No Easy Answers in Bioethics Podcast

Social Determinants of Health in Medical Education: Ajegba, Bogdan-Lovis, and Kelly-Blake – Episode 18

December 3, 2019 Brittany Ajegba photoLibby Bogdan-LovisKaren Kelly-Blake photo

This episode focuses on the topic of social determinants of health, or the social and environmental factors that influence our health and access to resources. How can social determinants of health be integrated effectively into medical education and clinical practice? Center for Ethics faculty members Libby Bogdan-Lovis and Dr. Karen Kelly-Blake speak with College of Human Medicine student Brittany Ajegba, who emphasizes the need for standardization when training physicians on social determinants of health. From medical education to clinical encounters, they provide a variety of perspectives on this increasingly important work.

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. This episode focuses on the topic of social determinants of health, or the social and environmental factors that influence our health and access to resources. Center faculty members Libby Bogdan-Lovis and Dr. Karen Kelly-Blake speak with College of Human Medicine student Brittany Ajegba, who emphasizes the need for standardization when training physicians on social determinants of health. From medical education to clinical encounters, they provide a variety of perspectives on this increasingly important work.

Brittany Ajegba: So, hi everyone my name is Brittany Ajegba, fourth year medical student at Michigan State University, College of Human Medicine.

Karen Kelly-Blake: I am Dr. Karen Kelly-Blake. I'm an associate professor in the Center for Ethics and the Department of Medicine.

Libby Bogdan-Lovis: And I'm Libby Bogdan-Lovis, assistant director at the Center for Ethics and Humanities. And I'm going to start off to establish a foundation for today's podcast on the challenges of integrating social and medical care. I'm going to borrow wisdom from Health Begins, and Health Begins is a social enterprise led by founder and president Dr. Rishi Manchanda. That organization provides training, clinic redesign and technology to transform health care and the social determinants of health. And the crux of their approach is to look upstream, as they describe it, to address the myriad of causes for poor health. And I think it's useful to review a few of their primary concepts. What we're going to talk about today is social determinants of health, which as they describe it are the causes of poor health found in underlying community-wide social, economic, and physical conditions. Then, social needs and health-related social needs are the effects of the causes as experienced by specific individuals or defined populations. And then there's structural determinants of health, which are really the causes of the causes, which include those broad socioeconomic and political climates that shape social hierarchies and lead to inequities. Our focus today considers social determinants of health from our own varying perspectives. For Karen and for myself as developers of curriculum content, and for Brittany as experienced by she's a fourth year medical student, but she entered MSU with a master's in public health. And she is in the Flint, Michigan community campus. And we should alert our listeners that the MSU College of Human Medicine has a community campus structure. And it makes available to students in the Flint campus access to the Leadership in Medicine for the Underserved, or we call it the LMU program. And with this program students like Brittany, like you, you work with and learn from under-served population such as those living in that post-industrial city. Finally, a paradigm usefully illustrating the benefits of addressing social determinants of health in clinical care is Dr. Mona Hanna-Attisha, whose careful attention to her pediatric patients helped uncover the Flint water crisis. And in fact our Center for Ethics and Humanities Acting Director Dr. Leonard Fleck wrote about this in his October blog, "Health Care and Social Justice: Just Take Two Aspirin for Your Tumor If You Cannot Afford Your Cancer Care." Notably, professional medical societies generally support screening for social determinants of health, but as recognized by the three primary concepts mentioned, to be effective, screening needs to be wedded to macro-level efforts that address the causes of the causes, that is the structural determinants of health. And to illustrate again with the Flint water crisis, this then took that community's collaborative efforts to force governance change. And so, Karen and Brittany, let's now launch into a frank discussion about controversies that are related to incorporating social determinants of health into medicine and into medical education.

KKB: So I think one of the first places we can start is, and Brittany not to put you on the hot seat...

BA: [Laughs]

KKB: But since you are actively engaged in medical school and a learner of medical education, and with your background, having a master's in public health from Columbia University, could you speak to the sort of challenges you've encountered being a student in engaging with social determinants of health as a learner? And what you think maybe some of the potential remedies might be?

