Poverty, Health, and Graduate Medical Education

Abstract

P overty is potentially the greatest predictor of poor health in the United States. Disease-specific and all-cause mortality rates increase in a consistent gradient with decreasing socioeconomic position. 1,2 Poverty is associated with a 5-year loss in life expectancy, 3 and the loss of quality-adjusted life years for those living with incomes in the bottom one-third of the population is significantly higher than are losses associated with smoking and obesity. 4 Although access to health care is one piece of a complex set of mechanisms contributing to health inequity, health care contributes only a small fraction of the impact on individual's health in the context of the broader social determinants of health (eg, poverty and low education level). 5 Given these circumstances, what is the role of medical education in attempting to attenuate this overwhelming problem that crosses all disciplines? One temptation is to intentionally maintain focus on what we can control— teaching and practicing the diagnosis and treatment of medical pathology. After all, as physicians, this is what we are trained to do, and to frame medical education and patient interactions in the context of poverty and the social determinants of health means we are working outside of our expertise. However, as physicians, we need to be ultimately interested in our patients' health, not just their health care. As the dominant recipient of societal dollars directed at improving the health of the nation, health care institutions and practitioners should be among those at the forefront in mitigating the effect of poverty on health. In addition, graduate medical education is funded, to a significant extent, by the U.S. government. Teaching hospitals already serve a disproportionate share of poor and vulnerable patients in this country, 6 and implementation of the Patient Protection and Affordable Care Act (Pub L No. 111-148, 2010) will likely result in an increased interaction of these patients with the health care system. 7