Integration of Social Determinants of Health in Undergraduate Medical Education: From Evidence to Implementation

Abstract

Over the past 50 years, there has been increased awareness of the importance of social determinants of health (SDOH) in undergraduate medical education (UME) curricula. Since the societal guidelines and accreditation standards started to address SDOH topics, it has further evolved to recognize the impacts of SDOH on the medical outcomes for our patients. Medical schools across the United States have been integrating SDOH content across the curriculum in response to expectations from accrediting bodies, guided by national organizations, and fueled by internal efforts of curricular reform and improvement. Since its inception in 2017, our college of allopathic medicine has made SDOH a major pillar in its vertically and horizontally integrated 4-year curriculum. To evaluate the depth and breadth of SDOH integration, we searched “eMedley,” our curriculum management system, for content specifically addressing these topics. We identified various curricular activities integrating SDOH-related topics across all 4 years, including hands-on learning projects, as well as small-group discussions and large group discussions with a heavy emphasis on the clinical impact of SDOH. Based on our review of current trends and our experience, we recommend a progressive competency-based transition of SDOH learning and assessment across pre-clerkship, clerkship, and graduate medical education to ensure a meaningful longitudinal learning process.

Introduction

Personalized medicine has recently gained momentum leveraging the unique genetic makeup of individuals to customize treatment strategies for different diseases [1]. Contemporary targeted therapies, relying on the identification of specific molecular or genetic markers linked to certain cancers, are successful in precisely addressing the abnormal components contributing to the disease, thereby minimizing adverse effects on normal cells [2]. Despite these important medical advances, it also is crucial to recognize that patient management requires interventions that necessitate broader social contexts. These uniquely pertinent patient variables are essential for promoting equitable and effective health outcomes. Where you live, who raised you, and the accessibility of essential resources for a healthy life—including family income, educational support, career opportunities, and healthcare accessibility—constitute critical elements influencing health awareness and, consequently, the well-being of both body and mind. These factors and other related non-medical conditions encompass the spectrum of social determinants of health (SDOH) [3].

The holistic approach to patient care requires healthcare providers to consider SDOH in their clinical practice. Recognizing the impact of SDOH in patient management has led to the integration of related skills and competencies throughout the continuum of medical education, including different health profession programs [4]. The Accreditation Council for Graduate Medical Education (ACGME) explicitly included SDOH among the residency training requirements under the competency of “System-based Practice” [5]. In undergraduate medical education (UME), the Liaison Committee on Medical Education (LCME), which is the accreditation body for education programs leading to the MD degree in the United States (US), requires all medical schools to address SDOH-related curricular topics and contents [6].

Beyond meeting accreditation requirements, organizations sponsoring the LCME have dedicated efforts to increase awareness of the importance of addressing SDOH in medical training. The Association of American Medical Colleges (AAMC) has endorsed the “Social Determinants Accelerator Act” and provided guiding resources to address SDOH in medical education [7, 8]. Similarly, the American Medical Association (AMA) has published several SDOH-related resources, including an online module [9]. Likewise, the American Association of Colleges of Osteopathic Medicine (AACOM) has been enhancing SDOH in medical education through resources addressing equity and disparities in healthcare [10].

The implementation and integration of SDOH-related accreditation requirements and societal guidelines varies among US medical schools. Across these different medical schools, the learning expectations for SDOH under different competencies are addressed through a spectrum of mandatory and elective curricular activities. Didactic sessions and assignments, focused on health equity, experiential learning through student-run clinics, and interprofessional education activities, are common methodologies [11, 12]. The assessment of student learning in these curricular activities includes the domains of knowledge, skills, and attitudes, with program evaluations predominantly relying on student surveys [12].

The overarching educational goal is to seamlessly incorporate relevant curricular content, with measurable SDOH-related objectives throughout all phases of US medical school curricula. However, despite all the regulatory requirements and the SDOH-related professional and societal guidelines, there remains a challenge in achieving explicit structuring and adequate coverage of SDOH content within medical school curricula [11, 13].

Medical education has been shaped by historical shifts in scientific knowledge and societal needs, with models and content evolving over many centuries. Over the past 50 years, there have been significant advances in understanding and incorporation of societal influences on health outcomes. This growing recognition of the impact of SDOH has influenced curricular development, guiding how future physicians are trained to understand and address these critical factors.

Globally, the attention to SDOH truly came to light in the early 1970 s, instigated by multiple seminal reports and initiatives. In Canada, the 1974 Lalonde Report drew the attention to “adequate levels of physical, mental and social activity” and their impact on health outcomes. This report allowed for government resources to be dedicated to investigating social and societal impacts on health disparities [14].

In the 1980 Black Report, Sir Dougals Black, then President of the Royal College of Physicians, analyzed health disparities that influenced health outcomes in the UK and found multiple social inequities, such as income, education, housing, diet, employment, and conditions of work [15]. These groundbreaking reports were pivotal in acknowledging the profound influence of social factors on health disparities and outcomes, laying the foundation for new studies and interventions.

