No, Practicing Medicine Is Not Just About Basic Biology

Ramie Fathy


September 20, 2019

Early on in my clerkship year, I had the opportunity to rotate at the Ob/Gyn residents' clinic at the Hospital of the University of Pennsylvania. The clinic offers low-cost services to members of the Philadelphia community, and yet nearly half of appointments are missed on a daily basis. Speaking with patients who were able to make their appointments, sometimes after several months of missed appointments, I learned that the limiting factors in their healthcare – and at times, that of their expected child – were logistical difficulties traveling to the clinic, getting out of work, or gathering the funds to hire a babysitter so that they could visit the hospital without having to worry about their children. In other words, the rate-limiting step in these patients' healthcare was not their medical condition but their social and economic condition.

In a recent Wall Street Journal article, a former associate dean at the Perelman School of Medicine at the University of Pennsylvania shared his opinion on the increase in medical school curricula that discuss the social determinants of health, or the conditions in which an individual is born, grows, and works that can influence health. In his op-ed, Dr Stanley Goldfarb outlines his concern that medical schools are increasingly focusing on these social factors and their "tangential" relationship to healthcare. These curricular elements, he believes, detract from students' learning of the basic scientific knowledge needed to practice medicine, which he worries will result in worse physicians in the future.

Dr Goldfarb is correct in one regard: medical schools are increasingly incorporating coursework on the social determinants of health. Before we get into why this shift in medical school education is not only a good thing, but necessary, I should address Goldfarb's central claim: that teaching the social determinants of health comes at the cost of future doctors' basic scientific knowledge. If that were true, we would expect the increased time spent on social determinants of health in medical school classrooms to be correlated with a decrease in scientific knowledge needed to practice medicine ― but it's not. In recent years, student scores on national board exams ― which are designed and validated to measure understanding the scientific knowledge needed to practice of medicine and have been linked to both higher physician quality and lower rates of patient complaints ― have continuously improved, including on the practical clinical knowledge exam. While I am not trying to make a causal claim and say that teaching social determinants of health improves basic scientific knowledge, these trends should reassure readers that future doctors are not compromising their education on the biological underpinnings and treatment of disease in favor of learning about the social and economic determinants of health. Medical school education is not a zero-sum game: it seems that medical students are capable of learning about both the biology of disease and the context in which it develops.

There is an expansive and growing body of literature outlining how social factors impact health, as well as how doctors who are familiar with this impact can work to address it. From the negative health effects of chronic stress from racial discrimination to growing up in a ZIP code with a lower average income or limited access to fresh food, the circumstances in which one lives have a demonstrated impact on access to healthcare and overall length of life. For future physicians, awareness of these factors or of ones own implicit biases can help to inform interventions and treatment recommendations as well as eliminate barriers to access and ultimately improve health outcomes. In other words, by preparing medical students to account for and address the contextual factors that can affect health, including their own behaviors,, medical schools provide their students with the skillset and knowledge needed to provide better, more holistic care to their future patients.

Doctors who learn about the social determinants of health are not only taught how to deal with these issues on a case-by-case basis: they are also empowered to address them on a larger scale by drafting and supporting policy changes. Physicians hold a privileged place in society. Their voices are heard and trusted, and they see and treat the effects of social issues like gun violence and racial discrimination firsthand. In fact, when surveyed, a majority of physicians agreed that their patients' social needs are as important as their medical conditions and that the health system should be better equipped to address those needs. Poised to propose and influence policies that impact the overall health of society at large, physicians have a responsibility to advocate for potentially health-improving policies and to combat existing structures that underlie poor health outcomes. Coursework that teaches trainees effective communication strategies and increases awareness of nonbiological factors that affect health is critical to empower physicians to fulfill this responsibility. And the medical schools that produce these doctors have an obligation to educate their students on these issues so that they may better identify and address them in the future.

Medical school is a time of professional development when students learn how to be a physician in addition to the knowledge necessary to practice medicine. Medical schools are responsible for teaching us to be caregivers as well as scientists, medical professionals who see the person behind the patient. Teaching the social determinants of health is crucial to mold practitioners who treat their patients as more than a collection of symptoms or a unifying diagnosis, but as members of society with unique experiences and limitations that may affect their health or healthcare. This is especially true in a time when medical students are increasingly found to become less empathetic during medical school and when effective curricular activities have been identified that can prevent this "erosion of empathy." The curricular components that best accomplish this goal, however, are not the traditional basic science courses but rather the experiential training, dedicated coursework on health inequalities, and extracurricular activities that cannot be found in a biochemistry or pathology textbook.

As one of the curriculum representatives at the Perelman School of Medicine at the University of Pennsylvania, I've seen the substantial effort that the school's administration has put into integrating education on the social determinants of health into our curriculum. Through our Doctoring course, for example, students are provided with a curated curriculum and space to learn about and discuss the social determinants of health. The school's various community clinics are a venue for students to apply the clinical knowledge they have gained in the classroom in order to provide basic healthcare to members in the community who have limited access to the healthcare system. Nearly on a daily basis, speakers are invited to educate students on issues ranging from human rights to racism in medicine. And just as Penn was the first medical school in the nation, it also has been a leader and innovator in education on how social conditions can influence health.

The art of medicine is in both diagnosis and dialogue. Just as humans cannot be viewed simply as a collection of biological processes, so too are patients more than their symptomatology. For medical practitioners to best improve health overall, they must understand the various factors that can influence health, both biological and nonbiological. Medical school classes on these issues don't detract from traditional medical knowledge but enrich it. After all, medical school is the stage of training that is meant to teach students about how disease develops, how it can be treated, and how it can be prevented. This makes medical school the ideal time for students to learn about the social determinants of health. These determinants represent important mediators of disease that can be addressed at both an individual and societal level to reduce the overall burden of disease.

Encourage medical schools to continue teaching their students about the social determinants of health. Dr Goldfarb's viewpoints overlook the tremendous influence of social context on an individual's health. Teaching future doctors about these social determinants of health doesn't make for worse physicians, but better ones, doctors who understand their patients, where they come from, and how to best help them. And that's better for everyone.

Ramie Fathy is a third-year medical student and curriculum representative at the Perelman School of Medicine at the University of Pennsylvania. The opinions expressed in this perspective are his own.

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