Stephen Haff is a second-year medical student at The University of Texas Southwestern Medical Center in Dallas. He helps to lead the school’s Healthcare in Underserved Communities elective class and wrote about its impact on the students’ medical education.
“Medical school is like learning about a car: we learn about the brakes, the tires, and the engine. But when we learn nothing about the road conditions or traffic laws these cars operate in, we are set up for failure on the road,” says Rigo Palomarez, a second-year student at The University of Texas Southwestern Medical Center in Dallas.
The analogy may seem simplistic, but it makes important points. If the physician is a mechanic, then the car is the patient. The mechanic can fix the car with precision, but it can be frustrating for the mechanic when the car continues to break down due to bad road conditions.
Those bad road conditions represent many of the social factors that affect patients every day: physical barriers to accessing health care, such as financial difficulty or food insecurity; or societal biases or prejudice against a population — factors that lead to significant disparities in health.
Today’s medical students want to be prepared to provide the best patient care. More than ever, that means understanding not only how to provide quality care, but also the patient’s experience accessing that care. Students at UT Southwestern are addressing this deficiency in knowledge through an elective, Healthcare in Underserved Communities, offered to all UT Southwestern MD and physician assistant students in their first and second years of school.
Students choose one of seven immersion experiences, each of which targets a different population that frequently has inadequate access to care. The experiences address health care for:
• The uninsured,
• The homeless,
• Patients in the federal Women, Infants, and Children (WIC) supplemental nutrition program,
• The LGBTQ community,
• Patients in correctional facilities,
• Patients with HIV, and
• Food-insecure patients.
The experience starts with students working with physicians and patients of a particular underserved community, and ends with a presentation about their experience. This is augmented by a panel discussion in class with physicians, social workers, and patients involved in that community’s health care.
Shawna Nesbitt, MD, an internist and associate dean of minority student affairs in the UT Southwestern’s Office of Student Diversity and Inclusion, created the class in 2016 with the help of then-first-year student leaders Umaru Barrie and Mahmoud Elguindy.
“In my experience at Parkland [Health & Hospital System] and UT Southwestern, we offer excellent clinical learning experiences. Yet we don’t take advantage of the fact that these are patients who come from many different backgrounds from every perspective of life,” Dr. Nesbitt said. “We need to teach students about who [their patients] are, and what their lives are like. A significant part of delivering excellent care is understanding your patients’ lives more completely to better instruct them. In medicine, health care disparities are due to patient and systematic issues, but physician bias and lack of understanding is one of the most challenging issues to overcome.”
Mr. Barrie, now a third-year student, says the elective’s purpose is to fill a gap in medical education.
“We wanted to give students an opportunity to see through the eyes of their future patients,” he said. “The immersion experience aspect is so much more powerful than simply reading statistics. These patients are more than just a data point.”
Students appreciate what the elective has to offer for multiple reasons. The first is an increase in knowledge about these patients and the communities in which they live. A pre- and post-survey shows that by the end of the experience, 50 percent more students feel “very knowledgeable” about how these populations are served.
Mr. Barrie uses what he learned throughout his clinical clerkships.
“I especially saw the benefit during my OB-Gyn rotation,” he said. “We learned through the Women, Infants, and Children experience about all the [public] programs available to this population. When a patient came into the office talking about WIC and CHIP, I had a better understanding of the patient’s situation than my other classmates, and was able to make a connection where they couldn’t.”
Thanos Rossopoulos, a second-year student, shadowed a physician working in one of Parkland’s Homeless Outreach Medical Services, or HOMES, mobile clinics. He was impressed with how the physician combined medical knowledge with an understanding of the patient’s socioeconomic situation.
“The physicians needed to prescribe a medication. However, they also understood that, being homeless, there were social factors that limited their [patients’] ability to access that medication,” Mr. Rossopoulos said. “The physicians knew the pharmacies that the patient could go to, their living situation, and their transportation difficulties. They explained not only the purpose of the medication, but how to get it, and explained it simply so the patient understood everything. I found their level of knowledge about these ‘extra’ factors incredibly important in the care of that patient.”
The elective also helps students understand the system from the patient’s standpoint, which helps them develop a better sense of compassion for their future patients.
Petra Constable, a second-year student, acted as a patient going through a Parkland clinic without the financial ability to pay for care.
“The process of ‘playing the patient’ gave me new perspective on the patient experience. I had to say, ‘I don’t have the money to pay for this,’ but I didn’t think about the problem of trying to go through multiple visits for a chronic condition and spend[ing] hours waiting in the waiting room, all while I may have a job or kids at home,” Ms. Constable said. “It really opened my eyes to all the social aspects that come into play when accessing the system, and how physicians may misinterpret that as ‘non-compliant’ when [patients] can’t keep up.”
Maya Hunt, a second-year student, learned that the patient’s difficulty may stem from simple communication.
“The elective left me frustrated that there are resources available to these patients, but if it is not communicated effectively to patients, then those resources are useless,” Ms. Hunt said. “In order to have them utilize what is available, they need to know they exist. How we, as health care providers, communicate that to them makes all the difference.”
Physicians involved in the elective also see the benefit. Lara Johnson, MD, interim medical director of HOMES, said, “Early exposure to these topics is so important. Medical school and residency can be a treadmill. When you get on a certain track, it can push you forward without allowing you to think about why you got on that track in the first place. Before you know it, you can get settled into your practice and forget about those populations that need the most help.”
Fred Cerise, MD, president and CEO of Parkland Health and Hospital System (PHHS), helped organize the student experience on navigating public health care without insurance. He also sits on one of the class panels. He found that the elective “is a good experience for the students because they don’t learn in their curriculum about the perspective of the patients trying to navigate the system. I was really impressed with what the students learned in a short time and the level of analysis in their presentations.”
Both physicians and students agree on the potential for expansion of the class.
“This needs to be integrated into our curriculum,” said Taylore King, current student leader of the elective. “To reach students with these topics at an early stage in their medical career will make us all better physicians.”
Esmaeil Porsa, MD, sees potential for this topic in residency. He is executive vice president and chief strategy and integration officer at PHHS and oversees health care services provided to local correctional facilities.
“We always talk about reducing waste in health care. Imagine if residents, especially in outpatient specialties, follow a patient for a day just to see the other side,” Dr. Porsa said. “They could identify the wasteful policies in the system, and use that experience to create a more productive system and happier patients.”
Tex Med. 2019;115(2):40-43
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