Dear Professor Malcolm Reed, (Lead Co-Chair of the Medical Schools Council),
I am a medical student in the UK writing to you to discuss the teaching we have had on Social Determinants of Health as part of our medical education and how it may be beneficial for this to be further developed and integrated into our curriculum. Currently I am undertaking my intercalated BSc in Medical Anthropology and wish to draw on the knowledge I have acquired through studying both Medicine and Anthropology to highlight the importance of understanding the role of larger socioeconomic structures in determining the way patients interact with healthcare systems. Moreover, I would like to propose that we are taught not only how social factors give rise to certain health conditions but also how these should be considered when discussing treatment plans. One of the major roles of a doctor is to not only identify the causes of illness but also understand how these can be optimally treated, and I believe that a deeper understanding of the social lives of patients is crucial to carrying this out. I hope to further demonstrate the relevance of the aforementioned points by closely examining the multitude of factors contributing to the rising rates of obesity affecting the UK and many other countries today.
The Whitehall study (Marmot et al, 1978) is often detailed in lectures as a starting point for understanding the role of social factors in determining health. By following 17 530 civil servants working in London over the course of almost eight years, the study found a clear correlation between grade of employment and coronary heart disease (CHD) mortality rates. Those who were employed into roles that were considered to be lower in status were found to be at a much higher risk of CHD mortality than those in higher grades of employment. After accounting for other factors such as differences in age or the presence of other medical conditions that could have contributed to these results, the correlations were still clear and it was strongly suggested by Marmot et al that research into the relationship between CHD mortality and psychosocial factors were crucial into better understanding the prevalence of coronary heart disease.
This study soundly demonstrates the complex connection between lifestyle and physical health. Many other reports and studies, some of which are also mentioned in our lectures, come together to provide a rich pool of literature further exemplifying this. What many of them do not address, however, is how these social factors affect the way in which patients can access or carry out the treatment plans routinely provided for conditions such as coronary heart diseases and obesity. Lower income for example, is now known to be associated with poorer health outcomes and lower life expectancy (Iacobucci, 2019) though the details of this are less commonly explored despite their importance. Understanding the reasons for this correlation such as being unable to afford better quality food, more expensive medication or having less time and liberty to attend medical appointments is crucial to allowing us as future doctors to construct effective treatment plans accordingly. Common recommendations for conditions such as high blood pressure, obesity and type II
diabetes for example are exercising regularly and eating healthier foods. The question to consider however, is whether or not these truly are practical solutions that can be carried out in the social contexts of individual patients.
Metzl and Hansen’s (2014) concept of ‘structural competency’ aptly demonstrates the necessity to study this intersection between doctor-patient and society-patient interactions. In the way that ‘cultural competency’ (Kleinman and Benson, 2006), a topic more readily addressed by physicians today, calls for doctors to be more aware of cultural differences between patients, structural competency calls for them to better recognise socioeconomic differences and the effects of this. As part of our medical training, we are often given case studies which firstly list signs and symptoms of a patient’s conditions and secondly, other details such as age, gender and race which are provided simply to support the process of concluding a diagnosis. Other social factors are often omitted. Metzl and Hansen list one of many examples which show why this should change. A patient diagnosed with type II diabetes for example is told to exercise more regularly – however, this is difficult for them because of the lack of gyms, parks and safe areas to walk in their neighbourhood. Another patient refuses to take certain medications, not because of a lack of trust in medical professionals but due to the high costs of buying this medication and difficulty accessing or buying certain foods that are required to be taken with the medication. It is hence important for doctors to learn how to obtain information like this and further how to integrate this into proposing healthcare plans. Petty et al (2017) were in fact able to demonstrate that integrating structural competency into the curriculum for pre-health undergraduates in the US allowed students to better identify and explain how socioeconomic factors contributed to patients’ health conditions and treatment outcomes. They concluded that these differences which medical students eventually encounter with patients in clinics are better understood and handled when medical students have been taught to recognise them earlier on in their medical education.
