Poverty is a significant public health concern affecting approximately 10% of Canadians. Recommendations to eliminate poverty have focused on areas of income, housing, access to food, and early childhood development. Calls for government action and provision of resources to healthcare professionals have been issued. Notably, educating medical trainees to address poverty has been absent from the discussion.
Low socioeconomic status (SES) is a risk factor for a multitude of medical conditions including cardiovascular disease, respiratory disease, cancer, and mental illness. In medical training, students are taught that socioeconomic status is a significant predictor of health, but there is little evidence to suggest that medical students are adequately trained to meet the unique health needs of people living in poverty. The virtual absence of education around screening and interventions to address poverty is puzzling, when contrasted with countless hours of medical training devoted to managing other common risk factors for diseases such as hypertension. What we do know from the sparse medical education literature on the topic is disappointing: medical students have less favourable attitudes towards people who are poor and are less willing to provide care for vulnerable populations by their fourth year of medical school. Clearly, there is much room for improvement in teaching trainees to address poverty.
Screening and interventions for poverty should be included in the medical curriculum. Medical students could be introduced to clinical resources aimed at addressing poverty and the recently developed, single-question screening test (“Do you ever have difficulty making ends meet at the end of the month?”), which has been shown to be reliable in identifying patients who are living below the poverty line. Questions around housing, neighbourhood, access to nutritious food, employment, income, and health insurance coverage could be integrated into the traditional medical interview, providing trainees with crucial information for patient care. Medical students also need to be taught how to incorporate their patients’ socioeconomic status into clinical decisions about screening and treatment options.
Making unwarranted assumptions or treating patients based on stereotypes could lead to cognitive errors in medical decision making and have devastating consequences. Medical training is the best time to positively influence students’ attitudes towards vulnerable patients. Medical students can be encouraged to reflect on potential biases when caring for patients who are poor. Fostering empathy for patients and families living in poverty should be a cross-cutting theme of a curriculum focused on alleviating poverty.
Educating students about interventions to address poverty should happen at the individual and community level. Trainees should be educated about housing, social assistance, and government benefits programs. Teaching students about referrals to other health professionals (e.g. social workers) and community organizations (e.g. disease-specific advocacy organizations, free income tax clinics) would be an important step to ensuring patients are well-supported. Discussion should also revolve around barriers for vulnerable populations in accessing healthcare, public health implications, and significant cost-savings for the healthcare system that could be achieved by addressing poverty.
Medical schools should also offer clinical electives and service-learning opportunities that are centered on caring for vulnerable populations. Some examples include the local-global health elective at Dalhousie Medical School, inner city health elective at the University of Toronto, student-led SWITCH clinic in Saskatchewan, and the Integrated Community Experience at the Northern Ontario School of Medicine.
One other promising avenue for change is advocacy training for medical students and residents. Health advocacy is recognized as a professional responsibility, but advocacy training is minimal throughout medical education. Teaching trainees to advocate for people who are poor should include didactic and skills-based sessions on communicating with government officials and effectively engaging with the media. Education around partnerships with institutional and community organizations as well as advocating for policies that will address the needs of people living in poverty will ultimately lead to better health for our society as a whole.
With recent attention to poverty in the healthcare field, there is no better time to incorporate poverty alleviation into the medical curriculum. In the midst of a rapidly aging population and climbing healthcare costs, training the next generation of physicians to tackle poverty is an urgent priority for ensuring the health and well-being of all Canadians.
A version of this post was originally published on KevinMD.com
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This is a very important issue at a time when the gap between rich and poor in Canada is expanding. Watch for an accredited CME module to be posted on cma.ca in coming weeks that addresses how physicians can deal with poverty in a clinical encounter. It is accessible to all 81,000 CMA members, which includes a large number of students and residents. Poverty must be viewed as a significant riosk factor for increased morbidity and mortality and, like any other risk factor, attempts must be made to mitigate its impact.
Great to hear that this module will be coming out. We look forward to seeing it.
Interesting discussion.
I am Community Health Centre Physician, like Mat Rose.
