Dartmouth Medical School Social Justice...

Dartmouth Medical School

Social Justice Curriculum

Report from the Social Justice Vertical Integration Group to Dean David

Nierenberg and the Medical Education Committee, 2011

Faculty

Tim Lahey (chair), Lisa Adams, Joe O’Donnell, Nan Cochran, Bill Young, Jaime

Bayona, Paul Manganiello, Peter Mason, Sarah Johansen, Jack Lyons, James

O’Connell (HMS, Boston’s Healthcare for the Homeless), Tommy Clark

(Grassroot Soccer)

Students

Paul Charlton, Maija Cheung, Alexandra Coria, Nick Ellis, Greg McKelvey,

Elizabeth Richey, Amy Thomas, Mike Woodworth

Collaborators

Global Health MPH Program group: John Butterly, Sam Finlayson, Karen

Toombs, Peter Wright, Paul Palumbo, Christopher Caruso, Adam, Keller,

Elizabeth Talbot, James Geiling, Shari Goldberg

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Table of Contents

1. Introduction .......................................................................................... 3

2. Executive Summary ............................................................................. 4

3. Vision Statement .................................................................................. 5

4. Goals ..................................................................................................... 6

5. Curriculum overview ............................................................................ 7

6. Teaching format ................................................................................. 11

7. Flagship sites for hands-on community outreach .......................... 16

8. Necessary infrastructure ................................................................... 20

9. Competencies and expectations ...................................................... 22

10. Conclusion ........................................................................................ 30

11. Appendix: Other Schools’ Social Justice Curricula ..................... 31

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1. Introduction

Students enter medical school inspired to comfort, counsel and cure the

sick. Learning the skills needed to accomplish this goal, however, can put

students into ethically complicated situations with people from different cultures

who have variable access to quality health care as determined by complex and

changing societal forces. Prominent among these forces is the impact of unjust

and inequitable distribution of health care resources.

The professional formation of future physicians requires not only the

development of traditional clinical competencies but also the development

of competency in the recognition, analysis and fight for the correction of

injustice and health inequities. The existing Dartmouth Medical School (DMS)

curriculum does not address these key topics adequately.

To define a curriculum in social justice and health inequity, the Social

Justice Vertical Integration Group (VIG) met for 90 minutes monthly starting in

January 2011 with interim work by individual committee members and sub-

committees on a wide range of related issues. The global health MPH curriculum

group led by John Butterly joined us in August 2011 to collaborate on our closing

deliberations. The recommendations in this document thus are the product of

approximately 150 hours of faculty work, approximately 100 hours of student

work, and represent the consensus of an impressive group of students and

teachers with whom I have been proud to serve.

Tim Lahey, MD MMSc, Chair, Social Justice Vertical Integration Group

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2. Executive Summary

We recommend DMS implement a Social Justice Curriculum consisting of

a combination of lecture and didactic teaching about key concepts paired with

hands-on experiential learning in underserved communities. Upon completion of

the DMS Social Justice Curriculum, students will understand the scope of

injustice and health inequity, understand and embrace the duty to fight the health

implications of injustice and health inequity, possess tools to fight injustice and

health inequity effectively, and will have gained hands-on experience working in

communities of need. These key topics should be addressed using a

combination of complementary small group, lecture and hands-on teaching

totaling 30 hours over the four-year curriculum. The importance of this material

should be signaled to students in part by the requirement that they achieve key

competencies in social justice topics before graduation. Specifically, we

recommend that DMS:

(1) add 15 hours of new social justice material to the curriculum;

(2) integrate an additional 15 hours of social justice material into the

existing curriculum via a collaboration between course directors and a

group of social justice-expert faculty and students; and,

(3) require ≥ 25 hours of hands-on work with communities of need.

Through these improvements to the curriculum DMS will nurture the

idealism of its graduates and prepare them for careers spent fighting effectively

against injustice and health inequity.

