Inequality in medicine: Be thoughtful about the way we educate our trainees

Earlier this year, I started teaching a course to first year pediatric residents at Stanford. In it, I challenge the trainees to identify the structural contexts in which patients and families make choices that may impact their health and well-being. Termed structural competency, the goal is to enable young physicians to understand and confront stigma and inequality as key determinants of health. We talk about educational attainment and health literacy, socioeconomic status and health access, social norms and health practices, institutional discrimination and health disparities, and the built environment and health behaviors. Together, we examine the fragile balance between resources and health, recognizing that local forces that manipulate resources effectively legislate health, by structuring choice and opportunity.

To illustrate these fundamental connections, it is often necessary to convert what otherwise exist as invisible forces in society into accessible, clinically-relevant language. This allows us to conceptualize the structural framework in which patients’ live, work, and play, within a medical model. It shrinks what seems like a diffuse and disconnected system of local policies and institutions into tangible drivers of health and disease that require socially-informed, clinical interventions. It transforms inequality, a sociopolitical phenomenon, into a silent but active participant in the clinical encounter. This makes addressing local infrastructure a central component of any community-centered, health promotion strategy.

But as we expand our purview beyond the exam room and encourage young physicians to adopt a global approach to clinical medicine, we must be very careful not to succumb to, what I will call, “the perils of pretending.” Here, there are 3 common pitfalls that warrant discussion.

1. The poverty simulator. In any educational endeavor, experience is perhaps, the greatest teacher. Without experiencing poverty first-hand, it may be difficult for residents to understand the challenges families living in poverty face when seeking medical care or selecting medical treatments.

One such simulator offers “players” a chance to live on a low-income budget. Other programs ask residents to navigate public transit to various appointments. At Stanford, I ask the residents to live on the average food stamp budget for a week. These self-reflective exercises are meant to influence learner attitudes about inequality and build empathy among providers as they realize what it takes to survive under certain conditions.

The problem with poverty simulators is that the process of pretending to be poor unfairly and inaccurately reduces the daily struggle of living in poverty to a series of poor choices, no pun intended. The “game” motif insinuates that some choices are superior to others while completely obscuring the larger network of policies and institutions that concentrate disadvantage and manipulate choice in low-income communities.

For example, if you live in a food desert, the choice to eat fresh produce is constrained by the proximity of those resources to your home. This “trade-off” requires bargaining between necessities and results in a loss either way. Buying cheaper food in your neighborhood may have adverse health consequences and expending the time and money to obtain healthy food on a fixed income makes other necessities unaffordable. This zero-sum reality profoundly limits choice.

To avoid this pitfall, it is important to be clear about the purpose of the exercise, which is to acknowledge that resource limitations have health consequences. The lesson is that poverty is not a deficiency of ingenuity or the manifestation of good or bad choices. There are no “right” choices when selecting between food and medicine. So if poverty is the result of eroding urban infrastructure and imbalanced resource allocation and is associated with poor health outcomes, then building infrastructure is a health intervention.

2. The absence of clinical models. While the associations between social determinants of health and poor health outcomes are well-documented, we lack comprehensive, evidenced-based clinical models for addressing complex trauma and chronic stress, physiologically significant exposures that are the downstream sequelae of poverty and inequality. Short of co-locating same-day necessities in medical clinics, like food pantries or legal assistance, there are few models to describe how physicians in particular and the medical system at large, should engage the sociopolitical drivers of health through clinical work.

In the absence of these models, some physicians pretend there is nothing that can be done, or worst yet, that these issues are not “medical.”

The problem is that we are complacent in our current clinical practice. Stagnated by the dearth of evidence and overwhelmed by the magnitude of the issue, we simply avoid it. We fail to universally screen patients for social determinants of health because we don’t know where to refer them. We refuse to inquire about these issues because we essentially lack confidence in our ability or aptitude to address them.

The solution here is to do it any way. Just as all politics are local, so too will be the formation and dissemination of novel clinical models that address these issues. So we must encourage our trainees to identify the most pressing needs in their communities and trial socially-savvy interventions in their continuity clinics. This is quality improvement at its best.

3. The conflation of race and risk. When seeking to address the “cultural” influences in a clinical encounter, it can be easy to minimize “culture,” to the readily identifiable traits in the visit. Here, “culture” becomes a monolithic, static archetype we project onto patients based on our unconscious bias about their physical attributes, like ethnicity, nationality, or language.

