Structural Competency: Curriculum for Medical Students, Residents, and Interprofessional Teams on the Structural Factors That Produce Health Disparities

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Abstract

Introduction

Research on disparities in health and health care has demonstrated that social, economic, and political factors are key drivers of poor health outcomes. Yet the role of such structural forces on health and health care has been incorporated unevenly into medical training. The framework of structural competency offers a paradigm for training health professionals to recognize and respond to the impact of upstream, structural factors on patient health and health care.

Methods

We report on a brief, interprofessional structural competency curriculum implemented in 32 distinct instances between 2015 and 2017 throughout the San Francisco Bay Area. In consultation with medical and interprofessional education experts, we developed open-ended, written-response surveys to qualitatively evaluate this curriculum's impact on participants. Qualitative data from 15 iterations were analyzed via directed thematic analysis, coding language, and concepts to identify key themes.

Results

Three core themes emerged from analysis of participants' comments. First, participants valued the curriculum's focus on the application of the structural competency framework in real-world clinical, community, and policy contexts. Second, participants with clinical experience (residents, fellows, and faculty) reported that the curriculum helped them reframe how they thought about patients. Third, participants reported feeling reconnected to their original motivations for entering the health professions.

Discussion

This structural competency curriculum fills a gap in health professional education by equipping learners to understand and respond to the role that social, economic, and political structural factors play in patient and community health.

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Most cited references 34

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Theories for social epidemiology in the 21st century: an ecosocial perspective.

Nancy Krieger (2001)

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Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.

Michael Krasner, Ronald M Epstein, Howard Beckman … (2009)

Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce. To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [Delta], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Delta = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; Delta = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; Delta = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Delta = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Delta = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; Delta = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; Delta = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Delta = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.

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Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care.

Philippe Bourgois, Seth M Holmes, Kim Sue … (2017)

The authors propose reinvigorating and extending the traditional social history beyond its narrow range of risk behaviors to enable clinicians to address negative health outcomes imposed by social determinants of health. In this Perspective, they outline a novel, practical medical vulnerability assessment questionnaire that operationalizes for clinical practice the social science concept of "structural vulnerability." A structural vulnerability assessment tool designed to highlight the pathways through which specific local hierarchies and broader sets of power relationships exacerbate individual patients' health problems is presented to help clinicians identify patients likely to benefit from additional multidisciplinary health and social services. To illustrate how the tool could be implemented in time- and resource-limited settings (e.g., emergency department), the authors contrast two cases of structurally vulnerable patients with differing outcomes. Operationalizing structural vulnerability in clinical practice and introducing it in medical education can help health care practitioners think more clearly, critically, and practically about the ways social structures make people sick. Use of the assessment tool could promote "structural competency," a potential new medical education priority, to improve understanding of how social conditions and practical logistics undermine the capacities of patients to access health care, adhere to treatment, and modify lifestyles successfully. Adoption of a structural vulnerability framework in health care could also justify the mobilization of resources inside and outside clinical settings to improve a patient's immediate access to care and long-term health outcomes. Ultimately, the concept may orient health care providers toward policy leadership to reduce health disparities and foster health equity.

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Author and article information

Journal

Journal ID (nlm-ta): MedEdPORTAL

Journal ID (iso-abbrev): MedEdPORTAL

Journal ID (publisher-id): MEP

Title: MedEdPORTAL : the Journal of Teaching and Learning Resources

Publisher: Association of American Medical Colleges

ISSN (Electronic): 2374-8265

Publication date (Electronic, collection): 2020

Publication date (Electronic, pub): 13 March 2020

Volume: 16

Electronic Location Identifier: 10888

Affiliations

[1 ]Resident, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles

[2 ]Associate Professor, Division of Society and Environment, Department of Environmental Science, Policy, and Management, University of California, Berkeley

[3 ]Associate Professor, Joint Program in Medical Anthropology, University of California, Berkeley

[4 ]Associate Professor, Department of Anthropology, History and Social Medicine, University of California, San Francisco

[5 ]Chief Diversity Officer, Samuel Merritt University

[6 ]Postdoctoral Fellow, Osher Center for Integrative Medicine, University of California, San Francisco

[7 ]Nurse Midwife, Boston Medical Center

[8 ]Clinical Instructor, Department of Obstetrics & Gynecology, Boston University School of Medicine

[9 ]MD/PhD Student in the Medical Scientist Training Program, Department of Anthropology, History and Social Medicine, University of California, San Francisco

[10 ]Undergraduate Student, University of California, Berkeley

[11 ]Assistant Professor, Department of Health Science and Recreation, San José State University

[12 ]Reproductive Health Specialist, Planned Parenthood Northern California

[13 ]Nurse Midwife, Highland Hospital, Oakland, California

[14 ]Medical Student in the Medical Scientist Training Program, Department of Anthropology, History and Social Medicine, University of California, San Francisco

[15 ]Health Policy and Management MPH Student, School of Public Health, University of California, Berkeley

[16 ]Senior Manager, Health Outreach Partners

[17 ]Postdoctoral Fellow in Global Health, Department of Sociology, Drexel University

[18 ]Medical Student, University of Chicago Pritzker School of Medicine

[19 ]Medical Student, Oregon Health & Science University School of Medicine

[20 ]Core Faculty, Department of Adolescent Medicine, UCSF Benioff Children's Hospital Oakland

[21 ]Associate Program Director, Internal Medicine Residency Program, Highland Hospital, Oakland, California

Author notes

^*Corresponding author: joshuaneff@ 123456gmail.com

Article

DOI: 10.15766/mep_2374-8265.10888

PMC ID: 7182045

PubMed ID: 32342010

SO-VID: 0bfda393-a23f-42f3-83fa-f1962e7c2519

License:

This is an open-access publication distributed under the terms of the Creative Commons Attribution license.

History

Date received : 02 February 2019

Date accepted : 18 October 2019

Page count

References: 49, Pages: 10

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Structural Competency: Curriculum for Medical Students, Residents, and Interprofessional Teams on the Structural Factors That Produce Health Disparities

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Abstract

Introduction

Methods

Results

Discussion

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Fracture and Structural Integrity

Most cited references 34

Theories for social epidemiology in the 21st century: an ecosocial perspective.

Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.

Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care.

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Cited by 71

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