Although the Lalonde and Black Reports are core foundational works in the SDOH arena, they were published outside the US and were not directly involved in the implementation of SDOH in UME curricula. Compared to those early global efforts, the US process of increasing awareness about SDOH in UME was more institutionally structured as part of accreditation requirements for medical schools. Prior to the publishing of the Lalonde and Black reports, the LCME in the US revised their Educational Program Standards in 1973 and removed the requirement of teaching specific basic and clinical science subjects in UME, while also emphasizing incorporation of content related to “preventive medicine, public health, and the social and economic aspects of the systems for delivering medical services.” The 1973 LCME educational standards also emphasized the need to “stress the physician’s concern with the total health and circumstance of patients and not just their diseases” [16]. Despite this change, the AAMC’s Medical School Objectives Project (MSOP) established in 1996 was the first major initiative aimed to define comprehensive learning objectives related to SDOH awareness [17]. In 2002, the LCME established an educational standard, among its earlier standards set, that requires faculty and students to demonstrate an understanding of different cultures and the impact on health literacy [16]. This standard later evolved into SDOH-related elements in LCME Standard-7 on “Curricular Content,” where Element 7.5 specifically addresses the medical consequences of societal problems, while Element 7.6 addresses health disparities and inequities among other required curricular content [6]. In 2003, the Institute of Medicine released a report titled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” calling for medical schools to incorporate SDOH teaching into their curricula [18].

The academic and professional societies, as well as related accreditation bodies, continued to guide medical schools on integrating SDOH into their curricula through establishing broad guidelines. Based on these guidelines, medical schools established different learning and assessment approaches in their models of integrating SDOH across the curriculum.

As medical education continues to evolve, there has been a growing recognition of the need to incorporate SDOH into training to better prepare future physicians for addressing health disparities. Over the past decade, medical schools across the US have increasingly recognized the importance of addressing SDOH as a primary strategy to achieve health equity [19]. There are varied examples in the published literature regarding the frameworks, pedagogical strategies, curricular content, and evaluation methods utilized by medical educators to teach and objectively assess SDOH. The three most widely recognized frameworks for educating health professionals to address the SDOH are from the National Academy of Medicine (NAM) [4], the World Health Organization (WHO) [20], and the US Healthy People Initiative (HPI) [21]. These frameworks overlap in many aspects and emphasize the importance of collaboration between educational and healthcare sectors as well as community partners to educate health professionals on SDOH. The “Results” section presents findings from our literature search, highlighting examples of medical school practices related to SDOH.

This article addresses the historic perspectives and current status and challenges in the effective integration and assessment of SDOH content within medical school curricula in the US, including our own experience at Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University (hereafter referred to as NSU MD).

Methods

Literature Search

A comprehensive literature search was conducted to identify relevant studies and articles pertaining to the topic SDOH Related Guidelines and Best Practices in UME. The search was performed using the National Library of Medicine (PubMed®) advanced search function and Boolean operators “AND,” “OR,” and “NOT using the keywords such as “Population health,” “Underserved,” and “Disparities,” and other related keywords. In addition, all societal guidelines and regulatory standards related to the incorporation of SDOH content in medical education have been reviewed and considered in the planning and implementation of the NSU MD process of curriculum development and delivery.

Curriculum Mapping and Evaluation of SDOH Integration in NSU MD

The structure of NSU MD curriculum is based on vertically integrated blocks that are sequenced to start with the pre-clerkship organ system-based and clinical skills courses in the first 2 years. The clerkship curriculum blends with the earlier curricular phase at the end of the second year and continues through the fourth year that hosts the electives [22]. The curriculum’s framework is built upon a scaffolding of mapped objectives starting at the session level, spanning across courses, and culminating in the competency-linked educational program objectives (EPOs).

To identify and evaluate SDOH-related contents across the 4 years of NSU MD curriculum, a structured curriculum mapping approach was implemented using the “eMedley” curriculum management system, an all-in-one platform for health science programs used by our school. A systematic keyword-based search strategy was followed to locate and assess relevant sessions.

The search process began with the AAMC-designated keyword “Social determinants of health” (coded as “K089” [23]), which AAMC defines as “The circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics” [23]. While the AAMC “Do not include” listed words were considered, flexibility was applied to avoid unintended exclusion of relevant sessions during the search on NSU MD’s eMedley curriculum map. To ensure comprehensive identification of relevant content, a supplementary literature review was conducted using PubMed®, leading to the inclusion of additional keywords including Community, Population health, Underserved, Cultural, Psychosocial, Equity, Discrimination, Bias, Sexuality, Disparities, Abuse, Lifestyle, Disabilities, Domestic violence, Malnutrition, and Insurance.

The eMedley system was first queried using for the academic year 2023–2024 using the keyword “Social Determinants of Health/SDOH.” The search results were manually reviewed to assess the relevance of each session by examining its objectives. Sessions that explicitly or implicitly addressed SDOH topics were retained, while those lacking substantial SDOH-related content were excluded. Further vetting was conducted using the additional keywords listed above to ensure that all relevant sessions were identified—even if they did not explicitly mention “SDOH” in their titles or objectives.

