Flipping social determinants on its head: Medical student perspectives on the flipped classroom and simulated patients to teach social determinants of health

Integrating the social determinants of health into curriculum: AMEE Guide No. 162

The World Health Organization (WHO) defines the Social Determinants of Health (SDOH) as the non-medical factors influencing health outcomes. SDOH is associated with conditions in which people are born, grow, work, and live. Medical schools and licensing bodies are increasingly recognizing the need for doctors and healthcare professionals to be aware of their patient's social context and how it impacts their states of health and disease. However, there is considerable variation in the approaches of different institutions and countries to incorporating SDOH into their curricula. In order to allow clinicians to adopt a holistic approach to patient health, equipping them with extensive knowledge of SDOH would give learners the confidence, skills, knowledge, and attitudes needed to effectively engage with patients and their families. This approach aids health professionals with knowledge of the influence of the social context and cultural factors that affect patients' behaviors in relation to health. Incorporating the SDOH in medical and health professional school curricula would contribute towards adequately preparing future healthcare practitioners to provide effective, comprehensive, and equitable care, especially to marginalized and underserved populations. The Guide will take an evidence-based approach grounded in the available contemporary literature and case studies. The focus will be on integrating SDOH into undergraduate and postgraduate medical curricula to promote an understanding of the social factors that influence patients' and communities' health. Ultimately, this guide seeks to contribute to the reduction of inequalities in health.

"The Water in Which We Swim:" A Unique, Post-Clerkship Multidisciplinary Course

OBJECTIVE

To improve patient outcomes and promote health equity, medical students must be taught not only biomedicine, but also the social sciences to understand the larger contexts in which patients live and health care operates. Yet, most undergraduate medical education does not explicitly cover these topics in a required, longitudinal curriculum.

METHODS

In January 2015 at Harvard Medical School, we created a two-part sequence (pre- and post-clerkship) of required, 4-week multidisciplinary courses-"Essentials of the Profession I and II"-to fill this gap. "Essentials of the Profession II (EOP2)" is an advanced social sciences course anchored in patient narratives and the lived experiences of students and includes clinical epidemiology and population health, healthcare delivery and leadership, health policy, medical ethics and professionalism, and social medicine that engages students to conduct structural analyses to be effective healers, advocates, and leaders.

RESULTS

Per student course evaluations, the overall course rating was 1.7 (SD 0.9, 1 = excellent and 5 = poor); its overall rating has improved over time; and it has scored well even when run virtually. It was rated highly in application of critical thinking, integration of the disciplines, and relevance for clinical work. Qualitative analyses of student responses revealed the following key course strengths: breadth of topics, teaching faculty and guest speakers, and small group discussions. The weaknesses included workload, lack of diversity of opinions, repetition, and time spent in lectures.

CONCLUSIONS

We argue that EOP2 is "essential" for post-clerkship medical education. It offers an opportunity to re-ignite and enhance humanism and activism; remind students why they chose the medical profession; equip them with frameworks and toolkits to help them to overcome challenges; and devise solutions to improve health care and patient outcomes that are applicable to their future training and ongoing practice of medicine.

Effectiveness of alternative approaches to integrating SDOH into medical education: a scoping review

BACKGROUND

There is increasing recognition of including social determinants of health (SDOH) in teaching for future doctors. However, the educational methods and the extent of integration into the curriculum vary considerably-this scoping review is aimed at how SDOH has been introduced into medical schools' curricula.

METHODS

A systematic search was performed of six electronic databases, including PubMed, Education Source, Scopus, OVID (Medline), APA Psych Info, and ERIC. Articles were excluded if they did not cover the SDOH curriculum for medical students; were based on service-learning rather than didactic content; were pilot courses, or were not in English, leaving eight articles in the final study.

