This document summarizes a presentation on social determinants of health and upstream medicine given at a global health conference. It discusses how health is determined by multiple social and environmental factors beyond just medical care. The presentation advocates for medical education that exposes students early to these broader determinants of health through real-world experiences with patients. It describes a curriculum implemented at Texas A&M involving students visiting patients at home and in clinics to learn how social issues impact health and develop plans to address one identified social determinant. Performance is assessed based on documentation and understanding of links between social factors and medical issues.

1. Social Determinants of Health –
Upstream Medicine
Presented at the
Global Community Engaged Medical Education Muster
Uluru, Northern Territory
27-30 October, 2014
By
Nancy W Dickey, MD
Professor, Department of Family Medicine
Texas A&M University Health Science Center College of Medicine

2. Faculty/Presenter
Disclosure
Slide 1
• Faculty: Nancy W Dickey, MD
• Relationships with commercial interests:
– Consulting Fees: Association of
Academic Health Centers
– Others: Employee of Texas A&M
University Heatlh Science Center
College of Medicine

3. Disclosure of Commercial
Support
Slide 2
• This program has received in-kind
support from Texas A&M University
Health Science Center in the form of
travel support
• AAHC consulting is not related to this
forum.
• Potential for conflict(s) of interest:
None
 Nancy W Dickey, MD, has received
funding from Texas A&M University
Health Science Center supporting this
program.

4. Mitigating Potential Bias
Slide 3
• The AAHC consulting is not related
to curriculum development or this
conference.
• The support of the University is in
support of an expectation of
developing curriculum and sharing
best practices across the globe. A
full report will be made back to
the university regarding my
presentation and additional
lessons learned for incorporation
into university curriculum.

5. Achieving “Total Health” requires
attention beyond the exam room….
Health is driven by multiple factors that are intricately linked—of which medical care is one
component. Total Health is a comprehensive solution that addresses all components.
Drivers of Health
Source: Determinants of Health and Their Contribution to Premature Death. JAMA 1993
| © 2011 Kaiser Foundation Health Plan,
5 November 27, 2014
Inc.

6. Teaching students the
breadth of their role…
• Get them early so they learn this is important –
even before they begin to learn physical diagnosis
and differential diagnosis
• Living laboratory
• “Relatively blatant examples
• Sticky” learning
– Associated with real patients
– Practice assessment & judgment
• As with procedural skills, technique, sequence,
and practice help promote “muscle memory”

7. The Curriculum
• WHEN: During the pre clerkship training phase
• WHO: M-1 Students in a longitudinal experience
through first 10 months of pre-clerkship
education
• HOW: Selected reading & discussion to learn
concepts
Active Learning Process through patient/client
interaction
• Assign two students to a patient
• Facilitate home visits
• Attend one or more clinic visits and access clinic medical
records
• Each team will select ONE social issue that impacts the health
measure/outcome of the assigned patient
• Develop a plan to address the social “upstream” issue
selected
• Additional credit for any team of students that actually takes
steps to implement the plan

8. Assessing Performance…

9. Assessing Performance…
• Readings followed by small group
discussion
• Documentation of clinic and
home visits
– Demonstration of
understanding link between
upstream issues and medical
issues
• Description of selection of
social/upstream issue(s)
– Demonstration of
understanding of concept
• Reasonableness of recommended
plan/intervention
*Steps taken to actually
implement may lead to additional
credit

10. Questions