The University of Connecticut Internal Medicine Program’s Health Equity Track is a three-year longitudinal curriculum integrated within the main residency curriculum designed specifically for residents who envision working towards eliminating disparities in health care and recognizing root causes of health inequities. By the end of this track, residents will receive the training necessary to address health disparities, promote diversity, health equity and inclusion (DEI) across their careers, and most importantly, better understand the concerns of the communities they serve.
Introduction
The United States has the highest per capita spending on health care, with nearly 30% of the budget, or $765 billion, wasted annually. Despite the large budget and availability of medical resources, the USA ranks 24th out of 188th nations in health measures such infant mortality, vaccination rate, violence, smoking and preventable diseases and is ranked behind many less developed countries.
Gaps in health equity, both clinical and non-clinical, play a major role in these statistics. Nearly 20% of someone’s health is based on the clinical care they receive, while the other 80% is a product of their environment collectively termed as the social determinants of health (SDH, or SDOH for the CDC’s acronym). The World Health Organization (WHO) defines SDOH as “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.” Examples of SDOH barriers patients may face are challenges within their physical environment, barriers within their social economic status and certain modifiable behaviors such as exercise and diet. Social, environmental and political factors such as barriers to a safe living environment, access to clean water, healthy air, food insecurities, issues with health literacy, or being uninsured can lead to worsened overall health. There are also certain vulnerable populations (e.g., immigrants, homeless patients, seriously mentally ill patients) who have additional barriers to care which reduce their quality and quantity of life.
The Society of General Internal Medicine Health Disparities Task Force recommends that learners in medicine:
- Examine and understand attitudes, such as mistrust, subconscious bias, and stereotyping, which practitioners and patients may bring to clinical encounters.
- Gain knowledge of the existence and magnitude of health disparities, including the multifactorial causes of health disparities and the many solutions required to diminish or eliminate them.
- Acquire the skills to effectively communicate and negotiate across cultures, languages, and literacy levels, including the use of key tools to improve communication.
Achieving equity in health care is consistent with our own GME program and the Capital Area Health Consortium’s member institutions’ missions, as described here:
- UConn GME program: Our commitment to DEI relates to our community of faculty, residents, and staff as well as the patients we serve. We value diversity, equity and inclusion in all aspects of health care including providing excellent patient care, within our academic and professional communities, and in research. Our faculty and residency programs recognize the important role diversity plays in creating a culture of collaboration and teamwork. To that end, our strategic effort and goals are as follows:
- Recruitment and retention of a diverse work force;
- Institutional and GME policies that are consistent across all of our affiliated hospital communities that allows for identification of best practices and identifying, reporting, and correcting mistreatment;
- Professional development and education of our GME community on cultural and structural competence;
- Patient care that demonstrates a commitment to our diverse communities with focused efforts in research, quality improvement, and institutional population health initiatives;
- Commitment to leadership in diversity, equity, and inclusion through program development.
- We strive to foster a safe and supportive environment in graduate medical education.
Learn more about diversity and inclusion.
Health Equity Track Mission
The mission of our Health Equity Track is to train and prepare the next generation of clinicians committed to caring for disadvantaged and vulnerable populations, and to promote health equity for all. To accomplish this, we focus on developing knowledge, attitudes, and skill sets needed to address these health inequities in the clinical setting, informed by the communities we serve.
Goal
By the end of this track, residents will be leaders within our Internal Medicine Program in promoting care consistent with Society of General Internal Medicine Task Force recommendations, and be able to:
- Define and describe terms such as weathering, bias, structural racism, social, environmental and political determinants of health, diversity, health equity, inclusion, and trauma-informed care.
- Assess root causes of health inequity in the communities we serve, and work with community members to promote positive paths forward.
- Identify bias, microaggressions, attitudes and behaviors that worsen disparities or detract from DEI in the health care setting, and develop effective responses to mitigate these.
- Assess patients for health care inequities, access available resources, and construct plans to address these in the clinical setting and beyond.
- Forge partnerships with community stakeholders and advocacy organizations critical to health equity and anti-racism efforts.
- Engage in the community through listening sessions, legislative advocacy, scholarship, research, teaching and volunteerism related to health care equity.
