Perceiving Structures: Social Medicine Immersion in the Bronx

“Family medicine is front line care,” said Dr. Robert Rock, research associate at Yale School of Medicine, 2017 Pisacano Scholar, and longtime advocate for social medicine education. “It’s often supporting people in their most vulnerable time, understanding how they can or can’t move through the system in a way that promotes human flourishing.”

This mission statement powered Dr. Rock and like-minded young physicians to dream big and make tremendous change in their own clinical environment.

During his family medicine training at New York City’s Montefiore Medical Center, Dr. Rock worked within a team of residents and junior faculty of color to refine and evolve the residency program’s Social Medicine Immersion Month (SMIM) curriculum.

SMIM’s evolution would become the basis of a 2024 research paper titled, “Design of a Social Justice Curriculum to Expand Critical Consciousness Among Resident Trainees.” The program, which officially began in 2019, continues to this day.

“Primary care in this country isn’t resourced well enough to insulate our physicians from understanding how poverty and these other issues impact the [patient’s] ability to live their best life. Once you see it, you can’t unsee it,” said Dr. Rock.

SMIM is a mandatory 4-week course within the Residency Program for Social Medicine in the Bronx borough of New York City. Its primary intent is to emphasize critical health equity teachings and examine the perspectives of those with marginalized identities, specifically for PGY-1 residents as they acclimate to providing care in an environment with as diverse a population as the Bronx.

As of 2020, the Bronx has almost 1.5 million residents including immigrants from West Africa, the Caribbean, Southeast Asia, and Eastern Europe. The New York City borough also contains the poorest congressional district in the United States, so there is considerable income inequality, food insecurity, and housing insecurity at play.

Despite adversity, the Bronx has a long history of activism and self-actualization. Residents understand their world and are consistently working to improve it. All those circumstances contribute to the individual care and empathy that family physicians must give their patients.

“I think a lot of people run into the brick wall of moral injury when the textbook is training you to do these things one way, but life comes at you a different way,” Dr. Rock said. “Creating spaces like [SMIM] really helps to situate a person in a larger context. Otherwise, you’re just going to get burnt out.”

Upon taking part in Montefiore’s SMIM program as a PGY-1, Dr. Rock connected with Luis Gonzalez-Corro and Vanessa Ferrel, fellow interns in the social internal medicine track, about perceived deficiencies in the curriculum. Their conversations attracted Chanel Diaz, MD, MPH, a third-year resident in social internal medicine track. They started to consider what it would take to improve SMIM for incoming family medicine residents.

“I was excited to take the [SMIM] course but, halfway through, I realized it needed a significant overhaul,” Dr. Rock explained. “We were going on community tours led by local activists, but we didn’t get a chance to sit down and discuss how it all fit together in their minds. I think that conversation is super crucial for any clinician. ‘Why is this happening?’”

One of Dr. Rock’s faculty champions was Dr. Oladimeji Oki, assistant professor at Montefiore’s department of Family & Social Medicine who currently helps lead the SMIM program. During his medical school rotations, Dr. Oki was struck by the simple way a family physician understood the limitations of his patient’s financial situation.

“I remember, there was one interaction that really wowed me,” Dr. Oki said. “We were seeing a patient for routine follow-up, and the primary physician pulled up the patient’s formulary of their medications. They went through each one and said, ‘Okay, these you get at your local pharmacy, and these others you’ll need to get through the Walmart generic plan instead.’ The doctor had taken time to write out different prescriptions and hand them in different stacks for the patient.

“You realize it’s not enough to simply write the prescription. The patient has to be able to afford it and take it,” recalled Dr. Oki, who was inspired by that interaction to always seek intimate patient care which understood the limitations of the patient and the environment and systems in which they live.

Overhauling SMIM was a logical conclusion to the belief that patient care significantly improves by understanding the life they’re living outside of the clinic. The residents and junior faculty believed that, but there was still work to do to convince leadership that change was necessary.

“It can be hard for large institutions that are well meaning to hear ‘What you’re doing is maybe not the best way,’ or ‘There is room for improvement,’” Dr. Oki said. “You’re in a situation where trainees who are having these great ideas suggest them to educators. That can potentially lead to some tension.”

Over time, and through countless conversations, the vision of SMIM began to shift from one of centralization within the hospital system to a more socialized medical concept.

“The framework was completely changing. This would be a course really centered around the community, that has community members leading a lot of these sessions or has residents who have lived experience leading and creating these sessions,” Dr. Oki explained.

The residents threw themselves into updating SMIM’s curriculum with no compensation. Whenever they weren’t practicing medicine, their free time was spent making calls and planning curriculum that would give incoming residents the ability to truly understand what patient care looked like for an incredibly diverse and environmentally challenged patient population. This program, after all, was for first year residents. What did they need to know to be the best physician in that environment?

New residents begin their year in the middle of summer. SMIM starts in the fall. “Residents have a few months to get their feet wet,” said Dr. Rock. “Then SMIM frees them of their clinical responsibilities, aside from a couple of primary care sessions per week. Instead, they have focused time to understand social medicine as it exists and manifests in the Bronx.”

As residents participate in SMIM, their education sessions largely take place in the family medicine department offices, but they also attend outings to community sites around the borough to engage with activists, volunteers, attorneys, and other thought leaders.

“The only way to understand the community you have is to be willing to take on a humility and actually listen to what the community is saying,” Dr. Oki said. “Maybe it doesn’t align with what you think or what you learned in school, but we’re really trying to hear their voices. How is the health care system failing them?”

That question continues to be examined. The SMIM program undergoes constant change as residents cycle out and new ones arrive. Each new class has its own ideas of how patient representation and empathy can be maximized to improve care.

“The responses were overwhelmingly positive,” said Dr. Rock. “People were saying, ‘This is what I came to this residency program for. Trainees have consistently stepped up to carry the torch and they’re supported by those faculty champions, who are invaluable in maintaining community relationships and championing these students.”

The work continues, as the SMIM program will welcome a new class of residents this fall. The goal for SMIM is continued evolution, and leaders are aware that any program not improving itself is instead diminishing its relevance. A new research paper documenting SMIM’s continued growth is also expected this fall.

Thank you to Dr. Rock and Dr. Oki for making this article possible. We’re proud to highlight this program and hope it will inspire others moving forward.

Aaron Burch serves as Editorial Content Manager for the American Board of Family Medicine. He has been writing professionally in the health care field since 2014.