BA: Yeah, sure. I think for me starting with that question you would have to assume that that's being talked about in the classroom. I think that in order to figure out what are some of the remedies, it's like let's start from the beginning. And I think for us, in order to kind of assess how social determinants is being brought into medical education, it would be just that, brought into medical education. And oftentimes what I have found is that the discussions around social determinants of health are fleeting, and they are quick. They are kind of an add-on, if you will. They are kind of an afterthought. I don't know if we have found a great way of integrating fully this idea of social determinants of health into medical education. It feels more an afterthought. And I think if we start to think about how we can then progress, that we have to address the fact that it seems at least in part an add-on. I think for me personally a lot of the things that I've felt as a medical student as far as my personal background or knowledge about social determinants of health comes from my background. It doesn't come from what I've learned in medical school. It comes from my public health degree. I was a sociology major in undergrad. And I had more experience and more kind of thought behind social determinants of health before even entering medical school. And so if I'm being frank, I'm not necessarily sure what's been added to that background while being in medical school. I think oftentimes, again as I said it tends to be something that is thrown into the curriculum because it's the new age thing to do. Let's focus on social determinants of health and therefore we have now physicians who are able to kind of at least say that they learned something about it. But again that's not necessarily the way I believe to approach, approach us thinking critically about the issues that are going on. Particularly in Flint. I think that while it provides a lens and it provides a place for us to kind of see the public health crisis that was going on in the Flint water crisis, I don't necessarily know if being a Flint student if I got access to how we will, as physicians, address the needs of the patients who we are serving. And that to me is kind of getting at the psychosocial dynamic that Libby kind of introduced us to.

KKB: So it sounds like based on what you've said, it's not just about making people aware of the social determinants of health, and the community and social needs of the patients, but it's also about what resources, what infrastructure is actually in place that we can address those needs in a meaningful way. That there can be resolution on the back end. And it sounds like what you're saying, and please correct me if I'm wrong, that that's not really something that you've gotten as a medical student. And the times that you've been exposed to that in medical school, it's not been in depth, and it has no, no breath that really will help you as you become a practicing physician.

BA: Correct. I think that oftentimes too as I said we've kind of gotten on the bandwagon in medical education of trying to address social determinants of health, but we haven't necessarily figured out what is the best way to actually teach physicians that. Again I kind of have my own background in sociology and public health which informs kind of the career choices I've made coming into medicine. But if you don't have that background it's like how, how are you supposed to learn not only what are they, but how are you supposed to address practically those issues. And I don't know if we figured out a good way for those who don't have a background in this work, how are they supposed to not only become learners, and things like that, but how are they then supposed to practically apply the information that they've taken away.

LBL: So Brittany let me then press you a little bit further, and I should clarify that you're a student in the College of Human Medicine under what we call the legacy curriculum.

BA: Yes.

LBL: And we introduced a new curriculum, the Shared Discovery Curriculum, four years ago. And in the Shared Discovery Curriculum, Karen and I have worked at developing curricular expectations. And I'm just going to review some of those with you it'd be interesting to get your feedback. So in the first experiences, which we call the early clinical experiences, the students get exposed to and they learn about ecomaps, which is a strategy to learn ups and downs about a patient's social network. And then they're assigned an exercise to identify social service resources and examine barriers to those resources, and suggest ways to overcome them. Then in their middle clinical experience or what we call the MCE, they have a required rotation with social workers, you may have heard about this. And then in the late clinical experience they're assigned exercises to learn something about the social circumstances in their own geographic region around their particular community campus. And then they're again asked to identify social service resources particular to a patient case presentation. Does that sound like that strategy might be effective? What do you think?

BA: Yeah I think that those are all great beginnings.

LBL: Yeah.

BA: I think that those are all things to start out with. I think that again having something is better than not having anything. The thing that I would argue is how do we make sure that's standardized across all... I guess my thing is how is it standardized? For instance, does what they're doing then actually, is it just another assignment that they feel they have to do, or is it something-

LBL: Yeah.

BA: -You feel that they're really going to take away and then apply it to, to their career choice. For me, I'm going into family medicine, I'm currently applying right now, and that seems amazing to me. I would love to work with social workers, I would love to work with, you know, doing a social map and ecomap, things like that. But I think for me that's the stuff I'm interested in again based on my background-

LBL: Mm-hmm.

BA: -Those are the things that I'm interested in. I'm much more interested in like the psychosocial circumstances of health than anything else. But again to the person going into vascular surgery, you know, how does that apply?

KKB: That is a conundrum isn't it because if the goal is that we are incorporating social determinants of health into the social part of medicine. The bio-psycho-social part of medicine, which we like to stress at CHM, how do you engage those students who feel that, well I'm not going to be a primary care physician, I'm going to be a surgeon, how does this apply to me? Why is this important to me? Why is this something that I need to spend my time on, aren't there other people who can do this kind of work, which then frees up my time? I believe perhaps there is a disconnect between understanding that you are part of a team, and is the idea that we are going to make it easier for the physician to disconnect from the team because there's a feeling that that work is higher-order work, and the work of actually investing in understanding the social context of the patient is lower-order work, and therefore should be sort of siphoned off to those sort of mid-level career healthcare workers. What do you all think about that?