The results from various SDOH-related assessments identified by this curriculum map search will be used in the ongoing program evaluation process to feed a pool of outcome measure data included in the longitudinal evaluation of educational program objectives achievements. The actual impact of the incorporation of SDOH in the curriculum of NSU MD will be evaluated through different outcome measures based on direct and indirect assessments of student learning. This mapping will be reviewed at multiple curricular committee levels to determine adequacy at individual phases including each academic year and between pre-clerkship and clerkship years. Satisfaction will be determined based on overall coverage of essential skills based on the perception of the committee and overall scholastic success of the students.

Results

Organizational and Medical School Approaches to Addressing SDOH

To enhance education on SDOH, various frameworks have identified essential domains and key components that shape learning and practice in this area. Notably, the NAM, the WHO, and the HPI frameworks provide structured approaches to integrating SDOH into education, as summarized in Table 1. The NAM framework centers on medical education, by clearly stating that, at early stages of health professions curricula, the primary SDOH-related educational outcome expected for students is to recognize the “ability to demonstrate an understanding of how social, political, and economic factors determine the health and health outcomes of individuals, communities, and populations” [4]. In alignment with this, clinical faculty are expected to demonstrate awareness of how the SDOH are integrated into clinical care, while non-clinical faculty are expected to improve curricular content by incorporating advancements in the understanding of SDOH and their impact at the individual and community levels [4]. The WHO framework provides a global policy and advocacy approach, aiming to reduce health inequities by advising governments and organizations on strategies to improve SDOH, and emphasizing intersectoral collaboration, recommending policies that address broader social structures affecting health, such as poverty, education, and housing [20]. Conversely, the HPI focuses specifically on the US, setting national health objectives and tracking progress in improving SDOH-related health outcomes, as identified by different components in five key SDOH domains [21].

Table 1.

Summary of domains and key components identified by different frameworks to enhance education on SDOH

Framework	Domains	Key components
National Academy of Medicine (NAM)	Education	▪ Experiential learning ▪ Collaborative learning ▪ Integrated curriculum ▪ Continuing professional development
	Community	▪ Reciprocal commitment ▪ Community priorities ▪ Community engagement
	Organization	▪ Vision for and commitment to education in the social determinants of health ▪ Supportive organizational environment
World Health Organization (WHO)	Socioeconomic and political context	▪ Governance ▪ Macroeconomic policies ▪ Social policies ▪ Public policies ▪ Culture and societal values
	Social hierarchy structural determinants	▪ Socioeconomic position ▪ Social class, gender, ethnicity ▪ Education, occupation, income
	Intermediary determinants	▪ Material circumstances ▪ Psychosocial circumstances ▪ Behavioral and/or biological factors ▪ Health system
Healthy People Initiative (HPI)	Economic stability	▪ Income ▪ Cost of living ▪ Socioeconomic status
	Education	▪ High school graduation ▪ Enrollment in higher education Language and literacy ▪ Early childhood education and development
	Health and healthcare domain	▪ Healthcare ▪ Access to primary care ▪ Health literacy
	Neighborhood and built environment domain	▪ Access to healthy food ▪ Quality of housing ▪ Crime and violence ▪ Environmental conditions
	Social and community context	▪ Social support ▪ Family circumstances ▪ Community engagement

In addition to analyzing the NAM, WHO, and HPI frameworks, our literature search identified various approaches used by medical schools to integrate and deliver SDOH-related content. While medical schools across the US primarily rely on the HPI framework to guide UME curricular development and delivery [11], there are no consensus guidelines for teaching and assessing knowledge, skills, and attitudes about SDOH. In 2017, an expert panel—including medical students, academic faculty, public health researchers, and community advocates from a broad US geographic distribution—recommended that SDOH should comprise 29% of the total medical school curriculum, and be taught continuously longitudinally throughout medical school [24]. The panel also advocated for incorporating SDOH-related content into standardized exams, with assessment methods that emphasize community and patient-centered elements [24]. Another study involved a survey among 32 US academic medical institutions to assess the commitment to teaching SDOH in UME. A 23-item survey was designed to evaluate the commitment to teaching SDOH, the teaching strategies and curriculum placement, learning objectives related to student knowledge, skills, and attitudes, as well as perceived barriers to teaching SDOH [25]. The study, which was published in 2020, revealed that 64% of the responding medical schools rated the priority of SDOH in their curricula as high or extremely high. Learning objectives in the knowledge domain focused on defining SDOH and understanding their impact on health and disease at both individual and population levels, while in the skills domain, learning objectives included conducting and documenting a full SDOH history, demonstrating cultural sensitivity and respect. SDOH-related attitude objectives emphasized healthcare teamwork, awareness of health disparities, and advocacy for patients and communities [25]. Based on this survey, it was found that a significant portion of SDOH curricula was offered in the first and second years of UME, with 50% of participating schools providing this education in more than one course. However, it was reported that there was no longitudinal theme across those multiple courses. Moreover, in only 25% of the cases, SDOH were integrated as an overarching theme throughout the curriculum, aligning it with the school’s mission. As for the teaching strategies, the survey revealed that medical schools utilized a wide variety throughout different stages of the curriculum. Case studies have been found to be the most common approach used during the first and second years, and history-taking tools that address SDOH were used in about half of the schools during the third year, while fourth year students were primarily engaged with community-based service programs or research projects in around one third of the cases [25]. A recent scoping review study provided a closer look into comprehensive SDOH curricula from six US medical schools, namely Wake Forest School of Medicine (Winston-Salem, NC), Mayo Clinic Alix School of Medicine (Rochester, MN), Rutgers New Jersey Medical School (Newark, NJ), Albert Einstein College of Medicine (Bronx, NY), Tulane University School of Medicine (New Orleans, LA), and University of South Carolina School of Medicine (Columbia, SC). The study results showed that these schools are divided in their approach to SDOH program design and enrollment. Three of the six schools had mandatory enrollment, while the rest had elective enrollment [11]. For example, the Mayo Clinic Alix School of Medicine offers its SDOH curriculum as a student-run clinic, with mandatory enrollment for a full year for second-year medical students [11, 26]. Conversely, the Albert Einstein College of Medicine offers its Health Disparity curriculum as a 3-month elective for first-year medical students [11, 27].

