A social emergency medicine curriculum: Bridging emergency care and health equity
Supervising Editor: Teresa Y. Smith, MD, MSEd.
INTRODUCTION
Social emergency medicine recognizes the essential role of the emergency department (ED) in identifying and investigating community health disparities and in creating solutions to promote health equity.1, 2 Social determinants of health (SDH), or the “conditions in the environments in which people are born, live, learn, play, worship, and age”3 as well as social needs and adverse structural factors such as systemic discrimination exacerbate inaccessibility to basic medical care and contribute to significant health disparities that exist across the life span.4-6 The 24/7 accessibility of the ED and the enactment of the Emergency Medical Treatment & Labor Act (EMTALA), a federal law requiring that anyone coming to the ED be stabilized and treated regardless of ability to pay, solidified the role of the ED as a safety net for medical and psychosocial emergencies.7 Disadvantaged and marginalized groups seek the ED for diverse reasons, including food, shelter, or respite, as well as for preventable emergencies disproportionately arising from the adverse social and structural factors that contribute to poor health.8, 9
The ED is the first to see the impact of unmet social needs like homelessness, food insecurity, and violence on health and health care utilization. Addressing these needs can improve population health, decrease recidivism, and mitigate health care expenditures.10-12 Emergency physicians have a unique position to recognize, study, and intervene upon adverse SDH and social needs in the community.13-15 Furthermore, addressing the psychosocial comorbidities related to an ED patient's chief complaint is valuable, if not crucial, to providing optimal care.14, 16
Persistent health inequities in the United States, especially those worsening in the wake of the COVID-19 pandemic, necessitate thoughtful and sustainable solutions. The next generation of physicians needs training in recognizing the social and structural forces that drive disparities so that they can practice equity-informed care. While social medicine should be taught broadly, it is important for EM trainees in particular to have formal curricula on social risks and social needs, because the low-acuity medical patient with complex psychosocial comorbidities is more common in EM than anywhere in the house of medicine.17, 18 Further, it is important to own this mission as the purview of EM so that the specialty may standardize, peer review, and validate best practices in social medicine.17, 18 Training EM residents to identify and address adverse SDH and other public health challenges is an important step to improving the overall health of the population and reducing health and health care disparities in this country.19, 20
CURRENT APPROACH
The Accreditation Council for Graduate Medical Education (ACGME), which determines accreditation for medical training programs in the United States, recognizes SDH as an important component of residency education.21 In 2017, the ACGME’s Clinical Learning Environment Review (CLER) published an issue brief recognizing the lack of formalized education about health care disparities and cultural competency among clinical learning environments nationwide.22 The ACGME common program requirements published in 2019 require that residents and trainees receive education in SDH and systems-based care. Specifically, the requirements state, “residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, including the social determinants of health, as well as the ability to call effectively on other resources to provide optimal health care.”23 Thus, the inclusion of topics of SDH and systems-based understanding of health and health care disparities is deemed a critical component of residency training across programs of all specialties.
EM residency education on these topics has largely not been standardized. A study by Betz et al.24 compared three U.S. EM residency programs and their individual approaches to incorporating public health content into their curricula. The first residency program developed a modular curriculum, where public health core principles were combined with a relevant EM topic during normally scheduled didactic time. Residents attended didactics and small-group discussions as well as a journal club. The second residency program created a 4-week public health–focused rotation for interested residents, where they rotated at the district health office, the New York City Poison Control Center, the Fire Department of New York/Emergency Medical Services, and the Office of the Chief Medical Examiner. Additionally, all EM residents were given two lectures on the public health function of EDs and on the health of their patient population. The third residency program developed a partnership between EM faculty, the state department of health, the university's program in public health, EM residents, and local community workers to develop experiences and modules to educate residents about public health and prevention. These included a grand rounds speaker series, simulation cases, partnership with a local free clinic, development of a youth violence recognition and prevention module for EM providers, and several residency events such as an intern orientation public health scavenger hunt and a residency-wide community service day. These three programs had varying approaches to incorporating public health into their curricula, each with their own strengths.
Helpful resources exist to disseminate social EM education. The section of International and Domestic Health Equity (IDHEAL) within the University of California, Los Angeles (UCLA), EM program has designed modules to teach interested providers about SDH and includes guidance for faculty to deliver this education to learners. Each module contains objectives, a clinical case, teaching and discussion points, and additional reading recommendations.25 Faculty at UCLA have also designed a poverty simulation, adapted from the Missouri Community Action Network, to provide interactive training for their residents.26
SocialEMpact.com is a valuable Web platform that directs learners to literature that highlight the importance of SDH in emergency care. Included on the site is access to the Announce podcast, where EM physicians discuss the impact of SDH on their patients.27
Very few EM residency programs throughout the country have developed formalized curricula addressing SDH using these valuable resources. Great potential exists for further development, dispersal, and assessment of such curricula.
