"Always remember the 'social determinants of health'" is a buzz phrase that I have repeatedly heard throughout my time in medical school. But I've rarely heard physicians really ask difficult questions about what leads our patients to become ill. Throughout the medical education process, we rarely discuss the powerful systemic structures that lead to poverty, inequality, environmental degradation and suffering. The medical school system does not teach us to confront the systems of power and the powerful who make decisions that affect millions. On the contrary, medical school functions as a highly efficient system of indoctrination to ensure that physicians are less likely to question or confront the systems of power.
Once in medical school, students typically have two years of classroom education followed by two years of clinical education (though some are beginning to vary this approach). The first two years are packed with information on microbiology, biochemistry, physiology, etc. Hours and hours must be spent memorizing chemical processes that will be forgotten shortly after they are regurgitated on an exam. In between these classes, students might have one or two required courses -- if even offered at all -- on "the social determinants of health." Unfortunately, in these required courses, the conversations are limited and do little to challenge traditional worldviews. In our classes, we may touch on poverty or inequality but do not discuss what structures create those circumstances.
Professors who have already been indoctrinated to think a particular way ensure discussions are kept "on topic," or within the traditional bounds of acceptable debate that do not challenge power. I personally have lost track of the number of times I have heard a professor say, "That is interesting, but it is just outside of the scope of the discussion we are trying to have." This is a highly efficient and subtle way of controlling thought.
As MIT linguist and philosopher Noam Chomsky has pointed out in The Common Good, "The smart way to keep people passive and obedient is to strictly limit the spectrum of acceptable opinion, but allow very lively debate within that spectrum."
The elite leaders of the US have used this strategy for a long time. In the 1970s, for example, in response to public mobilizations against this country's imperialistic military ventures, David Rockefeller and elite policy planners came out with a book-length report called "The Crisis of Democracy," which concluded that organizations, such as schools, universities and professional associations, which had been traditionally tasked with "indoctrination of the young," were becoming less effective. Their proposed solution to this problem was striving for a "moderation in democracy" by reshaping schools to produce "technocratic intellectuals" who would do their jobs quietly without challenging power.
Following this logic, in medical school, we efficiently limit the bounds of debate to a level that is comfortable. We do not dare explore the fact that those of us in medical school are often the same people who benefit from structures of oppression that actually lead our patients to becoming ill. We check off the box saying we are "teaching about the issues," but we really do not have the substantive conversations necessary that discuss the root causes. In our inability to grapple with the intricacy of such systems, we help to ensure their maintenance.
It is not just in the token social justice-related course that we have highly limited discussions. Where I attend medical school, we have a course on Evidence-Based Medicine (EBM), which is supposed to help students critically evaluate medical literature. In the course, we discuss the calculations necessary to determine whether a life-prolonging drug is "cost-effective." On the surface, this makes sense, but what is troubling is that we have these one- or two-hour conversations without even questioning why we are having that discussion. We do not ask who decides whether something that prolongs someone's life and brings joy to loved ones is "cost-effective."
When you start to think about it, the discussion as a whole becomes ridiculous. When a country spends trillions of taxpayer dollars on war and give billions in tax breaks to large corporations but has discussions around "cost-effectiveness" of medical care, we are having the wrong conversation. Discussions that may challenge underlying power structures and question the distribution of resources in our society are deemed "unrelated" to the subject at hand because, as many have probably heard from professors, "you have to learn these calculations or definitions for the boards."
Grading and Evaluating for Indoctrination
The structure of medical schools, which makes students reliant on grades and recommendations, helps to ensure that students will not step out of line or make those in power too uncomfortable. Throughout our time in school, medical students take exam after exam. The constant requirement to memorize large amounts of material ensures that we have little time to educate ourselves around other deeper social issues outside the classroom.
Becoming politically conscious requires work. You need to work to keep yourself informed and aware of the various ways profit is put over health in our society. The excessive, memorization-based workload ensures that students have very little of that extra time to dedicate to issues of justice. There's a talk going on against systemic racism or some practice destroying a community close by? You'd better think twice before attending, especially when you need to pass your upcoming exam in order to advance to the following year. You want to spend time reading on how environmental degradation affects the health of communities? You might want to re-think that when you have a board exam coming up that you need a particular score on in order to even get into a residency program.
During third-year clinical rotations, medical students' grades -- what will help determine where they are able to do residency -- are largely determined by those who observe them. This includes the nurses and physicians they work with on a daily basis. The arbitrariness of how exactly that grade is determined is quite obscure and this mystification helps to keep students in line. Administrators present the system as "standardized" with various rubrics, but it is the opinion of observers that ultimately determines whether the specified competencies have been met. When students know their grades are being determined by how people view them, they must be extra careful not to say anything that may bother the wrong person. This ensures they are much less likely to even think about questioning things said by authority figures.
Moreover, throughout their time at school, students must not ruffle too many feathers to be sure to get the appropriate letters of recommendation. Many schools (mine included) have what they call a "Dean's Letter," which gets submitted to residencies they will be applying to. This means it is crucial not to offend the wrong people.