Assessing SDOH Integration in NSU MD’s Curriculum

In compliance with regulatory standards, our new fully accredited NSU MD has aligned with the practices of other US medical schools by integrating content related to SDOH throughout its 4-year curriculum. Guided by course objectives mapped to EPOs, the curricular course content was developed by teams of interdisciplinary faculty who first identified basic and clinical science topics, along with related societal problems, and accordingly formulated the session objectives and schedule. The process of curricular design and development recognized the vital need of horizontal and vertical integration while effectively blending the content and efficiently scheduling related sessions, aiming for a meaningful learning experience.

Through a comprehensive mapping and evaluation of NSU MD’s 4-year curriculum, we identified SDOH-related sessions, including their objectives and teaching and assessment methods, as well as their placement within specific courses and curriculum phases (Appendix 1). Appendix-1 contents were updated with additional SDOH-related curricular activities that have been scheduled after the initial search. As shown in Table 2, NSU MD incorporated a variety of learning activities to deliver SDOH content including didactic sessions, small or large group discussions, team-based learning (TBL) and problem-based learning (PBL) sessions, community-based student-run clinics and service-learning projects, interprofessional education activities, and low- and high-fidelity simulations and case-based instruction through standardized patient encounters. All these SDOH-related learning activities are integrated into vertically structured blocks, starting with pre-clerkship organ system-based and clinical skills courses in the first 2 years, transitioning into the clerkship phase at the end of the second year, and continuing through the fourth year with elective courses [22] (Table 2). Table 3 summarizes the various types of assessments used for SDOH and the number of sessions for each category in NSU MD curriculum.

Table 2.

NSU MD curricular sessions addressing SDOH

Session type	Pre-clerkship phase	Clerkship ohase	Total
Service-learning projects	1	0	1
Large group sessions	33	4	37
Small-group sessions
Problem-based learning	6	0	6
Case-based learning	1	1	2
Team-based learning	1	0	1
Research journal club discussion	1	0	1
Simulation/SP encounter	3	0	3
Small-group session subtotal	12	1	13
Total	46	5	51

Please Refer to Appendix-1 for more details

Table 3.

NSU MD most frequently used assessments of SDOH

Assessment type	Pre-clerkship phase	Clerkship phase	Total
Participation	25	5	30
Exam—institutionally developed, written/computer-based	14	0	14
Exam—nationally normed/standardized, subject (NBME)	41	5	46
Exam—institutionally developed, clinical performance	19	2	21
Total	99	12	111

Please Refer to Appendix-1 for more details. Numbers refer to sessions addressed by listed assessments solely or in conjunction with other assessments

Discussion, Challenges, and Future Directions

A review of the published literature clearly reveals that the incorporation of SDOH into UME curricula is becoming increasingly recognized and valued in academic medicine communities in the US and worldwide. However, as previously mentioned, the approaches to incorporating SODH are broad, as medical schools have adopted a variety of learning and assessment strategies, each emphasizing different aspects of SDOH. In fact, US medical schools exhibit notable variation not only in their delivery methods but also in the duration, timing, and elective requirements of the SDOH learning modules [11, 28]. Among the identified curricular challenges is the need for SDOH content that emphasizes the acquisition of not only knowledge but also related skills and attitudes. This can be achieved by engaging students in focused learning activities that enhance their ability to apply SDOH concepts in healthcare. For instance, these activities can emphasize using SDOH approaches to promote equity and social justice, ultimately leading to improved patient outcomes [24, 29].