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3. Vision Statement

DMS will nurture its students’ sense of social justice, and will engage them

in hands-on projects and advocacy with communities of need. This work must be

informed by fluency with the core concepts that drive the recognition, analysis

and fight against social injustice and health inequities. The DMS Social Justice

Curriculum will empower graduates to champion the equitable delivery of heath

care.

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4. Goals

The DMS Social Justice Curriculum will prepare graduates to understand

and identify the root causes of health disparities via a combination of didactic and

small group teaching combined with hands-on advocacy in communities of need.

At graduation, students will

• Be able to identify and analyze the root causes of health disparities;

• Appreciate the role and responsibilities of the physician as a powerful

advocate for our society’s most vulnerable populations;

• Have experienced hands-on advocacy for the equitable distribution of

health care resources, locally and/or globally;

• Have developed tools for the effective and sustained fight against health

inequity in communities of need; and,

• Be prepared to lead teams that provide appropriate care for all.

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5. Curriculum overview

The DMS Social Justice Curriculum should address the scope of health

disparities, the ethical rationale to address health disparities, building skills in

interventions against health inequities, and most importantly, should include

hands-on work in a community of need fighting to fix health inequities.

This curriculum will require 30 hours of teaching, as distributed among

topics listed in Table 1. These 30 hours should be added to the existing

curriculum two ways: through the addition of 15 additional hours of new material

delivered via lectures and small group teaching, plus the integration into existing

material of 15 hours of social justice material. In recognition of the fact that some

social justice-related topics are already embedded in the existing curriculum, the

integration of 15 hours of social justice material into the existing curriculum in

collaboration with course directors will allow the thoughtful incorporation of this

material in parts of the curriculum where it is most deficient. Beyond in-class

coverage of these key topics, DMS should require students to participate in at

least 25 hours of direct hands-on work in communities of need; this will provide

students with the real-world experience that gives flesh to the concepts

presented within the bounds of the DMS campus.

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Table 1 Core Curriculum

Optional Focused Track*

Total hours over four years

Additional hours over four years

Scope of health disparities 7.5 0 1. Structural determinants of health disparities

including powerlessness, poverty, race, gender, sexual identity (Marmot) (share with health care delivery science track [HCDS])

2. Global includes domestic and international, rural and urban

3. Awareness of specific diseases that disproportionally affect the underserved

4. The ways physicians can perpetuate health disparities

5. Issues related to financing and systems of care (shared with HCDS)

Reasons to study and address health disparities 7.5 0 1. Ethics

a. Ethical justifications for work with underserved, including physician obligation to “give back”

b. Foundational bioethics tenants e.g. beneficence, non-maleficence, justice, autonomy

c. Ethical pitfalls of cross-cultural work in the clinic and in communities of need

d. Declaration of Human Rights and other seminal documents

2. Legal underpinnings of social justice work 3. Human rights and physician responsibility 4. Epidemiology (shared with HCDS)

a. Global health disparities b. Pathologies particular to

underserved populations 5. Recognizing and minimizing physician bias 6. Developing cultural and spiritual sensitivity

(shared with leadership track [LT]) 7. Maintaining idealism via mentorship,

community reflection, and service How to address health disparities 15 5

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1. Key concepts a. The concept of service b. Solidarity with the underserved c. Physician as advocate (LT, can

collaborate with campus Physicians for Human Rights group)

d. Working as part of a team (LT) 2. Key skills

a. Practice Farmer’s community development model

b. Conduct community assessments (HCDS)

c. Build infrastructure d. Transfer skills to allow for

sustainability e. Forming coalitions within a community f. Build trust and listening skills g. Develop leadership skills (LT) h. Assess the outcome of health

interventions (HCDS) i. Assign value in interventions to aid

prioritization (HCDS) j. Understand comparative systems

research (HCDS) k. Work with and lead service orgs l. Understand business models (LT) m. Understand basic medical

anthropology as a means of understanding health-related human rights abuses in a culturally-appropriate manner

