Beyond the Walls of a Hospital: Empowering Students and Surgeons to Incorporate the Social Determinants of Health into Clinical Care

When we first met, the two of us were just beginning our medical training. Through the campus grapevine—or at least what was left of it during the pandemic—we heard about Socially Responsible Surgery (SRS), the surgeons who “operate on the Social Determinants of Health (SDoH).” Not quite understanding how this worked or what they did, we met with the co-founder, Dr. Tracey Dechert. In her corner office in the Dowling building at Boston Medical Center, we asked the question: “We can be interested in surgery and public health?”

Dr. Dechert’s response: “We need students who are interested in both, there’s so much work to be done.” Many people, both inside and outside the field of medicine, conceive a narrow role for surgeons: they operate.

Congruent with this view, the job description does not typically include significant patient contact, holistic care, or tackling medical issues through a public health lens. But abundant research demonstrates that surgical outcomes depend on factors well beyond the operating room.1,2

As SRS co-founder Dr. Megan Janeway explains, “it is the elephant in the room, we should be identifying and addressing SDoH as we do for any other major risk factor or predictor of disease processes and outcomes. This is not beyond the scope of our practice but instead integral to the care of our patients.”2 For many reasons, including long-standing professional and educational norms, neither medical students—nor many surgeons—fully appreciate the linkage between SDoH and surgical outcomes.

This is broadly concerning for the field of surgery, and especially for medical students interested in becoming surgeons. A new generation of medical students desire a specialty in which they can address healthcare disparities, in part through SDoH principles.3 However, there is a traditional perception that SDoH and surgery are not compatible, and these students may opt-out of pursuing surgery before they are even exposed to the field. Many students don’t interact with surgeons until later in their training. One study found that only 31% of first-year medical students reported that they believe surgeons actively participate in medical education—this number jumps to only 51% by the fourth year.4 Medical students don’t seem to be getting the exposure that they need to make a well-informed choice. On one hand, these misconceptions may attract students who believe surgery consists solely of wielding the knife; and every bit as concerning, the field may be missing out on recruiting students who are also interested in public health.

The answer, as with many issues, is through education and changing professional norms. Specifically, we urge medical institutions to empower surgical trainees and surgeons at all levels to be advocates to improve their communities. Through exposure to ideas and practice, medical students begin to see that acknowledging and addressing SDoH is what surgeons do.

While there are many ways to approach the challenge, we have recently had success reaching a large number of medical students through the framework developed by SRS. SRS is an organization founded in 2014 at Boston University Medical Center that aims to bridge the gap between public health and surgery through advocacy, education, research, and service initiatives. The organization provides a vehicle to train globally minded surgeons, and combat the current inequities that exist in access to surgical care. Importantly SRS shows medical students early in their educational journey that holistic healthcare is important, if not necessary, for an effective career in surgery.

In one of our most successful projects, first-year and second-year medical students visit patients who have just undergone emergency surgery. During this visit, they screen patients for social risk factors that could impact their recovery and go over postoperative instructions—making sure patients have all the resources they need to follow these instructions. This project neatly combines the goal of improving patient care and health literacy while simultaneously providing medical students early clinical experience and exposure to the patient-centered care side of surgery. As a bonus, both self-perceived value and confidence in screening for SDoH were significantly improved among medical students who were involved.5

Over the past year, we have had dozens of conversations with students, residents, fellows, and faculty across the country who have been looking for ways to incorporate SDoH into early medical education. In just the past year we have started 8 more chapters and are in the process of developing 9 others, and at each of these institutions, students have flocked to join SRS.

The range of opportunities to intersect early surgical training and the SDoH is diverse. However, in our experience, each of the programs, activities, or events that we have helped to implement fit broadly within 3 categories. We offer them as examples for others to pursue and to encourage additional creative approaches:

Early Medical Student Exposure Programs: The aforementioned program for medical students to engage with patients receiving inpatient postoperative care is one example of how to directly link SDoHs to surgery. These “Service Learning Programs” are not only relatively straightforward to implement, but can be broadly applied to different SDoHs and can engage a large number of students. Community Engagement and Policy Involvement: Several institutions have engaged directly with their communities, encouraging their surgical teams to participate in various local programs. For example, some chapters have led Stop the Bleed events at local high schools, teaching people how to respond rapidly when someone has endured trauma.6 Other teams have gotten involved in advocacy by participating in fundraising and awareness events around gun violence, or connected with state and federal policymakers to advocate for legislative change. Bringing SDoH into Preoperative and Postoperative Surgical Care: It is invaluable for students to attend meetings where the surgical team has direct communication and tighter collaboration between preoperative and postoperative care providers to ensure that patients receive the resources and support they need, not just to get better, but to stay healthy. These experiences help socialize students into a professional culture that emphasizes the SDoH.

As medical students, we are exposed to a breadth of clinical knowledge and depth of the science behind clinical care. However, without the added understanding of our patients beyond medicine, we cannot fully care for them. Medical students’ perception of what it means to be a physician, continues to shift from a purely scientific and curative perspective toward a more holistic approach. For medical students aiming to determine which field they will pursue, understanding the intersection of clinical care and the SDoH is fundamental to the decision-making process. One of our mentors, Dr. Sheina Theodore, a surgical critical care fellow at Boston Medical Center said, “It is refreshing to see the issues of social determinants of healthcare which plague our communities being addressed by those sworn to take care of those very communities.” The field of surgery is well served by physicians with invaluable skills and technical knowledge. We advocate that the surgical profession find more ways to communicate to future doctors that this approach is not only possible in surgery, but essential to deepening our commitment to healing the communities we serve.

1. Fox M. Social determinants of health and surgery: an overview. The Bulletin of the American College of Surgeons; May 3, 2021. Available at: https://bulletin.facs.org/2021/05/social-determinants-of-health-and-surgery-an-overview/. Accessed May 4, 2022. 2. Janeway M, Wilson S, Sanchez SE, et al. Citizenship and social responsibility in surgery: a review. JAMA Surg. 2022;157:532–539. 3. Dechert T. Translational research: turning research into advocacy. Trauma Surg Acute Care Open. 2019;4:e000416. 4. Naylor RA, Reisch JS, Valentine RJ. Do student perceptions of surgeons change during medical school? A longitudinal analysis during a 4-year curriculum. J Am Coll Surg. 2010;210:527–532. 5. Janeway MG, Lee SY, Caron E, et al. Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening. Am J Surg. 2020;219:346–354. 6. Berry S. MD, FACS, [@Dr_Stepheny]. So proud of this group getting out in the community and teaching students to @acsSTOPTHEBLEED @stopthebleedday [Tweet]. Twitter; May 20, 2021. Available at: https://twitter.com/Dr_Stepheny/status/1395457848075866122.

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