend far more time discussing and documenting compliance to ACGME requirements than we actually do in executing them. Similar to our clinical work, the documentation looks great, but the patient/trainee has a sense of being shortchanged.

            Until we find a way to make sure that actual resources are devoted to well-meaning initiatives like yours, each one that comes along will remain essentially an unfunded mandate, which will be only very superficially complied with, since no one is given the extra time to really execute it in a high-quality way.
            This is one of the pitfalls of “doing a mix of patient care and advocacy/policy work.” Unless you are carrying a full-time patient load, it is very difficult to appreciate the level at which full-time medical workers are starved for time these days.

            Adding “just one more very important item” to the long list of tasks which your typical full-time doctor or nurse has to get through each day does not seem like that big a deal to someone who, if they have to spend five minutes extra at work, it means that they might be late meeting a friend for lunch, or ten minutes late getting to the gym. For a full-time medical worker, spending five minutes extra at work in the evening might mean that your child waits for you on a dark field at the end of soccer practice, because you are late to pick him up. When this level of subjection of one’s personal/family life to one’s work happens repeatedly, it erodes the worker’s job satisfaction very significantly, in ways that someone who has the choice to do only part-time clinical work, and thereby have a better life-work balance cannot really appreciate.

            But because today’s generation finds life-work balance to be very important (I happen to agree with this), they appear to be accomplishing that by flocking into policy positions, where they enjoy their life-work balance while contributing to the creation of policies that make full-time medical work increasingly difficult.

          • Matthew J. To

            Thank you for your valuable insights. Work-life balance is crucial and ensuring that physicians and trainees don’t burn out is just as important. I agree that consistently adding more items to the curriculum or to a healthcare provider’s list of responsibilities will eventually become unmanageable. Since our time is limited, perhaps we should start removing things from the curriculum that have little impact on patient care. We spend hours learning about medical conditions that may come up a few times in a medical career and sometimes little time addressing common experiences that impact our patients such as poverty.

      • Matthew J. To

        You make a good point about going directly to local institutions when there is a concern. Again, I believe there needs to be both: communication with the local institution and the wider public.

  • guest

    Because it’s not an illness, it’s a social evil, and doctors will never have the ability to adequately address it. We can’t even address the glaring inadequacies of our own healthcare system. But by all means, let’s mandate that doctors spend a lot of time paying attention to something else that they can’t really fix…

    • Matthew J. To

      While doctors by themselves will not be able to fix the problem of poverty, they can be trained to help. Showing empathy for those who are living in poverty and directing these individuals to other healthcare providers and community organizations could go a long way. Poverty has such a huge impact on health and there are some concrete things that can be done to address it. Even a few minutes of talking with patients about where they can seek support could potentially lead to time and cost savings in the long run.

      • guest

        Any doctor worth his or her salt will be empathic with a patient’s difficulties, whether they are related to SES, or to other things. If a doctor is not empathic, then there is either something basic lacking in their humanity, or something basic lacking in their training.

        Either way, the fix is hardly to expand medical education to include training in advocacy, or “effectively engaging with the media.”

        Furthermore, in my experience, the main barrier to doctors chatting with their patients about their economic difficulties, and directing a social worker to identify sources of help, have more to do with overworked doctors and non-existent social workers.

        Since it does not seem likely that additional mandates and initiatives will be accompanied by the provision of additional time or resources by which to successfully accomplish said initiatives, all that will be produced is more paperwork for providers to complete, documenting that they did something that they didn’t really do.

        • Matthew J. To

          Thanks for sharing your perspective. I agree with you that empathy needs to be central to the discussion. Tackling poverty is no simple task, but ensuring that trainees are well-equipped is a significant piece of the puzzle. Perhaps our healthcare systems need to shift their attention to encouraging healthcare providers to address poverty-related concerns and also reimburse them as it is clear it will have great benefits in the long-term.

  • Matthew J. To

    That’s a good point. There’s no easy fix and we will need a lot of people to invest their time and energy to help. Ultimately though, it will lead to better health for these individuals and the community as a whole.

  • Matthew J. To

    Thanks for sharing about the work that you’re involved with. That’s really exciting to hear! I would be very interested in hearing more about your experiences with this and how it can be integrated into the curriculum. How can I get in contact with you and your colleagues? Thanks!

  • Matthew J. To

    I agree and your patients are lucky to have you as their physician.

  • Matthew J. To

    Great, thanks!

  • Matthew J. To

    I found you on Twitter. Still new to this, but I think you should be able to message me.