3. Cultural and spiritual sensitivity (LT) 4. Fluency with shape of health care teams

(HCDS) 5. Role of CMS, reimbursement (HCDS) 6. Health care economics/cost 7. Roles of environmental health and

occupational health 8. Familiarity with basic legal issues in health

care disparities (human rights law/malpractice)

Outreach project 25 25 1. Hands-on work in community 2. The arc of a service improvement project –

part of curriculum provided to site mentors

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(can collaborate with Tuck First Year Projects group)

a. Inception b. Needs assessment c. Key collaborators in community d. Project assessment e. End of project decision-making re

intensification vs. expansion vs. fixes f. Succession planning

Longitudinal track-specific seminar including student presentations of long-term social justice projects 0 40 TOTAL 55 70

* The right most column refers to additional material that might be

incorporated into a master’s track, should one arise in the course of curriculum redesign.

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6. Teaching format

The four-year DMS Social Justice Curriculum will involve students in both

in-depth didactic and small group topical coverage of key issues which

complement longitudinal hands-on work in communities of need. By varying the

teaching approach, and linking all teaching to specific deliverable work in the

community, we will accelerate skills development, engage students in the

process of hands-on work with communities of need, and encourage a lifelong

sense of idealism, shared purpose and pragmatism. The content of each

teaching format should be integrated well with the content of other formats in

order to maximize the efficiency with which students acquire the necessary

information and skills.

A key component of the DMS Social Justice Curriculum is longitudinal

hands-on work in the community. This longitudinal experience provides real-life

experience, skills building and inspiration for the more abstract lessons acquired

in small groups and lectures. One long and evolving project could comprise the

four-year outreach experience, although multiple shorter projects would be

acceptable as long as sufficient investment and longitudinal community work are

involved.

Beyond acquiring competence with key concepts in service work, and

doing the work in community, a critical component of the DMS Social Justice

Curriculum are periodic student-led exhibitions of their experiences with hands-

on work in the community. This will help students synthesize learning

experiences and also will encourage students to mentor each other.

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Table 2 suggests how the content of community-based social justice

teaching can evolve through the four years of the curriculum.

Table 2 Core curriculum for all students Orientation Introduction to sites of need in the Upper Valley Year 1 Longitudinal community outreach experience

Mentored community outreach experience

Complementary topic coverage in small groups/lectures

Rationale for addressing health inequities

Integration/reflection End of year presentation re project planning and work done to make sure project is appropriate. Need to time presentations to not conflict with Boards.

Year 2 Longitudinal community outreach experience

Mentored community outreach experience


Integration with non-medical member of outreach community for sensitization to non-medical social issues that heavily impact medical access.

Integration/reflection End of year presentation re results of initially-proposed project and how it meshes with professional formation. Need to time presentations to not conflict with Boards.


Mentored community outreach experience if in this year it is compatible with redesigned clinical curriculum.


Topics covered in longitudinal seminar: women’s issues in social justice; impact of trauma on chronic diseases like diabetes, menstrual difficulties; epidemic control; infectious diseases field experience

Integration/reflection End of year presentation of results of continuing project and how it meshes with professional formation including career choices. Consideration of leadership succession. Need to time presentations to not conflict with Boards.

Immersion experience Either deeper full time immersion into community outreach site with which student has been previously engaged, or opportunity to engage with different (perhaps overseas) project to that degree. (This is situated in the third year here for the sake of example, but could occur at other points in student course of study as appropriate.)

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Mentored community outreach experience if in this year it is compatible with redesigned clinical curriculum.


Community leadership skills Culturally appropriate delivery of care How to assess and improve systems of care

Integration/reflection Final oral presentation of project experience, with expected incorporation of how student has either brought project to closure or transitioned to new student leadership. Need to time presentations to not conflict with Boards.

