An innovative Vanderbilt major developed to introduce future health care workers to the impact complex social issues have on health has successfully increased students’ ability to recognize the link between those issues and health outcomes without compromising their preparation for medical school, according to an article published in the online edition of Academic Medicine Nov. 30, 2016. The article is currently scheduled to appear in print in March 2017.
Lead author Jonathan Metzl, director of the Center for Medicine, Health, and Society, and co-investigator JuLeigh Petty, assistant director of Medicine, Health and Society, measured the program’s effectiveness through exit surveys completed by 85 graduating seniors as the first of three institutional analyses of the program.
A revolutionary approach toward premedical education
Though medical schools have been training doctors for several years to consider their own biases when interacting with patients, there has been less education about the important roles that social, economic, racial and political factors play in determining why certain conditions are worse or more prevalent in certain groups and who seeks and receives care—and none at the undergraduate level.
Vanderbilt’s interdisciplinary Medicine, Health and Society major was conceived to provide undergraduates with not only the biomedical foundations they need for advanced medical education but also mastery of the complex social factors that influence health and health care access.
“We combine the traditional sciences with sociology, anthropology, literature and critical race studies, among others,” said Metzl, who is the Frederick B. Rentschler II Professor of Sociology and Medicine, Health, and Society. “Of course it’s vital that doctors learn about people’s biologies, but what we’re learning is that it’s not enough if you don’t also understand the social context. Epigenetics, for example, teaches us that living in resource-poor environments can actually change your genetic makeup, so it’s very important for doctors to know not just about biology but also about society. The MHS major combines scientific expertise with cutting-edge approaches to social context—it’s truly a unique way to design a premed program.”
Following a curriculum redesign in 2013, the major now includes coursework that specifically address issues in structural competency, such as:
- Race and Ethnic Health Disparities
- Politics of Health
- Economic Demography and Global Health
- Global Health and Social Justice
- Community Health Research
- Medicine and Literature
The undergraduate environment is an ideal setting to introduce aspiring health care workers to these concepts, Metzl said, because it allows students to cover these ideas in greater depth than is feasible to shoehorn into an already-packed medical school curriculum. “This is the kind of skillset people want doctors to have now, and what we’re showing is that the undergraduate years are the ideal time to implement this paradigm change,” he said.
Metzl and Petty developed a testing instrument called the Structural Foundations of Health that included closed- and open-ended questions designed to demonstrate mastery in areas of what has been called “structural competency.” The prompts included a discussion of regional disparities in childhood obesity, racial disparities in cardiac mortality and the factors that might influence why the makers of a depression drug cast a white mother in their advertisement.
85 percent of students identified structural factors as contributing to childhood obesity, primarily individual- or family-level issues or social and political issues.
92 percent implicated structural factors in the cardiac mortality scenario, primarily due to socioeconomic differences, discrimination and race-based policies.
Interestingly, it was the third scenario that students struggled with the most. While 23 percent were able to identify the role gender played in the casting and messaging of the depression drug ad, only 5 percent identified race—indicating that students had difficulty recognizing that issues of race affect those in the majority, too.
“The past few years have shown us that debates over health are politically and morally charged. We are encouraged that our curriculum trains students to address these complexities,” said Petty.
MHS students were more racially and ethnically diverse than Vanderbilt’s student population at large, with 40 percent identifying as nonwhite. Roughly 40 percent of the surveyed students planned to become physicians; the rest were working toward careers in nursing, social work, public health, health care administration, the humanities and consulting.
Overall, these students reported feeling well prepared for their chosen fields. Medical school acceptance rates for MHS graduates (62 percent) were comparable to those majoring in molecular and cellular biology (65 percent) and neuroscience (61 percent). Nationally, the average medical school acceptance rate is 43 percent.
Future studies will compare the structural competence of MHS students against traditional premed students, as well as establish a baseline of structural competence in first-year students prior to the declaration of a major.