Similarly, the assessment and evaluation of SDOH learning is significantly variable, highlighting the necessity for a standardized approach. Campbell et al. reported differences in SDOH-related assessments and evaluation across many medical schools, noting that fewer than half of US medical schools incorporate related competencies and entrustable professional activities into their assessments [28]. These findings highlight the need for institutional and national assessment and evaluation systems that are capable of objectively measuring the extent to which graduating medical students have achieved SDOH-related program outcomes, and to what extent [24]. Such systems would leverage SDOH concepts to develop explicit and measurable competency-based learning expectations, enabling meaningful engagement and effective assessments throughout the curriculum. The initiative of the new set of UME foundational competencies, cosponsored by AAMC, AACOM, and ACGME, recognizes the importance of addressing healthcare equity and disparities in UME aligning the competency set content with the recommendations of the UME-GME Review Committee on transition to residency [30].

The NSU MD developed a curriculum that fosters a culture to support diversity and promote collaboration, critical thinking, and leadership. The overarching goal of the curriculum aims at improving patient care and better serving the various communities in South Florida. NSU MD’s Mission and Core Tenets include community engagement and elevation among their main elements. Hence, the curriculum committee and its curricular integration and evaluation subcommittee have created a taskforce charged with exploring the current implementations of SDOH-related curricular activities. The committee will also identify gaps that can be addressed through further curriculum and faculty development. The primary goals of this ongoing curriculum review and reform are to effectively integrate SDOH curricular activities, and to enhance students’ awareness of SDOH while also developing the competencies needed for a holistic approach to healthcare in their future practice.

We are currently amid curricular revisions aimed at expanding and better integrating longitudinal topics into our curriculum. Our vision is to better deliver a curriculum that aligns more closely with the career-based needs of our students. A major pillar of these reforms includes enhanced and improved integration of SDOH.

The challenges to successfully integrating SDOH into UME are multifaceted and must be addressed to ensure effective implementation. These include but are not limited to the following:

1. Availability of resources and varying interpretations among faculty of what defines “SDOH.” The availability of expert faculty with relevant experiences is crucial to increase institutional awareness on SDOH, guide faculty development on the scope and role of SDOH in medical education, and enhance SDOH content development and delivery. This should be coupled with a parallel availability of the logistics needed to implement the planned SDOH activities including but not limited to collaborative and or affiliated community outreach facilities and the related budgeted finance for staff and technology support.

2. The use of a standardized keyword list is essential for achieving national consensus. To address this, we have recently adopted the AAMC key terms for mapping, which align more closely with national perceptions.In NSU MD, wealso enhanced our curriculum map search by including other SDOH-related keywords, described earlier, to identify more content.

3. Programs need to build a consensus on the best modality to assess learning effectiveness of these topics. Establishing such assessment strategies is vital for the meaningful integration of the SDOH into the curriculum, as well as for measuring its effectiveness.

4. Identification of intentional tethers across pre-clerkship to clerkship and clerkship to graduate medical education. True longitudinal integration requires intentional deliberate communication between all three levels. This may prove to be the most challenging aspect to achieve, as these groups have historically lived as islands. The effective longitudinal integration of SDOH or any core topic requires this relationship to become more fluid in nature.

5. Identification tracking mechanisms to ensure that all students receive comparable training as planned. This is often challenging in clerkship or free clinic experiences unless the goals are clearly defined and broadly applicable.

6. The curriculum must be continuously and rigorously reviewed. While core topics tend to endure over time, even the subjects can exhibit nuanced differences within a 5-year span. Institutions must remain vigilant in monitoring social evolution to ensure that SDOH topics contribute to enhancing the broader health landscape, rather than unintentionally hindering progress.

As the searched literature and best practices guided our work, sharing our approach and challenges could enhance other medical schools’ efforts to effectively integrate SDOH curricular content in UME.

Conclusion

SDOH are crucial to a holistic patient-centered approach to healthcare, and essential for the development of future competent physicians. Currently, medical schools integrate SDOH into various courses and clerkships across the 4-year curriculum, with relevant content delivered and assessed using a variety of methods. However, there is still a need to integrate SDOH-specific learning expectations into related competency-based educational program objectives. This integration would allow an explicit assessment of student learning and provide valid outcome measures for the program evaluation. Similar to other medical schools, NSU MD curriculum map includes SDOH-related content spanning the 4-year program. This content is delivered through various methods, including didactics, case studies, and service-learning projects. Our SDOH-related learning objectives are addressed in a variety of institutionally developed and nationally standardized assessments. The ongoing curriculum reform at NSU MD prioritizes the integration and assessment of SDOH content as one of its main enhancements. In conclusion, integrating SDOH-specific learning expectations into competency-based educational program objectives is essential for valid assessment and evaluation. Despite its current integration into US medical schools, the concept of SDOH is continually evolving and should be regularly revisited to align medical education with the future needs of healthcare. Together with similar medical schools’ experiences, the NSU MD explicit approach of incorporating SDOH into the curriculum could guide other evolving medical schools in their efforts to establish a socially accountable medical education.

