The design and implementation of a longitudinal social medicine curriculum at the University of Vermont’s Larner College of Medicine

Background Despite an abundant literature advocating that social determinants of health (SDH) be taught during undergraduate medical education, there are few detailed descriptions of how to design and implement longitudinal core curricula that is delivered to all students and accomplishes this goal. Methods In this paper, we describe the design and implementation of a social medicine curriculum at the University of Vermont’s Larner College of Medicine (UVM Larner). Using Kern’s principles, we designed a longitudinal curriculum that extends through both preclinical and clinical training for all students and focused on integrating SDH material directly into basic science and clinical training. Results We successfully developed and implemented two primary tools, a “Social Medicine Theme of the Week” (SMTW) in preclinical training, and SDH rounds in the clinical setting to deliver SDH content to all learners at UVM Larner. Conclusions Extensive student-faculty partnerships, robust needs assessment, and focusing on longitudinal and integrated SDH content delivery to all students were key features that contributed to successful design and implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-021-02533-x.


Background
Social determinants of health (SDH) influence innumerable patient care outcomes from health care expenditures to life expectancy and professional satisfaction [1][2][3][4][5]. Physician educators are motivated to implement SDH as a central feature of undergraduate medical education [6][7][8][9][10][11][12][13][14]. This training has the potential to prepare future providers to notice the SDH, to gain tools to address them, and to reduce cognitive dissonance and "betrayals of purpose" [15] whereby SDH may exacerbate burnout through clinical productivity-driven incentives, helplessness about chronic health problems, and lack of insurance coverage [2,16]. Despite growing awareness of the tolls of healthcare disparities in the United States [17], significant obstacles to meaningful inclusion of SDH training in the undergraduate medical curriculum remain. These obstacles include the surfeit of foundational science material considered necessary for medical training, diverse faculty opinions about the educational utility of teaching SDH topics, and stricter average evidentiary standards for incorporation of SDH material into the curriculum compared to what justified the inclusion of traditional foundational science material [18][19][20].
Building on prior publications describing creative means of incorporating SDH into undergraduate medical education [14,[21][22][23][24], and linked to relevant curriculum objectives required by the Liaison Committee on Medicine Education (LCME) such as "Societal Problems" and "Cultural Competence and Health Care Disparities" [25], we describe the design and implementation of a novel longitudinal core curriculum in social medicine at the University of Vermont's Larner College of Medicine (UVM Larner).
This social medicine curriculum (SMC) includes diverse topics related to SDH and health disparities which utilize critical reflection, the incorporation of community voices, and experiential learning as essential teaching modalities. The UVM Larner SMC is deployed longitudinally to all learners, integrated directly into both didactic and clinical training, positions students as active learners who critique the existing health care system, engages them in interprofessional education, and is robustly assessed [21,23,[26][27][28][29].
Steps in the design of a novel social medicine curriculum

Problem identification and needs assessment
In 2018, a group of student advocates at UVM Larner, including the Class of 2021 student authors, were concerned that their medical education was not adequately preparing them to recognize or redress the SDH. These concerns drove the group to advocate for change. This group adopted the name Social Justice Coalition (SJC) and set out to use Kern's six steps of curricular development to advocate for change at UVM Larner [30]. Kern's process for curricular development has been used with success in various domains of medical education [31][32][33] and offers a logical and stepwise methodology for curricular development that spans problem identification and needs assessment to implementation and evaluation.
Students initially identified the problem through firsthand experience of both preclinical and clinical curricula, which constituted their first, informal phase of needs assessment. Thereafter, students undertook a second, formal, lecture-by-lecture needs assessment which involved an analysis of slides and teaching materials.
These needs assessments led students to identify key stakeholders (Table 1). Patients are the primary stakeholders in that all efforts to teach the SDH in medical training are geared at addressing the health burdens Further identification of faculty and administrators as joint stakeholders led to a targeted needs assessment phase. Key faculty, students, and course directors were invited to a series of meetings aimed at answering three key questions: Do you believe SDH is being adequately taught in the classroom? Where are the SDH currently being taught in the classroom? Where do you think there could be greater improvement of SDH education in the classroom?
This needs assessmentwhich we estimate took approximately 10 h per week for several monthsyielded two results: the formalization of a team of core students and faculty committed to this work and a clear map of where SDH content was already being taught ( Fig. 1).
The content map allowed us to see what was being taught and to identify gaps. There were many SDH topics that UVM Larner was already teaching: an orientation seminar about racism and bias, a first-year weekly small group discussion course called Professionalism, Communication, and Reflection (PCR), two public health lectures in the first 2 years of training, a 5 month Public Health Project with a community organization during the second year, 12 ethics lectures in the first 2 years of training, two clinical "bridge weeks" on Palliative Care and Global Health, and an annual interprofessional 4-h Cultural Awareness Conference.
The extensive needs assessment and mapping process cemented the student and faculty team and revealed key opportunities for further intervention. For example, although SDH content existed at UVM Larner, this content was separated from the foundational sciences curriculum in discrete courses, informally assessed, lacked space for critical reflection, had no centralized coordination, and lacked direct clinical integration.

