Incorporation of social medicine curriculum in academic and community health centres: a scoping review protocol

Abstract

Introduction

In the field of medicine, there has been a growing understanding of the impact of social and economic inequities on patients’ health outcomes. Social medicine was established with the intention of addressing these social and economic drivers of health when caring for patients. Physicians who practise social medicine aim to take an interdisciplinary and interprofessional approach to patient care with an emphasis on the promotion of health equity and patient advocacy. As the effects of social determinants of health (SDOH) on health outcomes have become more widely appreciated, medical professional organisations and accrediting bodies have advocated for formal education on the impact of SDOH in undergraduate and graduate medical curricula. The goal of this scoping review is to examine how undergraduate and graduate medical education programmes in the USA have implemented social medicine concepts into their curricula.

Methods and analysis

The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The review team worked with a medical librarian, who created a unique search for five databases (PubMed, Embase, Cochrane CENTRAL Register of Controlled Trials, ERIC and the Web of Science Core Collection). Additionally, we will conduct a grey literature search that includes medical school and residency programme websites, as well as Association of American Medical Colleges (AAMC), Council of Residency Directors in Emergency Medicine (CORD), Alliance for Academic Internal Medicine (AAIM) and Society for Academic Emergency Medicine (SAEM) conference abstracts. Two independent reviewers will assess all articles for eligibility. Data will be extracted using the Covidence data extraction tool. We will present the results of the extraction in tabular form. Themes identified during the full-text review and data extraction process will be discussed.

Ethics and dissemination

Data will be gathered from publicly accessible sources, so ethics approval is not necessary. The results will be disseminated through a peer-reviewed journal and reported at conferences related to medical education and social medicine.

Trial registration number

This protocol is registered on OSF (https://doi.org/10.17605/OSF.IO/7PZ8U).

Strengths and limitations of this study.

• This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews.

• This scoping review will include a wide breadth of academic programmes at both undergraduate and graduate medical education levels.

• This review will extend beyond manuscripts published in medical databases and will include programme data collected directly from programme websites.

• This scoping review will be limited by the ability to only identify and include academic programmes published in the literature or with programme information on a publicly accessible institutional website.

• This review will focus more narrowly on social medicine programmes specifically, which may limit the breadth of data collected on programmes which offer more generalised education regarding population health and social determinants of health.

Introduction

Social medicine

In the USA, there is a growing awareness that a strictly biomedical approach to patient care fails to address the complex social factors that affect patients’ health outcomes and contribute to health inequity.^{1 2} As a result, there is a movement in medicine to critically consider the social and economic influences on patient health, often known as the social determinants of health (SDOH), and also referred to as social drivers of health, social risk factors, structural determinants of health, health-related social needs, or non-medical drivers of health.³,⁵

The WHO defines the SDOH as ‘non-medical factors that influence health outcomes, including the conditions in which people are born, grow, work, live, and age’.⁵ It is now widely understood that these factors account for 80% of modifiable health outcomes, whereas direct medical care only accounts for 20%.⁶ Social medicine is defined as the practice of medicine that integrates the understanding and application of social drivers of health to patient care through an interdisciplinary and interprofessional approach with a focus on patient advocacy and health equity.⁷ Social medicine differs from population health in the sense that it is practised by understanding the social context of an individual’s pathophysiology, as opposed to understanding the social contexts that drive health outcomes for populations as a whole.⁸ Though the push for increased awareness of social drivers of health is relatively recent, the practice of examining the relationship between socioeconomic factors and health is not new.⁹ In fact, this practice dates back to the mid-19th century when Dr Rudolph Virchow drew connections between a typhus epidemic, poverty and living conditions.^{10 11} Similarly, social medicine is not a new concept¹²: one of the academic leaders in the field of social medicine, The University of North Carolina School of Medicine, established its Department of Social Medicine in 1978.¹³ Since its establishment, the department’s research has elucidated the structural drivers of disease and their effects on North Carolina communities and beyond, while disseminating this knowledge and framework through publications such as The Social Medicine Reader.¹³

Social medicine in medical education

There is a growing need for and interest in education to equip physicians with the skills needed to critically examine the social drivers that affect their patients’ health outcomes.^{14 15} In recent years, professional organisations, including the American College of Physicians, the American Medical Association and the Society for General Internal Medicine, have pushed to recognise the importance of the social drivers of health on patient outcomes and wellness.¹⁶,¹⁹ Some medical schools and academic hospitals have established departments (eg, social medicine) for the purpose of providing education to their students on topics related to social drivers of health.¹³²⁰,²² Additionally, the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME) included broad standards in their accreditation requirements to provide their students with content on the socioeconomic sciences and social drivers of health.^{3 23}