LBL: Well I think if, I mean, so I've done some reading on this. And it seems to me there is general consensus within the professional organizations that minimally, physicians should be screening for social determinants of health. And frankly, I think I'd be happy if they did the screening and then were aware of what those resources were, and who to go to to find those resources. And made that next step and did the referral. I think that would be a great start, and an improvement on what we currently have.

BA: I agree. I think that, you know, understanding the resources is a huge part of it. I think, you know, you can't necessarily defer it to the social worker or the case manager because again, it comes back to the question of whose job is it? You know especially as primary care physicians you kind of go in to this field trying to be kind of the first line of defense. Kind of being the ones to kind of coordinate all of the care, and I think, you know, if you don't do it then it's kind of like whose, whose job is it? I don't think that necessarily putting it off to a mid-level provider or a social worker or a case manager is fixing the problem. I think it's just kind of kicking the can down the road proverbially if you will.

KKB: So I'm gonna play devil's advocate a little bit, because I like what you said. Because that really is the notion and I think with the sort incorporation of patient-centered care, the whole sort of medical home model that came into fame a few years ago, this idea that the primary care provider was that sort of first line of defense. But I would potentially argue that that is an ideal model when the infrastructure doesn't necessarily exist for the primary care provider to be that first line of defense. When you are allotted 7 minutes, maybe 15 minutes, to spend time with the patient, some things are going to get left off of the agenda. So decisions are being made in, within the constraints of the clinical encounter, the visit. So what is the primary care provider to do if they are to be the first line of defense, when the infrastructure is not in place for them to do that most important work that many of them probably value doing. Any responses?

LBL: Well-

KKB: Any clarifications?

LBL: So we've talked about this a little bit in the past, and I would argue that if it's included in the electronic health record, and I am not going to go into all of the problems with the electronic health record, there are many. But minimally if you include screening for social determinants of health in the electronic health record, it would then prompt the clinician to think about some of, for instance, the barriers to full access and full engagement in care plan by the patient, and that's an important piece.

KKB: So what does screening look like?

LBL: Yeah.

KKB: I guess I am not familiar with, because that is sort of a new thing, this idea that we should be screening for the social determinants of health. But what does screening mean? Is there sort of like, is there or an algorithm, is there a rubric of some sort, what is being, what's in place that physicians are using to screen for social determinants of health? Because social determinants of health encompasses a wide range of social contextual areas impacting a patient's life. They can't screen for every one of those areas.

LBL: So, I would answer, and then I'm going to ask Brittany to weigh in here because you've actually seen electronic health records. I would imagine that aspirationally, and again it is aspirational, I don't think we're there yet. That a physician would screen for housing security, food security, safety, those sorts of things. And Brittany, can you help us out?

BA: Yes. And that's what I was just about to say, there, you're right, you're both right in the sense that Karen yes there are a number of things that kind of fall under this umbrella of social determinants of health. And if we kind of go back to the definition that Libby had mentioned as far as what are social determinants of health, right, I mean it's all the conditions that people are born, live, grow, work, and eventually die in. So that encompasses a wide range of things, kind of the causes and the effects. And I think that one of the things that at least I've seen that some doctors, again, not all, will ask particularly in kind of even more vulnerable populations like pregnant populations, things like that, are, pediatric populations, are do you feel safe at home. Do you have, well first of all, do you have a place to live? Let's start with that, and then if you do, do you feel safe there. What are things that you would change in your neighborhood if you could? What are things, so I've seen that. Again it's usually in those specific patient populations. That generally by no means is the kind of standard. I haven't seen that particularly asked in the electronic medical record. That's, I haven't seen that. But again, in some patient populations physicians will just ask. Maybe they have a background themselves in public health, I have seen that. Or they're just very kind of in tune with social determinants and so they will ask things around housing insecurity, food insecurity. I know the, the pediatric clinic in Flint has a food program with the market, with the Flint local market downstairs. You can get a food voucher every you come in for an appointment to get fruits and vegetables, things like that. So again, if you're in a, if you're in an environment in a place that kind of is attuned to issues surrounding social determinants of health you're much more likely to have a, a clinician ask those questions. However that by no means is the standard and that's not that's particularly detailed in the electronic medical record.

LBL: Yeah. And one of the things we've talked about too is the advantages of what you just described, and that is co-location of resources. So again aspirationally, it seems like if there could be social services available within the same site as the clinical care, that would be ideal.

