During my first days as a supervising resident physician at a large urban hospital, two questions were constantly on my mind, the key drivers of any medical decisions that I would make: How can we stop this from happening again? How can we prevent this suffering from getting worse?
These questions, and the principles that guided my approach to them, were largely those I established during my undergraduate education and my four years at the University of Pennsylvania’s Perelman School of Medicine — an understanding not only of physiology and diagnosis, but also of the importance of social justice in treating illness.
Which is why the recent essay in the Wall Street Journal by Dr. Stanley Goldfarb, former dean of curriculum at Perelman, is both disheartening and dangerous. Goldfarb suggests that medical education is focusing too much on social justice issues “rather than treating illness.”
It is true that medicine is one of the professions trying to solve challenges that are not “directly” within its purview, challenges that extend beyond the hospital or clinic and into other realms of social policy. But the reality is that in seeing patients, physicians grapple with unemployment, housing instability, and food access; systemic racism, sexism, and LGBTQ rights; immigration reform, climate change, and violence. All of these issues profoundly — not tangentially — affect our patients’ health.
Within a single week at the hospital, I took care of three patients who embodied the importance of understanding social determinants of health.
One was a middle-aged woman whose financial and housing instability, depression, and alcohol use disorder had led her to develop severe liver disease. She came into the hospital with dangerously altered mental status because she stopped taking lactulose, a laxative she had been prescribed to remove the neurotoxins from her body that her liver could not. Why did she stop taking the medication? She didn’t have regular access to a bathroom.
Another was a man in his mid-60s with significant heart failure and kidney failure. He knew he should take his water pill and avoid salty foods to prevent fluid from building up in his lungs. He came into the hospital with shortness of breath because he had stopped taking his medication, as he too often couldn’t get access to a bathroom. And after his recent unemployment and homelessness, his diet consisted mostly of salty fast food, since he had neither a kitchen to cook in nor money to afford healthier options.
And then there was a 20-something male who suffered immense physical and emotional trauma after stab and gunshot wounds irreversibly damaged his organs. As we carefully repositioned the various tubes placed in his kidneys, bladder, and intestines, one of many questions weighing on his family’s mind was whether they could afford food and housing, let alone the care he would require over the short-and long-term, and whether he might again be a victim of gun violence.
For the majority of my patients, it isn’t enough to understand the biologic basis of disease. My prescriptions mean nothing if we cannot address the social determinants underlying their health issues.
We are told that there is a looming shortage of primary care physicians. Yet Goldfarb focused on “oncologists, cardiologists, surgeons, and other medical specialists” and their need to “master more crucial material.” But even for those who choose to specialize — in oncology, cardiology, surgery, or any other specialty — a fundamental understanding of social justice is important to effectively delivering health care. Just as we establish basic biomedical knowledge through premedical undergraduate coursework, and formalize and contextualize this foundation in early medical school curricula, so must we approach education regarding social justice and social determinants of health.
I hope for a day when the field of medicine can narrow its focus to “scientific knowledge” and pathophysiology. Indeed, this is a day many physicians hope for in advocating stronger social safety nets, social justice, and broader policy change. But while these issues still grossly pervade American society and remain inadequately addressed by our institutional and governmental leaders, we must learn about and address them in order to ensure that our patients truly benefit from the treatments we prescribe.
In short, Goldfarb was wrong — if this country needs more gun control and climate change activists, medical schools are the right place to encourage them.
Pooja Yerramilli, M.D., is a resident physician in the Global Medicine Program at Massachusetts General Hospital and a graduate of the Perelman School of Medicine. She recently served as a consultant to the World Health Organization’s Office for Health Systems Strengthening.