RESULTS

The initial search yielded 654 articles after removing duplicates. In the first screening step, 588 articles were excluded after applying inclusion and exclusion criteria and quality assessment; we examined 66 articles, a total of eight included in the study. There was considerable heterogeneity in the content, structure and duration of SDOH curricula. Of the eight included studies, six were in the United States(U.S.), one in the United Kingdom (U.K.) and one in Israel. Four main conceptual frameworks were invoked: the U.S. Healthy People 2020, two World Health Organisation frameworks (The Life Course and the Michael Marmot's Social Determinants of Health), and the National Academic of Science, Engineering, and Medicine's (Framework For educating Health Professionals to Address the Social Determinants of Health). In general, programs that lasted longer appeared to perform better than shorter-duration programmes. Students favoured interactive, experiential-learning teaching methods over the traditional classroom-based teaching methods.

CONCLUSION

The incorporation of well-structured SDOH curricula capturing both local specification and a global framework, combined with a combination of traditional and interactive teaching methods over extended periods, may be helpful in steps for creating lifelong learners and socially accountable medical school education.

Using standardized mental health patient simulations to increase critical thinking and confidence in undergraduate nursing students

PURPOSE

The purpose of the activity described in this article is to engage undergraduate nursing students undertaking a mental health course in active learning that allows them to practice clinical decision-making and higher-order learning. A secondary goal is to increase students' comfort level with interviewing and interacting with mental health patients.

METHODS

Simulated interviews were performed with two standardized patients (SPs), one presenting with depression with suicidal tendencies and the other with generalized anxiety disorder. Students were given reflections to assess the effectiveness of the simulations as a learning technique. These essays were evaluated using five-step thematic data analysis.

RESULTS

Students demonstrated a high level of engagement with the SPs which lead to a deeper level of understanding and learning demonstrated in their reflections. All participating students felt more confident and better prepared for real-world encounters with mental health patients.

CONCLUSIONS

Students want exposure and practice in mental health as there is widespread under confidence in performing patient interviews and assessments. The use of simulations involving standardized mental health patients have proven to increase confidence and better prepare students for future experience while also circumventing any ethical issues which would be presented having non-licensed students assess actual mental health patients.

The experiences of community organizations partnering with a medical school to improve students' understanding of the social determinants of health: A qualitative study

PURPOSE

There has been increasing interest among national organizations for medical schools to provide students experiential training in the social determinants of health (SDH) through community partnerships. Despite this interest, there is limited data about how these experiential activities can be designed most effectively, and community organizations' views of partnering with medical schools on these curricula is unknown. The authors' objective was to determine community organizations' and clinical clerkship directors' perceptions of the benefits and challenges of utilizing academic-community partnerships to improve medical students' understanding of the SDH.

METHODS

The authors conducted a qualitative study consisting of open-ended, semi-structured interviews (between 2018 and 2021). All community organizations and clinical clerkship directors who partnered with a health equity curriculum were eligible to participate. Semi-structured interviews elicited participants' perceptions of the academic-community partnership; experience with the curriculum and the students; and recommendations for improving the curriculum. All interviews were audio recorded and transcribed. The authors used a directed content analysis approach to code the interviews inductively and identified emerging themes through an iterative process.

RESULTS

Of the fifteen participants interviewed, ten were from community organizations and five from clinical clerkships. Three primary themes emerged: (1) community organizations felt educating students about the SDH aligned with the organization's mission and they benefited from consistent access to volunteers; (2) students benefited through greater exposure to the SDH; (3) participants suggested standardizing students' experiences, ensuring the students and organizations are clear about the goals and expectations, and working with organizations that have experience with or the capacity for a large volume of volunteers as ways to improve the experiential activity.

CONCLUSION

This study found that community organizations were very willing to partner with a medical school to provide students experiential learning about the SDH, and this partnership was beneficial for both the students and the organizations.

Medical students' experiences of health inequalities and inclusion health education

BACKGROUND

Inclusion health groups experience a significantly larger burden of morbidity and mortality than the general public. Despite this, undergraduate medical education is often limited in its approach to inclusion health curricula, leaving students disengaged and lacking understanding.

