On a rotation in internal medicine last year during my third year of medical school, I spent several days watching the residents work to optimize a homeless patient’s insulin regimen. They were understandably concerned with his diabetes medications because he had been admitted in a diabetic coma, but the real reason for the coma, as far as I could see, had nothing to do with his medication regimen and everything to do with his social situation. With a long history of uncontrolled depression, anxiety, and IV drug abuse, the patient was living on the streets and continuing to take his insulin even though he had nowhere to refrigerate it. Diagnosed with diabetes as a small child, he knew the importance of controlling his condition but was prevented from doing so adequately by his homelessness. Without the extensive discussions about social determinants of health in my MPH program, I might not have had the sense to make this connection and advocate for my patient to be placed in housing that would allow for refrigeration of his insulin.
During a year off after college, I faced a problem. I was interested in primary care medicine as a vehicle for social justice and advocacy, but I felt that a career in public health could just as easily do the job. As I researched both professions, I found myself looking for MD/MPH programs as a way to pacify my indecision. Although I initially made the decision out of indecision, I was surprised to find that the combined MD/MPH program at Tufts actually provides ideal preparation for a budding primary care physician. Many characteristics of Tufts’ MD program are already geared toward providing a strong foundation in primary care medicine. However, in my opinion, it is the MPH coursework that truly prepares us.
In our MPH journal clubs, we became proficient analysts of the primary medical literature and learned to draw evidence-based practices from it for important primary care topics like cancer screening, physical exams, or immunization schedules. In our public health law course, we went a step beyond our MD classmates from discussing health privacy rules to reading and discussing the actual court cases that gave rise to those rules. This fluency in legal issues in medicine came in handy on a rotation when the psychiatry resident, on the phone with a relative of a patient, wasn’t sure how much information she was legally able to divulge. My familiarity with the Tarasoff case allowed me to help guide her conversation with that family member much more easily than if I’d only learned the HIPAA regulations like my MD classmates.
While our MD classmates were learning basic epidemiology and biostatistics, we were learning these subjects to a much greater degree. Specialists in a large research hospital often have a staff of biostatisticians to do this sort of work for them, but in primary care, it’s important to be competent in these skills to do such research without a large staff.
I think it was the courses that discussed social determinants of health, however, that made the biggest impression on me and seemed to have the broadest practical applications to primary care. Starting in the first week of first year, we learned in our MPH coursework that race, ethnicity, income, and zip code are sometimes just as significant predictors of health status as family medical history, diet, or the medicines you take. In primary care, recognizing these “social determinants of health” can help us understand why some of our patients might struggle harder to manage their disease than others.
After ten months devoted to clinical rotations, we finished our third year with a month devoted solely to public health elective courses. The experience proved to be a chance to make much-needed connections between what we’d seen in rotations and what we’d learned about public health.
Many of us had seen doctors treat mental health issues with less care and concern than they did physical health issues, often allowing patients to be discharged with no real mental health care plans in place and no referrals to outpatient mental health services. Similarly, physicians often swept substance abuse under the rug and discharged patients without addressing what was likely the root of their other health problems. We saw physicians in hospitals concerning themselves with only the “medical” issues – like my homeless patient’s diabetes – and ignoring the “social” problems, when our MPH knowledge told us that the “social” problems were often the cause or a major contributor to those “medical” issues. Although physicians are seldom the best providers to deal with these issues – social workers often do much better – it is still up to the physician to seek out those services for their patients.
This chance for reflection allowed me to see the gaps in care that exist between inpatient and outpatient medicine that I might not otherwise have noticed – gaps that are probably more pronounced in primary care than in subspecialty care. Learning about social determinants of health gave me insight into why the same disease may present different challenges to different patients. It reminded me that in order to best care for chronically ill patients, I have to look at the whole person and work together with him or her toward wellness. Since chronic disease management will likely dominate the future work of any primary care doctor currently in training, it is important that medical schools think critically about how best to train these physicians to face these unique demands.
Joshua St. Louis is a medical student who blogs at Primary Care Progress.