The symptoms of systemic discrimination and sweeping organizational problems are ubiquitous in the news and health care literature. Yet, medical students’ curricula focus on codes of professionalism, setting these issues, and the historical forces that created them to the side. While professionalism is undoubtedly an important aspect of being a physician, it is simply not enough to give students the background they need to recognize the historical contextualization of ethical problems. Without a solidified background in systemic medical ethics and history, are we as students as prepared to face these issues in daily practice as we are with common health problems?
In the current pandemic, patients in minority groups are facing worse outcomes and mortality rates. Health disparities have been growing since the inception of the U.S. health care system, yet this news was met with widespread surprise. The most common knowledge of similar systemic racial issues in health care revolves around the Tuskegee experiment, but this is just the tip of the iceberg. Sometimes these issues were more subtle, such as placing families in housing projects with high levels of lead to observe the children’s development. Sometimes they were as overt as injecting plutonium into minority patients. All of them caused tremendous suffering to patients. None of them are currently required to be taught by the medical school accrediting agency, the LCME.
First-year students can have deep, meaningful, and likely rage-fueled discussions about the Krebs cycle, which they will inevitably forget. But we are not required to learn how to discuss the systemic social issues patients face. This represents a clear discordance between prioritizing academic insight in the sciences and the humanities. Both are major determinants of health outcomes, making them highly valued by patients.
While almost every lecture in medical school has crucial clinical information, some can feel less imminently useful. For example, we learn about xeroderma pigmentosum, which occurs in one in one million people in the U.S. I often think about how difficult these diseases are to live with – and how few of us physicians will have a chance to help those patients. Yet, social issues cause pain, suffering, and even illness that we will encounter daily. Is it really useful for us to know about rare diseases we’ll likely never see when there are social conditions causing stress and pain to our patients right now? Or is it time to recognize that we are fully capable of learning and applying both?
Medical education heavily prepares us to treat patients through lessons in the mechanism of disease, ranging in depth from specific biomechanical issues to anatomical identification. Many cite this depth of knowledge as a specific reason for pursuing a career as a physician over any other role in health care, and it is the justification for a doctoral degree. Medical education does a fantastic job at this – for the overwhelming majority, graduates will be able to diagnose and treat a wide variety of conditions and help many people. Freedom in designing curricula has allowed for educational innovation and new ways to teach dense information, but a curriculum involving social issues and their historical context to the same depth as pathology is far too valuable to be left as optional. Medical schools having a rich curriculum that contextualizes modern ethical issues should not be the exception. It should be the norm.
As physicians in training, we must learn how to protect the most vulnerable. To do this, we must identify, discuss, and openly debate the systemic issues affecting those populations. Even now, studies have shown that the racially-based myths that African Americans have thicker skin and experience less pain persists in the minds of medical students today. Understanding the origins of these myths is not a matter of merely academic interest (in this case, it stems from the historical equivalent of “medical storytelling”). It is vital to preventing future harm. Medical education plays an essential role in dispelling these myths, all the more reason for historical ethics to be a requirement.
When my mother taught me how to drive, she handed me the keys and said, “A car is a tool, but if you don’t know how to use it, it quickly becomes a weapon.” When a medical school hands us the keys to practice, there must be an obligation for the system to teach us the inner workings of the car that is health care and how to drive it. In medicine, it makes little difference whether the people abusing the system realize whether they are doing so; the harm is still done. Medicine quickly becomes a weapon when wielded in ignorance. This extends to ignorance of social history and context. This harm could be easily avoided with a handful of lectures and discussions taken to the same level of importance as pathology and pharmacology topics. Even disagreement in these situations would allow students to practice patient advocacy. It is essential that this becomes a required norm in medical schools, as social determinants of health are just as crucial to know as other topics.
Patients deserve students and physicians who understand the issues they face when dealing with the health care system. For us to fulfill our duties as providers, we must be competent in the physical issues a patient is experiencing and how the system we work in affects those patients.
Jacob Riegler is a medical student.
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