I could never forget this patient. I knew him well.
I was in my second year of a grueling emergency medicine residency, and he came to the ER often. Each time, he was sent from an outpatient clinic with dangerously high blood pressure. And each time, we treated him and discharged him home.
He was often described as “noncompliant,” meaning that some of my colleagues assumed he wasn’t taking his medications as prescribed.
But during one visit, I had a few extra minutes and asked: Why had he run out of his medications again?
He told me his neighborhood pharmacy had closed a year earlier, and the next closest one required two buses and a long walk. By the time he got off work, it was often closed. Missing work to go earlier meant losing wages he couldn’t afford to lose.
This wasn’t noncompliance. He was living in a system that made adherence nearly impossible.
This patient changed how I understood medicine. His repeated ER visits weren’t about individual failure; they reflected structural barriers — transportation, access, work constraints — that shaped his health long before he arrived at the hospital.
When I attended medical school in the early 2000s, I was not formally educated to recognize or address those forces. At the time, the concept of “cultural competence,” which had individual-level framing, was technically part of accreditation standards, but it was often inconsistently taught and rarely connected to the structural factors.
Formal accreditation requirements to teach about health disparities and equity were not established until 2015, when the Liaison Committee on Medical Education (LCME) introduced Standard 7.6, which explicitly required medical schools to teach future physicians to recognize bias and understand how health disparities shape patient outcomes. The LCME standards have evolved appropriately since then in response to evidence and patient need, not ideology.
That’s why I was so alarmed to read that the LCME, under political pressure, has removed explicit encouragement for medical schools to teach students how barriers outside clinical settings — like unstable housing, lack of transportation, food insecurity, and insurance gaps — influence whether patients can access care and stay healthy.
These expectations were previously embedded in Standard 7.6. The broader standard still exists, but by stripping out this specific language, the LCME has made this content easier to deprioritize at a moment when its understanding remains essential to clinically competent care.
This change isn’t trivial. Accreditation standards signal what’s essential for doctors to know. What gets named gets taught; what disappears risks being deprioritized.
Medical education has long focused on what happens in the exam room: taking a history, performing a physical exam, making a diagnosis, and developing a treatment plan. But what happens outside the clinic often determines whether that plan succeeds.
If I hadn’t asked my patient a few more questions, I would never have known he lived in a pharmacy desert or that his work schedule made access nearly impossible. Without that understanding, I would have continued practicing incomplete medicine by treating disease without addressing the conditions that made it worse.
Physicians are expected to anticipate barriers and design care plans that patients can realistically follow. That’s impossible if we ignore the conditions shaping patients’ lives. When those factors go unrecognized, both patients and health systems suffer. The result is avoidable ER visits, preventable hospitalizations, delayed diagnoses, and higher costs.
I saw this repeatedly during my training.
There was the child with asthma whose symptoms kept worsening despite taking her medications, until we learned her family lived in a cockroach-infested apartment. Cockroach droppings, saliva, and body parts worsen asthma, yet the landlord refused to do anything. The middle-aged patient with diabetes who struggled to control her blood sugar because she lived in a food desert with little access to fresh food. The patient with sickle cell disease who delayed care after losing his job and insurance, only to return critically ill with complications requiring intensive care.
These encounters taught me that upstream factors are not abstract. These aren’t rare exceptions. They arrive at the bedside every day.
Patients’ realities aren’t peripheral to medical education. Medical schools should teach future physicians how to care for the whole patient, not just the symptoms they see in the exam room. That means helping students understand the social and structural barriers their patients face in their daily lives and lived experiences. These aren’t distractions from clinical care. They are often central to whether a treatment plan is realistic, whether a patient can follow it, and ultimately whether care works.
Medical schools can do this through case-based learning, community-based experiences, and clinical training that teaches students to ask better questions, listen more carefully, and better understand what may be standing in the way of health. We don’t expect medical students, or even practicing physicians, to solve every problem their patients face. But they should feel a professional and moral responsibility to recognize the systemic barriers affecting their patients’ health and to do what they can, within their role, to help address them.
Medical schools are also increasingly responsive — and sometimes preemptively reactive — to political pressure. At a time when U.S. health indicators like life expectancy and maternal mortality lag behind those of other high-income countries, less emphasis on teaching future physicians how structural conditions shape health outcomes is a step in the wrong direction. Especially since, in some areas, outcomes are not just poor; they are worsening.
There are many reasons for this, but one is clear: Too often, we fail to address the conditions that determine whether care happens at all.
Patients don’t experience illness in a vacuum. Their health is shaped by where they live, where they work, what they can afford, and what systems they can access. Ignoring those realities doesn’t make them disappear; it simply makes care less effective.
It’s vitally important that medical education reflects that reality.
In practice, the LCME’s changes will likely mean less time spent teaching students how housing conditions, food access, transportation problems, insurance gaps, and work constraints affect whether patients can take medications, make follow-up appointments, or stay healthy in the first place. It can also mean fewer moments in training when students are taught to pause, ask better questions, and understand what may actually be driving a patient’s illness.
That matters because medical students absorb not only what they are taught, but what their institutions signal is important. If these issues are treated as optional, future physicians may be less likely to look beyond the chart and more likely to misread the reasons a patient is struggling. They may be less prepared to build realistic care plans, less able to prevent avoidable harm, and more likely to blame patients for barriers they can’t control.
I saw the consequences of that kind of thinking firsthand. My patient with high blood pressure was not “noncompliant.” He was navigating a system that made staying healthy far harder than it should have been. We should be training physicians to see that clearly.
Uché Blackstock, M.D., is an emergency physician and founder and CEO of Advancing Health Equity. She is the New York Times bestselling author of “Legacy” and a member of the 2022 STATUS List.