Although 15 hours of Social Justice Curriculum content should be added

into the curriculum to provide new coverage for complex issues such as the

ethical foundations of service work or the epidemiology of health disparities, it will

also be key to formulate creative means of integrating an additional 15 hours of

social justice material into existing topic areas. This will not only facilitate

introduction of this material into the curriculum without the addition of new

teaching hours, but it will also provide opportunities to demonstrate concretely to

students how social justice work is part and parcel of all medical interventions.

Table 3 provides examples of how topics in social justice can be integrated with

topics from other fields already taught at DMS.

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Table 3 Lecture-based teaching

Case-based teaching in small groups

Complementary community outreach work

Ethical underpinnings of outreach work and scope of underserved communities in the area

Small group tour of community outreach organizations in Upper Valley

Students make connections to promising community sites with mentorship

Pathogenesis of type 1 and type 2 diabetes mellitus Biochemistry of starvation and obesity Epidemiology of health disparities Recognition and management of schizophrenia

Diabetic schizophrenic homeless man with frostbite who “fails” multiple short courses of oral antibiotics given in an ER amid chronic alcohol abuse

Diabetes education at Mascoma clinic Linking homeless people to coordinated psychiatric and PCP practices

Respiratory physiology of asthma

Obese homebound Vietnam vet with asthma

Meals on wheels

Culturally-appropriate communications including importance of viewing the problem through the eyes of the affected community

Anemia in Haiti relating to nutritional deficiencies, dietary practices in Haiti, factors influencing access to food, food beliefs, etc.

Participation in GHESKIO HIV education program

Disaster response medicine

Renal impact of crush injuries in Haiti earthquake victim

Direct outreach during humanitarian disaster

T cell immunity, immune responses to vaccines

Tuberculosis in Tanzania and T cell responses, vaccines, preventive therapy, role of HIV in TB epidemiology

Work in state health department with refugee population DOT

Recognition and management of PTSD

Recently homeless woman with history of PTSD from childhood assault desires pregnancy with new non-

Program improvements at homeless shelter or group for battered women

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abusive husband after years of STI and menstrual difficulties, associated DM, OSA

Parasitic illnesses Social determinants of disease

Addressing water insecurity and other infrastructure contributors to endemic diseases like river blindness, guinea worm and other parasites among population with diarrheal illnesses, malnutrition and associated medical illnesses

Work with parasite eradication team in developing world setting Internship with World Health Organization

Embryology Toxicology

Assessment and correction of facial anomalies in victims of toxic exposure e.g. the Bhopal disaster or Vietnamese exposure to Agent Orange

Work with low income housing projects on lead paint eradication and avoidance of other substances toxic to children

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7. Flagship sites for hands-on community outreach

Hands-on mentored longitudinal work in communities of need is the core

of the DMS Social Justice Curriculum. Without this, the topics covered in lectures

and small groups will feel pro forma and undervalued in the curriculum, thus

undermining students’ sense of importance of social justice work.

DMS and the Upper Valley are home to a wealth of community service

activities that can provide hands-on training to DMS students. Yet the

identification of a site of need alone is insufficient to ensure adequate teaching

for students – invested integrated mentorship is crucial. Examples of flagship

sites with demonstrated record of addressing student need, substantial

longitudinal institutional investment, and the availability of consistently excellent

mentorship include:

1. Domestic

a. Good Neighbor Clinic

b. Little Rivers Clinics

c. Ammonoosuc Clinics

d. Lamprey Clinic

e. Manchester free clinics with large refugee population

f. Dimmock Clinic -Boston

g. Boston Healthcare for Homeless

h. Lawrence Fam Practice

i. Codman Square and other Boston neighborhood clinics

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j. Indian Health Service Clinics in Gallup, NM, Tuba City, AZ, and

