Teaching the Social Determinants of Health in Medical Schools

Teaching the Social Determinants of Health in Medical Schools

LETTERS TO THE EDITOR Formal Inclusion of Bioethics in Medical Curriculum educational and training modules. This will ensure that doctors and expert...

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Formal Inclusion of Bioethics in Medical Curriculum

educational and training modules. This will ensure that doctors and experts produced in the field of medicine are not only scientifically trained but compassionate to serve the community and be accountable for their acts.


Dear Sir, The subject of bioethics is a part of formal medical education in many Western countries. Inclusion of discipline of bioethics in medical education was recognized many decades ago and initially the focus was on clinical and research ethics. With advancement in medical technologies and gene mapping etc a host of ethical issues emerged and ethical dilemmas were increasingly faced by the healthcare professionals. To address these issues there is a dire need to include bioethics in formal syllabus in the curriculum of medicine, both at the undergraduate and postgraduate levels.1,2 The need of teaching bioethics to medical students in Pakistan has been pointed out many years ago, but lack of and trained faculty formal curriculum development remained the hurdles in its implementation.3 For the development of faculty in bioethics in Pakistan initially a diploma programme in biomedical ethics was started. Later, masters programme in bioethics was also initiated at two institutes. With the availability of formally trained people in the discipline of bioethics, few medical universities and medical colleges incorporated bioethics in undergraduate medical curriculum though its teaching as a formal discipline, is not binding from the Pakistan Medical and Dental Council. In order to sensitize the medical fraternity and to educate them about bioethics, certificate courses, seminars, conferences and workshops on clinical and research ethics were held by those with interest in bioethics. There is still a feeling among many medical practitioners that formal bioethics education is not needed and the same can be learned while working in clinics with the teachers. This view is misleading. With continuous struggle from bioethics groups, Pakistan Medical and Dental Council (PMDC) has recently recognized one of the masters programme currently running in Pakistan. The degree can be registered with PMDC and one can be employed in medical colleges and universities for teaching bioethics. To conclude, it is time now for curriculum development committee of PMDC to endorse the viewpoint presented here and include bioethics as a formal discipline in medical education throughout the country as a mandatory subject. Postgraduate teaching and training institutes like College of Physicians and Surgeons Pakistan (CPSP) and other medical universities must incorporate bioethics related competencies in their


DuBois JM, Burkemper J. Ethics education in U.S. medical schools: a study of syllabi. Acad Med 2002; 77:432-7.


Persad GC, Elder L, Sedig L, Flores L, Emanuel EJ. The current state of medical school education in bioethics, health law and health economics. J Law Med Ethics 2008; 36:89-94.


Jafary AM. Bioethics and medical education. J Pak Med Assoc 2003; 53:1-2.

DR. JAMSHED AKHTAR Correspondence: Chief, Paediatric Surgery National Institute of Child Health Rafiquee Shaheed Road Karachi. E-MAIL: [email protected]

Teaching the Social Determinants of Health in Medical Schools: Challenges and Strategies Sir, Till the beginning of the twentieth century, physicians were oriented and expected to demonstrate a deep understanding of the patients' social, cultural and financial context as a part of the established treatment norms. Recent advancements in the field of medicine have enhanced physicians' dependency on technologybased treatment. There is a general apprehension and confusion in the minds of social scientists and medical educationists that it would make modern times physicians incapable to differentiate between social and technical interventions for disease prevention and control.1 World Health Organization has progressed to build a consensus on need to focus on social determinants of health.2 Hence, there is an increased demand to develop medical curriculum in a way that could enhance medical students understanding to disease aetiology in a broader horizon of bio-psychosocial model. This model would facilitate physicians to realize the sensitivity of

Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (1): 99-100


Letters to the editor

human health to social determinants of health. Along with the current developments, today's medical and allied health professionals should be sensitized to health inequities as an important determinant of health status of the patient. Commission on social determinants of health strongly recommends the role of health and education ministries, public health institutions and health management schools in the making of social determinants of health as a standard and an essential part of the curriculum. Also, research evidences have proven the stewardship function of the health sector in influencing to create health equity within a society.3 Though some medical schools offer behavioural and social science courses but students and faculty often fail to recognize and understand its importance. The challenges faced by the students and the teachers in appreciating the relevance of social sciences to clinical practice are worth addressing. The foremost barrier in introducing and promoting humanistic values in medical students is the teaching methodologies that do not involve real patients. Secondly, the content for teaching social science theories is vaguely defined, thus creating confusion about learning priorities. Moreover, little or no training of the faculty in this domain adds on to the problem. Social scientists and medical education experts have proposed an evidence based approach to overcome these difficulties. It has been suggested that teachers should adapt an integrative approach to teaching and learning. Biomedical, behavioural, and social sciences can actively be taught using Engel's bio-psychosocial model, as a link between the social sciences and the clinical practice.4 Engel's model rests on the principle that as the heart cannot be studied in isolation from the respiratory system, so the dynamics of illness cannot be understood without considering the social, cultural and financial context of the patient. Unlike the biomedical model of clinical reasoning, the bio-psychosocial model accommodates the observed associations between life


events and morbidity and the physicians' decisionmaking techniques on patients' health outcomes. Engel supports the doctor-patient communication as a vital tool in investigating the psychosocial determinants that may increase the patient's risk for developing a disease and reduce his or her ability to survive.5 Ideally, clinicians on teaching wards should be the role models in addressing both the biomedical and psychosocial problems. These role models can be trained by continuous teachers training programs. Nonetheless, identification of barriers and challenges and suggestion of evidence-based strategies in order to make social determinants of health a standard in medical teaching could be a way forward. This framework would embark on prevention and health promotion in the health care delivery system benefitting low and middle-income countries for acquiring better health outcomes.


Benbassat J, Baumal R, Borkan JM, Ber R. Overcoming barriers to teaching the behavioural and social sciences to medical students. Acad Med 2003; 78:372-80.


Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the advancement of teaching. Stanford: Carnegie Foundation for the Advancement of Teaching; 1910.


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Muntaner C. Teaching social inequalities in health: barriers and opportunities. Scand J Pub Health 1999; 27:161-5.


Borrell-Carrio F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med 2004; 2:576-82.


Correspondence: Dr. Farhan Saeed Vakani Department of Continuing Professional Education The Aga Khan University, Stadium Road Karachi. E-MAIL: [email protected]

Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (1): 99-100