When we do this, we are pretending that socially-assigned attributes, like race, are a proxy for risk. We track patterns of disease prevalence by these attributes and over time, come to associate the attribute with the disease. This logical fallacy then informs clinical practice and leads clinicians make inaccurate assumptions about certain patient populations, their relationship with disease, and the efficacy of certain medications to address their complaints (remember BiDil?).

The solution is to replace cultural competence with structural competence and educate young providers to interrogate the local context in which patients live, the resources at their disposal, and the networks they rely on to make medical decisions. We must of course, when doing this, not turn a blind eye to the ways in which local policies and historical discrimination produce predictable patterns of disease in certain communities. These patterns may make it seem as if the risk factor is easily recognized in the exam room (race, nationality) as opposed to the real risk factor that lives in our communities: structural inequality.

As medicine advances to address inequality as an important driver of health, we must be thoughtful about the way we educate our trainees to tackle this new frontier in primary care. While there will be pitfalls along way, if we tread carefully and together, we can transform the future of medicine in powerful and meaningful ways.

Rhea Boyd is a pediatrician who blogs at rhea, md. and can be reached on Twitter @RheaBoydMD.

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  • ninguem

    Reminds me of a line from that TV show “St. Elsewhere” from the 1980′s.

    A faculty member liked to get the residents out into the community’s poverty, learn what it’s like to be poor, and one episode Morrison was assigned to a prison medical clinic, there was a riot, the resident got beaten and raped.

    An argument at a faculty meeting afterwards, the surgeon Dr. Craig, to the faculty member who liked running the students to these programs.

    “I’m sick and tired of sacrificing residents, so you can feel like Mother Teresa.”

    One reason I remember the line, was right about that time, a medical school did have a program where the students were sent to an inner-city clinic and followed the families to house calls in the inner city. One female student got beaten and killed making her assigned house call in the ‘hood.

    I don’t know if the writers were aware of that story, it was in the medical press. I thought the timing was remarkable. It’s why I remembered the dialogue.

    Do this sort of thing with too heavy of a hand, and all you accomplish is motivate the students into dermatology and plastic surgery.

  • azmd

    Actually, the real focus should be on making sure that the clinical settings in which students, residents and primary care providers see these patients are amply equipped with social workers who can accomplish the tasks you outline above.

    No full-time clinician these days has time, in the context of a 12 minute visit, to discuss poverty or provide appropriate referrals to resources in any meaningful fashion. Expecting already overburdened primary care providers to function not only as physicians, but as social workers, is just unrealistic.

    I say this as a provider in the public sector who actually spends a fair amount of my clinical time addressing social service issues with my patients. I can do this for exactly two reasons: my caseload is capped at ten patients per day, and I have a full-time social worker assigned just to my service whose job it is to deal with paperwork and make the referrals I specify in my discharge plan. This may seem impossibly luxurious, but it is what it takes to really meet people’s social needs, and it is a full day. I go home most days at 6, completely drained.

    It didn’t take a huge amount of special education or consciousness-raising in order for me to be sensitive to social issues, and I suspect I am not too different from most other physicians. We really don’t need more classes on how poverty affects people. What we need are better clinical resources for the providers so they can do something about it.

    Someone who wants to really accomplish something in the field of public health will work on those barriers to care, although I recognize that it’s a lot easier to teach a class at a medical school.

    • ninguem

      “We really don’t need more classes on how poverty affects people. What we need are better clinical resources for the providers so they can do something about it.”

      Thank you, well said.

      • azmd

        This is something going on in the healthcare system that just drives me nuts: the ever-increasing number of chiefs telling the few overworked indians who are still out there plugging away trying to do good with limited resources, how they can do their jobs better.

        Seems to me everyone is rushing to get those cushy jobs being medical “leaders” probably because the actual clinical work has gotten so unrewarding. I would have a lot more respect for recent graduates who style themselves as “thought leaders” if I saw any indication that they had any interest at all in being out there in the trenches that they are preaching about.

        • James O’Brien, M.D.

          It’s been going on for decades, and we continue to elect them to head medical organizations, ignoring the fact that they could care less about doctors who treat lots of patients.

          Some of these preachy idealistic articles written by people with little real world experience are hard to take. Imagine if this were a blog for combat veterans and you were preached at about war ethics by someone whose experience was completing the latest version of Call of Duty.

