Medical students leave ‘indelible’ mark on the school’s curriculum

Seeing a critical need to reshape medical education to improve health equity and health outcomes, Yale School of Medicine (YSM) students Tehreem Rehman and Robert Rock have played an active role as the school evaluates and adjusts its recently revised curriculum.

Rehman and Rock, who are graduating from YSM this year, co-led the effort to create a new extracurricular elective, “U.S. Health Justice” (USHJ), for Yale students pursuing medical, physician associate, and nursing degrees. Rock also created and coordinated “Making the Invisible Visible: Art, Identity & Hierarchies of Power,” an art tour and reflection session exploring the expression of bias in western culture and its impact on patient-provider interactions. Originally developed as part of the USHJ elective, “Making the Invisible Visible” is now included in the required curriculum in the “Introduction to the Profession” course for first-year medical students.

The inclusion of this session into the required curriculum reflects the persistence and advocacy by Rehman and Rock to incorporate the health equity and social justice focus of the USHJ elective across the YSM curriculum. Their efforts have contributed to a cultural recognition within YSM of the importance of these discussions within the required curriculum. Indeed, recently, the school’s Educational Policy and Curriculum Committee (EPCC) adopted the recommendation of the Diversity, Inclusion and Social Justice in Medicine subcommittee to incorporate a health equity thread into the school’s curriculum.

Rehman and Rock each arrived at YSM in 2013 with the intent of using medicine to advance social justice. This goal stems in part from their personal experiences. Rehman is a Pakistani-American who grew up below the federal poverty level, and her volunteer experiences in high school and college, exposed her to health injustice and structural determinants of health inequity. Rock’s family is from Haiti. When his great aunt had cancer, he saw how language and cultural barriers resulted in a complete disconnect from her healthcare providers.

Once at Yale Rock and Rehman did not sense that domestic health equity was a priority at the school and had a hard time finding any sense of community around the issue. They co-founded the USHJ extracurricular elective as a means of addressing the dearth of topics related to health inequity and advocacy in the curriculum.

“We initially faced resistance but were ultimately able to get the support of several faculty members, administrators, and community leaders,” said Rehman. “The subsequent formation of a supportive and active community invested in health justice advocacy rendered this as one of my most rewarding experiences at YSM.”

Rehman and Rock both strongly believe that if medicine is not studied through a social justice lens, medical schools will not be adequately training medical professionals, jeopardizing healthcare, particularly for vulnerable and marginalized communities. Rehman said she has seen residents and attending physicians with inadequate training on the structural determinants of health inequity neglect to recognize and address factors such as unemployment, food insecurity, and unstable housing that impacted the symptoms and subsequent course of recovery for their patients. She also points out that she was “fortunate to find many role models and mentors during medical school who were doing an incredible job addressing health disparities locally and globally.”

Rock adds: “The medical curriculum and much of the scientific evidence it is based upon did not initially consider individuals outside of able-bodied, white, cis-gendered, heterosexual, men who were middle class or higher. For this reason, many of the medications and practice standards that exist within healthcare are not as effective in communities outside this idealized ‘normal.’”

The USHJ elective was intended as an initial step to close these gaps, note the students. The elective aims to educate health professional students about social determinants of health and the obstacles to favorable health outcomes encountered by marginalized populations, and to empower students by building the necessary skill sets to facilitate health justice movements and act as effective patient advocates. The elective extends well beyond a Yale classroom. Through activities like field trips and shadowing health care providers, students begin to build sustainable relationships with the New Haven community. Some topics covered are implicit bias, social determinants of health, homelessness, substance abuse, intimate partner violence, women’s health, incarceration, and LGBTQ issues in healthcare.

USHJ is now in its fourth year and has generated strong student interest, with over 100 students applying for 32 spots in fall 2017. But while Rehman and Rock are pleased with the extracurricular elective, they said they are frustrated there has not yet been more curricular change. Rehman stresses that continued advocacy for curricular reform is critical so that students “can become physicians for all communities and advocates for vulnerable and marginalized communities. We recognize that with the privilege of being physicians, particularly physicians trained at Yale, there comes great responsibility.” Rock believes “change is difficult because health professional education reform toward greater health equity requires an unlearning of many things we take for granted in the medical sciences and a fundamental restructuring of health professional education, from one that is ahistorical and apolitical, toward a biopsychosocial framework recognizing the structural determinants of health on the individual and community level. A level of auto-criticality within the health professions is necessary to achieve this level of fundamental reform.”

Rock thinks there are multiple places within the existing YSM curriculum where content from the USHJ course could be incorporated to augment the learning experience and, “if threaded together intentionally, the final product could be much greater than the sum of its parts.”