Curriculum
The Health Equity Track’s curriculum centers on community engagement, listening events and service for vulnerable and under-served populations to understand and tackle health disparities, as well as specific Diversity, Equity & Inclusion topics, accomplished via the categories below:
Learn
Track members each complete 12 modules from the ACGME EquityMatters series over the course of their three years (a total of four modules are completed each year, each less than 2 hours in length). Create an account for the free modules and log on here to access the EquityMatters curriculum. These modules prepare track members for DEI-informed leadership across their careers (the bold ones will be completed this year):
- Trauma-informed Cultures and History of Race in Medicine
- Building Safe and Courageous Spaces in GME and Steps Leaders Can Take to Increase Diversity, Enhance Inclusion, and Achieve Equity
- Patient Safety, Value and Health Care Equity: Measurement Matters & Using a Structured Approach to Recruit Diverse Residents, Fellows and Faculty
- Exposing Inequities and Operationalizing Racial Justice; and Whiteness: Power and Privilege in the Context of U.S. Racism
- Naming Racism and Moving to Action
- Gender Equity
- Sexual and Gender Minorities
- Black Experience in Medical Education; American Indian and Alaskan Natives in Medicine
- Asian, Pacific Islander and API American Experience; Latino, Hispanic or of Spanish Origin Experience
- Remaining Inclusive of and Supporting Non-Traditionally-Aged Learners and Disability Inclusion
- First-Generation and Low-Income Trainees in Medicine & Geography - The Impact of Place
- Creating an Inclusive Environment for Muslim and Sikh Trainees, together with 13: Health Disparities in Correctional Medicine and the Justice Involved Population (both are shorter modules)
Meet
Our monthly meetings are track-member facilitated. Meetings include member-led discussion of the quarterly ACGME modules and/or presentations on topics of interest. Ideas track residents propose, develop and lead are encouraged. Track members summarize their month’s track activities. Upcoming community events are planned at monthly meetings. Track welcome/kick-off event will be on July 11.
Community Engagement
Health Equity track members join and host community engagement events which are held approximately monthly to every other month. Community sessions that track members propose, develop and lead are encouraged. Events in 2021-2022 included a DEI-focused session with UConn Health’s Dr. Jeffery Hines, associate vice president and chief diversity officer, a breakfast discussion and meeting with advocates for Hartford’s homeless, footwear distribution events for the homeless, attending a multi-community interfaith alliance conference on local social justice issues, session on health disparity mapping via PolicyMap and data/informatics with Health Disparities Institute statistician, a legislative advocacy session on equity-focused Connecticut bill proposals with Health Equity Solutions non-profit, an anti-bias grand rounds, an SNMA-sponsored health screening fair at the Hartford Convention Center, and a community listening event on environmental health disparities.
For the upcoming 2023-2024 year, a few anticipated events include:
Summer: Exploring longevity success in a disadvantaged neighborhood: listening event, possible podcast.
Summer: Listening event: health impacts of living next to the Hartford landfill, and how to fight environmental racism and win (with podcast, video out of it, possible grand rounds)
Fall: Service event with Hartford’s United Way team. Listening event with North Hartford neighborhood advocacy group.
Winter: In conjunction with first year medical students, a community stakeholder panel in the North Hartford Promise Zone to understand the life expectancy gap this community faces and the community’s vision for paths forward to close the gap. Meal delivery, footwear distribution, and listening event with homeless clients at warming shelter in Hartford.
Spring: In conjunction with first year medical students: a community health advocacy fair featuring many area partner agencies and nonprofits involve in fighting disparities.
Summer: Sustainable upcycling community event. Community event on environmental justice and climate action efforts in Hartford and beyond.
Teaching and Mentorship
Bi-weekly Health Equity Curriculum contribution: Track members contribute four teaching topics each year for their residency peers, linked to the Yale Office Based Medicine curriculum. These emails benefit the entire Internal Medicine residency program and faculty. Each short work introduces a clinically relevant key health disparities topic, and teaches how to address it, such as resources and partnerships available within our community. The resources and partnerships presented will also be posted to our UConn IM blog for the benefit of our entire program, and be added to our topic bank.
Track residents serve as program mentors on how to capture and address social and environmental determinants of health. Wherever their clinical site, track members are asked to mentor students, fellow colleagues, and faculty in how to assess for, address, and code environmental and social determinants impacting health, as well optimize DEI-informed care delivery.
At fall and spring residency town hall meetings, track members summarize track events, service initiatives and research for the full residency program.
Advocate
Track members consider political determinants of health and conduct legislative advocacy. Over the winter and spring during Connecticut’s Legislative Season, track members will review several health-related bill proposals, engage in letter-writing or testify for health disparity topics. Ambitious track members may research and propose a bill of their own or as a group to the CT legislature to meet this requirement. This past year, track members met with Health Equity Solutions, an advocacy group who helped us identify and understand high-priority health-related bills. One of the bills we discussed, promoting support for Community Health Workers, successfully passed in the 2023 legislative session.
Serve
Health equity track resident focus on under-served and vulnerable populations at high risk for health disparities.
Neighborhood Clinics: Each resident has the option to participate in morning clinics at a Neighborhood Health Clinic each Y Block, serving Hartford’s uninsured and undocumented population. This rotation allows learners to experience care provided at these clinics, listen to and uncover social and environmental determinants of health for persons seeking care, and work with the field team’s social work and legal aid experts to connect patients with resources. Track members compile and maintain a resource list for use on site. Alternatively, track members may complete a project (see below).
Continuity or Specialty Clinics: Each resident has their continuity clinic at either UConn Farmington campus, Brownstone (Hartford Hospital) or the Gengras clinic (Saint Francis Hospital). UConn John Dempsey Hospital is the official hospital for the state of Connecticut and sees a high volume of Medicaid (Husky) patients. The Brownstone and Gengras clinics are located in inner city Hartford and take care of a predominantly Medicaid population. A track member may choose instead to spend their dedicated track Y block mornings completing a Health Disparities related QI or research project at their continuity or specialty clinic site instead of the Neighborhood Clinic. There are also opportunities to serve or complete QI/disparities research in other venues (e.g., incarceration medicine, environmental medicine, or as suggested by resident’s personal choice) upon request instead.