Goals and objectives of a social medicine curriculum
Encouraged by how much material was already being taught, the students and faculty developed a new SDH curriculum with the goal of training a cohort of critically reflective medical students who would be prepared to see and address the complex social manifestations of health burden today. We named this improved curriculum the Social Medicine Curriculum (SMC). This term alludes to the societal and public health perspectives that traditionally fall under the banner of SDH but also emphasizes the importance of critical consciousness and humanities training as articulated in the Social Medicine Consortium's consensus statement [34].
The design of the SMC started with the development of seven broad SMC learning objectives categories ( Table 2) as well as 184 related session learning objectives (Supplemental 1). These objectives were generated through student and faculty conversations and literature review.
These learning objectives focus on encouraging critical self-reflection and giving students the historical and narrative tools necessary to contextualize health disparities. The overarching goal is to improve patient outcomes by training a cohort of future physicians that is prepared to enter into a healthcare landscape that is increasingly governed by financial, political, and social forces, and to equip them with the interpersonal and narrative tools necessary to navigate this landscape to understand each patient's unique challenges in achieving their best health outcomes.
Critical self-reflection is an important tool for physicians embarking on work to redress the SDH. Being able to navigate and appraise one's own place in SDH issues such as systemic racism, housing insecurity, and homophobia for example is prerequisite to understanding material that does not have clear right or wrong answers, advocating for patients, and mitigating burnout [13,14]. Much of our work rested on the presence of the weekly small group discussions held already in the PCR course as space for SDH-focused critical reflection.
Upon completion of the needs assessment and learning objectives, we set out to design and implement a social medicine curriculum that was critically reflective, featured community voices, was longitudinally deployed to learners, integrated directly into existing preclinical and clinical curriculum, co-championed by diverse faculty, and regularly assessed. This curricular design involved three core organizing processes: Cross-Curricular Integration, Content Generation, and Clinical Social Determinants of Health Rounds.

Cross-curricular integration of preclinical training
To highlight its central importance to undergraduate medical education, and to ensure it would be given equal curricular footing with other foundational sciences, we focused on cross-curricular integration of the SMC. This involved two main processes: (1) drawing connections between existing SM curricular elements and the foundational sciences and (2) an intervention we call the Social Medicine Theme of the Week (SMTW). For each week of the first and second years of the preclinical curriculum, we developed a Social Medicine Theme, grounded in one of our seven broad SMC learning objectives categories (Table 2), and directly connected to what was being taught in the foundational science curriculum.
The creation of the SMTW allowed us to not only to draw topical connections between the foundational sciences and the SMC but also to link foundational science courses to the PCR course. This in turn allowed small groups of students to discuss and analyze SMC topics in more detail. PCR is a small group discussion course that meets for approximately 90 min weekly for the duration of the pre-clinical curriculum. Moderated by a faculty member, the course covers a broad range of topics from the role of medical interpreters, to abortion, to burnout and racism. The SMC harnessed the potential of PCR as a multidisciplinary discussion space where complicated topics could be reflectively discussed in a brave [35] and non-judgmental space.
The cross-curricular integration of SMC with foundational sciences and PCR is depicted by examples shown in Table 3. Beyond creating topical linkages between foundational sciences, PCR and the SMC, students volunteered to announce the SMTW each week to their class. This moment of student-led reflection, which typically lasts less than 5 min, draws student attention to curricular framing, and, as appropriate, to the SMC's goal of creating future physicians who are leaders of health care change. The SMTW announcements positioned students as active leaders of the curriculum integration process. We included a reminder on students' online calendars, asked course directors to notify faculty of the SMTW, and facilitated the addition of new aligned slides or discussion questions into key sessions. This material was linked to exam questions, case studies in active learning sessions, and the SJC tied the SMTW to extracurricular events such as lunch discussions around complementary topics.
This curricular scaffolding created opportunities for course directors to incorporate SM content into existing sessions. Table 4 depicts one example of how the SMTW created opportunities to integrate SM content directly into 1 week of basic sciences curriculum.
During this week, we established a SMTW titled "Housing and Water" based on the basic science content related to toxicology and microcytic anemias. The crosscurricular integration was realized first by the development of a new PCR session called "Environmental Health: Flint and Dakota Access" (Table 5) Then, a lecture slide was inserted into the Toxicology session about how poverty, nationality, and race make certain populations more prone to environmental harm with two associated learning objectives. Further, we posed slides into the "Clinical Decision Making" lecture that asked students to reflect on their assumptions about patient's access to housing and basic human rights based on their physical appearance in the clinical setting. This week, we also wrote two multiple choice exam questions that would appear on students' exams.
We performed an identical process as described above for each of the first-and second-year courses (first year seen in Supplement 2), with the goal of drawing connections between SM content and the basic sciences curriculum, assuring the content had a place to be discussed meaningfully and reflectively.