I spend almost all my clinical time working with people who live in poverty, and am fortunate to belong to a fantastic team that includes community developers and social workers. Together, we work on the social determinants of health at the community level, as well as one on one with individuals.
I absolutely agree that physicians as a whole have to be more aware of poverty. In our universal health care system, we will all treat poor patients, no matter where we work. And I am shocked day after day when my patients come back from specialists appointments and emergency room visits with prescriptions for the latest, greatest drug or physiotherapy treatment that they have got no hope of affording.
What a waste of everyone’s time!
How discouraging to the patient!
What a pain for the pharmacy who has to call around to try to get the prescription changed!
The first step doctors could take to address poverty issues is to recognize who is poor and tailor their treatment suggestions to the individual.
Gosh, don’t we do that for other things already?
You have renal failure? Guess I won’t prescribe you an NSAID.
You have a penicillin allergy? Then I won’t prescribe you penicillin.
You have no drug plan? Then I won’t prescribe the fanciest brand name medication.
Before most doctors will be able to consider things like “prescribing income” or advocacy we need to master these basics.
Maybe we can get the EMR vendors working on a program to alert us when we’re prescribing off the patient’s drug plan (or lack of same).
Great points and I agree with you that even asking simple questions can have a huge impact on patients.
I am a primary care physician practicing in an inner-city community health centre in Alberta. This issue is obviously near to my heart. Practically aortic valve, actually.
I stumbled accidentally into the joy and challenge of providing primary care to this population as a family med resident, and have never looked back. There was nothing in medical school or residency (over 15 years ago) that directed me to, or even less prepared me for, providing care to this population. Fortunately, the team of nurses, outreach, physicians and everyone else at the health centre took great care and made great efforts to help me become a skillful care provider.
I strongly support the idea of increasing our learner-physicians’ (and practicing physicians’) knowledge and skills with this population. These skills are largely transportable to all sorts of complex, marginalised or difficult populations.
I believe we need to mindful that there are organisations–largely community health centres and social support agencies–that have decades of practical experience in helping people in these communities get their needs met. Typically, they welcome the opportunity to share their knowledge and passion. For example, the North End CHC in Halifax is a superlative organisation, and typifies how a community health centre should respond to its clients’ needs (this is an unsolicited endorsement!). I assume Dalhousie U has partnered with NECHC, and if not, what a great shame!
It is my experience that too often educational and service-providing healthcare organisations–read: medical schools and healthcare bureaucracies–think they have just discovered an unmet need and immediately set about re-inventing the wheel. I encourage anyone who pursues expanding knowledge in this population to take a very close look at who in their community is already providing care to the population, and partner with them in providing support, care provision and mutual learning opportunities, in a way that meets everyone’s needs, particularly the target population’s. Anything less seems at best ivory-towerish and at worst willfully ignorant.
Thank you so much for sharing your perspective and it’s encouraging to hear about the work you are involved with. I totally agree with you that there are some organizations doing great work already and we need to collaborate with them in order to comprehensively meet the needs of our patients and communities.
I agree in that the clinical skills of physicians should be maximized, but I do think the referrals should be closely integrated in a clinic setting. One such initiative in the US is called HealthLeads, which allows physicians to “prescribe” (refer) resources (food, fuel assistance, housing, etc…), and this is “filled” by college volunteers who are knowledgable in navigating these resources.
I have heard great things from these programs in Baltimore city, specifically. That being said, these initiatives are only most appropriate in settings with a high proportion of low-income patients.
Thanks for sharing James. This sounds like a neat initiative and I think having referrals closely integrated with the clinical setting is a great idea.
I agree with Dr. Pooks in that I wonder if physicians should be the ones that spearhead this. By the time patients in poverty present themselves at hospitals, in some ways many other institutions have either already failed them or they have elected not to use those resources for whatever reason.
Is this role not the purview of Public Health?
In the Romanow Report he notes, “A health care system – even the best health care system in the world – will be only one of the ingredients that determine whether your life will be long or short, full of fulfillment, or empty with despair.”
