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Teaching about Health Equity and Advocacy? Consider the Hidden Curriculum

Our best intentions and goals as health professions educators can be easily undone or reinforced by the hidden curriculum.

As the intern completed her presentation on rounds, she said, “Dr. Campbell, this is Ms. Williams’* third admission in three weeks. She is clinically stable and can be discharged today but I’m worried she will soon be back in the hospital.” Imagine with me two possible scenarios: the first where the team discounts the intern’s fears and pushes for a quick discharge; the second where the team stops to explore what non-medical issues might be contributing to the patient’s readmissions, and works with the social worker to connect the patient with resources that help address those issues. What lesson does the intern learn from scenario one versus scenario two? Which hidden curriculum is at play in each scenario?

My introduction to social determinants of health (SDoH) was not by a professor during a class in medical school, but by one of my most memorable patients during residency - a patient like Ms. Williams whose constellation of chronic medical conditions were difficult to manage and resulted in her returning to the hospital in an almost predictable pattern. Her low health literacy, limited transportation options and unstable housing - all SDoH - were significant contributors to her repeated hospital admissions and overall poor health. As defined by the World Health Organization, SDoH are the “conditions in which people are born, grow, live, work and age”. These include such conditions as access to healthy food options, housing, employment and transportation. Since the publication of the 2002 Institute of Medicine landmark report “Unequal Treatment”, the impact of SDoH on health disparities in the U.S. have been well-described in literature.

In addition, there has been a growing interest in teaching students in the health professions about SDoH - how to identify and address these issues in order to reduce these health disparities and achieve health equity for all. While this is a worthy goal, we should consider possible hidden curricula at work that might undermine or reinforce our efforts. The hidden curriculum defined as “a set of influences that function at the level of organizational structure and culture” is not always negative or harmful. In fact, we can harness its power to reinforce the lessons we hope our learners receive in their formal curriculum.

In the article “Beyond Curriculum Reform: Confronting Medicine’s Hidden Curriculum” Hafferty highlights four areas to consider as contributors to the hidden curriculum: policy development, evaluation, resource allocation and institutional nomenclature. I will use this framework to suggest four questions educators can ask in order to identify and address possible hidden curricula as you begin to develop and implement formal curriculum on SDoH, health equity and advocacy. 

  1. Are there policies in place at your institutions that support or run counter to the message in your curriculum? Can patients easily access care at your institutions? Are all patients able to receive care regardless of insurance coverage? Free clinics affiliated with your institution, prescription vouchers for patients who cannot afford medications on discharge, acceptance of a wide variety of insurance coverage for patients who need referrals to specialists or need to establish care with a primary care physician are some examples of ways learners know that your institution is truly invested in ensuring health equity for all. 
  1. Does the evaluation process accurately assess the attitudes, skills and behaviors you are teaching in the curriculum? Are you consistently providing learners with timely, specific and actionable feedback on how they are identifying and addressing SDoH? Do you engage and seek input from the social workers who are on the front lines, working with patients and communities? Ideally, the evaluation should be done across all training sites and in a variety of clinical settings (both inpatient and outpatient rotations). Educators should also spend time reflecting with the learners about the impact of their SDoH-related intervention and care on the patients’ health. 
  1. Have appropriate resources been allocated to ensure this curriculum is effective in achieving stated goals and objectives? You will prioritize and spend time/effort/money on what you value. How much time do you spend discussing these issues on rounds, during morning reports or noon conferences? (I try to include one or two slides on SDoH or health equity issues in my case conferences regardless of the medical diagnosis). Do you have enough case managers in clinic/on the wards who can help connect patients with resources to meet their needs? Is the electronic health record optimized to ensure providers capture the information and have easily accessible templates and referrals for patient care? Is there support for faculty involved in teaching this curriculum (salary support and faculty development funding)? 
  1. Are you using language at your institution that reflects the value you place on health equity? Does the language you use reflect that you respect and value all patients regardless of their socioeconomic status? Are such terms as “social admit” or “frequent flyer” still being used to describe patients with recurrent hospital admissions?

This is by no means an exhaustive list, but a way to begin the discussion with stakeholders at your institution in order to identify and address any hidden curriculum that could impact your learners. As my intern completed her presentation on Ms. Williams, the senior resident encouraged her to take some time to explore with the patient the non-medical issues that might be at work – including health literacy, financial limitations as well as social support at home. We consulted with the case manager, advocated for our patient and we were able to set Ms. Williams up with resources she needed at home. This experience reinforced the message of health equity and advocacy which we have shared in our formal curriculum and turned out to be in many ways more impactful than any lecture I could have presented.   

References

  1. Smedley B.D., Stith A.Y. & Nelson A.R. (Eds.). (2002). Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington DC: The National Academies Press.
  2. Hafferty F. Beyond Curriculum Reform: Confronting Medicine’s Hidden Curriculum Academic Medicine 1998; 73:403-407.

*Names have been changed for privacy

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Comments 1

 
Atipong Pathanasethpong, MD, MS on Tuesday, 06 March 2018 22:02
Address SDoH and fix the hidden curriculum

I'm a firm believer in addressing the SDoH, and we certainly have a lot to improve on this issue. We say we should care for the people, not the diseases; in practice we still often put too little emphasis on our patients and too much emphasis on their illnesses. The system isn't helping either. That's a forceful hidden curriculum in the making, and we all know better than to actually believe that formal curriculum can outdo the hidden curriculum.

I have a suggested reference on the topic of SDoH, one that I can say is the most emotionally impactful piece of academic literature I have ever read: Social determinants of health: the solid facts. 2nd Edition. Edited by Richard Wilkinson and Michael Marmot and published by WHO Regional Office for Europe. http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

I'm a firm believer in addressing the SDoH, and we certainly have a lot to improve on this issue. We say we should care for the people, not the diseases; in practice we still often put too little emphasis on our patients and too much emphasis on their illnesses. The system isn't helping either. That's a forceful hidden curriculum in the making, and we all know better than to actually believe that formal curriculum can outdo the hidden curriculum. I have a suggested reference on the topic of SDoH, one that I can say is the most emotionally impactful piece of academic literature I have ever read: Social determinants of health: the solid facts. 2nd Edition. Edited by Richard Wilkinson and Michael Marmot and published by WHO Regional Office for Europe. http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
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