KKB: So what would those social services look like in the same location. Are you talking about a social worker who's there as part of the clinic team, or are you talking about a food bank in the clinic? What exactly are you referring to as being resources there available.

LBL: All of the above. I think that would be ideal.

KKB: So in a sort of, a world where all those things could happen, [laughs] we could imagine that those things would be in place in a clinic site so that somebody could come and get all those things addressed. But we don't live in that world, I don't necessarily foresee that world on the horizon. So considering the limitations of our current situation, and understanding that physicians are not necessarily knowledgeable about social service resources, how do we engage students and policymakers to sort of enforce this idea that this is important, and that these are things to which we should be aspiring. How can we make the argument that doing these kinds of things leads to better health outcomes?

BA: Yeah I think, again, the thing that I kind of go back to when I talk about this kind of work being introduced into medical education is standardization. I think that as I mentioned just before, you know, some clinicians ask the questions, not all. I think that's kind of where Libby was going with when you introduce things into the electronic health record, you can't miss it. That's something that would be standardized across all fields, across all clinicians. And I think that that kind of goes into the, my point about how we introduce this into medical education. I think that it has to be something that we try to standardize across all students, across all schools. I think that when we talk about why this work is important, people have to first know what it is. Social determinants of health. A lot of people don't, even if they're in the medical field, don't even know what that is. And then oftentimes too what happens is if you know what it is, you find yourself kind of falling victim to the daunting task of how to address it. But I think just starting out with standardization would help a lot as far as figuring out how to standardize that type of curriculum in a medical education setting. So all students have to do it, and I think Libby mentioned a couple of examples of what the new curriculum is doing. All students have to do it. I think asking the question of why they think it's important would give great insight into what students even think about social determinants of health.

LBL: Mm-hmm.

BA: I mean, do they feel like that is a social worker or mid-level's job? Or do they feel like as a physician, no, people go to the doctor fairly often, it's my responsibility, and it's my responsibility to try to address those needs. But you can't begin to address those needs if you don't see how social determinants even connects with health. So if somebody comes into your office with hypertension, it's not just hypertension, right. It's not just high blood pressure. It's like what are the things, what are the social circumstances that inform that high blood pressure. Do they live in a food desert? Okay, then electronic medical record, we can ask about food insecurity. Do they have a place to live? Are they, do they have employment? All those things that contribute to stress. How does stress equate with blood pressure. You know, things like that. We have to kind of I think get creative and think outside of the box here as far as how we can standardize this.

LBL: So if I can put a plug in Karen to respond to you, the National Academies of Sciences, Engineering, and Medicine just released their report “Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health.” And their approach, they have the five activities to strengthen social care integration, and they suggest it includes awareness, which would be the screening piece, adjusting clinical care to accommodate the social barriers, assistance with connecting patients to needed social services, and then alignment to synergize investment in the community, and advocacy to collaboratively steer resources towards those health care needs. The other thing I think, so I think that probably will change the conversation. But the other thing I think we need is to look at some of the models. And so we don't live in a world where all those resources are available, but there are models out there. And I think the work that for instance Health Begins does where they put, they have speakers who describe how they got to their particular structure is useful. So we can look at models as well.

BA: Yes, no and I think that there are certain, and again models if we're getting creative don't necessarily have to come other models with a medical education. I feel like there were a number of public health initiatives that were done that were not necessarily popular, people didn't really know what the effects are. Like we could talk about smoking cessation. Now pretty much every building is smoke-free. It's like that was not popular at the beginning, that was a public health initiative that kind of, people had to kind of get on board with, but again that's a standardized thing. It's not some places allow you to smoke some places don't allow you to smoke, that's kind of a standardized thing. And we can go into airlines, there's a bunch of other kind of industries that have a standardized model for how they go about training their professionals to deal with kind of these issues. And I think even again just kind of getting creative and looking maybe to other things that would help us with trying to standardize how we as students are trained.

KKB: That's an excellent point that you make. You're right, we don't have to just look at medical education models when there are a whole host of models where people are engaged in this kind of work, who are actively engaged in programming and social justice activities to address social determinants of health across a whole range of spaces. So I think one of the things that we haven't talked about that we should perhaps talk about is this idea that we're not engaging in an either/or proposition. We're not saying that it should be the primary care provider or the social worker, care manager, or someone else. We're saying potentially that we need to look at a team approach. Oftentimes perhaps we just give lip service to that idea that healthcare functions best when we are collaborating as a team, when many of us who go and visit our doctors, we don't necessarily experience that in the doctor's office. Where we feel that we have a team that's taking care of us. That's potentially one of those models that we actually need to make real and applicable. That is not an aspirational idea, it's something that we can do right now, and possibly models existing where they are doing that and doing it well. What are your ideas about this idea of inter-professional teams? And can we instill in students the importance of that, and that it is important, and it is not just a throwaway idea.