EqualHealth, a non-profit global organisation with a focus on health equity, created the Social Medicine Consortium in 2015 and has been convening annual conferences since 2016 to further the integration of social medicine into medical education.^{7 24} As part of this effort, the Social Medicine Consortium has developed a teaching toolkit that serves as a guide for medical schools and academic hospitals seeking to establish a social medicine department within their programmes.²⁵ In this guide, they recommend that social medicine education should be fully integrated into the curriculum using an interdisciplinary approach at both the undergraduate and graduate medical education levels.²⁵ In addition, they also recommend that education should not only include classroom-based didactic learning, but also community-based experiential learning.²⁵

Despite available resources and recommendations, uptake by medical education programmes remains slow and heterogeneous. Additionally, data regarding the success of integrating SDOH concepts into undergraduate (UME) and graduate medical education (GME) is lacking.²⁶ While programmes like EqualHealth have created guidelines to incorporate education on Social Drivers of Health, LCME and ACGME guidelines are vague.^{3 23} The LCME states medical schools should ‘ensure that the medical curriculum provides opportunities for medical students to learn to recognize and appropriately address biases in themselves, in others, and in the healthcare delivery process’, and ACGME states residents should be able to ‘demonstrate an awareness of and responsiveness to the larger context and system of healthcare, including the structural and SDOH, as well as the ability to call effectively on other resources to provide optimal health care’.^{3 23} Furthermore, there is no one definition of social medicine to which all programmes ascribe, and the focus has a wide variety across institutions.²⁶

Rationale for this scoping review

The main objective of the proposed scoping review is to examine how social medicine and its elements have been incorporated into medical education at the undergraduate and graduate levels since its formal establishment in modern medical education with the foundation of the aforementioned University of North Carolina Department of Social Medicine in 1978. We aim to identify and examine established social medicine departments along with established programmes whose curricula align with the Social Medicine Consortium’s teaching toolkit, although they may not use the specific title of social medicine. Of the social medicine programmes included in this review, we will delineate those who offered direct experiential learning with patients through the programme from those who educated students with the intention of applying learnt skills to patient populations outside of the programme. With the goal of social medicine being to recognise the individual patient as a whole and to address the social factors that contribute to their health, we have chosen to focus on programmes that address SDOH broadly as opposed to those that hone in on one particular social determinant. This criterion is not to undermine the importance of these educational activities, but to allow us to examine comprehensive social determinants curricula. It is anticipated that the results of this scoping review will inform medical educators on how medical schools and residency programmes are increasing awareness of the social drivers of health in their students and cultivating critical skills needed to identify and address these barriers to health equity. Ideally, the results of this scoping review will play a role in examining the presence and efficacy of medical education regarding health equity and the social drivers of health at the undergraduate and graduate medical education levels.

A preliminary search of PubMed revealed three previous scoping reviews that examined the social drivers of health curricula at various levels of medical training. The first review, published in 2019, examined training pertaining to social drivers of health in primary care residency programmes.²⁷ An additional review, also published in 2019, reviewed education solely at the UME level.²⁶ The third review, published in 2024, examined education exclusively at the GME level.²⁸ The search strategy for the proposed scoping review is broader with the intention of capturing medical education programmes at both undergraduate and graduate medical education levels, while also including medical education programmes found in the grey literature (programme websites, conference abstracts, etc) that would otherwise not be captured with a traditional database-centred literature search. This review aims to capture social medicine programmes at both the UME and GME levels to examine the curriculum at all educational levels and explore how the progression of training and responsibilities is reflected in social medicine programmes at academic institutions.

Methods and analysis

The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews.²⁹ We registered this protocol through Open Science Framework (https://doi.org/10.17605/OSF.IO/7PZ8U). The study began in September 2024 and will conclude in December 2025.

Stage 1: defining the research question

Since data regarding the incorporation of social medicine concepts into US medical education programmes is limited, we aim to broadly determine where UME and GME programmes stand in terms of incorporating these concepts into their curricula. This scoping review will answer the following questions: what has been done to incorporate social medicine into UME and GME curricula in academic and community medical centres in the USA? what clinical programmes exist within these centres and what services do they provide?

