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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.”

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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.

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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.

  • Dr. Yerramilli,
    It is clear to me that poor living standards and poverty impact your patients’ health. But how did indoctrination in social justice principles assist you in treating a gunshot wound?

    • social factors determine who ends up suffering from gunshot wounds and who doesn’t. ignoring these factors ignores opportunities for prevention, which is within the scope of medicine.

    • Preventing gunshot wounds is the purpose of law enforcement, not medicine. Do you think that physicians are better at policing than police?

  • I really hate these lectures from others on “social” justice. Justice is justice. It needs no qualification. The universities continue to dole out this nonsense. Brought to you by the same folks behind identity politics and post modernism. Why can’t people just learn to be decent and forget all this social justice crap. It really is not that difficult.

  • ” .. patients with preventable adverse events may be more likely to experience personal bankruptcy than they are to get bills waived ..”

    How very odd. Even U.S. Sen. Spreading Bull (D), a lawyer and not a finance professional, no longer tries that “medical bankruptcy” deceit anymore, after her alleged “research” provided months of laughter in Finance PhD classrooms —

    https://www.theatlantic.com/business/archive/2010/07/considering-elizabeth-warren-the-scholar/60211/

    Someone who is a bankrupt before cancer .. is still a bankrupt afterwards. Period. There is no other country in the world that has it, any other way. Really. Look it up. Thanks.

    • Urko, your article doubting healthcare problems is almost a decade old. This article is current and hits the nail on the head, based on the awful things occurring to patients and bedside providers in my state.

  • My state, NC, is rated as one of the most expensive healthcare states in the country, and it also ranks as one of the worst for access to care. Staff to patient ratios aren’t ideal. Healthcare profitability is high, CEO/CFO pay is high, consolidations have made systems huge, malpractice insurance costs are low, but it patients with preventable adverse events may be more likely to experience personal bankruptcy than they are to get bills waived or to get any compensation or even a heartfelt apology. For so many reasons, I applaud this article for pulling back the curtain on some of many tough realities. I feel for bedside providers and patients.

  • ” .. If one does not really see what AK 47’s really do to humans ..”

    Fact & reality: last weekend, seven were gun-murdered in Chicago, politically controlled by the (D) for 75+ years.

    Why don’t the (D) do something about that, first? What are the (D) waiting for?

    Until the (D) do something about Chicago’s gun-murders, all their blather means nothing. Zero. Zip. Nada.

  • Back in the day our local county hospital had Primary Care Clinics that were matched with medical care inpatient units.
    The resident failed to mention the great importance of other medical professionals functioning as a team because any Social Justice issue is worthy of great effort and what one observed in the medical world is only one side of a very ungainly elephant.
    Free medical clinics are part and parcel and many of the docs I worked with after residency volunteered several times a month.
    There also needs to be bridges made between the medical world and policy making and philanthropy. If one does not really see what AK 47’s really do to humans, one is immobilized by sheer ignorance and policy and philanthropy can be easily co- opted by the powers that be.

  • Medical schools could use psychological tests to identify those applicants with undesireable character traits, lack of empathy being foremost.

  • ” .. if this country needs more gun control ..”

    Seven were gun-murdered last weekend in Chicago, controlled by the (D) for 75+ years.

    Sir, are you offering to patrol those areas? Unarmed? Armed? How much life insurance do you have?

    Talk is the cheapest cheap there is. Actions at the front lines matter.

  • As a retired physician I will respectfully pass on a lesson learned. Being your “Brothers Keeper” is a critical element in a moral physician. Love the critique!

  • Many times patients will not take the iniative to tell the dr if their recomendations or prescriptions can actually be followed up. So it is up to drs to ask if the patient can think of any obstacles to carry out the plans. Then the drs can try to come up with possible options or workarounds.
    The patients may be so concentrated on daily survival routines, that they haven’t been asked to think creatively for months or years.

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