Putting the responsibility of dealing with the determinants of health on acute care institutions seems to be trying to close the proverbial stable door after the horses have bolted.
Our intention with this article was not to decide that acute care institutions should be responsible for dealing with the social determinants of health. Rather, it is meant to open up a discussion about how poverty-related concerns can be met through various avenues. Tackling poverty should happen on multiple fronts including during medical training and at the hospital, community, and government levels.
I agree with the premise that poverty is probably one of the biggest determinants of health, but I don’t believe doctors like myself should be the edge of the spear in tackling it.
Medical school is to build clinical skills, learn communication skills and become a skilled clinician/diagnostician. As a practicing physician, my skills are mostly clinical and my services are scarce, valuable and expensive. Any time dealing with non-clinical issues is time away from my primary focus and skillset, and in my mind is a misuse of resources that would be better served being done by a non-MD/allied professional whom is an expert in those skills.
Of course physicians should advocate for their patients whenever possible, but if I spend time doing tasks other are better able/trained to do, whom will fill in my clinical roles as an MD that have gone unfulfilled?
It would make a lot more sense for me to be able to do social work or financial aid referrals in an outpatient setting, similar to the way we do with referrals to other doctors and services. However, there doesn’t seem to be much social work support in the community setting readily accessible from a primarty care standpoing and I do not see much of an appetite to bring more insured services on board.
But as a doctor, don’t you want to be sure that your patient is able to follow their recommended treatment? Surely knowing about their socio-economic status is important from that perspective?
For example, a patient comes to your practice with a bad cough that turns out to be a chest infection. You write a prescription and send them on their way. A week later, the patient comes back and their condition has worsened. Turns out they didn’t fill their prescription because they don’t have prescription drug coverage and work a minimum wage job. And, on top of that, they’ve had the heat turned down low in their apartment to reduce their hydro bill. And they’ve continued going to work because they can’t afford to take a day off.
As a doctor, you can’t solve all of these problems. But if you had asked about whether your patient ever has difficulty making ends meet at the end of the month you could have helped to find a way to fill their prescription. Perhaps they could apply for a particular government program? Or speak to an organization that supports low income people with health care needs?
As Dr. Pooks pointed out, physicians’ time is scarce, valuable and expensive. And in this case, a few more minutes of talking to your patient could have prevented an avoidable second visit and led to a better outcome for your patient.
Poverty by Canadian standards is not really poverty.
There are many people in Canada who are living without their basic needs met e.g. having their own home or access to nutritious food. Perhaps you are suggesting that the conditions these individuals face is not as “extreme” as in other places, but it could also be considered even more shocking that this exists in a wealthy nation like Canada.
While medical students and physicians by themselves will not be able to fix the problem of poverty, they can be trained to help and create change. I agree with Steve B that even a few minutes could make a big difference for these individuals e.g. helping them determine if they are eligible for certain government benefits, directing them to other healthcare providers and community organizations. Recently, there has been some research demonstrating that addressing poverty-related concerns (e.g. cost-related medication nonadherence, lack of housing) could actually lead to time and cost savings in the long run both for these individuals and the healthcare system e.g. reducing avoidable emergency department visits and hospitalizations [1,2].
I understand that addressing these concerns currently does not match with our clinical training. The intention of this article is to propose that poverty is in fact, a clinical issue because it has a huge impact on health. Medical training and patient care should shift to reflect this. As we suggest, there is wide variability in how students and physicians as well as medical schools and healthcare institutions decide to address poverty-related concerns. I think the main idea is that there are some concrete steps that each of us can take, whether it be directing our patients to resources and/or advocating for policy changes.
1. Madden JM, Graves AJ, Zhang F, Adams AS, Briesacher BA, Ross-Degnan D, Gurwitz JH, Pierre-Jacques M, Safran DG, Adler GS, Soumerai SB. Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D. JAMA. 2008 Apr 23;299(16):1922-8. doi: 10.1001/jama.299.16.1922.
2. Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009 May 6;301(17):1771-8. doi: 10.1001/jama.2009.561.