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Between #MeToo & #TimesUp, the last year has been a high water mark for the awareness of the challenges faced by women in our society. In honor of Women’s Heritage month, the Beyond Flexner Alliance brings you a newsletter this month highlighting the amazing and diverse work being done on gender inequities across health professions; work often being done by women in academia to highlight the trials they face in their training and the tribulations their patients face in achieving health equity. We encourage you to explore the full breadth of leading content we are highlighting this month from an academic study of bias faced by female dental students to a new WHO strategy to address gender inequity and even a media plea for more women to participate in clinical trials. There is a lot of ground to cover, but we hope to have a curated a few highlights for members of the Beyond Flexner Alliance to stay on the leading edge of work in gender health equity.
Social Mission Champion Spotlight
Dana D. Hines, PhD, RN
Dana D. Hines, PhD, RN is known as an emerging nursing leader in transgender health and for her work on issues related to access to HIV care, affirming environments of care, and cultural competency training and education for clinicians. Prior to entering academia, Dr. Hines worked for the Marion County Public Health Department in Indiana as an HIV surveillance coordinator and clinical quality program manager. During this time she led several health disparities projects aimed at improving engagement in HIV care. Since joining the faculty at GW School of Nursing, Dr. Hines has continued to focus her research on health disparities impacting transgender women, a population rarely offered research opportunities and who have historically been exploited or subsumed under the category of men who have sex with men. Health inequities persist in this population because of stigma, discrimination, and because healthcare providers are inadequately prepared to manage the complex health and social needs of transgender individuals. Dr. Hines’ approach to research targets disparities related to HIV, lack of healthcare provider knowledge, and treats participants as equal partners in the research process.
Faculty are too often the major barrier to change in health education institutions and health systems. Faculty tend to view themselves as teachers, who teach, and the students as learners, who learn. However, this view is fundamentally oppressive. We can improve our ability to instill social medicine in health professions education if, instead of learning coming from a teacher bestowing knowledge on a student, learning comes through experiencing the reality of health inequity together, as students AND teachers, and working together to create new knowledge for all parties and the radical change that must follow it.
This may seem theoretical, but when protests erupted across Haiti on July 6 after the government’s announcement of significant increases in fuel prices, we knew that the content of our sixth annual social medicine course, “Beyond the biomedical basis of disease,” would ensure that students recognized the structural drivers of the unrest rather than accept the superficial news headlines, and that we needed more than ever to move forward with holding the course in Mirebalais, Haiti as planned (1). We began on July 9, despite the unrest, via a webinar by human rights lawyer Brian Concannon (2). We sought to come together as students and teachers (virtually for the first week and then in person for weeks two and three), sharing our experiences through discourse, to generate an understanding of the unrest in Haiti as being driven by structural injustice, rather than an oversimplified and racist narrative insistent on labeling Haitians as vicious plunderers (as a black American, this trick is all too familiar) (3). One of the foundational sessions in our three-week long social medicine immersion course is “Neoliberalism and Health Care,” which explores the complex web of international aid, from the International Monetary Fund’s structural readjustment programs to the real-life impact of tied aid. With this course under their belts, students would not fall into the trap of blaming Haitian leaders alone for the recent unrest, but would recognize the behind the scenes hand of global development paradigms.
Racial and ethnic minorities continue to be subjected to a sustained pattern of disparate treatment in health care with no panacea for the confluence of contributing factors. In the 2003 provocative landmark report, Unequal Treatment; Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine (IOM) exposed a painful truth about the health care system. When racial and ethnic minorities enter the clinical arena, they are less likely to receive routine medical procedures, appropriate cardiac medications, or essential clinical services. The differences in how minorities are treated in health care contribute to their higher rate of disability and mortality.
Since the 2003 IOM report, the tendency for racial and ethnic minorities to receive an inferior level of care has not abated. A 2007 systematic review conducted by the Department of Veterans Affairs (VA) found that African American male veterans received less aggressive pain management for osteoarthritis, providers gave them less information about cancer, and clinical decision making varied based on the veteran’s race. More recently, the Agency for Healthcare Research and Quality revealed in the 2016 National Healthcare Quality and Disparities Report that “most disparities have not changed significantly for any racial and ethnic groups…especially among people in poor and low-income households, uninsured people, Hispanics, and Blacks.” Although the gap in health insurance coverage between minorities and whites has narrowed, differences have actually widened for quality indicators such as annual foot exams and prevention of lower extremity amputations among diabetics. Indeed, the persistence of health care disparities, which the Institute of Medicine defined as “differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness or intervention,” is alarming and depicts a dismal reality for ethnic and racial groups.
Innovating to Improve Care Now and In the Future: Screening for and Addressing Social Determinant of Health Needs
Bonnie Ewald, MA, is a Program Coordinator at the Center for Health and Social Care Integration at the Rush University Medical Center.
Physicians and other health care providers can learn a lot from the world of social work. Social work, as a discipline, has long been engaged in addressing social factors that influence health. Through interprofessional collaboration with social workers as part of the team, we can both address social determinant needs today and improve the capacity of healthcare providers less seasoned in doing so. Many interprofessional education initiatives, such as the Camden Coalition’s student hotspotting program, aim to have student groups work with individuals and community resources, which will enhance those students’ care in the future. But we must also focus on how to adapt health care now to better identify and address social determinant of health needs.