Stage 2: identifying relevant studies (search strategies)

To identify studies to include or consider for this scoping review, the review team worked with a medical librarian (AGS) to develop detailed search strategies for each database. Search terms were reviewed by the research team to check for accuracy and relevance. The medical librarian developed a unique search for each database. All final searches were peer-reviewed by another librarian according to the Peer Review of Electronic Search Strategies checklist prior to execution.

We searched the following databases: PubMed, Embase, Cochrane CENTRAL Register of Controlled Trials, ERIC and the Web of Science Core Collection. A grey literature search included medical school and residency programme websites and AAMC, CORD, AAIM and SAEM conference abstracts.

As this review is focused on programmes in the USA, results were limited to the English language. All database searches were conducted on 24 September 2024. A total of 23 471 citations were retrieved from database searches and grey literature sources. Duplicates were removed by the librarian (AGS) using Covidence’s duplicate detection.

The full search strategies are provided in online supplemental appendix A.

Stage 3: screening studies for inclusion

For database searches, articles obtained through the search strategy described earlier were exported to Covidence for the purposes of screening. Duplicates identified by the Covidence software will be manually resolved by the reviewers. The number of articles excluded at each stage will be recorded.

During phase 1 of screening, reviewers will independently review papers to determine whether each article is eligible for inclusion based on the inclusion and exclusion criteria listed in this section. All papers marked as eligible will be reviewed in phase 2 of screening.

During phase 2 of screening, reviewers will independently review the full-text articles that were included in phase 1. Reviewers will contact the authors of the articles to request additional information if necessary.

Any disagreements during the screening phase will be resolved through discussion with an additional reviewer who has been designated as the tie-breaker. Each reviewer will review 100% of the other reviewers’ papers. Inter-rater reliability will be determined by a kappa calculation, with a target value of 0.8 or greater.

The inclusion criteria are as follows:

• One of the main focuses must be SDOH, structural determinants of health and/or health inequities.

• Must be affiliated with an academic programme that teaches UME or GME students in the USA.

• Programme objectives must be targeted toward preparing students to better serve patients on an individual basis (direct interaction with patients, standardised patients, health fair participants, etc).

• Must have an interdisciplinary approach (social sciences, medicine, psychology, etc).

• Must focus on the individual experiences of patients in the context of their social/structural determinants of health.

The exclusion criteria are as follows:

• Programme is based outside of the USA.

• Programme’s main focus is centred around population health, global health or public health.

• The year of publication is prior to 1978.

• Programme focuses on an individual social determinant of health as opposed to social medicine more broadly.

• The duration of the programme is less than half a day (4 hours).

• The target population is not primarily medical learners (medical students or residents).

For grey literature searches, programme websites and conference abstracts searched will be recorded in a shared Microsoft Excel spreadsheet. The criteria listed earlier will be used to screen these sources for inclusion and data extraction. Reviewers will contact programme administrators to request syllabi if additional information is necessary.

Stage 4: data extraction

Data will be extracted from articles, programme websites and conference abstracts determined eligible in phase 2 of screening by two independent reviewers using the Covidence data extraction tool (articles from databases) and Microsoft Excel (data from programme websites and conference abstracts). All of the items input into the Covidence data extraction tool may not pertain to each article. If additional unanticipated data is encountered during the extraction process, it will be recorded.

The data extracted will include:

• Basic information about the article.

  • Authors.

  • Year of publication.

  • Study type.

• Course objectives.

  • Social/structural determinants of health.

  • Community-specific health issues.

  • Health issues in a global/larger context.

  • Advocacy.

  • Health equity.

• Course content.

  • Social/structural determinants of disease.

  • Models of payment and health financing.

  • Population health and research.

• Teaching methods.

  • Didactic lectures and group discussion.

  • Practical/field experiences (eg, community outreaches).

• Audience.

  • UME/medical students.

  • GME/residents.

  • CE/attendings.

• Teaching team

  • Professors.

  • Departments.

Stage 5: analysis and presentation of results

Data will be reported in narrative, tabular and diagrammatic forms. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram will be used to summarise the article screening and data extraction process. We will present the results of the extraction in tabular form.

Themes identified during the full-text review and data extraction process will be discussed. Articles with similar themes will be grouped together. Overall conclusions from the scoping review will be discussed. Limitations of the review and opportunities for future research will also be discussed.

Patient and public involvement

None.

Ethics and dissemination

Data will be gathered from publicly accessible sources, so ethics approval is not necessary. The results will be disseminated through a peer-reviewed journal and reported at conferences related to medical education and social medicine.