Teaching Social Drivers of Health in Medical Training

It’s easy to imagine a first-year medical student sitting in a large lecture hall, learning about cell biology and the Krebs cycle. But today we know that it’s just as crucial for future care providers to learn about food insecurity and homelessness. According to the National Academy of Medicine, social drivers of health — also known as social determinants — are responsible for at least 80% of our health.

Social drivers can include access to nutritious food, stable housing, transportation, healthcare, community support, and more. Recognizing the wide-ranging impact that social drivers have on health is helping the medical community identify and address systemic issues that contribute to chronic health conditions such as high blood pressure, diabetes, obesity, and asthma. 

This broader view of health is driving new approaches to care — and making its way into higher learning as well, said Kamilah Weems, director of strategic initiatives and partnerships for the American Association of Medical Hospitals, which represents 170 medical schools in the United States and Canada and more than 400 teaching hospitals and health systems.

Health educators are increasingly teaching social drivers to address health beyond traditional clinical tests and treatments. For example, simple lifestyle factors that can have profound medical implications: “Take a heart patient who might be 65 years old and is told they need to avoid salt,” Weems said. “If they live in an urban food desert, or a rural area where it might be an hour to get to the closest grocery store, that may not be easy to achieve. These are the sorts of things that physicians need to know about their patients and where and how they live, to try and understand what other resources are available to help them.”

Medical students trained to assess social factors can consider non-medical interventions and partnerships, Weems said. “What it might look like is asking a patient to describe where they live. Asking a patient ‘How did you get to your visit today?’ Or ‘How are you getting home?’ 'Can you tell me about the neighborhood or area where you live?' 'What type of work do you do?’ These are the types of questions that care providers can ask.”

Unique Approaches to Teaching About Social Drivers

Schools and teaching hospitals are finding a variety of ways to teach about health equity and social drivers, Weems said, and many are offering nuanced curricula in keeping with the changing definition of health. "It's not really one size fits all, and that's a good thing, because each medical school develops a curriculum that's relevant to their own local community.” Some examples of this type of instruction:

• The International and Domestic Health Equity and Leadership section at UCLA was founded to “define and promote the role that academic emergency medicine can play in the promotion of health equity and the elimination of health disparities.” It includes teaching modules focused on issues such as food insecurity, homelessness, violence intervention, and transportation as well as a course on social medicine taught at the UCLA David Geffen School of Medicine.  
• At the New York University Grossman School of Medicine, first-year medical students attend lectures and workshops on social drivers of health, healthcare systems, and health policy, including an initiative called “Healthcare by the Numbers” to give students the chance to study and make recommendations based on New York State hospitalization data. The school also offers a 12-week scholarly concentration in social drivers during clinical training.
• At Wake Forest School of Medicine in North Carolina, faculty implemented a health equity curriculum for third-year medical students that included health equity simulations, online modules with scientific data on the issues, and experiential learning via partnerships with community-based organizations such as Help Our People Eat (H.O.P.E.), which provides food to people experiencing food insecurity.
   

A Greater Awareness of Social Drivers and Their Impact

Social drivers can have a real and measurable impact on health. For example, a study published in Pediatrics found that children were at higher risk of serious asthma, resulting in emergency department visits or hospitalizations, if they lived in areas that had lower educational attainment or where violent crime was present. Another study found higher rates of chronic disease in adults ages 18 to 65 years old  with low incomes and experiencing food insecurity.

“A whole-health approach to medicine requires a whole-person perspective, including diagnoses and treatment plans that look beyond clinical conditions. It’s a systemic shift in thinking — a team approach to care that addresses physical, behavioral, and social drivers of health,” said Dr. Shantanu Agrawal, chief health officer of Elevance Health. To facilitate the shift, he said, this evolving perspective of health also needs to be woven into medical training for care providers. 

Weems agreed: “A third- or fourth-year medical student, or someone in residency who is presenting on a patient during rounds, has to talk about the clinical plan of action: ‘How are you going to clinically treat that patient?’” she said. They might also need to involve social workers “to understand if there are other resources that this patient might get access to, such as gift cards for grocery stores or help with transportation to a grocery store. All of these factors go into offering good care.”

As the view of healthcare expands to a whole-health perspective, diverse health, government, and community-based organizations will need to work together to address the social drivers of health, Weems said. “Physicians and healthcare systems that promote healthy choices alone won't eliminate health disparities,” she said. “There have to be other public organizations like education, transportation, government, and housing that also need to take action to improve the environment and the conditions where people live.” 

Elevance Health recognizes the crucial role that social drivers play in health, which is why we have partnered with many community-based organizations and worked internally to fight food insecurity, provide social support and health literacy, improve access to healthcare, support maternal and child health and reinforce our whole-health approach in myriad other ways.