Why the ABCs Matter More than Ever in Medical Education

In kindergarten, we learn the basics—how to count to 10, sound out letters of the alphabet, and write our names. We also begin making sense of the larger community around us. Our teachers and families guide us to be honest and kind, share, take turns, and listen, and in the process, the groundwork for developing meaningful and thoughtful connections with our peers takes root.

These ABCs of life are taught early in our development when we're curious, enthusiastic, and wide open to discovery, but their underlying importance is enduring, especially in medicine, where connections continue to matter more than ever.

There is certainly a disconnect in health care today. In North Carolina, 10.4% of residents lack health insurance and 15.5% report that cost prevents them from seeing a doctor [1]. While our infant mortality rate has reached an all-time low, it continues to be above the national average at 6.8 deaths per 1,000 live births, with African American babies more than twice as likely to die as white babies [2]. The poverty level in Forsyth County alone is 16.4% [3], with 21% of children experiencing food insecurity [4].

Equally staggering is that health care delivery accounts for just 20% of a patient's health outcome, with socioeconomic factors, physical environment, and health behaviors making up the remainder [5].

As a vascular surgeon, I've seen these inequities at play firsthand. Early in my career, we often overscheduled dialysis access surgery patients, as one or two typically would not show up. When a patient missed a procedure, we would label them unfairly as irresponsible, unconcerned, or even lazy—until we dug deeper.

We asked a simple question that shifted my perspective. We asked, “Why?” When we made room and time to connect with our patients, we found that many struggled with social barriers related to transportation, housing, food insecurity, family support, and income. While invisible to us at the outset, these factors were determining the care patients received, holding true to their name as social determinants, or social drivers of health. The World Health Organization rightly defines these as the conditions in which people are born, grow, live, work, and age that inform their health [6].

Asking, “Why?” and the connections it opens has stuck with me as a surgeon and now as CEO of Wake Forest Baptist Health and Dean of Wake Forest School of Medicine. Our institution's vision is to be a preeminent learning health system that promotes better health for all through collaboration, excellence, and innovation. We live out this vision in our daily practices and organizational culture, and we're training our students to adopt and elevate this mindset of better health for all.

Connecting care starts with our students and transformative learning. This year, 31% of our incoming class of 145 medical students call North Carolina home, and we are hopeful that many will stay in the state after graduation to practice primary care [7]. However, regardless of their final destination, all of our learners need to be educated about the importance of social drivers and have opportunities to be on the front lines, at the very first point of health care.

Learning about social drivers is more than just a “feel good effort” [8]. Our students are our future, so we are intentional about creating experiences for engagement that mirror our diverse population, expand our touch, and advance equity at the community level.

Last year, 315 students volunteered at our student-run Delivering Equal Access to Care (DEAC) clinic in downtown Winston-Salem's Innovation Quarter, where they provide free health care to underserved, uninsured adults in the Piedmont Triad. Students are the boots on the ground in this service-learning experience, exposed to social drivers of health through interactions that develop competence, compassion, humility, and empathy. While they provide medical care, they also address unmet social needs like smoking cessation through counseling and food insecurity though a fresh produce program. Since its start in 2006, the clinic has evolved to reflect its success, with specialty clinics now offered in cardiology, pulmonology, dermatology, and psychiatry, and plans for gynecology and glucose management underway.

We are also growing our longitudinal health equity curriculum to provide experiential learning opportunities with local partners like Crisis Control Ministry, Samaritan Ministries, H.O.P.E. (Help Our People Eat) of Winston-Salem, and others. The Population Health: Reducing Health Disparities curriculum is introduced in the students' third year, when clinical rotations begin and barriers to care access become apparent. Through a series of 10 modules that span clerkships from trauma surgery to pediatrics, students see how social drivers impact vulnerable populations and learn a range of skills, such as strategies for how to interact with non-English speaking patients and discuss alcohol and substance abuse with patients. Students also add to their toolkit a knowledge of available community resources, an important step in physician development.

Another way our students are woven into the community is through our Mobile Health Clinic, which began traveling to schools, homeless shelters, and local organizations last fall. Through partnership with the School Health Alliance for Forsyth County and Wake Forest Baptist Community Health Alliance, they provide preventive care services like immunizations, blood pressure and diabetes management, and nutrition and food access to medically underserved children and adults in our region.

These are just some of the many ways we're bridging care to the community and creating lasting change, as the experiences our students have today will shape their behavior tomorrow. Together with our learners, let's continue to ask, “Why?” and dig deeper to create thoughtful, meaningful connections that illuminate our patients and build trust. As we continue growing medical education and training programs, it's clear that the ABCs of life—listening, being kind and respectful, and sharing our stories and ourselves—matter more than ever for improving health not just for some, but for all.

• ©2020 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.