Preclinical content generation
The above work of cross-curricular integration allowed us to link many SDH-related topics to existing foundational science topics. Some content of the ideal SMC drafted through our needs assessment and learning objective generation was not yet covered in the existing UVM Larner curriculum, thus requiring new content generation.
One example of Content Generation was already discussed in the prior section, specifically the creation of a novel PCR session titled "Environmental Health: Flint and Dakota Access" (Table 5). Another example was during a SMTW titled "The Genetic Basis of Race." The theme was based on the week's basic science training in genetics and served to highlight eugenics and the University's historical participation in this movement. The PCR session was entitled "Eugenics and the Culture of Medicine" and can be seen in Table 6.
When generating new content, we used diverse resources from the medical humanities such as literature, visual arts, music, podcasts, policy, and law. Throughout we featured voices from outside of medicine and paired these resources to discussion questions that fostered critical self-reflection as a means of enhancing professionalism and clinical competency as well as challenging the expectation that complex questions need to have simple answers [13,28,36].
During the design of the SMC, we believed it was critically important to recruit community members and other healthcare professionals into educator positions  [21]. Prior to our intervention, PCR already featured a number of sessions that featured diverse voices including nurses, physicians dealing with substance use, refugee interpreters, transgender community members, and others. Such opportunities to transform community members with complex lived experience into educators is an essential element of humanizing SM content, revealing how issues like poverty, substance abuse, racism, and homophobia truly impact health [37].
New content generation ultimately led to the creation and/or revision of 17 PCR sessions as well as the revision of two Public Health lectures, a substantive redesign of a dozen ethics sessions in the Foundations of Clinical Sciences course, the creation of dozens of small group discussion questions for the foundational science first-year courses, and hosting a variety of extracurricular lunch-time sessions on current events. Clinical integration of SDH training is an essential feature of any undergraduate medical curriculum [21]. The clinical environment offers students the opportunity to see the reality of how SDH principles impact patient lives.
Based on our initial needs assessment we noticed the same issues with SDH training in the clinical environment: the content was sparse, separated from the rest of the curriculum, and informally assessed.
To address these shortcomings, we performed a literature review to look for tools that could be used to deliver SDH training in the clinical environment. Interventions included those that did not directly relate to caseload in clinical environment [36,38,39] such as teaching kitchen approach [20], which demonstrated that experiential cooking and nutrition education improved trainees' abilities to counsel patients on diet and nutrition. In addition, the review revealed a number of approaches that focused on a select cohorts of students [21,22,[40][41][42]. Ultimately, we turned to a Longitudinal Integrated Curriculum which focused on using a rounds based technique [43] that required students actively reflect on how the SDH impact their patient caseload, and to create space for students to discuss these issues with peers and faculty.
With this framework in hand, students and faculty met with clerkship directors to elaborate the intervention to their particular contexts. SDH rounds are currently in an early implementation phase in the Psychiatry and OB/GYN clerkships. Discussion with other clerkship directors is currently ongoing.

