Going beyond clinic’s 4 walls to address health’s social roots

Brendan Murphy , Senior News Writer

Almost 170 years ago, German physician and anthropologist Rudolf Virchow drew a strong correlation between adverse socioeconomic conditions and sickness.

In an 1848 report, entitled “On the Typhus Epidemic in Upper Silesia,” he noted that inhabitants of an impoverished Prussian province died quicker and got sicker than their peers elsewhere in the country.

“There cannot be any doubt that such a typhoid epidemic was only possible under these conditions and that ultimately they were the result of poverty and underdevelopment in Upper Silesia,” Dr. Virchow wrote.

Dr. Virchow’s research presented a problem, and in the nearly two centuries that have gone by medical professionals have struggled to solve it.

“[170] years ago, health was really public health,” Tonya L. Fancher, MD, MPH, told AMA Wire®. “Then we sort of split away from public health for a while. And now that’s coming back.”

Addressing the social determinants of health means confronting the reality that the health of an individual patient, or a population of patients, is not treated exclusively within the four walls of medical setting.

“We are increasingly teaching students that the health of patients happens not just in the clinic or one-on-one in the office, but it really happens in their home environment,” said Dr. Fancher, associate dean of workforce innovation and community engagement at University of California, Davis School of Medicine. “In order for us to provide the best care we can, we need to understand that home and work and outside environment.

“As we started to work together with our public health and social science colleagues, increasingly we recognized that we are all getting at the same issue, the quality of life for our patients, and that we all look at it through a different lens,” she added. “Ultimately, what we all need to do is come together to optimize that.”

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New textbook is first to teach “third pillar” of medical education

The importance of optimizing the collective health resources available to underserved communities is highlighted in the “Socio-Ecological Determinants of Health” chapter in Health Systems Science, a 2016 textbook that is the first to explore the “third pillar” of medical education. (The chapter was co-written by Dr. Fancher, with co-authors Elizabeth G. Baxley, MD, and Daniel Goldberg, JD, MPH.)

At UC Davis, a collaborative approach to combating the social determinants of health is being instilled among medical students. One such initiative is a collaborative clinic in which medical students work with nurse practitioner students and pharmacy residents.

The trajectory of an individual’s lifelong health is significantly shaped during childhood. According to research cited in Health Systems Science, “conditions—whether favorable or adverse—during early childhood have a significant and enduring impact on population health, not simply across one individual’s lifespan, but internationally as well.”

With that, Dr. Fancher’s pediatric colleagues at UC Davis are partnered with undergraduate students in expanding family care beyond a clinical setting. As part of an elective course, undergrads with an interest in medicine and public health are trained to act as neighborhood clinical advocates for families at risk of adverse health outcomes.

“When there’s something beyond the scope of the treating physician, they bring the advocate in and ensure that the family has access to resources, that they are following up with them and helping them to troubleshoot any barriers,” Dr. Fancher said.

One of the best resources for understanding socioeconomic struggles within a community are the people who live in and have leadership roles in that community. To facilitate an open dialogue with the communities they are serving, students at UC Davis hold an annual conference during which they bring in community members and regional leaders to teach.

“It allows us to flip the idea that the professors at UC Davis are experts,” Dr. Facher said. “Now we’re saying that’s not the case. It’s really these folks in the community that are the experts, and we are here to learn from them and understand how we can be of best help to those folks.” 

Health Systems Science,  which is already in use in medical schools across the country, was co-written by experts from the AMA and faculty from 11 of the 32 member schools in the AMA’s Accelerating Change in Medical Education Consortium.

The book retails for $59.99 and can be ordered from the AMA Store and the publisher, Elsevier, as well as from Amazon and other online booksellers. AMA members may order it from the AMA Store for $54.99. Individual chapters are available from Elsevier’s Student Consult platform for $6.99 each.