Education

Accreditation standards already require that medical curricula address social, political, economic, and cultural factors that influence health. Yet most clinical faculty have no background in the social sciences, and in the absence of a theoretically and methodologically rigorous approach, well-intentioned initiatives unintentionally reinforce erroneous assumptions and ineffective interventions, for which social scientists provide crucial correctives.

For example, social scientists challenge the mischaracterization of race in medical education as a biological variable rather than a social category and illuminate historical roots of “race specific” data in clinical medicine algorithms as well as their perverse effects, that can amplify rather than ameliorate racial disparities in treatments and outcomes [4,5]. Similarly, correctives for cultural competency training can reproduce cultural stereotypes, suggesting that the beliefs and behaviors of patients themselves are responsible for unequal health outcomes. Dually trained physician-social scientists Hansen and Metzel introduced the alternative of “structural competency,” which focuses on how clinical practitioners can address the community conditions, institutional forces, and policies that drive health outcomes, in collaboration with community members, non-health sector agencies, and policy makers [6]. This insight and intervention stems from the theoretical and methodological repertoire of social sciences.

To tread the complex terrain at the interface of the biological and the social requires cultivating a deep understanding of both, as well as their interrelation. This endeavor can be mutually enriching for both social sciences and medicine [7–8]. For example, social scientific scholarship has retooled and enhanced one of the oldest and most important methods of clinicians, history taking, as seen in the movements to integrate narrative medicine [9], mini-ethnographies [10], and assessment of structural vulnerability into clinical training (see Table 1). Systematic observation, a bedrock of ethnographic method, is also crucial to medical care.

Achieving the goal of fully integrating social sciences in medical teaching practices will require:

1. Curriculum reform that prioritizes rigorous social science and community engagement;
2. Robust inclusion of social science and humanities scholars on academic medicine faculty and among those receiving medical research funding.

Research

Social sciences generate advanced knowledge on complex health problems, yet their relational, systemic, and ecological methods differ from biomedical research methods—such as randomized control designs—which are currently favored by many funders. Cutting edge life science fields such as epigenetics, neuroplasticity, and the microbiome show how biological systems shape, and are shaped by, their environments, offering a new paradigm for translational science. Social sciences enable biosocial approaches, that regard biological and the social as mutually constitutive, in collaborations with life scientists and clinicians.

To include social sciences as basic sciences in the study of health and medicine would involve delineating paths from social science findings to the development of “social technologies,” i.e., community, institutional, and policy level health interventions that are necessary for the effectiveness of molecular technologies in improving health. Social science scholars are equipped to set standards for community engagement for creating medical knowledge. By practicing such engagement, they expand the expectation of community involvement to the basic sciences and clinical trials. This can help to redress a crisis of public trust in medical sciences and research participation, which is especially acute in communities of color [11].

To foster these approaches, clinical journals must publish social science and biosocial research and have social scientists on their editorial boards and among their reviewers to assess and elevate the standards of social scientific scholarship. In addition, health funders must have social scientists among their leaders and on grant review sections to evaluate proposals addressing relevant aims and methodologies. Requests for proposals can explicitly encourage structural analyses and require dissemination plans that elucidate systemic impact and engender research-community accountability. Such reforms could greatly shift the national priority setting toward social-structural health equity.

A model can be found in the Robert Wood Johnson Foundation’s Cultures of Health initiative that promotes health at systemic levels to operationalize health in all domains of policy making—in urban planning, transportation systems, and community cohesion in addition to healthcare delivery. This model shows that to transform biomedicine into a biosocial practice, social sciences must inform the development of community, institutional and policy interventions.

Clinical practice

Unrealistic time constraints, fragmented and difficult-to-access systems of care, and payment models that reimburse medical procedures and specialty care at much higher rates than comprehensive primary care reinforce poor healthcare delivery. We need interprofessional clinical teams that partner with systems and organizations outside of healthcare to collaboratively apply the knowledge, skills, and resources to effectively address social dimensions of clinical care. Examples include medical-legal partnerships that address legal issues impacting health, housing assistance as healthcare, and food pharmacies for food insecurity. To achieve these goals, we need to shift funding priorities and the allocation of resources toward social factors that shape health and illness.

To understand the social conditions of the communities that they serve, clinical practitioners must also respond to community members’ knowledge of their own needs. Social sciences provide the tools to create community partnerships, including participatory program development that incorporates community member observations and analyses. Inadequate tools and resources for such partnerships can lead to unintended harms. Academic medicine should adopt the evidence base that comprehensive healthcare for all includes understanding the social context [11]. Examples of this include historically Black and Hispanic-serving medical schools in the United States that prioritize addressing social conditions of health and community engagement that foregrounds community knowledge and expertise.

Social scientists should provide the knowledge base for instructional teams—inclusive of community leaders, non-health sector leaders, community resources, and partnerships—to enhance shared decision-making and to close the gap between populations at the bottom and the top of the health gradient. To this end, social scientists must help clinical systems develop incentives and pay structures that align to include social indicators as quality care measures, such as value-based payment for performance on positive population health outcomes. Examples include innovation programs with the US Center for Medicare and Medicaid Innovation that provide financial incentives in health systems to provide social care and accountable care organization incentives to integrate social care into healthcare delivery [12]. They must also inform the design and dissemination of roadmaps to address socio-economic causes of poor health in clinical practice.

Academic medicine currently prioritizes individualized and fragmented solutions to complex health problems. Considering what we know about social determinants of health, the incorporation of social sciences into the pillars of academic medicine would only be consistent with its commitment to evidence-based practice. Social sciences are crucial to equipping future and current medical professionals to improve clinical care and population health.

Acknowledgments

This essay is indebted to discussions among members of REMEDYS (Raising Equity in Medical Environments through interDisciplinarY Social Scholarship), a network of social scientists and social medicine practitioners who aim to re-envision medical research and education through integration of social sciences in medical training and research. Led by physician-scholars Helena Hansen and Liza Buchbinder, the network came together in 2021 in response to calls to address racial disparities in health, as well as racism in the medical profession and education. We thank all the members of REMEDYS for their engagement with this work, especially Sue Estroff (UCSF), Kelly Knight (UCSF), Carolyn Sufrin (Johns Hopkins), Lauri Andress (UNM), Philippe Bourgeois (UCLA), Joel Braslow (UCLA), Liza Buchbinder (UCLA), Seth Holmes (UC Berkeley), Carla Keirns (The University of Kansas) and Jeremy Greene (Johns Hopkins). Thanks to Ethel Roxas for all her administrative assistance.