Discussion
In response to national mandates to prepare physicians to resist racism and other forms of injustice in medicine, and following a local institutional needs assessment  informed by national literature of social medicine, we created a social medicine curriculum at UVM Larner by drafting 184 SMC learning objectives housed in seven overarching categories, devising the SMTW as an effective platform for cross-curricular integration, generating new curricular content, and using SDH rounds to integrate this content into the clinical environment. This work aimed to train students to recognize and redress the SDH in a fashion that utilized existing resources, focused on teamwork, and could offer a practical process that could be generalizable to other institutions. Key lessons learned during the creation of the UVM Larner SMC include the pivotal importance of small group critical reflection on SMC content, the strategic importance of extensive faculty engagement, the value of longitudinal curricular integration extending into clinical training, and initial reflections on SMC assessment [21,24].
When revising or creating new sessions for the SMC, we focused on opportunities for students to develop skills in critical reflection. Critical reflection is essential to SDH training in that it encourages students to centralize their own role in health inequity, reflect on burnout, and to understand that forces like poverty, racism, patriarchy, and climate change are human-made forces without clear solutions [14].
The already existing Professionalism, Communication, and Reflection (PCR) course at UVM Larner created space for critical reflection and served as the foundation for integration into the basic science curriculum. Our initial needs assessment and onboarding of faculty and administrators identified the potential of PCR in our work, and established allies who would allow us to expand and grow it. Institutions that do not have a comparable longitudinal reflection course might struggle to generalize our work to their institution, but the needs assessment and faculty engagement that led us to PCR could yield alternative opportunities.
Faculty support and involvement as stakeholders has been the central reason for our success. Course directors, administrators, and faculty leadership have provided invaluable feedback and mentorship through every phase of design and implementation, they performed tasks that would have been impossible for students, including speaking directly with lecturers, posting SMTW announcements weekly in the students' online calendars, and keeping students apprised of logistical concerns. After the initial cohort of students has graduated, faculty members can ensure the curriculum continues, and that lessons in implementation are not forgotten between class years. Our collaborations reinforced our belief that much of this work needs to be driven by faculty and staff with content expertise, institutional knowledge and longevity, and tangible support for the ongoing work of curricular leadership.
Though our work began with students at UVM Larner, we believe this process could begin at other institutions with faculty. Our needs assessment and early exploration phase cemented our student and faculty team, and this process could have similar successes elsewhere.
To further support faculty, we have hosted a half-day social medicine teaching session, and one grand rounds on social medicine education. Moving forward, we plan to establish regular expert-led faculty training in facilitation skills and SDH content to ensure that small group Table 6 P CR session titled "Eugenics and the culture of medicine" discussion sessions and SDH rounds allow for reflective and nonjudgmental exploration. This form of facilitation is not a formal part of faculty training and is essential to a healthy and growing SDH curriculum. Incorporating faculty development as an integral part of the continued improvement of this curriculum will also help establish sustainability as students' involvement is transient by nature.
We attended closely to the importance of assessment in the design of the SMC, frequently assisting course directors in creation of multiple-choice exam questions that linked to SMC material. That said, reflective essays and observed performance in clinical settings may be superior to multiple choice questions in assessing understanding of social medicine material and impact on patient outcomes [22,44,45]. Our nascent SDH clinical rounds offer faculty the opportunity to explore topics with students, and to require students to make formal SDH presentations which, in the future, can be evaluated by objective standards.
Longitudinal curricular integration is a central strength of the SMTW approach to social medicine teaching. The SMTW has allowed us to pinpoint where social medicine content fits naturally into the basic science curriculum and creates efficient means to develop discussion questions, slides, and exam questions. This strategy makes social medicine feel like an integral part of medical training. Despite our integration success so far, there are still many weeks of the curriculum where the SMTW is not sufficiently integrated outside of the PCR session for that week.
The SMTW approach has also made it possible to deploy our curriculum universally to all students. The literature cites a number of models featuring SM tracks for select students [21,22,[40][41][42], and although these models offer the potential of deeper training for students who are destined to become leaders in healthcare, we believe they miss an opportunity to build capacity and awareness in all future physicians.

Next steps
There are two forms of evaluation that are needed at this time: a programmatic evaluation of our work thus far), and a longitudinal evaluation to assess the impact of the curriculum on students' future practice as physicians. Does talking about racism in a small group session result in students recognizing their own role in various systems of oppression? Does it equip students with the tools to make change? Do SDH rounds give students tools to improve patient care, affect change, and reduce burnout? Despite successes in fostering critical self-reflection and involving voices from the community in PCR, we have yet to incorporate service-learning into the curriculum, which is an essential task for any social medicine curriculum. Soon, we hope to unlock crosscurricular integration of an existing community-based course called the Public Health Project to fully harness the experiential power of service learning in the SMC [24].
In the clinical environment, we have so far succeeded in integrating SDH rounds into two out of eight core clerkships. We hope to continue to work with clerkship directors to explore SDH rounds as a modality for teaching Social Medicine, or to find other clinical tools that will allow students to apply a Social Medicine lens to the patients for which they care.
As essential next steps in improving our educational methods, we plan to continue to build our SMTW through preclinical training, offer expert-led faculty training, expand our clinical SDH rounds, and begin assessment of impacts on burnout, student reflections, and patient outcomes. We recognize that the clinical years offer unique challenges due to constantly changing schedules, geographic and temporal diversity, and demanding hours of training, but we believe that the use of small group sessions similar to the PCR groups featured earlier in the curriculum have potential to facilitate ongoing reflection upon clinical experiences by third-and fourth-year students.

Conclusion
We identify several major contributors to the successful design of the novel SMC at UVM Larner, including a student-led needs assessment, the Social Medicine Theme of the Week, the utilization of a year-long small group discussion space for critical reflection, the creation of SMC learning objectives, commitment to cross-curricular integration with foundational sciences, and adjunctive events such as SDH rounds. These processes can be generalized to other institutions with different baseline foundational science curricula and SDH-related content, and we are dedicated to ensuring durable student-faculty collaborations that empower future physicians to be effective agents of change and critical advocacy in health care. This work is not done. Next steps include curricular evaluation and faculty development. As Audre Lorde once said, "revolution is not a one-time event" [46].