We should focus our educational efforts to influence health outcomes at levels above individual interactions. Risk for disease begins well before our patients see us in the clinic. —Carrie L. Francis, MD
Explore This IssueJune 2021
Teaching Residents and Fellows
The inclusion of social determinants of health in otolaryngology residency/fellowship post-graduate curricula is currently spotty throughout the country. Of the experts who provided comment for this article, none saw an intentional effort to incorporate these determinants into the curriculum at the organizational level.
“I think individual departments are picking up the mantle and doing some teaching on their own,” said Oneida Arosarena, MD, professor of otolaryngology–head and neck surgery and associate dean for diversity and inclusion at the Lewis Katz School of Medicine at Temple University in Philadelphia. She added that a lecture on social determinants of health and bias in medicine is offered yearly at her institution, and the subject is also regularly included in journal clubs. She would like to see it included in the curriculum, however, and thinks it would fit nicely into the section on medical ethics or quality improvement.
In linking social determinants of health to a quality improvement issue, for example, she cited the importance of determinants such as access to transportation and health insurance as significant influencers of healthcare delivery. “This is both an ethical issue and a quality improvement issue for outcomes,” she added.
Dr. Brown would also like to see implementation of curricula on social determinants at the organizational level for residents and fellows. The GME program at his institution is one of nine in the country currently participating in a pilot program as part of the ACGME Pursuing Excellence in Clinical Learning Environments: Quality Improvement in Health Care Disparities Collaborative to develop and implement health disparity curriculum. The curriculum developed at his institution included four components: social determinants of health and social needs, impact of systemic racism on healthcare, cultural humility, and use of quality improvement techniques to evaluate healthcare disparities. The two big components seen in most of the other eight participating programs, he said, were the social determinants of health and social needs component and the cultural humility component.
Three otolaryngology residents participated in the first year of the program, he said, adding that the program is entering its second year soon.
Dr. Megwalu would also like to see a general overview of health disparities included in the curriculum, with specific examples on how social determinants of health affect health outcomes in otolaryngology. “This would hopefully encourage [residents and fellows] to consider these factors when recommending or discussing treatment plans for patients,” he said. He also thinks that training in implicit bias would be helpful so that clinicians learn to recognize and address unconscious thoughts and attitudes that can negatively impact the care of disadvantaged patients.
Carrie L. Francis, MD, associate professor in the department of otolaryngology–head and neck cancer and associate dean of workforce innovation and empowerment, faculty affairs and development, at Kansas University Medical Center in Kansas City, Kansas, also would like to see training that addresses bias and racism, as she sees social determinants through the larger lens of structural determinants. “I agree with health profession and public health scholars who describe these forces [social determinants] as structural determinants of health, as they’re rooted in social and political structures and policy that are tied to the many “-isms” that exist in society,” she said.
She emphasized the importance of educating residents, fellows, and faculty on structural factors that result in inadequate access to and delivery of healthcare services in many minority and marginalized communities. “We should focus our educational efforts to influence health outcomes at levels above individual interactions,” she said. “Risk for disease begins well before our patients see us in the clinic.”
This call for a more proactive approach to healthcare, and to expanding focus to populations of patients, is one that Dr. Bergmark would also like to see. “We need more collaboration across surgical and medical fields and across healthcare systems to improve access to care at a population health level,” she said. For example, she wondered whether a coordinated effort could help lower the rates of delayed presentation of head and neck cancer, perhaps by increasing insurance rates, given the better survival in patients who present with lower stage cancer. She also questioned what a more coordinated approach would do for increasing HPV vaccination rates. “We should measure ourselves based on our outcomes, and increasingly these include regional population health data in our outcome metrics,” she said. “Some of these efforts will include increased focus on health policy and social issues.”
Building on the quality improvement aspect of including social determinants of health in the curriculum, Dr. Brown said that a key connection for residents and fellows, as it is with all clinicians, is the impact on what providers care about—clinical and surgical outcomes. “We want patients to show up for appointments, so we want to make sure they have adequate transportation. We want them to have great postoperative care, so we want them to have food security as well as clean and safe housing,” he said. “I don’t think our field knows enough about how to assess our patients’ social determinants of health and then address their social needs. Therefore, I believe [social determinants of health] should be a part of the curriculum so people at least have awareness and maybe we can move toward some more action about what we can do as otolaryngologists.”