Medical education leaders agree. When YSM instituted a new curriculum in fall 2015, Deputy Dean Dr. Richard Belitsky emphasized that the curriculum would be responsive to a feedback process and evolve. Student advocacy has played a significant role in this feedback process, resulting in the EPCC commissioning and funding a faculty and student led subcommittee in 2016 to study diversity, inclusion, and social justice gaps in the curriculum. In spring 2018, the subcommittee recommended the development of a robust health equity curriculum, and a Health Equity Leadership group will be created to develop the curriculum thread and work with the course, clerkship, and elective directors to implement and advise on curriculum content. Other recommendations of the subcommittee under consideration are the establishment of a curricular Experiential Learning Program involving projects based on community-identified needs and priorities in New Haven, and a Certificate in Health Justice for those advanced learners who are seriously considering careers anchored in health justice work; this could be modeled after YSM’s existing Certificate in Global Medicine.

YSM Associate Dean Dr. Nancy Angoff explains that beyond the USHJ course, Rehman and Rock have helped change the framework in thinking about medical education: “Robert and Tehreem leave Yale Medical School having created a course and community engagement around health equity and social justice that has led to major curricular change and focus. Their mark on the culture of the school is indelible. I expect that they will advance in their careers as the leaders that they have already proven themselves to be.”

After the launch of the USHJ course, Rehman and Rock initiated the USHJ Collaborative, to build a network of students from across the university, medical residents, and New Haven community members who would focus on health equity in the city beyond the boundaries of the course. Rehman said the insights garnered from connecting with students from the Schools of Management, Forestry & Environmental Studies, Public Health, and Divinity “was crucial for developing a better understanding of health injustices, that are largely informed by factors outside of the walls of the hospital, and means of advocating for change.” Both students credit the Robert Wood Johnson (RWJ) Clinical Scholars Program and the community partnerships they established over the years for making it possible to design the USHJ course. According to Rock, the core faculty of the RWJ clinical scholars program “role-modeled the integrity necessary to be both an academic and a citizen in a place like New Haven.”

Rehman’s and Rock’s impact on the school, and the broader community, has been widely recognized. Last month Yale President Peter Salovey and New Haven Board of Alders President Tyisha Walker-Myers presented them, and Kayla Ringelheim (SOM ’18, SPH ’18), with the “Graduate Ivy Award” during an annual event which recognizes members of the Yale and New Haven community who have strengthened the bonds between the two entities. The award citation noted that the collaborative “facilitates the development of strong bonds between students, New Haven residents and local organizations. For example, Yale health students have begun regularly working at the Little Red Hen Community Garden in West River to help increase access to healthy food and joined the Yale Primary Care Internal Medicine’s community-walking program which promotes walking as a healthy activity and encourages casual conversations between community members and physicians.”

This community engagement also motivated students in the USHJ Collaborative to get involved in community discussions around a proposed move of the Yale-New Haven Hospital Primary Care clinics from several neighborhoods, including West River, to a single center in the Long Wharf area of New Haven, which is difficult to reach without a car from many neighborhoods, because of inadequate bus routes.

Rehman’s and Rock’s efforts to promote health equity and social justice extended beyond Yale and New Haven. Rock has given presentations on his art tour in forums around the country, including New York City, Houston, Washington, D.C., and Cleveland. Rehman co-founded “Systemic Disease,” an initiative seeking to address bias in medicine through storytelling. Rehman has connected with students and faculty from across the country who are committed to exposing pervasive bias at their institutions and developing bias-reporting systems and other measures to create more diverse and inclusive environments.

Rehman and Rock said they are eager to continue advancing social justice through medicine. Rehman’s residency will be in emergency medicine (EM) in the Advocate Health Care (Advocate Christ Medical Center) Program in Oak Lawn, Illinois. During her EM rotation at Yale, Rehman saw how the emergency department operates as a safety net for medical care. She encountered patients with complex health care needs that were often linked to socioeconomic factors — for example, a homeless patient who has severe diabetic foot ulcers because the person is unable to take properly refrigerated insulin. Rehman said she is excited to enter this specialty in part because she views EM physicians as serving on the front lines of health care for surrounding communities, able to intervene with the support of interdisciplinary team members in fields such as social work, law, and mental health at a population level with public health screenings and programs.

Rock will be an intern in the Department for Family Medicine & Social Medicine at Montefiore Medical Center in The Bronx, New York. Since his interests have always been at the intersection of healthcare and the community, primary care seemed like a natural path for him, he said, and he believes Family Medicine will provide the best skill set for what he envisions for himself as a future physician. Rock believes that Montefiore is “ahead of the pack when it comes to addressing the social determinants” and that he will be better able to focus on honing his clinical craft, while surrounded by mentors actively working to reform the healthcare system.

In the long term, Rock said, he hopes to work as a primary care family physician in a neighborhood health center that is both a community center for the arts and education, in service to promoting population health in the area.

Rehman hopes to merge her clinical practice with public health work. “I am eager to find a position in which I can help design and implement community-based interventions addressing structural determinants of health and subsequently advocate for their adoption into local, state, and national policies,” she said. “As physicians, we cannot restrict our social responsibility to our clinical work. Health of the community, not just the individual, falls under our scope of practice.”