I’d like to reinforce that to learn about social factors is not to detract from the importance of learning the biomedicine behind pathologies – rather, I believe they can complement each other to further improve patient care.
On this note, I move to discuss the dynamic of our teaching on obesity during my first two years of medical school. My reason for choosing this particular issue is that in the majority of lectures we have had on obesity, whether from a biomedical or social perspective, it has been highlighted that obesity is a risk factor for various other serious health conditions including stroke and CHDs. Further, we have been made acutely aware that obesity costs the NHS billions of pounds a year with a risk of this significantly increasing in the future if not urgently addressed (Health matters: obesity and the food environment, 2017). The seriousness of obesity has been made clear and its increasing prevalence tells us that we are likely to encounter obese patients as future doctors. Despite this, we have been taught little about how to effectively treat obesity. Lectures have centred around understanding weight gain on a cellular and biochemical level or explaining statistically that obesity is associated with lower incomes and unhealthy food intake. Drugs to target obesity are few and often low in efficacy while diets are also presented as often being unsustainable. It is here I propose that an approach that considers the role of social factors in determining treatment would allow us to treat obesity more effectively.
Cheng (2012) described how treating two young sisters who both suffered from morbid obesity and other serious coexisting conditions was becoming challenging as they became difficult to get into contact with and treatment plans were not adhered to. She soon learnt, however, that their mother had been unable to respond to her calls as her phone service was disconnected due to lack of payments. Further, the young girls were unable to leave the house to exercise as they lived in a high-crime neighbourhood. With this new knowledge, Cheng was able to organise for someone to check in with the family either by phone or in person regularly and adjust treatment accordingly. Ultimately, learning about the social context of the family resulted in not only better health outcomes but also a more effective use of resources and the physician’s time. Had Cheng have assumed that the mother was intentionally choosing not to help treat her daughters adequately, she may have continued to simply try and educate her on why exercise and a more nutritional diet is important, as is often done.
Medvedyuk et al (2017) also analysed different models for how obesity is viewed and linked to adverse health outcomes and found that better recognition of social determinants of obesity by physicians can contribute to reducing stigma around obesity. Understanding how broader social structures that are not in the control of the patient play a role in obesity means there is less victim-blaming and unintentional stigmatisation. Consequently, patients may often feel better supported and engage better in implementing beneficial lifestyle and behavioural changes.
I hope to have demonstrated here the many possible benefits of assimilating the teachings on social determinants of health and treatments for diseases and conditions. Although I recognise the importance of learning these two aspects independent of each other – biomedicine is crucial in allowing us to make diagnoses and suggest medications or surgical procedures – I believe that combining them at times can lead to better health outcomes for patients and provide a more holistic understanding of health to medical students. I have learnt a lot during my time at medical school thus far and hope to have positively contributed to the teaching of future students.
I look forward to hearing your thoughts.
Cheng, J., 2012. Confronting the Social Determinants of Health — Obesity, Neglect, and Inequity. New England Journal of Medicine, 367(21), pp.1976-1977.
GOV.UK. 2017. Health matters: obesity and the food environment. [online] Available at: <https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment–2> [Accessed 22 March 2021].
Iacobucci, G., 2019. Life expectancy gap between rich and poor in England widens. BMJ, p.l1492.
Kleinman, A. and Benson, P., 2006. Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLoS Medicine, 3(10), p.e294.
Marmot, M., Rose, G., Shipley, M. and Hamilton, P., 1978. Employment grade and coronary heart disease in British civil servants. Journal of Epidemiology & Community Health, 32(4), pp.244-249.
Medvedyuk, S., Ali, A. and Raphael, D., 2017. Ideology, obesity and the social determinants of health: a critical analysis of the obesity and health relationship. Critical Public Health, 28(5), pp.573-585.
Metzl, J. and Hansen, H., 2014. Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, pp.126-133.
Petty, J., Metzl, J. and Keeys, M., 2017. Developing and Evaluating an Innovative Structural Competency Curriculum for Pre-Health Students. Journal of Medical Humanities, 38(4), pp.459-471