Fort Defiance, AZ

k. Tuba City

l. Fort Defiance

m. Family practice sites in communities of need

n. Upper Valley Haven (homelessness and food insecurity)

o. Headrest (suicide prevention and substance abuse hotline)

p. WISE (abuse)

q. COVER: inadequate habitation and how that predisposes to an

individual’s health status

r. Prison: those who are incarcerated, Dr. Mason had a prison

outreach in the past

s. LISTEN: food and housing insecurity

t. ACORN, Upper Valley HIV services

u. Upper Valley Pediatrics (Mark Harris and Rebecca Yukica’s) in

Bradford, VT

v. Planned Parenthood of NH

w. Vermont PACE program - http://www.pacevt.org/

x. Claremont Good Beginnings

y. Albert Schweitzer Fellowship domestic projects (for those who

are accepted)

z. Safeline (domestic violence in Chelsea VT)

aa. Burch House (domestic violence in Littleton, NH)

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bb. Hannah House in Lebanon (residential support for

pregnant/parenting teens).

cc. Clara Martin Centers (multiple locations, one in Bradford,

Wilder-Mental Health Support Services)

dd. High Horses Therapeutic Riding Program (for those with mental

or emotional disability)

ee. David's House

ff. VNA Hospice of VT/NH.

2. International

a. DarDar program in Tanzania

b. GHESKIO and Partners in Health in Haiti (Mirebalais, Les

Cayes, Cange)

c. Kosovo

d. El Rosario, Honduras

e. Human Resources for Health, Kigali, Rwanda

f. Hôpital Albert Schweitzer, Gabon, via Albert Schweitzer

Fellowship

g. Hôpital Albert Schweitzer, Haiti

h. Lwala Hospital Kenya (lwalacommunityalliance.org)

i. Siuna Nicaragua

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Despite this wealth of Dartmouth-affiliated outreach sites, currently

students engage with domestic and international outreach sites in a haphazard

fashion. Sometimes this work is productive for the community, and formative for

the student, and other times it can be less productive and even damage student

idealism. Thus, a key part of the experiential component of the DMS Social

Justice Curriculum will be the creation of a mechanism for matriculating students

into proven outreach programs that provide high quality community interventions

and expert student mentorship. This matriculation mechanism will require a more

solid relationship between DMS as a teaching institution and these flagship

community outreach sites.

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8. Necessary infrastructure

1. Matriculation support. A key missing capacity at DMS is a system to

facilitate student matriculation into community service projects with

established faculty mentors. This could be a major function of the

proposed Center for Health Equity at DMS.

2. Proven mentorship. Longitudinal interactions with experienced on-site

mentors is critical to the success of student social justice projects. DMS

has a large number of faculty who can serve in this capacity, and a key

function of the Center for Health Equity could be the maintenance of a list

of experienced mentors who can be paired with students on a regular

basis.

3. Faculty mentorship support. Key components of faculty mentorship

support include

a. Protected time to administer and teach in the social justice

curriculum.

b. Financial incentive (salary) for being an active teacher in this and

other areas.

c. Academic and professional advancement for teaching.

d. Financial support for meetings and professional development.

4. Administrative support. To accomplish the goals above, the Center for

Health Equity should have resources to accomplish the following:

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a. Overall administrative oversight – part time faculty member, full

time administrative assistant, office space for meetings and

collation of student resources on service projects

b. Service project inventory upkeep

c. Student and faculty matriculation into those projects

d. System to allow small group of involved faculty to vet any new

student- or faculty-proposed service sites. Evaluation of such

projects will be grounded in idea that “service” should be

understood inclusively as long as related to health.

e. Grading, interactions with registrar, etc.

f. Web site development and maintenance.

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9. Competencies and expectations

In March 2010, in response to education domains delineated by the

American Council of Graduate Medical Education, the faculty of Dartmouth

Medical School ratified a new set of core medical school competencies as

promoted by Dean Nierenberg and the Medical Education Committee. Many of

these competencies speak directly to the importance and content of a medical

school social justice curriculum. The relevant general medical school

competencies are summarized along with complementary social justice-specific

competencies in Table 4. These competencies can be used to inform new

evaluation systems that can be put into effect once the Social Justice Curriculum

is taught at DMS in order to ensure graduates achieve basic competency with

key social justice skills.

