Teaching medical trainees to see societal infrastructure as a clinical issue

Waseem Jerjes^*Marcin KlingbajlAzeem Majeed

• Imperial College London, London, United Kingdom

Medical educators must accept this latent curriculum and look instead to openly incorporating infrastructural issues into clinical education. Trainees must learn early on to respond to and recognise infrastructural failure as part of clinical practice proper and not as ancillary issues of public health. Only thereby will future doctors truly reach the determinants of the health of their own patients. 21,22,23 Transport infrastructure failures hinder healthcare access, causing significant numbers of missed medical appointments annually in England, particularly in rural and disadvantaged areas. 24 There is measurable clinical impact: delay in cancer diagnosis, poorer control of chronic disease, and increased emergency hospital attendances. 25,26 Rural Scotland, for instance, has had higher cardiovascular and cancer mortality rates as a direct result of delay and interrupted therapy due to inadequate transport connectivity. 27 These are repeated globally and enhance the global scope of infrastructural determinants of health. In sub-Saharan Africa and globally, inadequate sanitation contributes to over 564,000 diarrhoeal deaths annually, most of which are preventable with improved infrastructure. 28 In rural India, frequent electricity outages severely disrupt essential healthcare services such as dialysis and neonatal intensive care, substantially compromising patient safety and clinical outcomes. 29 In American cities, minority groups disproportionately face environmental hazards, such as contaminated water supplies, with high-traffic examples including Flint, Michigan, wherein infrastructural neglect directly caused clinical instances of toxicity to lead. 30,31,32 Clinically, these deficits present as missed appointments, delayed diagnoses, medication failures and preventable exacerbations-patterns that perpetuate avoidable harm. 24,27,29,33,34 Recognising these patterns as clinical emergencies clarifies thresholds for action beyond symptomatic care when infrastructure is the proximal driver of harm. To truly respond to health inequities related to infrastructure, curricula for health professionals will need to transform to teach students to see infrastructure not as a contextual factor but as an essential clinical predictor of the health of the patient. 1,7,35 Having established infrastructure as a clinical determinant, we now turn to what must change in formal training. In clinical training today, there is minimal focus on the external environment and the direct impact it and the supporting infrastructure have on disease propagation and outcomes for the patient. Medical students are constantly taught to carefully review specific organ systems individually, but they are often not taught to systematically review environmental parameters like the quality of housing, access to transport, or energy security-elements as important to the wellbeing of the patient as are laboratory tests or radiology reports. The interventions below operationalise this shift within existing teaching blocks with minimal disruption. This approach converges with the H&P 360 framework within Health Systems Science, which extends the history and examination to seven domains that include context, resources, and systems navigation. Incorporating our infrastructure prompts within an H&P 360-style template makes housing, energy security, transport, and water safety routine elements of clinical data-gathering rather than ad-hoc social notes. 8 The inclusion of an infrastructure approach as part of the curriculum of medicine requires practical modifications to clinical training. 6,36 An important one is to teach students to take comprehensive infrastructure-led histories as a routine. Just as they are instructed to routinely question the history of smoking habits, the history of the family's health, or drug regimen, they should just as routinely question the character of the patient's surroundings, household heating, access to safe drinking water, and consistency of power supply. Inclusion of such questioning early on normalises the recognition of the significance of infrastructure as clinically relevant so that students will discover and thereby intervene against the environmental determinants of disease.Another effective approach is using case-based learning scenarios to illustrate clearly how infrastructural deficits directly lead to clinical presentations. 12,20,37 Examples such as an elderly person whose diabetes control is frustrated through limited access to healthy foods can vividly outline how infrastructural environments directly dictate clinical courses. Through the integration of such cases into the curriculum, educators can illustrate directly the correlation of infrastructural realities to disease control with clinical futility of repeated therapy in the absence of intervention on environmental determinants A successful method for framing the clinical significance of infrastructural deficiencies is the use of structured case-based learning exercises. 1,5,9,22,38 These educational approaches map directly to H&P 360 domains-for example, infrastructure-focused history ↔ context/resources; community placements ↔ systems navigation; and advocacy skills ↔ teamwork and health systems improvement. 