Based on her own family history, this medical student knows that future physicians need training in health disparities and social determinants of health.
By Tehreem Rehman
When I was growing up, my mother often recounted the story of a dermatologist who figured out that the fungal infection in her hands stemmed from sensitivity to dishwashing liquid. He had asked basic questions about her living circumstances during the first visit, recommended she wear gloves when washing dishes from that point on, and saw improvement in the follow-up appointment. He didn’t charge her for the second appointment as he knew my mom was uninsured at the time and struggling financially. When my mom inquired about the fee, he simply said, “Your getting well is my fee” and gave her sample medications.
Hearing this account made me realize what a significant impact socioeconomic status has on health. As a minor and an American citizen growing up in New York City, I was fortunate to be automatically insured. I took for granted regular visits to the pediatrician. However, when my mom immigrated to the United States, access to basic medical care was a luxury.
It would be naïve, though, for me to confine the implications of this account to unequal access to health care services. What was particularly salient for me was that this physician took the time to learn more about my mom’s living conditions. In the end, where and how she lived served as the most helpful indicators of the treatment she needed. Narratives such as these were always at the back of my mind as I often saw the impact class has on health. After 9/11, my father was the target of several hate crimes, and he felt compelled to close his small business as a result of these threats. Our financial situation progressively worsened over the next several years. During high school, I began to notice that unlike my peers, obtaining fresh fruit or certain meats was a luxury for me. We eventually began using food stamps and the range of food we could purchase narrowed. As I became more weight conscious as a teenager, it became more difficult to eat healthier. A gym membership was out of the question. And running outside wasn’t safe.
Personal experiences like these spurred my investment in health justice and my decision to go to medical school to address health inequities in the community. Health disparities in the United States are undoubtedly a significant phenomenon. From 2003 to 2006 alone, minority health disparities cost nearly $230 billion
. More important than the financial burden of health disparities
in this country, however, is the social burden that such inequities inflict on historically marginalized populations. As Martin Luther King, Jr., so eloquently said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane
.” Medical professionals are in the unique and privileged position of advocating for patients in a manner that is not confined to the clinical setting. Primary care providers are conventionally in the best position to address social determinants of health, but as my mother’s story shows, specialists can (and should) do it, too. Whether it’s through community-based outreach, education, political activism, or research, medical professionals have the ability to address the various factors that impact health. In order to truly care for patients from historically marginalized populations, however, it is particularly important to address social determinants of health.
Many American medical schools have recognized the need for medical students to learn about health disparities in order to best serve their communities. At the University of Michigan Medical School and The University of Chicago Pritzker School of Medicine (PSOM), for example, medical students go through intensive training on health disparities. UCSF has a special track that focuses on the urban underserved population. My hope is that Yale, too, can soon join these schools in enhancing its social medicine content in response to student demand. Fortunately, various faculty members have voiced strong enthusiasm for such a program.
Several studies note collateral benefits of health disparities curricula. University of Chicago concluded that their required health disparities course increased enrollment of under-represented minority students. This is a clear step towards increasing diversity in the physician workforce, although greater measures still need to be taken with respect to class. In the meantime, under-represented minority and economically disadvantaged medical students may be able to educate their classmates about health inequities based on their own experiences—ideally, while avoiding tokenization by their peers. Studies also show that the added emphasis on health disparities may help retain under-represented minority faculty. However, health disparities is not a “minority” issue; it’s an American issue that we all need tackle together.
Because of my own experiences, along with the demonstrated benefits of a social medicine curriculum, a fellow medical student and I are hoping to run a pilot course. We hope to measure the impact it has on students’ understanding of health inequities in the United States, and identify potential areas for improvement for a full-fledged course. Topics will include exploring the internal biases we all have against people from different backgrounds; the scope of health injustices in our society; ethical questions related to equitable distribution of resources; political advocacy and legislation; social determinants of health, such as housing and access to food; maternal and child health, and mental health. Neighborhood tours will show students how the concepts discussed in class apply to our immediate surroundings.
We’ll follow current literature on health disparities curricula, such as a recent article that discusses the inclusion of role-playing and a skills-based workshop on recognizing and overcoming subconscious bias. Furthermore, the Society of General Internal Medicine’s Disparities Taskforce Speakers Bureau offers a rich database of potential speakers.
While it would certainly be a positive outcome of the course if more students chose to go into primary care, the main objective is to expose Yale medical students to social medicine and the health inequities that exist in their own backyards. Many studies have unfortunately indicated that the attitudes or actions of individual medical providers can contribute to the existence of health disparities. Such an awareness would undoubtedly benefit medical students’ future encounters with patients as they develop a deeper understanding of the history of the relationship between various populations and the medical establishment, the significant roles that race, ethnicity and class play in the lives of patients, and the nature of their patients’ communities.
Tehreem Rehman is a first-year student at Yale School of Medicine. She has previously served as the National Chair of the American Medical Student Association's Race, Ethnicity, and Culture in Health committee and as a National Editorial Advisor for New Physician Magazine. Tehreem is interested in clinical interventions for violence, addressing gender power dynamics in the clinical setting, and the impact that health inequities have on women of color and low-income backgrounds.