A Case-Based Critical Care Curriculum for Internal Medicine Residents Addressing Social Determinants of Health

Abstract

Introduction: Graduate medical education on social determinants of health (SDOH) is limited. Residents often directly care for vulnerable populations at safety-net hospitals, yet curricula thus far are based in the ambulatory setting.

Methods: We developed a case-based curriculum integrating SDOH with critical care topics to standardize knowledge and improve skills and attitudes of internal medicine residents working with these patients. We conducted a needs assessment, identified systematic social risk domains, and modified a published curriculum to develop the content. Case-based discussions were conducted weekly in the medical intensive care unit, while knowledge, attitudes, and skills were assessed daily during multidisciplinary rounds. A 360-degree assessment was completed with pre- and postcurriculum surveys and self-reflection.

Results: Eleven residents completed postcurriculum surveys. Both pre- and postcurriculum, residents reported confidence in identifying and describing how SDOH affect care. After the curriculum, residents could name more resources for patients experiencing health disparities due to substance abuse (pre: 47%, post: 73%) and financial constraints (pre: 50%, post:64%). This curriculum was recognized as the first training many residents received (pre: 31%, post: 91%) with formal feedback (pre: 16%, post: 64%).

Discussion: Implementing a curriculum of social risk assessment in critically ill patients was difficult due to competition with clinical care. Participating residents said they "loved the open dialogue" to reflect on their experiences; this became an avenue to "debrief on specific patient encounters and [how] SDOH brought [patients] to the ICU." Future directions include qualitative analysis of reflections and assessment of curricular impact on trainee resiliency.

Keywords: Case-Based Learning; Critical Care Medicine; Diversity; Health Equity; Inclusion; Interdisciplinary Medicine; Social Determinants of Health; Social Risk.

Figure 1.. Curriculum map. The first session occurs during orientation and reviews how to screen for social determinants of health (SDOH). Learners then apply the screening in patient interactions and discuss social risks during multidisciplinary rounds. They receive feedback from the care management team and from their attendings, as well as individually reflecting on their knowledge before and after the curriculum, within the 360-degree assessment and feedback. The SDOH concepts are reiterated and applied to critical care cases during the weekly case discussions.

Figure 2.. Sample schedule based on a 4-week medical intensive care unit rotation.