8 Table 1 presents thorough examples illustrating direct correlations between ubiquitous clinical presentations and discrete infrastructural deficiencies to further establish the imperative of including conceptualisation of the role of infrastructures explicitly as part of medical school curricula.Clinical rotations in communities directly affected by infrastructural deprivation similarly embody transformative teaching potential. 13,18,30,39 Medical schools can intentionally assign students to rural counties which lack public transport, socio-economically disadvantaged neighbourhoods with shelter inefficiencies, or neighbourhoods with healthcare infrastructural lacks. Such experiences not only demonstrate the determinant function of infrastructure on health outcomes but also oblige trainees to experience the profound frustration and powerlessness of the patient ensnared in patterns of preventable disease. Through immersion with the community directly affected, students can begin to learn empathy and moral accountability for infrastructural advocacy as part of their professional selves.Educational modules that are truly interdisciplinary with practitioners from civil or urban planning and public health further enrich medical training. 2,9,14,40 Interprofessional learning allows students to see the value of alternate perspectives and innovative solutions beyond the standard model of medicine. For instance, architecture or urban planning workshops may expose trainees to innovative models of housing that were specially designed to promote respiratory health or to reduce the risk of falls in frail elderly populations. In these truly interdisciplinary exercises, students not only learn more but gain the confidence to engage productively in systemic advocacy with clear vision for the intersectionality between the built environment and clinical outcomes.Ultimately, for such curricular innovations to bear lasting impact, medical schools ought to incorporate into clinical education itself a culture of advocacy. 19,30,31,34 Education for students on advocacy skills-how to present the evidence associating infrastructural gaps with clinical outcomes, how to frame the product of policy decisions, and how to collaborate with community stakeholders-instructs students with practical skills for executing real transformation. Cultivating reflective practice on advocacy interactions-both achievements and barriers overcome-can solidify the confidence and competency of trainees to confront infrastructural determinants across the span of their careers. Curricular change must be matched by professional practice. Reframing clinical responsibility to include infrastructure requires broadening common understandings of medical professionalism. 3,8,16,29 Traditionally, clinicians understand their own work through narrow lenses, diagnosing and curing disease for individuals. Though critical, this perspective misses the larger structural determinants of the health of their patients. Clinicians regularly witness patients experiencing recurrent health crises stemming from external environmental conditions and yet often perceive these issues as not their responsibility. Breaking this narrow perspective is essential since clinicians are the only practitioners with the potential to bridge individualised patient care with social dimensions. Framed through Health Systems Science, this is the move from competent clinicians to effective "systems citizens" who can act on infrastructure when it is the proximal driver of harm. 7 One critical barrier is the demarcation between clinical practice and advocacy for public health. 7,17,19,26,34 Clinicians already routinely walk social advocacy paths: arranging accommodation support for high-risk patients, advocating for benefits support, or assistance with disability advocacy. Elevating this existing advocacy to the level of infrastructure is then second nature. Clinicians are regularly directly exposed to the health implications of infrastructural abandonment. Viewing such infrastructural failings as tangible clinical issues, not distant policy matters, helps clinicians to look beyond fixation on symptoms to removal of the causative sources.Repositioning clinical responsibility requires training for advocacy and systems-based practice. 4,7,18,27,39 Medical education should systematically instruct students and trainees to investigate, record, and report health outcomes influenced by infrastructure. Structured advocacy module-based educational interventions, community-based practical attachments, or inter-disciplinary projects can considerably enhance the competency of trainees to engage effectively in structural advocacy. Training clinicians to present clinical evidence to decision-makers-highlighting, for instance, the direct relationship between damp housing conditions and chronic respiratory illnesses-enhances their to influence healthrelated infrastructural choices.Clinicians are highly qualified professionals with high social status, so they are especially well-suited to champion infrastructural investments. 