          • ninguem

            James O’Brien – “…..It’s been going on for decades, and we continue to elect them to head medical organizations, ignoring the fact that they could care less about doctors who treat lots of patients……”

            Funny you should mention that. For all the years that I have belonged to various organizations in organized medicine, not once have I ever been given a ballot to elect a medical leader.

            That includes hospital medical staff.

            And it’s one of the many reasons why I belong to very few medical organizations anymore.

  • Margalit Gur-Arie

    I don’t know, but there is something very disturbing about a bunch of rich and privileged kids playing a game of pretend poverty….or what their thought leaders think poverty is….

    • azmd

      It is, however, consistent with the philosophy that giving a lecture to medical students about poverty is the same thing as actually doing something to help the impoverished.

  • guest

    Great! An idealistic young physician who is interested in fighting poverty! Let’s hear all about the free clinic she works at and the volunteer work she does among the underserved…

    Oh wait….a quick check of the writer’s blog and some googling reveals that ” Boyd’s ultimate goal is to work at the state and federal levels of government,” and to have a “high government position.”

    So, yet another recently minted physician who has no intention of practicing medicine, either among the underserved or anyone else. In about ten years she’ll be telling people like me that budget cuts necessitate my seeing 20% more patients daily and oh, by the way, they will each need to have a “food insecurity inventory” completed regardless of its relevance to the patient’s presenting problem….

    • QQQ

      In others words, the doc is full of baloney!

  • Thomas D Guastavino

    One of the requirements of my med school was that the students do a ride along with then EMTs. Since ours was an inner city school I saw some things that to this day the memory sends chills down my spine. However, perhaps the greatest benefit of witnessing poverty first hand is a greater appreciation of needs to be done to correct it. Suffice it to say what we are doing is not working.

    • guest

      I completely agree with this, but what this blog post describes does not appear to involve anything like what you describe, and what I experienced by rotating for months in a crumbling inner-city hospital in New York while I was a resident. Dr. Boyd has her students live on a food stamp budget for a week. If that’s the only exposure to poverty they are getting from her course, it’s hard to imagine that there’s much benefit in terms of effectively raising awareness of the social forces that contribute to poverty. The student who is truly interested in working with impoverished patients likely already has empathic awareness that living healthily on food stamps is challenging. The student who is planning to pursue a career as a pediatrician in Palo Alto will probably not be materially affected in any way, and may actually feel annoyed and resentful, since such “exercises” are generally not as engaging as actually getting out into the real world and working with the underprivileged.

      What I see above is a self-congratulatory blog post larded with buzzwords such as “quality improvement” and “socio-political drivers,” along with infuriating suggestions such as the one that already-overburdened PCPs should be required to “universally… screen for social determinants of health” even though she readily admits that resources available to address those determinants are largely absent.

      • KoharJones

        I read this post with so much appreciation–
        As a family physician taking care of patients in an inner city community health center, I know the social determinants of health are key. And I am lucky, because I can screen for them–and treat them, by referring patients to a social worker or to Health Leads (college volunteers who maintain a database of social services in the community, and connect patients to food or electricity or summer programs or English classes as their social needs require). We have a new initiative, called HealtheRx, where all the patients are given a handout when they check out with the resources in the community that pertain to their diagnosis (eg diabetes: exercise classes, grocery stores).
        I am also an educator, and appreciated Dr Boyd’s clear sighted description of what structural competency means. An understanding of and desire to confront:
        Educational attainment and health literacy. Socioeconomic status and health access. Social norms and health practices. Institutional discrimination and health disparities. Built environment and health behaviors.

        I will borrow these phrases to frame my next community health elective.
        She has provided a framework to teach structural competency.
        And rather than advocating for, she warns against the pitfalls of poverty simulators, the absence of clinical models and conflating race and risk.
        I am so glad that I work in a clinic that though flawed by bureacratic ineptitude in many ways still allows me to screen for and address the social determinants of health. And I will encourage the future physicians I train to understand the health consequences of social determinants, and gather the data needed to address them (if you don’t ask, you don’t get data, and without data you can’t prove that you need funding to address an invisible problem).
        Dr Boyd is making the invisible visible, in a meaningful way.

  • Rob Burnside

    March on, Dr. Boyd, and never mind the cynics. They seem to be ignorant of the relationship between awareness and transformation. Or, they’ve lost the ability to believe they can make a difference. Or both. I hope your approach is adopted nationwide.