Table 4 DMS core competency, ratified 2010

Specific social justice core competencies

Social Justice Curriculum learning objectives

1.e. LEARN and APPLY knowledge in several additional areas that have become important in delivering excellent healthcare to patients, including disease prevention, risk factor modification, end-of-life and palliative care, substance abuse, pain management, medical ethics, and medical-legal issues.

1.e.1. UNDERSTAND the role of education, culture, environment, occupation and social status in one’s ability to understand medical messages and participate in their own care. 1.e.2. APPLY knowledge of social and cultural determinants of disease in patient interactions. 1.e.3. UNDERSTAND specific ethical and

1. GAIN an understanding of the specific ethical obligation to serve those without the ability to pay for health services, and the social and economic ramifications of delaying or denying service. Be familiar with several specific examples from literature or the student’s experience. 2. ACQUIRE familiarity with major relevant legislation, including but not limited to: Medicare/Medicaid rules;

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medico-legal concepts related to service of the underserved.

environmental and occupational protections; malpractice law; major human rights treaties, laws and covenants; etc. 3. COMMUNICATE effectively with those of varying educational and social backgrounds, and to assess their understanding of the interaction using standardized tools. 4. ADDRESS topics such as disease risk, end-of-life and palliative care, substance abuse, pain management with patients while considering their individual access-to-care issues and social context. Be able to cite several specific techniques or examples.

2.i. PARTICIPATE AT AN APPROPRIATE LEVEL, and always under appropriate supervision, in the performance of common operative procedures (e.g. appendectomy, laparotomy, pelvic surgery, complicated labor and delivery, etc.). Learn the indications, contraindications, potential complications, and postoperative management of such operative procedures, and how thoughtful physicians elicit both

2.i.1. KNOW the importance, history and acceptable forms of informed consent. 2.i.2. RESPECT the right of the patient to choose among procedures or refuse a procedure due to preference, if well-informed about the risks and benefits of the procedure.

1. BE COMFORTABLE regularly and proactively eliciting patient preference and discuss pros and cons of common procedures in a manner understandable to the patient. 2. ASSESS competency to make medical decisions. 3. ENUMERATE the requirements of a valid informed consent, acquire informed consent from a surgical patient and assess understanding of

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patient preferences for treatment, and patient informed consent.

that consent.

3.h. COMMUNICATE EFFECTIVELY WITHIN AN ELECTRONIC MEDICAL RECORD, observing proper protocols for protecting patient confidentiality, clearly identifying the author of each note, avoiding promulgation of misinformation, and maintaining the professional content of this important repository of patient information.

1. ABIDE by ethical and institutional guidelines on patient confidentiality. 2. INVOKE the roles of different patient team members in finding accurate patient information, including medical histories, social situation and demographics.

4.c. SUBORDINATE one’s own self-interest appropriately, in order to consistently place the patient’s interests first. Avoid real and perceived conflicts of interest. Recognize how your own personal opinions and biases can interfere with your own ability to deliver quality care to every patient.

4.c.1. RECOGNIZE how provider bias can perpetuate health disparities, and develop personal strategies to combat bias.

1. DESCRIBE and CRITICALLY ANALYZE specific situations, from literature or personal experience, in which patient care or quality of medical research has been compromised due to care provider bias. 2. DEMONSTRATE understanding of what qualifies as a conflict of interest.

4.d. ADHERE to high ethical and moral standards, demonstrating honesty and integrity in all activities.

4.d.1. UNDERSTAND the ethical underpinnings of social justice work. 4.d.2. EXEMPLIFY integrity in dealings with faculty and peers.

1. DISCUSS the ethical framework of medicine, including but not limited to: autonomy, beneficence, non-maleficence, informed consent, futility and other major ethical concepts. 2. DEMONSTRATE, through faculty, colleague and other evaluations, a

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high degree of respect for medical ethics, honesty and transparency in clinical work. 3. DEMONSTRATE understanding of the specific vulnerabilities of particular populations, rendering them more prone to violations of ethical precepts, including but not limited to: research populations; foreign, refugee and migrant populations; undocumented immigrants; children; ethnic and social minorities; the under-educated; etc.

