Teaching Future Doctors to See Patients as People, Not Conditions
On their first day of classes, the newest cohort of MD students at Tufts University School of Medicine didn’t dive into biochemistry or physiology. Instead, they started their education focusing on how social factors, such as housing instability, health care costs, and racism, affect health outcomes and create inequities.
“Our job as doctors is not simply to care for a single patient in front of us at that moment in time,” says Amy Lee, an associate professor and vice chair for academic affairs in the Department of Family Medicine. “Our job is to impact the health of populations overall, to bring better health to our society. So it’s important for our students to understand that there are things that they can do, from the individual level for patients to community-level advocacy, all the way to policy-level advocacy.”
Tufts’ new medical school curriculum, rolled out for incoming students in 2019, is working to center these historically overlooked aspects of health care. Students begin their education with a three-week course on the social determinants of health, how the U.S. health insurance system works, and professionalism and ethics in medicine. As they go on to tackle anatomy, cellular biology, and other basic science topics, these larger themes are woven through the curriculum.
“All of these things have a huge impact on health, but sometimes aren't talked about a lot in typical medical school curriculums,” Lee says. “This is a much more systematic way to make sure all of our students are really understanding some of the key health issues confronting U.S. patients today.”
Traditionally, medical education has started with the hard sciences. Medical students need a deep understanding of the body’s systems, as well as how things can go wrong and what treatments are available. Curriculums are structured to break down this monumental amount of information into manageable chunks.
This structure is valuable, says Richard Glickman-Simon, an assistant professor of public health and community medicine, who helped develop the new curriculum and directs several of the courses. But it doesn’t leave a lot of space for examining patient issues from a community- or population-level perspective.
“It tends to focus down on a problem as being a derangement, or something wrong on the molecular or cellular level,” Glickman-Simon says. “You really can’t serve patients by just focusing on what their molecules are doing. It’s very powerful, but it’s insufficient. You can miss the big picture.”
The COVID-19 pandemic has served as a poignant reminder of why these topics are essential to a physician’s education. While anyone could catch and spread the virus, communities of color in the U.S. suffered disproportionately high rates of illness and death. These disparities have been linked to a number of factors, including living conditions brought about by discriminatory housing policies, the body’s physiological response to prolonged stress from racism, and systemic inequities in access to health care. Ongoing issues in the U.S. health care system also hindered the country’s ability to respond to the pandemic and disrupted the rollout of testing and vaccines.
In the new curriculum, Tufts students are using the pandemic as a framework to discuss the lack of public health infrastructure in the U.S., the roots of vaccine hesitancy, and the country’s history of medical racism. This knowledge will help the future physicians address specific concerns with individual patients, as well as effectively advocate for the needs of their community.
“It was a really helpful frame to know that Tufts was prioritizing social determinants of health inequity—looking at racism in medicine, misogyny in medicine, and a lot of these larger threads that we then continue to follow throughout medical school,” says Emma Noyes, MG20 (MBS), M24. “There’s a lot of work still to be done to make sure that we’re covering all of this material comprehensively and effectively, but it felt like they were really trying to make that a priority for us from day one.”
As the students dive into the more traditional aspects of a medical education, they take a parallel course, aptly named Threads, that weaves the social determinants of health and other important aspects of patient care through the rest of the curriculum. While students are studying neuroscience, for example, they speak with a panel of advocates in the Threads course to discuss how doctors could better meet the needs of and establish trust with patients with neurodevelopmental differences. When students are learning about diseases of the reproductive system, they have a Threads section on why Black mothers in the U.S. are significantly more likely to die from pregnancy-related complications than white mothers.
“I feel like Tufts is really training doctors to look at the whole picture, and treat the patient like a human instead of like a condition,” Noyes says. “It’s very important to understand the pathophysiology, but it’s equally as important to understand what’s preventing your patient from coming to the appointment to see you, what is getting in the way of the patient maximizing their care and maximizing their health overall.”
The redesign also includes a new mentorship structure for medical students. The students are each assigned a physician coach—someone working in the field who will help students grow over their four years of training. The coaches foster discussions about key concepts the students have studied in Threads and their other coursework and help them take on leadership roles in the areas they most are passionate about. Coaches don’t assess or grade students; they help them find their strengths and develop a professional identity, Lee says.
“That really gives a new kind of support to our students to develop into the kind of physicians that they want to be,” Lee says. “Our expectations of what it means to be a doctor have expanded. Physicians have important roles in society beyond just caring for an individual patient, and we want our students to be fully prepared to take on those kinds of leadership and advocacy roles.”