    • guest

      When the “cynics” commenting are the ones who are actually in the trenches dealing with poverty, I am not sure that we can be accused of ignorance, or of not making a difference in the world.

      Dr. Boyd’s “awareness” of poverty appears only to have resulted in her determining that she would like to be a bureaucrat when she grows up. Those of us who work with the poor know only too well that bureaucrats don’t “transform” anything. But the idea that you can make a difference by becoming a government official is very popular among our medical graduates these days.

      Perhaps this is the cynical part, but it is hard to imagine that this keen interest in non-clinical work isn’t at least partially driven by the fact that bureaucratic jobs are nice, 9-5 jobs with no call, generous benefits, no regulators threatening you with penalties if you fill out forms wrong, and no need to walk in the shoes of those whose lives are adversely affected by your decisions.

      • Rob Burnside

        You make some good points, and some not so good. I’ll substitute “oblivious” for “ignorance.” There’s no such thing as an ignorant cynic–it takes practice and, as you say, experience. I doubt anyone even vaguely familiar with what you’ve been through in those trenches would deny you your right to pessimism. I don’t. I simply know from my own experience that it does no good.

        • guest

          I am endlessly optimistic, possibly even joyful, about the work I do and see an important part of my job as communicating hope to all of my patients.

          That is entirely separate from my awareness that much of my day-to-day work life and what I am able to accomplish is significantly impeded by the type of bureaucratic nonsense being described in the blog post, and the people whose livelihoods derive entirely from generating it.

          • Rob Burnside

            Your first paragraph is heartening. The next paragraph tells me you may be distilling something from the blog that really isn’t there, unless you feel it’s implied. I don’t. I think the salient point Dr. Boyd makes is the need for a new understanding of poverty in 21st century America, and how form impacts function. Though it can be a loaded term nowadays, I believe we should not recoil from the word “transformation.”

          • guest

            I would certainly welcome transformation that could meaningfully impact poverty. I just don’t happen to believe that meaningful transformation is generally achieved by people in “high government positions” (Dr. Boyd’s stated career goal) who begin their careers not by working with the poor, but by seeking policy positions in which they can mandate such changes as forcing already overworked direct care workers to collect even more data during their already too-brief interactions with their beleaguered clients.

            This is not something I “distilled” from the blog post, it’s a specific suggestion (the only one in the post) she is making for how to go about effecting change:

            ” We fail to universally screen patients for social determinants of health because we don’t know where to refer them. We refuse to inquire about these issues because we essentially lack confidence in our ability or aptitude to address them.
            The solution here is to do it any way.”

            This is entirely characteristic of the ineffective bureaucratic mindset that we on the front lines have to deal with every day: “We don’t care if you don’t have the time and the resources to complete this action. Just do it anyway, and fill out the form saying that you did it. We don’t really want to hear about any barriers to doing it in a meaningful way.”

            A prime example of the outcome of such bureaucratic behavior is the regular discovery in various states, over the years, that the state’s Child Protective Service division was doing a terrible job of protecting children, who subsequently died. Public outcry is invariably followed by an official inquisition, and then the discovery that the case workers responsible for protecting the children were being asked to carry an impossible caseload. In a career in the public sector which has spanned thirty years and three states, I have seen this pattern repeated over and over again.

            Running a successful social service agency is not rocket science. You need to give the line workers the resources they need to get their jobs done, or the jobs don’t get done and your clients don’t get helped. Ignoring this reality in favor of “transformative ” policy changes looks much more glamorous on your CV and is much more publishable, but it’s not a substitute for having realistic expectations of what your line workers can do. And if you’ve never been a line worker, but instead hopped right from residency to a “high government position” then your ability to accurately assess what line workers will and won’t be able to do with existing resources, will be limited to non-existent.

          • Rob Burnside

            We’re not far apart. I was a line worker most of my working life and I’m intimately familiar with the dismay you project. One of the worst aspects is the feeling that no one at the top is really thinking about things from the bottom up, and sadly, that’s often true. But it’s beginning to change–the only saving grace I can find in satisfaction surveys.

            However, I have a strong feeling the information Dr. Boyd wants collected could prove very beneficial to patients and physicians alike.

      • SteveCaley

        Being a bureaucrat means NEVER having to grow up! :) The Eternal High School beckons…

  • guest

    Yes, the Health and Hospitals Corporation hospital in which I trained was a crumbling wreck complete with 1940′s era open wards with 30 beds per ward, but working in it brought home to me in a visceral way what the everyday lives of my patients must be like. It was an invaluable empathy-building experience. That hospital has been torn down and replaced by a shiny new facility with semi-private rooms, but the healthcare delivered by HHC, last I heard, was about the same. You can put lipstick on a pig…etc.