Rush University Medical Center developed an interprofessional leadership group and partnered with other hospitals and agencies on the West Side of Chicago including Catholic Charities, Patient Innovation Center, UI Health, Presence Health, and Sinai Health System to form what is now known as West Side ConnectED. In this effort, the institutions are working to identify and mitigate the health and social needs of those living on the West Side of Chicago and being served by the hospitals respective emergency departments: including areas such as food insecurity, housing instability, utility needs, transportation, and access to care (including having a primary care provider and insurance). This screener was designed at Rush for discrete data collection and integration into the Epic electronic health record system, allowing for better reporting and care management. (Similar initiatives are underway across the country; if interested, we recommend reading about efforts by Health Leads, Oregon Community Health Information Network, and the Centers for Medicare and Medicaid Services.)
A medical school, by definition, is a professional school, preparing graduates for their future profession. What are we preparing graduates to do? As we debate the future of our health care system, we must decide if physicians are responsible for improving health in a broader sense, or only for diagnosing specific patient problems and prescribing treatments.
Professions come with the expectation that you use your knowledge to improve people’s lives. Medical students prepare for clinical care, but do medical schools teach doctors to advocate for their patients holistically? Are doctors trained to meet the Triple Aim by promoting population health?
This blog was originally posted in the Josiah Macy Jr. Foundation Fall Newsletter on November 13, 2017.
Morehouse School of Medicine (MSM) was the first institution to receive the Josiah Macy Jr. Foundation Award for Institutional Excellence in Social Mission. We spoke with Valerie Montgomery Rice, MD, president and dean, to learn more about her institution’s efforts.
In your opinion, what does it truly mean when a school has a strong social mission?
I think about that question all the time. For me, when a school has a strong social mission it is leading the creation and advancement of health equity. I’ve boiled that down to mean giving people what they need, when they need it, and where they need it.
It goes beyond making sure our students have core medical knowledge. It is about ensuring our future clinicians understand the basic needs of the individual, the community, and the entire population. That means considering whether a patient can afford his or her co-pay, to understanding the barriers patients face with adequate housing, access to transportation and the ability to purchase fresh fruits and vegetables. These social factors are often the greatest barriers to people being able to reach their optimal health. If a school has a strong social mission, it is embedding these health equity themes into all of its education and training.
In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”(1), Fitzhugh Mullan argues that medical schools should be committed to their social mission, which is “…about making health not only better but fairer—more just, reliable, and universal”. This means commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, and increasing diversity within the health professions. He cites some medical schools as having made significant advances, including Morehouse, Mercer, Florida International University, and the AT Still Mesa Campus. But he also talks about “mainstreaming”, the need for consciousness about, and more important implementation of, social mission in all medical schools.
I believe that the most important measures of a health professions school’s social mission are its outputs, the criteria used by Mullan and colleagues in their seminal 2010 article (2): Are its graduates diverse? Do they practice more in underserved areas? Are they in primary care specialties? Studies show that a well-functioning health system needs at least 40-50% of physicians in primary care; the US is well below 30% and decreasing.
As a safety net dentist, I’m sadly accustomed to my patients telling me that they are in pain. Even in Massachusetts, where most patients are insured and Medicaid provides dental coverage, the vast majority of my patients must wait unconscionably long to finally get a dental appointment, and often have not had reliable access to dental care. Yet the patient telling me this story wasn’t at a dental office – he was at a primary care visit with my preceptor, speaking to me as a first-year medical student.
I chose to enter medical school because I was heartbroken by how the separation of medicine and dentistry harmed my patients. Throughout my medical training, I have only seen even more unaddressed dental need. I have met patients with endocarditis or pneumonia from untreated tooth infections, patients with malnutrition because they can no longer chew, and far too many patients with pain they simply cannot stop. This suffering falls disproportionately on the most vulnerable, including communities of color, older adults, low income people, people with a history of incarceration, people with mental illness or substance use disorder, and rural dwellers.
Julie Orban is a research associate at The George Washington University Milken Institute School of Public Health.
In today’s complex health care environment, given that stakeholders and policy experts commonly expect demonstrable evidence of quality, accountability and improvement, measurement has become an integral part of doing business. Now that social mission has been identified as part of the mission of health professions education, there is a desire to obtain and quantify data to advance health equity and reduce health disparities. The measurement of social mission performance in health professions schools is nascent. Various organizations such as THEnet and ASPIRE have pioneered the development of measurement tools. There is promising consistency in the philosophies that govern the measurement tools of these two organizations and leadership at schools using these tools have described great benefits in going through the assessment process. However, usage has been mostly limited to medical schools rather than health professions schools in general, and the tools themselves are primarily targeted to schools looking to excel in social mission, rather than all comers.
Republicans and Democrats in Congress continue to battle over repealing the Affordable Care Act (ACA). Whether ACA is carried out as planned or replaced with something entirely new, our physician workforce is unlikely ready to meet the changing healthcare needs of the nation. Shifts in demographics, the rise of chronic disease, and escalating health care costs are placing new demands on the knowledge and skills of our doctors. Most American medical schools, however, continue to educate their student doctors in the same ways of decades past.The Association of American Medical Colleges predicts a shortage of 35,600 primary care doctors by 2025. We need more primary care physicians and a more diverse workforce, in cities as well as rural communities and formally designated health professional shortage areas. We need a workforce that understands the importance of prevention and is judicious in its use of limited financial resources for health.Medical schools are a key part of the supply pipeline that can help meet the changing health demands of the American people, but are they aligned with the nation’s emerging healthcare needs? Do they even consider themselves part of this essential pipeline?