In the 19th century, there may have been no more consequential biomedical scientist than Rudolph Virchow. His scientific research at a molecular level has had a profound impact on modern medicine even today, more than 150 years later.
For me, however, it is his work in social medicine that has made a lasting impression on my understanding of the responsibilities clinicians have to the health of their society. Virchow could have been content with his contributions to pathology and molecular biology, but he had the wisdom to recognize the powerful social, economic and political factors that influence the manifestation of disease. He started a weekly newspaper called Medical Reform to highlight how socioeconomics affect health disparities. The newspaper’s banner famously declared “physicians are the natural attorneys of the poor.” His 1848 report on a typhus outbreak in Upper Silesia remains a landmark public health investigation that highlighted the role of poverty, famine, and political corruption as root causes of the outbreak.
A deep body of literature has shown that race, gender, income level, sexual orientation, disability status, and insurance status have a profound impact on one’s experience of health and healthcare in the United States. Recent outbreaks such as Ebola and Zika reflect the extent to which health systems in the developing world lack the capacity to not only respond to health crises, but to provide basic medical care worthy of people’s inherent dignity.
As clinicians, we have a unique vantage point from which we can understand how these social and systemic factors impact our patients. We hear their stories and experience their tragedies. And yet, most often, we have not been trained to understand what we can do about it.
Medical education can empower future health professionals to meaningfully improve health equity. We can teach students and residents about topics in social medicine, and help them develop advocacy skills to work at a social and systemic level to improve health outcomes. Perhaps even more importantly, it can give trainees the opportunity to reflect on their values and their professional identity and ask them what role they would like to play in fixing the injustices that are rooted in our healthcare system.
My current institution, Cambridge Health Alliance, has made social medicine and research- based health advocacy a core component of the internal medicine residency program. The required, longitudinal curriculum emphasizes experiential learning. We have described this course in a paper published in Academic Medicine and a news article in STAT News. Our goals in the course are to 1) clarify and develop the values that brought residents to train in a residency program hosted in a safety net health system, 2) explore the role physicians can play in improving systemic health equity, 3) improve knowledge of topics in health equity, social determinants of health and health policy, 4) develop skills in research methodology, leadership and health advocacy, and 5) provide mentorship and role modeling to support career development that may incorporate health advocacy. Residents work on a year-long research-based health advocacy project that gives them a real time experience of physician advocacy at a systemic level.
Not only have the projects resulted in robust scholarship (such as a recent project on the impact of the Affordable Care Act on individuals with chronic disease that was published in the Annals of Internal Medicine), they have given residents an opportunity to translate their research findings into policy recommendations. Residents also learn community organizing skills that were developed by Harvard Kennedy School Professor Marshall Ganz.
Course evaluations suggest that our course helps residents reconnect with the idealism that made them want to pursue a calling in medicine. We hope that the course can help heighten their sense of self-efficacy, supporting them as they realize the power they have to make change in what often feels like a dysfunctional and unfair healthcare system.
Rudolph Virchow provides us with a remarkable example of a physician who always asked what role he could play in improving people’s lives, especially those who were marginalized in their community. If we truly care about solving the vexing healthcare problems of our time, we must find the answers in the idealism and passion of our students and residents. As medical educators, we owe them the opportunity to not only learn about these challenges that face us, but to equip them with the training they need to become meaningful change agents.