Abstract
Background
The influence of societal inequities on health has long been established, but such content has been incorporated unevenly into medical education and clinical training. Structural competency calls for medical education to highlight the important influence of social, political, and economic factors on health outcomes.
Aim
This article describes the development, implementation, and evaluation of a structural competency training for medical residents.
Setting
A California family medicine residency program serving a patient population predominantly (88 %) with income below 200 % of the federal poverty level.
Participants
A cohort of 12 residents in the family residency program.
Program Description
The training was designed to help residents recognize and develop skills to respond to illness and health as the downstream effects of social, political, and economic structures.
Program Evaluation
The training was evaluated via qualitative analysis of surveys gathered immediately post-training (response rate 100 %) and a focus group 1 month post-training (attended by all residents not on service).
Discussion
Residents reported that the training had a positive impact on their clinical practice and relationships with patients. They also reported feeling overwhelmed by increased recognition of structural influences on patient health, and indicated a need for further training and support to address these influences.
Similar content being viewed by others
INTRODUCTION
A large and growing body of evidence indicates that societal inequities in the United States and globally correspond to marked disparities in health.1 – 6 The influence of such inequities on health has long been noted by clinicians and public health practitioners, but such content has been incorporated unevenly into medical education and clinical training.7 – 16 Proposed by clinicians and scholars in the medical social sciences, a “structural competency” framework calls for a “shift in medical education…toward attention to forces that influence health outcomes at levels above individual interactions.”17 (p. 126–27) “Structures” or “social structures” in this sense indicate the policies, economic systems, and other institutions (policing and judicial systems, schools, etc.) that have produced and maintain social inequities and health disparities, often along the lines of social categories such as race, class, gender, and sexuality.17 This article examines structural competency as a paradigm for teaching medical trainees about health disparities by exploring the development, implementation, and evaluation of a structural competency training for medical residents.
SETTING AND PARTICIPANTS
The structural competency training was developed by a working group comprising physicians, nurses, medical anthropologists, health administrators, community health activists, and graduate and professional students in several disciplines, and was implemented in June 2015. Participants in the training included a cohort of 12 residents in a California family medicine residency program serving a patient population predominantly (88 %) with income below 200 % of the US federal poverty level.
PROGRAM DESCRIPTION
The training consisted of a single 3-h session. The overarching goal was for residents to recognize and develop skills to respond to illness and health as the downstream effects of social, political, and economic structures.17 The following learning objectives (LO) correspond with curricular content (See Table 1). By the end of the training, residents were to be able to:
-
(LO1) Identify the influences of structures on patient health
-
(LO2) Identify the influences of structures on the clinical encounter
-
(LO3) Generate strategies to respond to the influences of structures in the clinic
-
(LO4) Generate strategies to respond to the influences of structures beyond the clinic
-
(LO5) Describe structural humility as an approach to apply in and beyond the clinic
Structural humility,17 inspired by cultural humility,18 encourages a self-reflective approach, working in collaboration with patients and communities to develop understanding of and responses to structural vulnerability.11 , 19 – 21
PROGRAM EVALUATION
The training was evaluated with post-session surveys administered immediately following the training and by a focus group with residents 1 month after the training. Post-session surveys included written-response questions such as “Please share your candid thoughts on this training: What parts worked well? What parts did you like? What should we change? How could we make this training more effective?”. The focus group consisted of semi-structured inquiry about training experience, effectiveness, and impacts on clinical practice post-training, including questions such as “Have you talked about the topics discussed in the training over the past weeks? If so, which ones and in what context?”. All residents completed the surveys (response rate 100 %), and all residents without conflicting residency obligations participated in the focus group. Qualitative data were analyzed with directed content analysis techniques,22 , 23 coding recurrent language and concepts to identify key themes (see Table 2). The evaluation was deemed exempt by UCSF’s Committee on Human Research (CHR), IRB no. 15–16392.
DISCUSSION
Two key themes emerged from our structural competency training evaluation data. First, the residents in this program reported that the training had a substantial influence on their attitudes and their clinical practice in the weeks after the training. Residents continued to often think about and discuss the content of the training. They reported that the terms and concepts they had learned led them to more frequently take note of the structural forces impacting their patients’ health, and that sharing this vocabulary with colleagues “lowers the barriers to having these conversations.”