4.i. ADVOCATE FOR better care for each patient (care that is safe, effective, patient-centered, timely, efficient), as well as better health for the population, and lower total per capita cost of health care.

4.i.1. UNDERSTAND the various avenues and tools available to conduct effective health advocacy, including the importance of having a well-informed argument and thoughtful strategy before engaging in advocacy. 4.i.2. APPRECIATE the elevated status of physicians in our nation and community, which empowers them as advocates and conveys responsibility on individual physicians. 4.i.3. CONDUCT effective, well-informed advocacy on behalf of underserved or

1. CITE specific examples of advocacy (at a national, regional, institutional or individual patient level) that led to better healthcare, better economic efficiency, or treatment more in line with equitable provision of care to all patients. Be able to relate these examples to the need for accountability of providers and health systems to the patients they serve. 2. DEMONSTRATE the ability to construct and communicate an informed and effective advocacy message to decision makers at a national, regional, institutional or team level.

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disenfranchised populations or individual patients.

4.j. UNDERSTAND THAT ACCESS TO BASIC HEALTH SERVICES IS ESSENTIAL TO MAINTAINING PERSONAL HEALTH for people everywhere, but especially for those without insurance or financial resources, and those living in medically underserved areas.

4.j.1. UNDERSTAND the relationship between power structures and access to medical care. 4.j.2. DESCRIBE AND PROJECT the social, economic and medical consequences of poor access to basic health services. 4.j.3. IDENTIFY populations and individuals at risk for poor access to basic services, and the determinants of access. 4.j.4. UNDERSTAND THE IMPORTANCE AND AVAILABILITY of ancillary services and programs essential for engaging individuals in the healthcare system. 4.j.5. KNOW the basic structure of our country’s health insurance and service delivery systems, and barriers to access of those systems.

1. OBTAIN FAMILIARITY with the burden of preventable and treatable diseases in populations with limited access to care, and methods and metrics used to measure that burden. 2. DEMONSTRATE knowledge of the medical and nonmedical consequences of poor access to care, using several specific disease examples. 3. EMPLOY evidence-based screening tools for prevalent and/or treatable diseases that disproportionately affect those with poor access to care (such as depression, substance abuse, HIV, etc.) 4. DESCRIBE the various barriers to access to medical care, and demonstrate a nuanced understanding of the roles of social workers, educational programs, housing assistance, food programs and other social services in health maintenance and access to medical care. Be able to give direct examples of personal interactions with these services. Know

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how to direct patients to them appropriately. 5. DESCRIBE with basic familiarity the barriers to getting adequate health insurance, and to differentiate between insured, uninsured and underinsured patients.

5. f. MAKE YOUR OWN PRACTICE ENVIRONMENT A LEARNING ENVIRONMENT, committed to daily improvements in safety, efficiency, and patient satisfaction.

5.f.1 DEVELOP THE ABILITY TO DESIGN AND IMPLEMENT a longitudinal project that will promote the health of underserved populations and the knowledge and understanding of the student. 5.f.2. BE ABLE TO ASSESS the impact of community medical interventions, and modify practice accordingly. 5.f.3. COMMIT to maintaining current, modern accessibility standards, including medical, technological, physical and policy improvements within your practice.

1. DEMONSTRATE facility with research tools and modern methods for accessing a changing evidence base, and be able to apply new methods to delivery of your services to underserved populations. 2. IDENTIFY areas for improvement for service delivery and access to care, including community outreach, mobile service provision, web-based access to counseling and behavior change tools, etc. 3. CARRY OUT a mentored service, quality-improvement, research or other project designed to address an identified need related to healthcare access or quality for an under-served population in the United States or abroad. 4. ASSESS predetermined outcomes of a longitudinal project and communicate that assessment professionally

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to an audience of mentors, supervisors and peers.

