Residency is commonly thought of as a proving ground for the skills required to practice within a given specialty. But a big variable is the context in which care is delivered—for example, practicing medicine in the Bronx is a whole lot different from practicing in Bel Air. And this begs the question: How effective can health care be if it doesn’t account for the social determinants of health?
An AMA Insight Network webinar explored this question with Catherine C. Skae, MD, senior vice president for graduate medical education at Montefiore Medical Center, in New York City. Montefiore is four years into a multipronged curriculum that investigates social determinants of health at four community-based primary care training programs.
The curriculum is funded by a grant from the AMA Reimagining Residency initiative, which was launched in 2019 to transform residency training to best address the workplace needs of our current and future health care system. Through nearly $20 million in grants over five years, this initiative funds 11 projects to help create a meaningful and safe transition from undergraduate medical education to residency, establish new curricular content and experiences to enhance readiness for practice, and promote well-being in training.
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Something was not right
“When I look at some of the poor outcomes in the Bronx, I scratch my head,” Dr. Skae said. “There’s 62 counties in New York state, and we always come up on the bottom” of a number of health care metrics.
It’s ironic, she said, because New York City is in many ways a resource-rich environment.
“There's just so much opportunity here to connect people—our patients, our communities—with resources that they may never have heard of,” she said. “That’s a huge part of the work of this grant.”
Montefiore’s social determinants of health curriculum has now been implemented in four of its residency training programs: family medicine, internal medicine, obstetrics and gynecology, and pediatrics. Those include nearly 300 trainees per year.
It started with a needs assessment, and the results were not what Dr. Skae and her colleagues expected. Case in point: 46% of graduates in those four programs had minimal to no knowledge of how to refer patients to community resources.
“These were people who have been here three or four years,” Dr. Skae said. “This inspired so much more work to look at the system in which we're practicing, because you could be the most amazing radiation oncologist, and if your patient cannot get here five days a week, their health outcomes are going to suffer. If they're due for chemotherapy on a certain day of the week, of the month, and they cannot get here, it leads to worse health outcomes.”
Learn more about the AMA GME Competency Education Program, which delivers education to help subscribing residency institutions effectively meet ACGME requirements and prepare learners for practice. The “Navigating Health Systems to Improve Patient Care” learning series covers topics such as social determinants of health and improving population health. The program provides an award-winning virtual experience, with quality education designed for residents on the go. Learn more.
If you don’t ask, you won’t know
Residents in the four residency training programs now review the answers to at least 10 questions asked through a universal screening, including:
- Are you worried that in the next two months you may not have a safe or stable place to live?
- In the last 12 months, did you worry that your food could run out before you got money to buy more?
- Does anyone in your life hurt you, threaten you, frighten you or make you feel unsafe?
They then get support from a best practice toolkit, service directories, resource sheets and the ability to make referrals to community health workers.
Montefiore physicians looking to get patients the resources they need used to rely on bulky binders passed around clumsily from one doctor to another. Now everything is electronic, and residents are screening about 10,000 patients a month.
“These numbers, they don't surprise me, but it's really overwhelming,” Dr. Skae said. “Knowledge is one thing. Experiential learning—and doing something about it—is a whole other.”
