Doctor-patient interactions are typically routine, with doctors understanding little of their patients’ lives beyond the exam room. But medical schools are ushering in a culture shift in medicine – one that’s focused on more than just a patient’s symptoms.
The clinic at the Union Gospel Mission men’s shelter, northwest of downtown Dallas, opens at 5 p.m. Patients begin to trickle in at five on the dot. The clinic primarily serves the homeless shelter next door, and offers checkups, vaccines and over-the-counter medications.
It’s free, and it’s run by medical students.
Neeta Malviya is a fourth-year student at the University of Texas Southwestern Medical Center. She’s graduating this spring and wants to work specifically with low-income and homeless people. On a chilly Tuesday evening, she checked in with 44-year-old Christopher Stine.
In the exam room, Malviya asked a slew of question: “How are you feeling today? What brings you in?”
Stine hurt his knee lifting weights, and it’s been bothering him for a few months. Malviya knew he was homeless, so she guessed he probably moved around a lot during the day.
“Honestly, the biggest thing I’ve learned is that with these patients, you have to think outside of the box. 'Will this patient be able to do this treatment, do they have a social support network?'” she said. “There’s so much more that goes into taking care of a patient and their health than just giving them a medicine.”
For Stine, an over-the-counter painkiller was the best the clinic could offer that day. But the students don’t cut corners here when evaluating their patients. Malviya checked his blood pressure, asked him about other medications and health complications and checked for skin problems.
“It seemed like an awfully thorough examination for some Ibuprofen,” Stine laughed.
But he knew this thoroughness was for the best. He said he appreciated that his doctor for the day, Malviya, paid special attention to his life outside the clinic.
“It’s important for them to understand the homeless as far as it relates to their difficulty obtaining medications and getting transportation to the pharmacy to pick up medications, money to pay for medications or regular medical care,” he said.
What Stine is describing is something doctors call the “social determinants of health.”
“Social determinants of health are all the other factors that are influencing health,” said Dr. Nora Gimpel, an associate professor at UT Southwestern in family and community medicine. “Jobs, family conditions, the environment, access to health.”
It’s the understanding that where and how people live, their religious and cultural beliefs, their income and education all have significant impacts on their health – and what’s “best” for a patient isn’t always what’s possible.
“I can prescribe the medication that I think can work best for a particular condition, but first, the patient may not be able to afford it. Second of all, they may not even have the transportation to grab the medication. Maybe the patient cannot read. So if we don’t ask, we assume,” she said.
What happens when doctors assume? Gimpel said they too often call patients “non-compliant,” thinking the patients didn’t do this or that because they didn’t want to or simply neglected to. Gimpel said instead, doctors should ask “why,” listen, and include their patients in some of the decision making. Gimpel said that kind of approach makes for better, more thorough medicine.
A 2007 study in the American Journal of Public Health even suggests that those social determinants influence health outcomes more than medical advances – and that money would be better invested in combating disparities in care than on new technology.
Maggie Leland, a second-year medical student at UT Southwestern, said students and doctors can be resistant to those methods. Some doctors say they don’t have time to be both healthcare provider and social worker – but Leland said that comes with consequences.
“If someone wants to be the type of doctor that doesn’t take those considerations into account, that’s fine, but you have to realize going into it that you’re only going to be able to provide adequate medical care to people with enough money, enough education, and abilities to challenge you or ask questions,” she said. “It’s easy to fall into that, and we don’t want to.”
And ideologies at medical schools are shifting – or at least, they're circling back. UT Southwestern’s CART program – the Community Action Research Track – has been helping lead the way since 2009. Its students – like Leland – volunteer and do projects in different neighborhoods.
“It can be field research where you go out and collect actual data from patients and from people. It could be analyzing a program that already exists, field-testing something, trying out a new medication in a novel setting,” she said.
Jamael Thomas is also a second-year student in the CART program. He’s not from Dallas, and said he’s learned a lot about the barriers to health here that make prescribing something as basic as exercise a challenge.
“They may not be able to go to a park to exercise because it’s possible that maybe the park isn’t safe, but also, they can’t leave to go outside because there are dogs roaming and they don’t want to be bitten by dogs,” Thomas said. “I didn’t know that was even a thing in Dallas, but apparently it is.”
Jordan Hoese, also in CART, said she believes most people go into medical school hoping to serve the broadest population possible.
“But I do think it might be a little bit of a matter of awareness – like there are all these really broad social factors at play, and [CART students] have to go out of our way to be exposed to them because we’re interested in them and because we care about them,” she said. “But for other people, they may just not know they’re there.”
That’s why the CART program is growing little by little every year, Dr. Nora Gimpel said. And more programs like it are rewiring medical training. In Fort Worth, there’s the Center for Community Health at the University of North Texas’ Health Science Center, which was created in 2007. And in Austin, there’s the University of Texas’ new Dell Medical School, which touts that community is at the core of its curriculum.
The goal? A world of medicine, where doctors talk less and listen more.