Appendix 1 NSU-MD Identified SDOH Related Curricular Content

Curricular Phase	Course/Clerkship	Session Title & Type	SDOH Related Learning Objectives	Assessment Type
Preclerkship	Professional Immersion	Community and Population Health; Discussion, Large Group (> 12)	Define and describe some of the social determinants of health	Participation
			Define and describe the triple aims in healthcare
			Define population health, public health, health disparities and health equity
			Develop an appreciation of the continuum of medical care for individuals and the health of populations
		Confronting Bias; Discussion, Large Group (> 12)	Discuss implicit/unconscious bias and its role in healthcare
			Highlight the role of intersectionality in promoting equity in healthcare
		United Way: Confronting Bias, Discussion, Large Group (> 12)	Discuss implicit/unconscious bias and its role in healthcare
			Eliminate misconceptions about diversity & its effects
			Emphasize the value of diversity
			Enhance human relations and development
			Highlight the role of intersectionality in promoting equity in healthcare
	Fundamentals	LGBTQ Proficiency Training; Discussion, Large Group (> 12)	Outline the foundational key concepts of the LGBTQ +  + acronyms	Exam—Institutionally Developed, Written/Computer-Based; Exam—Nationally Normed/Standardized, Subject (NBME)
			Define sexual orientation, gender identity & gender expression
			Utilize inclusive language through pronouns
			Discuss microaggressions and strategies to avoid them
			Describe the importance of allyship
		Lifelong Learning: Ethics—Unconscious Bias in Medicine; Discussion, Large Group (> 12)	Differentiate between explicit and implicit bias (unconscious bias)
			Discuss specific"bias-mitigating"techniques that can be used in the clinical environment
			Identify where personal unconscious biases may reside in everyday interactions with patients
		Genomics/Research Journal Club; Discussion, Small Group	Appreciate the benefits of genomic-based tests for Public Health, precision epidemiology, and precision medicine
		Problem-Based Learning-Case-7	Explain precautions, considerations, and psychosocial issues for diagnosing and treating an elderly patient that differ from those for a young adult
		Problem-Based Learning-Case-10	Explain the importance of sensitively approaching patients who may suffer from poor body image, and appreciate the risks of body dysmorphic disorder
		Professional Development and Wellness: Ethics—Unconscious Bias in Medicine Discussion, Large Group (> 12)	Differentiate between explicit and implicit bias (unconscious bias)
			Identify where personal unconscious biases may reside in everyday interactions with patients
			Discuss specific"bias-mitigating"techniques that can be used in the clinical environment
	Hematology	Introduction to Service-Learning Project; Discussion, Large Group (> 12)	?Reflect on the challenges faced by vulnerable populations and ideate potential strategies to address them	Exam—Institutionally Developed, Written/Computer-Based; Exam—Nationally Normed/Standardized, Subject (NBME)
			Reflect on the role of physicians as advocates for vulnerable populations and brainstorm ways to maintain community connectedness
			Identify barriers to health care faced by underserved, low-income populations
			Identify the most relevant and current health issues of this vulnerable population and its relation to preventive medicine, health equity and public health policy
		Problem-Based Learning-Case-13	Examine the impact of financial considerations for patients when factoring insurance coverage for medical procedures
	Gastrointestinal, Nutrition, Endocrine, Reproductive	Case Based Discussions on LGBTQ Healthcare; Discussion, Large Group (> 12)	Discuss health care inequities experienced by gender and sexual minorities	Exam—Nationally Normed/Standardized, Subject (NBME)
			Describe how intersectional identities impact healthcare disparities for LGBTQ + individuals Apply cross-cultural
			communication skills in interactions with patients from different backgrounds
		Preconception Counseling, Prenatal Care and Risk Assessment & Clinical Aspects of Dealing with Patient Infertility; Discussion, Large Group (> 12)	Assess risk factors for pregnancy complications, including screening for intimate partner violence
		Malnutrition in Hospitalized Patients & Introduction to Enteral and Parenteral Nutrition; Discussion, Large Group (> 12)	Explain the importance of nutrition screening, assessment, and intervention in patients with malnutrition	Exam—Institutionally Developed, Written/Computer-Based; Exam—Nationally Normed/Standardized, Subject (NBME)
		Nutritional Pathology; Discussion, Large Group (> 12)	Define malnutrition and describe the types of malnutrition
			Discuss the causes and effects of protein energy malnutrition, including kwashiorkor, marasmus and anorexia nervosa
			Define obesity as a form of malnutrition and pathophysiologic dysfunction
	Cardiovascular, Pulmonary, Renal	Problem-Based Learning; IQ Case 6	Discuss the different lifestyle changes and medical treatments for a patient with angina and identify which affect the underlying disease and which affect the symptoms	Exam—Institutionally Developed, Written/Computer-Based; Exam—Nationally Normed/Standardized, Subject (NBME); Multisource Assessment; Narrative Assessment; Participation; Peer Assessment; Self-Assessment
		Problem-Based Learning; IQ Case 9	Describe the impact of physician bias on patient safety
		Problem-Based Learning; IQ Case 17	Explain the rationale for assessing psychosocial circumstances of patients being considered for transplant surgery
		Cultural Competency; Discussion, Large Group (> 12)	Analyze the historical context of health disparities	Exam—Nationally Normed/Standardized, Subject (NBME)
			Summarize strategies to advocate for patients in the clinical setting