This structure creates physicians who seek constant advancement, even if that means compromising our own moral compasses. What students are ever going to question a dean or say something "offensive" during an orientation when the same person is responsible for the letters that will get them into their choice residencies? If a student is conditioned to acquiesce to that dean at orientation, how likely will they be to challenge a large pharmaceutical company extending a patent on a life-saving drug that their patients need? How likely will they be to challenge companies like Chevron that are continuing to destroy the environment?
We learn to stay quiet and support the status quo without even becoming aware. The system's subtlety is largely what makes it so effective at indoctrinating students. Chomsky summarized the process well in a 1986 talk he gave called, "The Right Turn," in which he highlighted how dissenters are filtered out of institutions of higher education:
You undergo pressures to conform and those pressures are effective. What they do is weed out independent people. If you decide, "Well I'll conform a little, I'll do what they say, but I'll keep my independence of mind," as soon as you begin to do that, you're lost -- unless you are a very rare individual. What happens is you begin to conform and you begin to get the privilege of conformity. You soon come to believe what you are saying, because it's useful to believe it. Then you've internalized the system of indoctrination, distortion and deception. Then you are a willing member of the privileged elites that control thought and indoctrination.
The mechanisms of control are hard to notice as the structure becomes so normalized students do not question it. Since attending medical school, I constantly hear how important it is to "get the right people on your side." I have been wanting to write this article for a long time, and I know many other students who hold the same views, but it has always been too risky to potentially offend the wrong people. The system is highly efficient in making sure students like me "fall in line" and simply follow orders.
I am not naïve enough to believe that medical school is the only place where the conditioning of thought occurs. This is something that begins at a very young age in our schools and through messages displayed in the mainstream corporate-controlled media. Medical school is just one of the many places where this indoctrination occurs. We are unfortunately pursuing what the legendary educator Paulo Freire referred to as the "banking model of education" in which information is deposited for medical students to receive, memorize and repeat. We need to pursue a more liberating educational structure in which medical students are empowered to think critically about deep systemic structures of power and how they lead to illness.
Rather than conditioning well-meaning students to acquiesce to power, medical schools should make an effort to expand the discussion about social determinants of health to a deeper level. It is not enough for future physicians to be aware that structural inequalities exist. In medical school, we should learn that it is an obligation for physicians to join the fight for social justice. We should be discussing how we can incorporate knowledge around the social determinants of health into board testing (assuming board exams are here to stay). Medical schools should also require students to set aside time to become involved with activist movements that critique and challenge those in power. Some will argue that these changes would be too difficult to make, or that there is not enough space in curriculum for such measures, but we must challenge this thought process.
Medical schools, such as Duke University, have been able to limit their basic science curriculum to one year, leaving students with more freedom to explore other interests. It is clear that schools around the country are beginning to realize that much of the information covered in basic science courses is overly in-depth, will not be retained in any long-term capacity, and will not lead to more effective physicians. "Remember it for the board and forget it after that" is a common phrase students hear. This speaks to the superfluous nature of the information we are forced to study. The current model focuses on making sure students memorize so much esoteric information, just to perform well on a test, that we forget why we are in the field: to help people. We begin to disregard the larger picture, and in turn, we become less effective physicians and patient advocates.
Ultimately, there needs to be a shift in focus of what exactly constitutes "health" and how physicians take part in "treating" health issues. We need to move beyond superficial discussions around social determinants of health. We must begin to create activist physicians who recognize that truly caring for patients requires that we work to confront, question and address unjust systems of power. Poverty, inequality, racism, militarism and materialism -- all facets of "structural violence" -- lead to the deterioration of the health of individuals and communities. These are the issues that affect the largest portion of the population. We need to explore ways that we can join in the fight to restructure these oppressive systems that destroy the health of communities. A greater proportion of the medical community must come down from its ivory tower and become involved where the real activist work is being done to change the structure of our society at a fundamental level.
There are already groups of medical students around the country that are beginning to recognize the need for this shift in focus. Groups, such as "White Coats for Black Lives," "Radical Public Health" and "Students for a National Health Program (SNaHP)" are working to push the boundaries of medical education. We need to work together to build the structures that we want to see incorporated into our medical system.
Time is of the essence. We are currently experiencing one of the largest mass extinctions in history as global warming continues to ravage our planet. The military-industrial complex continues to expand throughout the globe, leaving death and destruction in its path. Income and wealth inequality continue to expand, leaving more and more to suffer. If we do not begin creating physicians who are willing to confront powerful structures, our patients, our children and the Earth as a whole will continue to suffer and perish.
The words of Dr. Martin Luther King, Jr. are more relevant today than they have ever been. In his speech, "Time to Break the Silence," he said, "True compassion is more than flinging a coin to a beggar; it is not haphazard and superficial. It comes to see that an edifice which produces beggars needs restructuring." If we want to truly address patient and community health as medical students and physicians, we must recognize that providing health care is more than just providing procedures, medications, advice or services for our patients. It is more than just remembering that the social determinants of health can lead to illness. We must realize that the edifice that creates illness needs to be rebuilt and join in that process.