Diversity, Equity, and Inclusion Project
Track members interested in completing the track with honors, or at the honors with distinction level, will complete a DEI project that applies the topics and skills learned in our track. Most resident choose projects that involve teaching, scholarship such as research, advocacy, volunteerism, or quality improvement. Here are some of the projects completed or underway by our residents:
- Delivered Grand Rounds on responding to patient bias in the inpatient setting.
- Developing podcasts on local community environmental determinants of health.
- Connected unhoused persons with work footwear.
- Designed an outpatient HIV/AIDs and substance use rotation.
- Taught a longitudinal health system science curriculum for second year medical students (VITAL).
- Developed an online Health Equity curriculum for medical students in Guatemala.
- Participated in QI projects at their resident clinics (e.g., diabetes management, HPV vaccine).
- Volunteer service for our local community.
- Research project with a faculty member focused on health disparities.
Dedicated Track Time
Track monthly meetings are one evening a month. Track members lead one of these monthly meeting annually.
Community listening, service and other track events occur approximately every month to every other month, at mutually agreeable times with our community partners. Track members lead one event annually.
In Y blocks, one morning each of the 2 weeks is dedicated track time. As noted above, one morning may be spent at the neighborhood clinic, working on track project, completing modules, preparing teaching topics and/or preparing to host a monthly meeting discussion or event.
Track Certification
Each resident is asked to meet with the health equity track director every 6 months to ensure they are progressing within their program goals. At the conclusion of the track, participants will have developed skills and experience necessary to become experts on health disparities and social conditions common to our vulnerable populations, appreciate community concerns, and be able to promote diversity, equity and inclusion in health care across their careers.
In summary, for successful completion across three years, all track members:
- Join the majority of monthly meetings, leading one per year
- Attend the majority of health equity community engagement sessions, leading one per year
- Complete four ACGME EquityMatters modules per year
- Contribute four teaching/resource pieces per year to bi-weekly Health Disparities curriculum (with resources also added to the UConn IM blog), summarize track work for the residency town hall, and help mentor peers about health disparities/DEI.
- Contribute legislative advocacy activity each year (letter-writing, testimony, or equity-related bill proposal)
- In dedicated Y block time, option to serve four mornings at neighborhood health clinic, or spend four mornings at continuity/specialty clinic dedicated to completion of a health disparity-related QI or research project, or option to spend time working on other health-equity related project of track member’s interest, for presentation to group and beyond.
Members interested in pursuing certification at the Honors level in the track successfully complete the above each year, attend the majority of monthly meetings and community events, plus:
Propose, develop and complete a DEI-related research, community advocacy, or QI project, and present it at Grand Rounds, annual research day, QI session, or other venue, and/or submit to regional/national meetings or publications.
In addition, Honors level members demonstrate consistent engagement, leadership and mentorship within the track.
Members interested in pursuing certification at the Honors with Highest Distinction level in the track successfully complete all of the above, plus:
Complete an elective rotation at a FHQC (or equivalent experience tailored to member’s interest), accomplishing and presenting a separate site-specific DEI-focused project during the rotation, or,
Ally with a DEI advocacy partner over the course of three years to complete and present a sustained DEI-focused project complementing that organization’s mission, or,
Partner with a local family or community group in need, meeting at least monthly and demonstrating sustained commitment to emotional support and health care navigation over the three years, and present annually to track members (whilst preserving HIPAA protection) on DEI barriers to care encountered, track member support provided, including resources and services found to meet needs, or,
Publication on DEI topic, or piece of policy and/or legislative advocacy successfully achieved.
Honors with Highest Distinction level members demonstrate consistent engagement, leadership and mentorship within the track.
Additional Information
For more information regarding the Health Equity Track within UConn’s Internal Medicine Residency Program, please contact the Health Equity Track Director, Kirsten Ek, M.D., at ek@uchc.edu or our General Internal Medicine Fellow, Dr. Simon Abi-Saleh at abisaleh@uchc.edu.
References
Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington (DC): National Academies Press (U.S.); 2010.
GBD 2016 SDG Collaborators. Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016. Global Health Metrics | Volume 390, Issue 10100, P1423-1459, September 16, 217.
Bradley, E. H., B. R. Elkins, J. Herrin, and B. Elbel. 2011. Health and social services expenditures: Associations with health outcomes. BMJ Quality and Safety in Health Care 20(10):826-831.
WHO (World Health Organization). 2012. What are the social determinants of health? (accessed June 8, 2020).
Smith WR, Betancourt JR, Wynia MK, Bussey-Jones J, Stone VE, Phillips CO, Fernandez A, Jacobs E, Bowles J. Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med. 2007 Nov 6;147(9):654-65. doi: 10.7326/0003-4819-147-9-200711060-00010. PMID: 17975188.
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