		Disability Inclusion in Medicine; Discussion, Large Group (> 12)	Discuss the concept of disability and define ableism	Exam—Nationally Normed/Standardized, Subject (NBME)
			Summarize barriers to health care faced by individuals with disabilities
	Practice of Medicine-1	Introduction to medical jargon and health literacy; Discussion, Large Group (> 12)	Explain how health literacy differs from general literacy and how poor health literacy can lead to poor patient outcomes and increased cost of care	Exam—Institutionally Developed, Clinical Performance; Participation
			Demonstrate techniques that improve the health literacy of our patients
		Introduction to Public Health and the Social Determinants of Health; Discussion, Large Group (> 12)	Define the basic concept of Public Health focusing on social determinants of health
			Identify needs of the community and develop an intervention with and for the community being served
		Introduction to the Musculoskeletal Patient Encounter; Discussion, Large Group (> 12)	Demonstrate the ability to consider the social determinants of health and how they may impact a patient’s view of care, access to care and health outcomes
	Practice of Medicine-2	Morning Report Culinary Medicine; Discussion, Large Group (> 12)	Identify strategies to assist patients in sustaining health, and preventing and managing disease by choosing high-quality, healthy food	Exam—Nationally Normed/Standardized, Subject (NBME); Exam—Institutionally Developed, Clinical Performance; Participation
			Practice a basic, patient specific approach to food preparation and acquisition to patients attempting to make dietary changes
			Practice basic culinary skills to prepare healthy meals
		Morning Report MI Healthy Diet and Physical Activity; Discussion, Large Group (> 12)	Identify barriers and challenges to dietary and lifestyle change
			Define dietary variety to understand the relationship between dietary variation and health
		Motivational Interviewing; Smoking/Weight gain; Discussion, Large Group (> 12)	Analyze how one’s own biases, attitudes, preferences, and approaches to partnering with patients in decision-making impact the doctor-patient relationship and health outcomes
		Morning Report Genomics and Bioinformatics; Discussion, Large Group (> 12)	Explain implications for the individual as well as the family, the potential for discrimination, and the potential effect on insurance coverage
		Morning Report Reproductive Ethics; Case-Based Instruction/Learning	Describe disparities in cervical cancer prevalence and outcomes in the Hispanic community
			Discuss social determinants of health related to cervical cancer outcomes
			Outline barriers and facilitators to cervical cancer screening and preventative care in the Hispanic community
			Demonstrate culturally competent communication skills needed for patient education regarding cervical cancer screening and prevention
		Morning Report Reproductive Ethics/Cervical Cancer Health disparities in the Hispanic Community; Discussion, Large Group (> 12)	Describe disparities in cervical cancer prevalence and outcomes in the Hispanic community
			Discuss social determinants of health related to cervical cancer outcomes
			Outline barriers and facilitators to cervical cancer screening and preventative care in the Hispanic community
			Demonstrate culturally competent communication skills needed for patient education regarding cervical cancer screening and prevention
		Review Motivational Interviewing Rubrics and Resources; Discussion, Small Group	Describe the various barriers that may prevent patients from changing risky behaviors
			Identify barriers and challenges to lifestyle change
		Motivational Interviewing and Adherence to Medications; Discussion, Large Group (> 12)	Analyze how one’s own biases, attitudes, preferences, and approaches to partnering with patients in decision-making impact the doctor-patient relationship and health outcomes
		Service Learning Projects (SLP) and their Presentations; Discussion, Large Group (> 12)	Analyze a relevant public health problem and formulate an appropriate course of action	Exam—Institutionally Developed, Clinical Performance; Exam—Nationally Normed/Standardized, Subject (NBME); Exam—Institutionally Developed, Oral; Participation
			Recognize and contribute to the initiatives of preventive medicine and public health carried out by other health professionals
		Simulation Session; Discussion, Small Group	Demonstrate understanding of cultural determinants of health and inclusion of diversity during patient encounters and compare personal and social biases that impact quality of care and health outcomes	Exam—Institutionally Developed, Clinical Performance; Exam-Nationally Normed/Standardized, Subject; Participation; Peer assessment; Self assessment
	Brain, Body, Behavior	Health Disparities; Discussion, Large Group (> 12)	Classify the types of health disparities and identify populations as risk of health inequity in the US	Exam-Nationally Normed/Standardized, Subject (NBME)
			Describe the relationships between the various major categories of socioeconomic and environmental factors that have been shown to disproportionately affect health outcomes for people of color, and other marginalized groups
			Explore individual and institutional actions that can mitigate health disparities in emergency, hospital and primary healthcare settings Recognize the role of implicit bias in medical errors and substandard care within the healthcare system
			Review the historical context of racial discrimination in medicine and biomedical research (including the perpetuation of medical misconceptions)
		Human Sexuality; Discussion, Large Group (> 12)	Describe the components of sexual functioning
			Explain the development of human sexuality throughout the lifespan
			Describe psychosocial and physiologic changes that occur throughout the lifespan and their effect sexual functioning