    • SteveCaley

      I bridged the Old Boston City Hospital, and the New Boston City Hospital. Can’t disagree.

    • Patient Kit

      I personally know some very good people who work in the HHC system here and their patients are very lucky to end up in their care. I think I’ve mentioned before that my sister is a psychotherapist (MSW, not MD) who works at an outpatient clinic affiliated with Woodhull Hospital in Brooklyn.. She could have easily worked elsewhere. She’s very good at what she does and she has been doing it for 20 years. She stayed because she loves treating the population she treats. She really cares deeply about her patients, many of whom have had very hard lives.. But she often says it’s like working at St Elsewhere meets The Wire.

      Whatever it’s faults, HHC serves as a true safety net for many poor here in NYC. Also, when police officers are shot, they often end up in Bellvue’s Level 1 Trauma Center ER. Many would be devastated if HHC ever disappeared.

      That said, when I found myself with cancer, on Medicaid and in need of surgery last year, I bypassed
      HHC and went with the NY Presbyterian Hospital system instead., where I got excellent care covered by Medicaid. And my sister would do the same.

      Which HHC hospital did you train in (that closed and was replaced by another hospital)? Just curious about the ever-changing history of NYC hospitals.

      • guest

        It was Queens Hospital Center (the old Queens General). A grand crumbling wreck of a campus. On the first floor, by some elevators in the back, were some great old WPA murals of the clinics. I used to love to look at them while I waited (forever) for the elevator to come (it wasn’t safe to use the stairs).

  • wiseword

    Use public transportation? Oh, the horror of it! I bend my head in shame. I’ll conceal my MetroCard lest my social status be compromised.

  • SteveCaley

    Actually, it seems a bit like “scared straight,” and entirely within the keeping of the New Healthcare.

    As medicine advances to address inequality as an important driver of health, we must be thoughtful about the way we educate our trainees to tackle this new frontier in primary care. While there will be pitfalls along way, if we tread carefully and together, we can transform the future of medicine in powerful and meaningful ways.
    I am glad to see that in Stanford, medicine is addressing inequality. From what I have seen of the rest of the country, our nation and especially the powerful has run screaming from the concept, and most especially in healthcare, for the twenty-five years of my practice. Nobody since Lyndon Johnson talked about such things in public with the slightest intent of doing anything about it.
    This is a country that believes that competition will, inherently in its eternal magic principle, create the Best Environment for anything. Anyone who has been through the medical training shark tank knows that the hammer comes down on the hindmost.
    The pediatric first-year resident with $300,000 in debt and an unplanned pregnancy in the works should look poverty in the face. The door is always open, if she does not keep in step.
    Keeping in step involves thoughtful and provocative insight into socioeconomic conditions, and perhaps a publication or two. A specialty reputation in Inner City Primary Care, perhaps a MacArthur fellowship to study the problem. Medical academia survives by studying the obvious, due to its obsolete tradition of being “sciency.” Another paper on the blueness of the sky – another line for the resume.
    But the door is always open – and there is ALWAYS someone watching. Every class can have only ONE chief resident. If you are running forward fast enough, they cannot stab you in the back.
    Nothing here is new since 1980 – it has always been like this, including the sensitivity training and biopsychosocial aspect. Since it does not involve doing anything about the problems it finds, it is mere whimsy.

  • Patient Kit

    The NYC hospital where I had my surgery for OVCA and where I’m still being treated by an awesome doc accepts Medicaid and also has a grand piano in it’s lobby.

    • DeceasedMD

      the point i was making was not about anyone in particular, but about a system problem. I am delighted you had such a good experience. Most hospitals now spend excessive money going into things unrelated to care to impress and it seems to work. In many places, care does suffer. You need to remember it is very different depending on where you live and host of a lot of other factors. The point is do you want your health care dollars going into this?

      • Patient Kit

        I understand you’re point and I agree with you. I guess I was being a little unsuccessfully facetious. When did the grand piano trend start in hospitals? They seem to be everywhere now. Hospitals, competing aggressively for patients, are spending money on very superficial hotel lobbyish things. They seem to think that’s what will attract and/or distract patients. The pianos could almost become a symbol of the upside down priorities of our healthcare system.

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