6.i. IDENTIFY THE ROLE OF THE PHYSICIAN in addressing the medical consequences of common social and public health factors (such as racial, socioeconomic, and cultural factors that affect access to and quality of care) that contribute to the burden of disease (such as malnutrition, obesity, violence, and abuse).

6.i.1. RECOGNIZE the role of physician activism in health outcomes. 6.i.2. UNDERSTAND the contribution of physician incentive systems to the inequitable distribution of health resources.

1. ARTICULATE the ways in which community advocacy can contribute to patient health outcomes. 2. OBTAIN FAMILIARITY with healthcare financing, and how this can impact the delivery of medical care.

Expectations. Formal grading of material is one criterion students use to

gauge how seriously they should study the material. Given the importance of the

core values taught in the social justice curriculum, and the importance to a career

in medicine of competency in this material, student competency in social justice

curriculum material should be tested as formally as material in traditional

biomedical topics. Specifically, comprehension of lecture material, participation in

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small group projects, and the quality of student engagement in community

service outreach work and (for those in the special master’s track) performance

in related thesis work should be graded critically and with high expectations.

Longitudinal mentorship from supported faculty is essential to the success and

accuracy of evaluations of student competency in community service outreach

sites. Similarly, mentors play a key role in the master’s student evolution toward

thesis work, although end-of-year community service symposia at which students

present their ongoing or completed thesis project work and hand-off projects to

incoming students are another opportunity for professional development and

evaluation.

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10. Conclusion

The creation of a new DMS Social Justice Curriculum will nurture student

idealism and prepare DMS graduates to be leaders in the recognition, analysis

and fight against injustice and health inequities at home and abroad.

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11. Appendix: Other Schools’ Social Justice Curricula

We assessed the format of other institutions justice curricula in the

formulation of these recommendations, and provide some examples below as a

reference.

University of Michigan

Summary: coherent focus on social justice issues, visits to sites of service,

longitudinal case discussions, projects, conferences/small groups/and seminars,

the opportunity to do core rotations in year 3 at service sites, and an elective

"path of excellence" in Global Health and Disparities.

Description of Health Equalities and Disparities Features:

http://www.med.umich.edu/lrc/medcurriculum/highlights/disparities.html

Curriculum Snapshot:

http://www.med.umich.edu/lrc/medcurriculum/mep/curriculum/diagram/m1

m2.html

University of Vermont

Focus on integration with a progression from learner to teacher, evaluated

by competencies. Relevant features include longitudinal small groups that yield

a public health project, in addition to a separate required scholarly project, and

teaching requirement.

Curriculum features:

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http://www.med.uvm.edu/ome/Downloads/UVMCOM_VIC.pdf

Snapshot:

http://www.med.uvm.edu/ome/downloads/VICDIAGRAM.pdf

main page:

http://www.med.uvm.edu/ome/TB1+RL+I.asp?SiteAreaID=515

University of New Mexico

Features an early community health immersion experience, a required

scholarly project, competency based evaluations, and 2 coordinated years of

required instruction in SJ related issues among other topics.

Features:

http://hsc.unm.edu/som/admissions/phase1.shtml

Snapshot:

http://hsc.unm.edu/som/admissions/docs/2014%20Curricular%20Map.pdf

Rush

Pairs students and relevant community service projects. This may be a

model with applicable traits for us.

http://www.rushu.rush.edu/service/

Brown

Linkages of global health resources from undergraduate upwards.

http://med.brown.edu/GHI/about

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Cohesive medical school specialization track in SJ

http://med.brown.edu/education/concentrations/advocacy.html

Harvard

Compulsory classes in SJ for medical students, facilitation of service

rotations internationally, and coordination of a range of phases of SJ involvement

from undergraduate to medical to post grad.

http://ghsm.hms.harvard.edu/uploads/pdf/global_med_ed.pdf

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