LBL: Well I'd add that, you know, with the emphasis on value-based health care now, that unless you pay attention to social determinants of health, you can't expect to have an effective clinical encounter. That if you write a script for a patient and they can't fill it, it's not an effective clinical encounter, right? It's not successful. That you need to be aware of those in order to have successful clinical encounters. Where the patient can, then can move towards wellness.

BA: Yeah I agree. I think that again ideally the, the goal is to have kind of an inter-professional working relationship where you're meeting with everyone of part of a team every single day about every single patient. But again going back to what we were talking about before about the constraints. So again it's kind of like if you only have 15 minutes to address with these patients, what I would argue is maybe figuring out a way where you can either have group, group sessions, like group patient sessions, or you can have kind of outside time. Maybe your individual appointment is 15 minutes but then you have another provider who's also on that same team speak to you for an extended 15 to 30 minutes. And therefore your full appointment ends up being, you know, almost close to an hour. Again, that kind of would require a very aligned, you know, alignment of the stars if you will. But I think kind of getting into this group model that I've seen in some practices allows for you to have your individual sessions where you kind of get your clinical needs met, but then you also have group patient sessions where people can talk about the kind of psychosocial circumstances that they're dealing with as well.

LBL: That model I know is used in prenatal care, I think it's called "centering," and it's very effective.

BA: Centering pregnancy. Yeah. they say that's actually one of the best ways to reduce pre-term births, unnecessary ER visits, you know, people have more autonomy and empowerment over their health because they feel like they're more actively involved and actively engaged in their, in their health care decision making, and things like that. So that might be one way in which you not only have a team effort, but you kind of then add the social determinants piece as well.

KKB: So I've never heard of this model around pregnancy. So is insurance paying for those group visits?

LBL: It does.

BA: It does, yes. It's covered by insurance, yes. But again not every place has that, you know.

KKB: Mm-hmm.

BA: Not every not every clinic-

LBL: Right.

BA: -Has that. Not every place has that. And I've actually only seen that at a couple of sites. I think again being in Flint you see that there is a kind of at least awareness about, of course, what social determinants of health are, and they're trying to put in place these kind of infrastructural things to help address some of those needs like food insecurity with having the pediatric clinic right above the market. So that kind of solves at least one piece of the puzzle. But again oftentimes it's not in the same location. You can get referrals, so I'm not saying that they don't do a great job of trying to address the needs of the patients and then refer outward to those services, housing services, food services, transportation issues, things like that that a lot of patients have. But I think again it's not all in the same location. So that's another limitation.

KKB: And that's another barrier correct?

BA: Yes.

KKB: So I would like to know if we have some concluding statements we would like to make as we wrap this very intriguing and frank discussion, I think. Brittany do you have any concluding statements you would like to make?

BA: Yes, I think that of course coming from my perspective, social determinants of health are, you know, increasingly important. And I think that the way that we get students, and not just students interested in primary care or who happen to be in an underserved clinical community, is we try to standardize what it is that we are learning in order to train clinicians who have this wherewithal to figure out how social determinants connects with health, you have to have that training. You have to have that education and that understanding before you go out and practice on your own. And so I think as we kind of move into how we can figure out how to engage and train future clinicians about social determinants of health, it starts there. So I think we need to try to standardize what it is that we're being trained to do.

KKB: Libby, your final thoughts?

LBL: The only other thing I can think of is I put a plug in for the very unpopular health record, electronic health record, and say in a future world I could envision a really smooth, interoperable health record where once you screen, then you can look at resources available to that patient for where they live, and for what their needs are. I think that would be wonderful.

BA: I agree. [Laughs]

KKB: [Laughs] That would be fantastic. I guess my concluding statements would be just to piggyback on what both you and Brittany have spoken to, is that this is important work. This is not a throwaway, this is not something that should happen as a pass through, this is something that is real, this is something that affects how people live every day, it affects how people work, it affects how people are going to be well and maintain wellness. And so I will end by saying it is the right thing to do. So if we operate on that premise, then folks are going to have to decide which side are they on. I want to thank you both for a very lively, frank, and honest discussion. Thank you very much for your time.

LBL: Thank you.

BA: Thank you.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at for full episode transcripts and other resources related to this episode. A special thank you to H-Net: Humanities and Social Sciences Online for hosting this series. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel in the Center for Ethics. Music is by Antony Raijekov via Free Music Archive.