Ryan Meili

Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project

Background: Many medical students come into medicine with altruistic motives; few carry this altruism into their practice. As a result rural, remote and international areas are underserved by the medical community. Teaching social accountability may help students remain altruistic and encourage work in underserved areas. Making The Links (MTL) is a project designed to teach medical students the social aspects of medicine via service-learning. Aims: The purpose of the study was to explore student reflections on their experiences during the MTL program. Methods: Qualitative data analysis was conducted using structured open-ended written questionnaires. Fourteen students, representing three student cohorts, participated in the study. Data was collected between 2005 and 2007. Results: Six themes emerged from qualitative data analysis. (1) relationships, (2) social determinants of health in real life, (3) community development, (4) interdisciplinarity, (5) linking health and communities, and (6) personal learning. Themes reflected the opportunities and challenges experienced by the students during the MTL project. Students reported that MTL was an essential component of their medical training. Conclusions: MTL is a promising model for using service-learning to teach social accountability in medical training.

Turning Virchow upside down: medicine is politics on a smaller scale

The famed German pathologist and statesman Rudolf Virchow said, ‘Politics is medicine on a larger scale’. Income, education, employment, housing, food security, the wider environment – these social determinants of health are the factors that make the biggest difference in whether we will be ill or well, whether our lives will be long or short. Therefore, Virchow’s quote is often used to exhort decision-makers to recognise their influence on the health of a population and to see their role as being in service of greater health. This is an excellent idea, and if politicians truly did see themselves as the public’s physicians, we would have a far healthier society to show for it. This understanding of the social determinants of health has grown in recent decades to influence our thinking on politics and public policy. Only now is it starting to influence the practice of medicine. With the concept of the determinants comes the realisation that the healthcare we have tended to emphasise – physicians, pharmacist, hospitals and surgeries – accounts for at most 25% of health outcomes and likely far less. This has made a generation of physicians start to question their practice and think differently about the best ways to improve their patients’ health. If politics is medicine on a larger scale, than perhaps the inverse is true. Perhaps medicine is politics on a smaller scale. Whether it is in their choice of location, practice population or changing their methods, more and more physicians are taking the classic public health parable of the river to heart. Rather than spending all of their time downstream fishing kids out of the river, they want to head upstream and stop them from falling (or being pushed) in the first place. The question is, how do you leverage the frontline presence of the physician to make changes in the causes (or as Sir Michael Marmot would say, the causes of the causes) of illness? A variety of initiatives around the world seek to answer that question in creative ways. In the UK, a charity called Pathway: Healthcare for Homeless People supports primary care physicians who specialise in healthcare for homeless people, vulnerable migrants and other excluded groups. These physicians now lead Pathway teams in hospitals, working in non-hierarchical multi-disciplinary and multiagency teams to support and advocate for homeless patients, both within the hospital and with the housing and social care system which should support them on discharge. The central belief is that homeless patients – who tend to live in chaotic circumstances – provide an ideal stress test for our systems, revealing gaps in services and breakdowns in communication. By improving the care of homeless patients, we may improve systems that benefit all of our patients. The health consequences of failing to address health inequities impact rich and poor alike; putting systems in place that offer excellent service for those who are most difficult to treat helps to improve the system for all. California physician Rishi Manchanda has proposed a new category of healthcare professional called the ‘Upstreamist’. This new model of clinician has the skills and responsibility to ensure that her clinic or hospital systematically: (1) asks about where patients live, work, eat and play; (2) addresses upstream problems through interventions at patient, clinic and population levels; and (3) builds partnerships with upstream actors, guided by data and equipped with specific skills for upstream process innovation, performance improvement, advocacy and policy development. He, his cofounder Laura Gottlieb and his colleagues at HealthBegins have identified a goal of 25,000 Upstreamists by 2020. In Canada, the Centre for Effective Practice group has developed a Clinical Tool for Poverty, which

Being and Becoming a Helper: Illness Disclosure and Identity Transformations among Indigenous People Living With HIV or AIDS in Saskatoon, Saskatchewan

Saskatoon has nearly half of the diagnoses of HIV in Saskatchewan, Canada, with an incidence rate among Indigenous populations within inner-city contexts that is 3 times higher than national rates. Previous research does not adequately explore the relations between HIV vulnerabilities within these contexts and the experiences of illness disclosure that are informed by identity transformations, experiences of stigma, and social support. From an intersectionality framework and a constructivist grounded theory approach, this research involved in-depth, semistructured interviews with 21 Indigenous people living with HIV and/or AIDS in Saskatoon, both male and female. In this article, we present the key themes that emerged from the interviews relating to experiences of HIV disclosure, including experiences of and barriers to the disclosure process. In the end, we highlight the important identity transformation and role of being and becoming a “helper” in the community and how it can be seen as a potential support for effective community health interventions.