			Identify sexual disorders commonly seen in men and women
		LGBT Experiences/Approaches to Care; Discussion, Large Group (> 12)	Describe approaches to primary care for LGBTQ + people
			Discuss strategies to promote the social and emotional well-being of LGBTQ + people
			Summarize issues of concern for LGBTQ people when accessing care
		Postpartum Psychosis: Physiology & Clinical Features; Discussion, Large Group (> 12)	Elucidate how health disparities in maternal care in the US affect the diagnosis of postpartum depression
		Reflection Session: TED Talk Elyn Saks: The Center Cannot Hold; Discussion, Large Group (> 12)	Appreciate social stigma and barriers to mental health care experienced by individuals with schizophrenia
		The Opioid Epidemic; Discussion, Large Group (> 12)	Describe contemporary public health and pharmaceutical approaches to addressing opioid abuse
			Discuss the role of public health evidence in shaping policy designed to address opioid use disorders
			Recognize the epidemiological evidence underscoring pain and substance use disorders as a public health problem/emergency
		Trauma and Neglect; Discussion, Large Group (> 12)	Examine the role of social support networks as buffers against trauma and stress
		Fall in Geriatric Patients; Team-Based Learning	Emphasize the importance of considering social determinants of health in the holistic patient-centered approach of healthcare	Exam-Nationally Normed/Standardized, Subject (NBME); Participation; Exam—Institutionally Developed, Written/Computer-Based
	Practice of Medicine-3	Morning Report: Intimate Partner Violence; Discussion, Large Group (> 12)	List IPV mandatory reporting requirements in Florida	Exam-Nationally Normed/Standardized, Subject (NBME); Exam—Institutionally Developed, Clinical Performance; Participation
			Recognize clinical situations and findings appropriate for IPV screening
			Assess safety upon disposition planning for patients experiencing current or past IPV
			Recognize that a successful interaction is not necessarily one that results in a patient disclosing violence or leaving a violent relationship
		SP Encounter: An IPV Wrist Injury Case; Discussion, Small Group	Recognize and respond interpersonally to various common forms of abuse in the clinical setting	Exam-Nationally Normed/Standardized, Subject (NBME); Participation; Exam—Institutionally Developed, Clinical Performance; Oral Patient Presentation; Peer Assessment
		Morning Report: Bias; Discussion, Large Group (> 12)	Critically evaluate clinical case scenarios to identify examples of implicit bias	Exam-Nationally Normed/Standardized, Subject (NBME); Exam—Institutionally Developed, Clinical Performance; Participation
			Utilize effective leadership skills to appropriately guide small group discussions on implicit bias
		Morning Report: Race in Dermatology; Discussion, Large Group (> 12)	Describe health disparities related to race and various dermatological conditions
			Utilize effective resources with different images of dermatological conditions
			Analyze images of skin pathologies in a variety of skin tones
			Identify strategies to improve dermatologic care for persons of color
		Morning Report: End-of-Life Care; Discussion, Large Group (> 12)	Demonstrate cultural humility when discussing sensitive topics with patients of varying backgrounds
Clerkship	Longitudinal Clerkship Curriculum	LGBTQ Health; Discussion, Large Group (> 12)	Understand the language and identities of sexual orientation and gender identity	Exam—Institutionally Developed, Clinical Performance; Exam-Nationally Normed/Standardized (NBME), Subject; Participation
			Discuss the health challenges encountered by LGBTQ + people
			Understand the major health concerns and primary care issues for various groups within the LGBTQ + communities
			Discuss the basics of Gender-Affirming Hormone Therapy
			Discuss the basics of prescribing Pre-Exposure Prophylaxis (PrEP) to prevent HIV
			Understand ways to create an inclusive practice to enhance the patient experience
		Bias and cultural awareness in healthcare; Discussion, Large Group (> 12)	Define bias and cultural awareness
			Identify various types of biases in health care
			Recognize strategies to overcome bias
			Describe the importance of cultural awareness in health care
	Transition to Residency	Working to support Diversity, Equity, and Inclusivity for the resident; Discussion, Large Group (> 12)	Define structural competency and its relationship to health disparities. (CO 8)	Exam-Nationally Normed/Standardized, Subject (NBME); Participation
			Describe the structural competency framework and training goals in medical education. (CO 8)
			Compare cultural and structural competency. (CO 8)
			Apply knowledge to respond to structurally related factors in the clinical setting. (CO 8)
	Obstetrics and Gynecology Clerkship	Common Gynecologic Problems; Discussion, Small Group	Understand the process for screening for intimate partner violence during an ob/gyn visit	Exam-Nationally Normed/Standardized, Subject (NBME); Participation
	Pediatrics Clerkship	Child Protection Lecture; Discussion, Large Group (> 12)	Recognize the statistics of child abuse and child neglect in the USA	Exam-Nationally Normed/Standardized, Subject (NBME); Participation
			Learn to differentiate physical exam findings between accidental and non-accidental injuries in children
			Learn appropriate questions to ask in the history that might help differentiate child abuse from other causes
			Understand possible mechanisms that might help prevent cases of child abuse and child neglect

Author Contribution

All authors contributed to writing and reviewing the manuscript drafts and have read and approved the final submitted manuscript.

Declarations

Competing Interests

The authors declare no competing interests.