RECOMMENDED APPROACH
In these authors’ opinions, the ideal social EM curriculum should be longitudinal and fully integrated into the standard residency curriculum, with an educational focus on SDH and social needs that affect the program's specific patient population. Additionally, the curriculum would place the SDH and social needs of the population within the context of structural forces such as racism and historical policies that perpetuate their existence. The following is a curriculum model based on Kern's six-step approach for curriculum development, including: (1) general needs assessment, (2) targeted needs assessment, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) evaluation and feedback.28
The ACGME common program requirements describe the general need for residency training regarding SDH, while the targeted need has been identified by our specialty and is driven by the social factors of each programs’ patient population. The overarching goal of the curriculum would be to address biases, attitudes, and beliefs with respect to the patient population and provide training in recognizing social risks and addressing social needs (see Table 1 for a comprehensive list of objectives of the curriculum).
| Cognitive objectives | |
| By the end of the curriculum, each resident should be able to: |
Describe the demographics of their ED’s patient population. Define SDH, social needs, and health and health care disparities. Identify key social needs and SDH of their patient population. Identify resources on a departmental, regional, and national scale that address the social needs and SDH of the patient population. Identify faculty mentors within their department with whom to collaborate on social EM research and advocacy. |
| Affective objectives | |
| By the end of the curriculum, each resident is expected to: |
Rank social needs and SDH as important in patient outcomes and health disparities. Rank SDH education as an important part of their training as an EM physician. Rate SDH education as valuable for treating underserved patient populations. Rate that they are more likely to address SDH when treating underserved patients. Identify as a belief that they have received targeted training on SDH and health disparities. |
| Psychomotor objectives | |
| By the end of the curriculum, each resident will: |
Report having asked questions of their patients about social needs impacting their ED care. Report having used resources taught during this curriculum while treating patients in the ED at least once per week on average. |
| Process objectives | |
| By the end of 1 year of curriculum, the residency program will be able to demonstrate that: |
Each EM intern will have completed a learning session during orientation on demographics of and health/health care disparities affecting their patient population. Each resident will have received 4 or more hours of instruction on social EM/SDH topics in 1 year of training. Each resident will have received a repository of educational information on SDH and health disparities. Each resident will have received an easily accessible database of social services for patients. |
The exact content of the social EM curriculum, while it could be regionalized, will differ across institutions due to varying patient populations, but the implementation should be standardized. Examples of relevant SDH and social needs to cover could include (but should not be limited to) homelessness and unstable housing, food insecurity, lack of insurance, poverty, immigration status, racism, LGBTQ, cultural barriers, language barriers, incarcerated and criminal justice involvement, domestic violence, gun violence, human trafficking, mental health, and drugs of abuse.
To minimize barriers such as competition with clinical duties, delivery of social EM content should be fully integrated into normally scheduled resident education (e.g., resident conference, journal club, intern orientation). Educational strategies could include the incorporation of SDH into discussions that are already mandated as part of the core curriculum, such as morbidity and mortality, grand rounds, and journal club.
Finally, there should be a formalized approach to feedback and evaluation of the curriculum. A framework such as Moore's could be used to measure curriculum effectiveness, with the ideal curriculum measuring learner satisfaction and knowledge and impacting the learners’ specific patient population.29 An example of a well-validated survey that measures learner knowledge is one developed by Weissman et al.30 to assess residents’ preparedness to provide cross-cultural care. Additionally, ongoing feedback of the curriculum is necessary to continue to address the changing social landscape.
AN ILLUSTRATIVE EXAMPLE
One residency program in Philadelphia used this theoretical foundation to institute a longitudinal social EM curriculum. The program identified targeted needs by surveying learner attitudes, knowledge, and perceptions of the general concepts of SDH as well as social needs of the patient population they serve. With help from departmental and institutional leadership, the program worked to understand the history of the communities’ relationship with the health care organization along with zip code–specific health disparities. These targeted needs informed the creation of a social EM grand rounds series, department-wide journal club, and an experiential social EM scavenger hunt, all of which were fully integrated into the preexisting conference schedule. The major barrier during the implementation of the curriculum was the inability to engage with the community in in-person experiential educational opportunities due to the COVID-19 pandemic and resulting social distancing requirements. Future plans for this curriculum based on feedback from learners and key stakeholders include the incorporation of “SDH Morbidity and Mortality Conference” into the preexisting quality and safety curriculum, including an evidence-based health disparities update of any core lecture topic, as well as more experiential opportunities to engage in and learn from the patient population and community that they serve.
CONCLUSION
Health and health care disparities that permeate ED patient experiences necessitate thoughtful and sustainable solutions. Emergency medicine can and should play a key role in mitigating these disparities in the future. Development of a standardized and effective social EM curriculum would teach future EM physicians how to identify social determinants of health and address the social needs that affect their patients, thereby advancing and promoting health equity among the population.
CONFLICT OF INTEREST
The authors have no potential conflicts to disclose.