Along these lines, residents stated that the training had a positive influence on their relationships with patients, helping them to “build a partnership.” Further research can help clarify the ways that a structural competency framework might influence the practice and experience of clinicians. For instance, does approaching patients with this more contextualized, structural perspective promote empathy for marginalized or stigmatized patients in the long run? If demonstrated, this would be an important finding, as empathy has been associated with improved patient health outcomes, increased patient satisfaction, and decreased provider burnout.24 , 25
Second, residents reported feeling overwhelmed by their increased recognition of structural influences on health. They expressed a need for practical strategies to address structural vulnerabilities in and beyond clinical settings.11 Though we concluded this iteration of the training by focusing on practical ways providers and patients might engage with the effects of harmful social structures, residents wanted more time to discuss these possibilities and more examples of what others had done in the past.
These findings raise several questions for further investigate. For instance, to what extent are the changes in orientation described by the residents impactful in themselves?14 , 26 Research suggests that without a structurally informed perspective, even the best-intentioned providers may be more likely to exacerbate or miss opportunities to address health disparities in their delivery of care.9 , 27 – 34 Thus, such changes in perspective, while not in themselves sufficient to address the structural issues underlying health disparities, may have a meaningful effect on the health care experiences and outcomes of structurally vulnerable patients. Additionally, some feelings of distress may be inevitable and perhaps appropriate—possibly even motivating—when providers who witness the harmful results of structural inequities on a daily basis begin to more actively reflect on this influence. Subsequent efforts designing and researching structural competency curricula can explore the most constructive ways to prepare trainees for a range of possible reactions, including distress.
This study has several limitations. First, our assessment of learners’ attitudes, knowledge, and skills was limited to qualitative analysis of participants’ self-reported impressions. Quantifying and evaluating these outcomes by external measures and assessing the effects of structural competency training on distal outcomes such as patient experience and patient well-being would be valuable next steps. Second, as our training was an isolated intervention at a single residency program, we cannot assume generalizability of our findings. For instance, it is possible that the learners in this residency program, which emphasizes care for underserved populations, were more receptive to this material than other medical trainees would be. Conversely, it is possible that structural competency training would be even more impactful in settings in which such topics are not frequently considered. Finally, though the influence of the training as reported by residents 1 month afterwards was striking, our evaluation addresses neither the longevity of this impact nor the potential effects of incorporating structural competency curricula longitudinally.
Given that social structures are among the primary determinants of illness and health, curricula to help clinicians recognize and respond to social structures are needed.12 – 17 , 31 – 33 , 35 – 37 Our findings suggest that trainees’ engagement with structural forces and their downstream effects deepens when they share concepts and vocabulary for recognizing and describing such phenomena. Structural competency appears to be a promising foundation for developing this shared understanding.
References
Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(2):19–31.
Centers for Disease Control and Prevention. Establishing a Holistic Framework to Reduce Inequalities in HIV, VIral Hepatitis, STDs, and Tuberculosis in the United States. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2010. http://ses.sp.bvs.br/local/File/Establishing%20a%20Holistic%20Framework%20to%20Reduce%20Inequities%20in%20HIV,%20Viral%20Hepatitis,%20STDs,%20and%20Tuberculosis%20i. Accessed 20 November 2016.
Krieger N. Proximal, distal, and the politics of causation: what’s level got to do with it? Am J Public Health. 2008;98(2):221–30.
CSDH. Closing the gap in a generation: health equity through action on the socialdeterminants of health. Final Report of the Commission on Social Determinants of Health.Geneva, World Health Organization; 2008.
Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health. No easy solution. JAMA. 1993;269(24):3140–5.
Marmot M. The Health Gap: The Challenge of an Unequal World. London: Bloomsbury Publishing; 2015.
Virchow RC. Report on the typhus epidemic in Upper Silesia. Am J Public Health. 2006;96(12):2102–5.
Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine then and now: lessons from Latin America. Am J Public Health. 2001;91(10):1592–601.
Farmer PE, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical medicine. PLoS Med. 2006;3(10):e449.
Westerhaus M, Finnegan A, Haidar M, Kleinman A, Mukherjee J, Farmer P. The necessity of social medicine in medical education. Acad Med. 2015;90(5):565–8.
Bourgois P, Holmes SM, Sue K, Quesada J. Structural vulnerability: operationalizing the concept to address health disparities in clinical care. Acad Med. 2016.
