Emergence and Inclusion of Social Emergency Medicine into Emergency Medicine Curricula

By Erin Shufflebarger, MD - Fellow, University of Alabama at Birmingham

Edited by Lauren Walter, MD

The interplay between social determinants of health (SDoH) and patient health and care management is widely recognized. The World Health Organization’s Commission on SDoH emphasized the importance of increased awareness of SDoH as well as education and training specifically related to SDoH as a way to improve health equity.1 Given the unique relationship of SDoH and acute care in the emergency department (ED), the field of social emergency medicine (SEM) has emerged.  Many interventions have been implemented in the ED as a way to address population health needs.2 Despite this recognized overlap between SDoH and Emergency Medicine (EM), EM training has previously lacked a formalized curriculum related to SEM.  The integration of a SEM curriculum into education for medical students, residents and fellows is critical to identifying and addressing SDoH in the ED as we promote greater health equity for our patients, or “the attainment of the highest level of health for all people.”3

The feasibility of integrating SDoH-specific education as part of an EM clerkship was described in 2019 by Moffett et al. This three-part curriculum was designed for fourth-year medical students participating in an EM clerkship.  First, the student was asked to interview a patient specifically regarding their SDoH, follow them through their ED stay, discuss a plan for home care with the ED social worker, and write a summative reflection.  Second, students met in small groups to further explore the SDoH of one of their patients from the first assignment.  The goal was to generate a research plan for addressing the identified SDoH and social needs of the patient.  Finally, the small groups met and presented their findings to the larger group and a formal discussion followed.  A total of 56 students participated in this curriculum. The authors found this curriculum, which consisted of patient interaction, identification and assessment of social needs, and brainstorming of ways to address these needs, to be a feasible addition that was well received in the fourth year EM clerkship.4

EM residency education too has lacked a formalized SEM curriculum; however, recent publications have begun to address this gap in the literature. In September 2021, Stillman et al. published a commentary that highlighted this need for formalized SDoH education and proposed a longitudinal SEM curriculum integrated into the existing residency curriculum.5 This commentary proposes fourteen cognitive, affective, psychomotor and process objectives for this curriculum.  For example, a proposed cognitive objective is that each resident can identify SDoH and the social needs of their patients. Process objectives suggested include an intern orientation session on health and healthcare disparities and an annual minimum of four hours of SEM education for each resident. Though the content of the curriculum may vary by institution based on the patient population and their specific needs, this paper discusses the importance of standardized implementation.5 

Another mechanism by which SEM can be incorporated into resident education is simulation. A study by Ward-Gaines et al., also published in September 2021, discussed use of simulation specifically designed to educate EM residents about health equity.  The specifics and objectives of the eight cases are described in the publication.  One case involved a 71-year-old African American patient with report of medication noncompliance who presented with weakness and was found to be in atrial fibrillation with rapid ventricular response.  Objectives for this specific case include recognizing of the patient’s mistrust of physicians due to historical structural racism and the need to display empathy to establish rapport. The simulation addressed multiple cultural competencies including stereotyping/bias, homelessness and substance use disorder, privilege and microaggression.  Twenty residents completed this simulation.  Participants reported that this mass simulation experience improved their understanding of important concepts in health care disparities.6 Another example of SDoH-focused simulation is poverty simulation. The Missouri Community Action Network has developed an interactive, immersive poverty simulation in which participants are introduced to the realities of poverty.7 While this poverty simulation can be used by a variety of participants, it has been successfully integrated into an EM intern orientation to introduce SDoH concepts.8  In 2017, an institution incorporated this tool into a single-day simulation session during orientation for EM, internal medicine, family medicine, and obstetrics & gynecology interns. The poverty simulation introduced these interns to the importance of considering SDoH when caring for patients.8

With the introduction of SEM education for both medical students and residents, EM physicians should be able to recognize SDoH and begin addressing social needs in the ED.  For those with specific interest in the intersection between population health and the ED, fellowship training is becoming increasingly available.  These fellowships include opportunities for research, education and advocacy.9

Current, a formal, standardized SEM curriculum for undergraduate and graduate medical education is lacking.  Despite this, there is exciting work being done in the realm of education and intervention related to SDoH.  An awareness of the impact of SDoH on patients in the ED is not just the job of social workers and SEM trained physicians. Instead, every EM physician should have an awareness of these topics and should seek to address social risk and social need in the ED as a routine part of advocacy and care for every patient.  The goal of health equity begins with education. 





References

  1.  Marmot M, Friel S, Bell R, et al. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-9. 

  2. Walter LA, Schoenfeld EM, Smith CH, et al. Emergency department-based interventions affecting social determinants of health in the United States: A scoping review. Acad Emerg Med. 2021;28(6):666-74.

  3. Disparities. HealthyPeople.gov. Updated October 27, 2021. Accessed November 17, 2021. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities. 

  4. Moffett SE, Shahidi H, Sule H, et al. Social Determinants of Health Curriculum Integrated Into a Core Emergency Medicine Clerkship. MedEdPORTAL. 2019;15:10789.

  5. Stillman K, Owen DD, Mamtani M, et al. A social emergency medicine curriculum: Bridging emergency care and health equity. AEM Education and Training. 2021;5(S1):S154-7.

  6. Ward-Gaines J, Buchanan JA, Angerhofer C, et al. Teaching emergency medicine residents health equity through simulation immersion. AEM Education and Training. 2021;5(S1):S102-7.

  7. The Poverty Simulation. Accessed November 17, 2021. https://www.povertysimulation.net/about/. 

  8. Hsieh DH, Coates WC. Poverty Simulation: An Experiential Learning Tool for Teaching Social Determinants of Health. AEM Education and Training. 2017;2(1):51-4.

  9. Fellowship Spotlights. SocialEMpact. Accessed November 17, 2021. https://www.socialempact.com/fellowship-spotlights.

John PurakalComment