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