It is a cold Monday morning as you trudge to yet another mandatory medical school lecture.
Is it more physiology or anatomy?
Maybe it is a mock clinical simulation …
As you find a seat in the lecture hall, the projector warms up and the guest lecturer introduces himself.
You squint to see the title slide more clearly … and there it is.
“An introduction to public health principles.”
You groan as loudly as a patient with a perforated viscus presenting in the emergency department. What is this farce? How is this medicine? How will this make me a better physician?
These thoughts are commonly shared by many students, either directly or silently festering like an abscess waiting to be drained. When students envision a future in medicine, topics associated with public health and preventive medicine are often seen as frivolous, detracting from “real medicine.” After all, how do health promotion paradigms help in generating a differential diagnosis? How does understanding health policy help me learn procedural skills? Surely for me to be the best physician possible, “real medicine” is what I need to focus on.
It is fair to argue that more education is needed on topics such as anesthesiology, mock clinical scenarios or research methods, to name but a few. The medical education curriculum could always use more time to teach more subjects in detail. Even in the limited number of hours in which public health principles are taught, a greater emphasis is placed on epidemiology, leaving less time to discuss topics like the social determinants of health. Many students are not even aware of the numerous career possibilities for public health physicians in Canada.
But an unfair corollary is that public health and preventive medicine topics require less time or are less important in becoming a good physician. This common misconception is understandable … when adequate prevention exists, one rarely notices the background efforts required to maintain that foundation.
Medical students instinctively understand how to advocate for their patients or help them access critical social services. But what is the context (the social determinants of health) that contributes to the patient’s condition? How can we instigate change in our surroundings so that our collective community achieves improvements in health? More importantly, how can we support those around us trying to improve the health of our communities?
I think back to the young male who presented to the emergency department with acute psychosis. Like any other physician, I tried to converse with the patient, examined the medical records and was fortunate enough to obtain limited collateral information from the law enforcement officer who escorted the patient. The emergency room physician had already initiated treatment for his condition.
What stood out for me was the diagnosis: “acute psychotic episode.”
Most people would not think twice upon reading this. After all, this was why the patient was here. Unfortunately, there was limited recognition of the population factors associated with the diagnosis that could hinder recovery.
This patient had started using stimulants and hallucinogens as a coping mechanism for a tumultuous home life. Having been exposed to various substances by his immediate family, his upbringing significantly increased his risk for various maladaptive health outcomes. He had limited social support outside of his immediate family. His struggles with addiction, combined with dropping out of school, made it difficult for him to improve his circumstances. Given his poor finances, food security was inconsistent at best. He was often found without a permanent address. With his addiction and limited skills, holding down employment was difficult.
This patient had been admitted so many times that the psychiatric unit knew his life story. Despite attempts to connect him with an outpatient psychiatrist and ancillary resources, he continued to struggle, resulting in continued admissions to hospital.
As I finished my consult notes, I arrived at the section “impression and management plan.” At the time, I had written “unspecified psychotic disorder” but thinking back … his real diagnosis was substance use disorder, poor social supports, challenging social upbringing, limited education, homelessness, victim of abuse, limited financial supports, maladaptive coping mechanisms and societal prejudice.
How can we address a diagnosis this enormous?
A critical step is to advocate for better social support services, including supervised consumption sites to reduce risk of overdose. Increasing subsidies for low-income housing and vocational rehabilitation could provide a foundation to reduce recidivism. Health education and promotion of mental health topics, discussion of substance use and supportive listening techniques could reduce barriers and stigma associated with this population group. These are topics within the pillars of public health and preventive medicine.
To some, incorporating public health education in medical school is a “waste of time.” It does not improve “my” ability to tie a suture, perform microsurgery or generate a differential diagnosis. However, better understanding of the social determinants of health from an individual to a societal level can help physicians incorporate a broader range of interventions for their patients and build an appreciation of allied health professionals and expertise. Most importantly, promoting and supporting initiatives in the community is an important step to improving the collective health of our society.
The COVID-19 pandemic has highlighted the importance of health-care professionals working collectively to address population health. The diagnosis is clear – how we intervene as a collective is central to our society’s health. Being aware of public health principles and incorporating them into both individual patient care and population health is critical moving forward.
I hope that those students’ groans will become cheers by the time I teach public health and preventive medicine. After all, what better way to start a cold Monday morning than by keeping each other warm?