11,17,26,32 Society values clinicians' knowledge highly and listens to them with respect when they talk about determinants of health. This respected position allows clinicians to initiate effective dialogue with policymakers, local government leaders, and community organisations and to directly correlate infrastructural conditions with measurable clinical outcomes. For example, clinician advocacy about air quality evoked policies to reduce rates of pollution in cites and then hospitalisation for many respiratory diseases subsequently declined.Ultimately, repositioning clinical responsibility to include infrastructure advocacy enhances rather than detracts from the clinician's professional role. 2,8,17,24,40 It creates an ethical and practical responsibility for involving the holistic determinants of the health outcomes of patients. Through the restructuring of medical professionalism to include systemic advocacy, clinicians break cycles of preventable disease, reduce health inequities, and promote the attainment of genuine, long-lasting patient well-being. Such restructuring not only broadens the scope of clinical practice but also anchors medical care to its core moral imperative: to do no harm by addressing the determinants of disease.To minimise role creep and protect wellbeing, responsibility is team-based rather than physician-centric. Physicians retain accountability for recognising when infrastructure is the proximal driver of harm and for initiating an appropriate route, while the interprofessional team (nursing, physiotherapy, pharmacy, social worker, link workers) undertakes most actions, with public health, housing, planning and engineering engaged when hazards are recurrent or structural. This preserves feasibility, embeds advocacy within existing pathways, and develops "systems citizens" capabilities across professions-not only doctors. Advocacy and action on infrastructural determinants should be distributed across the whole care team and its community partners, rather than added as an extra burden to physicians. Responsibility is allocated by proximity to the problem and capacity to intervene: physiotherapists are often first to identify unsafe stairs or lack of grab rails; pharmacists frequently detect transport barriers or non-collection; nurses and social workers can activate housing repairs or welfare routes; link workers connect patients to local authority and voluntary services; and recurrent or area-wide hazards trigger involvement from public health, housing, planning and engineering. To operationalise this, routine histories across professions include infrastructure red flags; a simple spot-route-act pathway sets who notices, who acts, and when to escalate; multidisciplinary team (MDT) huddles or inbox rules surface unresolved risks; and low-burden documentation (tick-boxes or smart phrases) limits cognitive load. Framed as team-based, pathway-driven advocacy, this approach keeps actions practical and time-bounded, aligns with existing scopes of practice, and mitigates burnout risk while ensuring that infrastructure is addressed when it is the proximal driver of harm. With curricular and professional shifts the next step is scaling and evaluation. Future educational strategies should prioritise curricular innovation, integrating practical advocacy training and interprofessional collaboration into clinical teaching. Rather than treating infrastructure as a peripheral concern, medical schools should commit to producing graduates who are systemic advocates capable of addressing structural determinants within their practice. Achieving meaningful curricular transformation will require the adoption of structured strategies, careful use of facilitators, and the removal of barriers to maximise the clinical impact of infrastructure-focused training (Table 2).One potential future direction is the establishment of dedicated educational partnerships between medical schools, urban planners, housing authorities, and transport organisations. These partnerships could offer structured clinical placements designed explicitly to illustrate infrastructure-driven health outcomes, providing trainees first-hand experience in systemic advocacy. Similarly, integrating emerging digital technologies into medical training can help clinicians map and visualise infrastructure-related health inequalities, facilitating targeted interventions and advocacy.Another approach is the creation of specialty clinical advocacy curricula with instruction on policy analysis, health effects assessment, and stakeholder communication. Practical advocacy training for students-how to interact effectively with policymakers, communicate complex clinical evidence, and enlist community collaborations-provides future clinicians with the necessary skills for effectuating structural change. Pilot curricula assessing the outcomes of such interventions on confidence for the trainee, patient health measures, and community effects might yield essential evidence for broader curricular implementation.Ultimately, organisations should champion clinician-driven research into infrastructure as a clinical determinant through the systematised documentation of correlations between specified infrastructural interventions and measurable health benefits. Scaling up such research might establish robust evidence platforms to guide policy decisions and clinical practice guidelines where the direct clinical implications of infrastructure are accepted formally. Such research would additionally endorse the promotion of infrastructure as part of clinical practice with more organisational and professional support.The future of medical education lies not in reinforcing outdated boundaries but in proactively redefining clinical roles to include infrastructure advocacy. Such proactive curricular and professional development prepares clinicians to better promote health, close gaps, and promote the built environments essential to the wellbeing of patients and communities.