Chin MH, Clarke AR, Nocon RS, et al. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med. 2012;27(8):992–1000.
Gonzalez CM, Fox AD, Marantz PR. The evolution of an elective in health disparities and advocacy: description of instructional strategies and program evaluation. Acad Med. 2015;90(12):1636–40.
Kumagai AK, Lypson ML. Beyond cultural competence: critical consciousness, social justice, and multicultural education. Acad Med. 2009;84(6):782–7.
Ross PT, Wiley Cene C, Bussey-Jones J, et al. A strategy for improving health disparities education in medicine. J Gen Intern Med. 2010;25(Suppl 2):S160–3.
Vela MB, Kim KE, Tang H, Chin MH. Innovative health care disparities curriculum for incoming medical students. J Gen Intern Med. 2008;23(7):1028–32.
Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126–33.
Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117–25.
Hansen H. Faculty Roundtable Discussion on Curricular Reform. 6th Biennial National Conference for Clinician-Scholars in the Social Sciences and Humanities: Policies and Politics of Care, Philadelphia, April 18, 2015.
Quesada J, Hart LK, Bourgois P. Structural vulnerability and health: Latino migrant laborers in the United States. Med Anthropol. 2011;30(4):339–62.
Holmes SM. The clinical gaze in the practice of migrant health: Mexican migrants in the United States. Soc Sci Med. 2012;74(6):873–81.
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.
Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284–93.
Halpern J. What is clinical empathy? J Gen Intern Med. 2003;18(8):670–4.
Wear D, Kuczewski MG. Perspective: medical students’ perceptions of the poor: what impact can medical education have? Acad Med. 2008;83(7):639–45.
Bourgois P, Schonberg J. Righteous Dopefiend. Berkeley: University of California Press; 2009.
Holmes SM. Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States. Berkeley: University of California Press; 2013.
Waitzkin H. The Micropolitics of the Doctor-Patient Relationship. The Second Sickness: Contradictions of Capitalist Health Care. New York: Rowman & Littlefield; 2000:119–164.
Wear D, Aultman JM. The limits of narrative: medical student resistance to confronting inequality and oppression in literature and beyond. Med Educ. 2005;39(10):1056–65.
Rivkin-Fish M. Learning the moral economy of commodified health care: “community education,” failed consumers, and the shaping of ethical clinician-citizens. Cult Med Psychiatry. 2011;35(2):183–208.
Calman NS. Out of the shadow. Health Aff. 2000;19(1):170–4.
Wear D, Zarconi J, Aultman JM, Chyatte MR, Kumagai AK. Remembering Freddie Gray: Medical Education for Social Justice. Acad Med. 2016.
Knight KR. addicted.pregnant poor. Durham, NC: Duke University Press; 2015.
Davenport BA. Witnessing and the medical gaze: how medical students learn to see at a free clinic for the homeless. Med Anthropol Q. 2000;14(3):310–27.
Willen SS. Confronting a “big huge gaping wound”: emotion and anxiety in a cultural sensitivity course for psychiatry residents. Cult Med Psychiatry. 2013;37(2):253–79.
Metzl J. The Protest Psychosis: How Schizophrenia Became a Black Disease. Boston: Beacon Press; 2009.
Acknowledgments
The authors want to thank the residents and faculty of the residency program where we conducted the training; Mariah Hansen, Adrienne Pine, Michael Harvey, Brett Lewis, and the Critical Social Medicine Working Group for their help developing this training; and Jodi Halpern, Nancy Scheper-Hughes, and Colette Auerswald for their input and support in the development of this project.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Funders
This research was funded by small grants from the Greater Good Science Center and the UC Berkeley-UCSF Joint Medical Program; the Critical Social Medicine Working Group’s efforts to develop the training were supported by a grant from the University of California Humanities Research Institute and a grant from the University of California Social Science Matrix.
Prior Presentations
This paper has not been presented previously.
Conflict of Interest
The authors declare no conflicts of interest.
Rights and permissions
About this article
Cite this article
Neff, J., Knight, K.R., Satterwhite, S. et al. Teaching Structure: A Qualitative Evaluation of a Structural Competency Training for Resident Physicians. J GEN INTERN MED 32, 430–433 (2017). https://doi.org/10.1007/s11606-016-3924-7
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-016-3924-7