METHODS

We conducted two research studies to explore medical students' experiences of inclusion health education. All participants were studying medicine at the University of Leeds at the time of data collection. We gathered experiences of both compulsory and elective inclusion health education via semi-structured interviews. Interview responses were audio-recorded, transcribed and analysed thematically.

FINDINGS

We identified several key findings across the two studies. Firstly, medical students felt unprepared to work with inclusion health groups. Further to this, medical students have a preference for interactive teaching and learning in inclusion health education. Finally, encountering inclusion health groups by chance (on placement) or choice (optional initiatives) present different opportunities.

DISCUSSION AND CONCLUSION

Our research suggests that simply being exposed to inclusion health groups through lectures and on placement is not considered sufficient by medical students, and in fact can lead to the perpetuation of misinformation and stigma. Participants perceived that optional initiatives or 'choice encounters' had profoundly positive impacts on attitudes and interest, particularly when there were opportunities to learn directly from individuals with lived experience of exclusion. We suggest that a flipped classroom approach to inclusion health education along with integrated experiential learning would provide medical students with comprehensive and patient-focused learning opportunities.

Evaluating Usability in Blended Learning Programs Within Health Professions Education: a Scoping Review

Knowledge was mapped about how usability has been applied in the evaluation of blended learning programs within health professions education. Across 80 studies, usability was explicitly mentioned once but always indirectly evaluated. A conceptual framework was developed, providing a foundation for future instruments to evaluate usability in this context.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01295-x.

The trends and outcomes of flipped learning research between 2012 and 2018: A descriptive content analysis

As an innovative active learning method, flipped learning provides students with several opportunities. This study was conducted to reveal the trends and outcomes in research into the flipped learning approach published between 2012 and 2018. Descriptive content analysis was used to review 316 research and conceptual articles published in academic journals included in five significant databases that ascribe to journals the highest impact factor. The results indicate that most of the studies are conducted with students as the most frequent study group and with a mixed-method research design in the subject areas of education and medicine. The flipped learning approach is mostly conducted in higher education. As a region, Asia has taken the lead in flipped learning studies. Finally, the outcomes of flipped learning indicate an increase in student performance and positive influence on cognitive, affective, and soft skills.

Teaching the Social Determinants of Health in Undergraduate Medical Education: a Scoping Review

BACKGROUND

To provide optimal care, medical students should understand that the social determinants of health (SDH) impact their patients' well-being. Those charged with teaching SDH to future physicians, however, face a paucity of curricular guidance.

OBJECTIVE

This review's objective is to map key characteristics from publications about teaching SDH to students in undergraduate medical education (UME).

METHODS

In 2016, the authors searched PubMed, Embase, Web of Science, the Cochrane and ERIC databases, bibliographies, and MedEdPORTAL for articles published between January 2010 and November 2016. Four reviewers screened articles for eligibility then extracted and analyzed data descriptively. Scoping review methodology was used to map key concepts and curricular logistics as well as educator and student characteristics.

RESULTS

The authors screened 3571 unique articles of which 22 were included in the final review. Many articles focused on community engagement (15). Experiential learning was a common instructional strategy (17) and typically took the form of community or clinic-based learning. Nearly half (10) of the manuscripts described school-wide curricula, of which only three spanned a full year. The majority of assessment was self-reported (20) and often related to affective change. Few studies objectively assessed learner outcomes (2).

CONCLUSIONS

The abundance of initial articles screened highlights the growing interest in SDH in medical education. The small number of selected articles with sufficient detail for abstraction demonstrates limited SDH curricular dissemination. A lack of accepted tools or practices that limit development of robust learner or program evaluation was noted. Future research should focus on identifying and evaluating effective instructional and assessment methodologies to address this gap, exploring additional innovative teaching frameworks, and examining the specific contexts and characteristics of marginalized and underserved populations and their coverage in medical education.